ERNSTING’S
EBOOK
AVIATION AND SPACE MEDICINE
Professor David P. Gradwell
Professor of Aerospace Medicine,
King’s College London; Honorary
Consultant in Aviation Medicine,
Guy’s & St Thomas’ NHS Foundation
Trust, King’s Health Partners; and
Civilian Consultant Advisor in
Aviation Medicine (Royal Air Force)
Air Commodore David J. Rainford
Retired Consultant Physician and
Consultant Adviser in Renal Disease
(Royal Air Force); previously,
Defence Postgraduate Medical
Dean, Consultant Physician to the
UK Civil Aviation Authority
and Senior Consultant Adviser in
Medicine to the Royal Air Force of
Oman
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ERNSTING’S
EBOOK
AVIATION AND SPACE MEDICINE
FIFTH EDITION
‘This book can be recommended to all students for the diploma
in aviation medicine course and examination, and to physicians,
AVIATION AND
psychologists and engineers involved with the practice of aviation
medicine….’
Journal of the Royal College of Physicians of London
of a previous edition
Ernsting’s Aviation and Space Medicine applies current understanding
ERNSTING’S
in medicine, physiology and the behavioural sciences to the medical
SPACE MEDICINE
challenges and stresses that are faced by both civil and military aircrew,
and their passengers, on a daily basis.
The fifth edition of this established textbook has been revised and
updated by a multi-disciplinary team of experienced contributors, and
includes new chapters on space physiology and medicine, passenger
safety, rotary wing operation by land and sea, and UAVs. It remains the
recommended textbook for those studying for the Diploma in Aviation
Medicine of the Faculty of Occupational Medicine of the Royal College
of Physicians, recognized worldwide as a standard in the field, and for
similar overseas qualifications.
Key features:
• Convenient – embraces all aspects of aviation medicine in a single
volume, divided into four parts for ease of reference: Aviation
Physiology & Aircrew Systems, Space Physiology & Medicine, Clinical
Aviation Medicine and Operational Aviation Medicine
• 
Comprehensive – covers all forms of military and passenger-carrying
aircraft, including issues surrounding passenger safety and transport
of the sick and injured
• 
Aids detailed understanding – focuses on the principles underlying
the standards in the field rather than just the standards themselves
• 
Applicable worldwide – addresses international issues, including
worldwide regulation of medical standards, and travel and disease
• 
Accessible – new chapter summaries enable rapid assimilation of
key points while key references and suggestions for further reading
encourage in-depth learning
FIFTH EDITION
The changes made in this revision ensure that Ernsting’s Aviation and
Gradwell and
Space Medicine remains an essential companion for all civil and military
aviation medicine practitioners, both when preparing for professional
Rainford
examinations and in daily practice. It is also a key reference for those in
the many disciplines of the behavioural and life sciences that include
FIFTH EDITION
some study of aviation, its physiology and related issues. In addition,
the text is recommended to those with a wider interest in the medical
problems of professional or recreational flying, air transport and the
aviation industry.
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ERNSTING’S AVIATION AND SPACE MEDICINE
FIFTH EDITION
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 ERNSTING’S
AVIATION AND
SPACE MEDICINE
FIFTH EDITION

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K17577_C000.indd 2 17/11/2015 15:29
 ERNSTING’S
AVIATION AND
SPACE MEDICINE
FIFTH EDITION
Edited by
Professor David P. Gradwell
Professor of Aerospace Medicine, King’s College London;
Honorary Consultant in Aviation Medicine,
Guy’s & St Thomas’ NHS Foundation Trust,
King’s Health Partners; and Civilian Consultant Advisor
in Aviation Medicine (Royal Air Force)

Air Commodore David J. Rainford

Retired Consultant Physician and
Consultant Adviser in Renal Disease (Royal Air Force);
previously, Defence Postgraduate Medical Dean,
Consultant Physician to the UK Civil Aviation Authority
and Senior Consultant Adviser in Medicine to the
Royal Air Force of Oman

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business

K17577_C000.indd 3 17/11/2015 15:29

Chapter 7; Chapter 8; Chapter 9; Chapter 10; Chapter 11; Chapter 12; Chapter 14; Chapter 16; Chapter 19; Chapter 22; Chapter 23; Chapter 24; Chapter
26; Chapter 30; Chapter 31; Chapter 33; Chapter 34; Chapter 35; Chapter 37; Chapter 41; Chapter 43; Chapter 49; Chapter 50; Chapter 54; Chapter 55;
Chapter 57 © Crown Copyright 2016

All other material © 2016 by Taylor & Francis Group, LLC

CRC Press
Taylor & Francis Group
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Version Date: 20151102

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 Contents

List of contributors ix
Air Vice Marshal Professor John Ernsting xiii
Preface xv
Acknowledgements xvi
Abbreviations xvii
The colour plate section appears between pages 426 and 427

Part I: Aviation Physiology and Aircrew Systems 1

1 The Earth’s atmosphere 3

Revised by David P. Gradwell
2 Cardiovascular physiology 13
Revised by Jane Ward
3 Respiratory physiology 29
Revised by Jane Ward
4 Hypoxia and hyperventilation 49
Revised by David P. Gradwell
5 Prevention of hypoxia 65
Revised by David P. Gradwell
6 Oxygen systems, pressure cabin and clothing 79
David P. Gradwell and Alistair J.F. Macmillan
7 Long duration acceleration 131
Nicholas D.C. Green
8 Short duration acceleration 157
Matthew E. Lewis
9 Head injury and protection 165
Matthew E. Lewis
10 Restraint systems and escape from aircraft 175
Matthew E. Lewis
11 Human physiology in the thermal environment 189
Michael Tipton and Graeme Maidment
12 Thermal protection and survival 199
Michael J.A. Trudgill and Graeme Maidment
13 Vibration 213
J.R. Rollin Stott
14 Anthropometry and aircrew equipment integration 229
Michael J.A. Trudgill and Michael J. Harrigan
15 Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew 245
J. Lynn Caldwell
16 Optics and vision 263
Paul Wright and Robert A.H. Scott

K17577_C000.indd 5 01/12/2015 08:19

 vi Contents

17 Spatial orientation and disorientation in flight 281

J.R. Rollin Stott and Alan J. Benson

Part II: Space Physiology and Medicine 321

18 Space physiology and medicine 323

Michael Barratt

Part III: Clinical Aviation Medicine 355

19 International regulation of medical standards 357

Anthony D.B. Evans, Sally Evans and Gwynne Harper
20 Aeromedical risk – A numerical approach 373
Anthony D.B. Evans
21 Cardiovascular disease 385
Gordon Williams
22 Hypertension 421
Edward Nicol
23 Respiratory disease 427
Gary Davies
24 Aviation gastroenterology and hepatology 441
Gareth D. Corbett
25 Metabolic and endocrine disorders 449
Raymond V. Johnston
26 Renal disease 461
Andrew Timperley
27 Haematology 467
Paul L.F. Giangrande
28 Malignant disease 477
Revised by Tania Jagathesan
29 Neurological disease 493
Damian Jenkins and Ralph Gregory
30 Ophthalmology 507
Robert A.H. Scott and Paul Wright
31 Otorhinolaryngology 527
Revised by Saliya Caldera
32 Aviation psychiatry 535
Geoffrey Ewing Reid
33 Orthopaedics and trauma 557
Ian D. Sargeant and Jon M. Kendrew
34 Decompression illness 567
Jane E. Risdall
35 Medication in aircrew 579
Andrew Timperley
36 Aviator fatigue and fatigue counter measures 583
John A. Caldwell
37 Infectious disease and air travel 601
Andrew D. Green, David Hagen and David W. Mulvaney
38 Human immunodeficiency virus 615
Ewan Hutchison
39 Cabin crew health 623
Nigel Dowdall
40 Commercial passenger fitness to fly 631
Michael Bagshaw
41 Military aeromedical evacuation 641
Ian A. Mollan

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 Contents vii

42 Civilian aeromedical retrieval 649

Geoff Tothill
43 Patient transfer: The critically ill 659
Neil McGuire

Part IV: Operational Aviation Medicine 671

44 Pilot selection and training 673

Robert Bor, Carina Eriksen and Margaret Oakes
45 Crew resource management 685
Revised by Stephen R. Jarvis
46 Air traffic control 697
John Roberts
47 Errors and accidents 707
Sarah Harris
48 The flight deck and cockpit 723
Michael Bagshaw
49 In-flight communications 737
Graham M. Rood and Susan H. James
50 Noise 747
Graham M. Rood and Susan H. James
51 Aircrew and cosmic radiation 769
Robert Hunter
52 Motion sickness 781
Alan J. Benson and J.R. Rollin Stott
53 Passenger safety in civil aviation 797
Revised by Nigel Dowdall
54 Rotary wing operation by land and sea 805
Mark S. Adams
55 Uninhabited aerial vehicles 815
Dale Daborn
56 Aircraft hygiene 825
Michael J. Kelly
57 Accident investigation and aviation pathology 831
Matthew E. Lewis and Graeme Maidment
Appendix 849
Index
861

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K17577_C000.indd 8 17/11/2015 15:29
 Contributors to the fifth edition
Mark S Adams BSc MSc MBBS MFOM DAvMed MRAeS L/RAMC
Colonel, Aviation Medicine Consultant/Pilot Physician
(British Exchange Officer), Survival Analysis Division, U.S.
Army Aeromedical Research Laboratory, Fort Rucker, AL,
USA
Michael Bagshaw MB MRCS FFOM DAvMed DFFP FRAeS
Visiting Professor of Aviation Medicine, King’s College
London, London; Honorary Civil Consultant Adviser
in Aviation Medicine, British Army; Visiting Professor,
University of Cranfield, Cranfield, UK
Michael Barratt MD MS
Astronaut Office, National Aeronautics and Space
Administration, Johnson Space Center, Houston, TX,
USA
Alan J. Benson BSc MSc MBChB FRAeS
Lately Visiting Consultant, Royal Air Force Centre of
Aviation Medicine, Henlow, UK
Robert Bor DPhil CPsychol FBPsS UKCPReg FRAeS
Consultant Clinical, Counselling and Health Psychologist;
Lead Consultant Psychologist, Royal Free London NHS
Foundation Trust; Director, Dynamic Change Consultants,
London, UK
Saliya Caldera FRCS RAF
Wing Commander; Consultant Otolaryngologist, Head
and Neck Surgeon, ENT Department, The Royal Hospital
Haslar, Gosport, UK
J. Lynn Caldwell PhD
Diplomat, American Board of Sleep Medicine, US
Air Force Research Laboratory, Human Effectiveness
Directorate, Dayton, OH, USA
John A. Caldwell PhD
Experimental Psychologist, Human Effectiveness
Directorate, US Air Force Research Laboratory, Wright
Patterson Air Force Base, OH, USA
Gareth D. Corbett MBBS MRCP(UK) (Gastroenterology) RAF
Consultant Gastroenterologist, Addenbrooke’s Hospital,
Cambridge, UK
Dale Daborn BSc(Hon) MBBS MRCGP DAvMed MA(Dist) LLM(Dist) RAF
Group Captain, Royal Air Force; United States Air Force
Exchange Flight Surgeon, Chief of Aerospace Medicine
(Interoperability), Washington, DC, USA
K17577_C000.indd 9
Gary Davies MBBS MRCP(I)
Squadron Leader, Specialist Registrar in Respiratory
Disease — Royal Air Force, Prestwood, UK
Nigel Dowdall MSc MBChB MRCGP MFOM DRCOG DipAvMed
Head of Aviation Health Unit, UK Civil Aviation Authority,
Gatwick Airport South, Crawley, UK
Carina Eriksen MSc, Dip Psych, DPsych, CPsychol, BABCP Acc
Chartered and Registered Psychologist, Middlesex, UK
Anthony D.B. Evans MBChB MSc DSc MFOM DipAvMed
Chief, Aviation Medicine Section, International Civil
Aviation Organization, Montreal, Canada
Sally Evans MBBS DCH DRCOG DAvMed FFOM FRCP(Edin) FRAeS
Chief Medical Officer, UK Civil Aviation Authority, Gatwick
Airport South, Crawley, UK
Paul L.F. Giangrande BSc MD FRCP FRCPath FRCPCH
Consultant Haematologist, Oxford University Hospitals
NHS Trust, Oxford Haemophilia Centre and Thrombosis
Unit, Churchill Hospital, Oxford, UK
David P. Gradwell BSc PhD MBChB FRCP FRCP(Edin) FFOM (Hon)
DAvMed FRAeS
Professor of Aerospace Medicine, King’s College London;
Honorary Consultant in Aviation Medicine, Guys &
St Thomas’ NHS Foundation Trust, King’s Health Partners;
Civilian Consultant Advisor in Aviation Medicine (Royal Air
Force), London, UK
Andrew D. Green MBBS FRCPath MFPH DTM&H
Wing Commander, Defence Consultant Adviser in
Communicable Diseases, Defence Medical Services
Department, Ministry of Defence, London; Senior Clinical
Lecturer in Medicine, University of Glasgow, Glasgow, UK
Nicholas D.C. Green MBBS BSc DAvMed MRAeS RAF
Wing Commander, Royal Air Force Specialist in Aviation
Medicine, Royal Air Force Centre of Aviation Medicine,
Henlow, UK
Ralph Gregory MD FRCP
Consultant Neurologist, Poole Hospital NHS Foundation
Trust, Dorset, UK
David Hagen BSC MD FFPH FRSPH
Retired Consultant in Communicable Disease Control,
Public Health England, Horsham, UK
ix
17/11/2015 15:29
 x  Contributors to the fifth edition
David Gwynne Harper MBBCh MRCGP DAvMed MRAeS MRI RAF
Group Captain, Cyprus
Michael J. Harrigan MBBS MMedSc DAvMed FFOM FAsMA MRAeS
Lieutenant Colonel RAMC; Consultant Occupational
Physician and Army Consultant in Aviation Medicine,
Aircrew Equipment Integration Group, Royal Air Force
Centre of Aviation Medicine, Henlow, UK
Sarah Harris
Human Factors Accident Investigation and Prevention
Specialist, Ottawa, Canada
Robert Hunter MBS BSc MSc (Rad Biol) GP(T) MFOM DAvMed
Head of Flight Safety, British Air Line Pilots’ Association,
West Drayton, UK
Ewan Hutchison MB ChB MSc MFOM MRCGP DAvMed FRAeS
Head of Aeromedical Centre, UK Civil Aviation Authority,
Gatwick Airport South, Crawley, UK
Tania Jagathesan MBBS BSc(Hon) MFOM DAvMED
Consultant in Occupational and Aviation Medicine,
Aeromedical Section, Civil Aviation Authority, Gatwick
Airport South, Crawley, UK
Susan H. James MSc MIoA
Capability Team Leader, Defence Technology Division,
QinetiQ, Farnborough, UK
Stephen R. Jarvis PhD MSc BEd(Hon) FRAeS CErgHF MIEHF
Director, Jarvis Bagshaw Ltd, Milton Keynes, UK
Damian Jenkins MBE MA(Oxford) BM BCh MRCP
Fellow in Medicine, St Hugh’s College, Oxford
Army Registrar in Neurology, Oxford, UK
Raymond V. Johnston MBA FRCP FFOM FFTM DAvMed
Consultant in Aviation and Occupational Medicine;
Formerly Vice President, Faculty of Occupational
Medicine, London, UK
Michael J. Kelly MBA FCIEH
Head of Food Safety and Environmental Health, British
Airways, Waterside (HMAG), Harmondsworth, UK
Jon M. Kendrew MBBS(Lond) MRCS(Eng) FRCS(Tr and Orth) RAF
Wing Commander; Royal Air Force Consultant,
Orthopaedic Trauma Consultant, Royal Centre
for Defence Medicine, Queen Elizabeth Hospital,
Birmingham, UK
Matthew E. Lewis MD MSc MBBCh DAvMed RAF
Wing Commander; Officer Commanding Accident
Investigation and Human Factors, Royal Air Force Centre
of Aviation Medicine, Henlow, UK
Neil McGuire BMedSci(Hon) BM BS DA(UK) FRCA FFICM FFMLM RAF(Rtd)
Consultant in Anaesthesia and Intensive Care Medicine;
Clinical Director of Devices, Medicines and Healthcare
Products Regulatory Agency; Honorary Consultant,
Oxford University Hospitals Trust, John Radcliffe Hospital,
Oxford, UK
Alistair J.F. Macmillan BSc MBChB MFOM
Formerly Principal Medical Officer (Research), Royal Air
Force Centre of Aviation Medicine, Henlow, UK
K17577_C000.indd 10
Graeme Maidment MA PhD BM BCh FRCPath MFFLM DMJ(Path)
DAvMed DipFHID DPMSA ARCM LTCL MRAeS RAF
Wing Commander; Consultant Histopathologist and
formerly Senior Specialist in Aviation Medicine; Head of
Aviation Pathology Department, Royal Air Force Centre of
Aviation Medicine, Henlow, UK
Ian A. Mollan MBChB MSc DAvMed MFOM MRAeS RAF
Wing Commander; Officer Commanding Aviation
Medicine Training Wing, Royal Air Force Centre of
Aviation Medicine, Henlow, UK; Honorary Senior Clinical
Lecturer, University of Otago, NZ
†Helen Muir OBE
Professor of Aerospace Psychology, Cranfield University,
Cranfield, UK
David W. Mulvaney MSC, DLSHTM, PMRAFNS
Squadron Leader, SO2 Healthcare Governance,
HQ AIR; Health Directorate, RAF High Wycombe,
Buckinghamshire, UK
Edward Nicol MD MBA DAvMed FRCP FACC FSCCT RAF
Wing Commander; Consultant Cardiologist, Clinical
Aviation Medicine Service, Royal Air Force, Centre of
Aviation Medicine, Henlow; Royal Brompton Hospital,
London, UK
Margaret Oakes PhD
Consultant Psychology, Dynamic Change Consultants,
London; Specialist Counselling Psychologist, Berkshire
Healthcare NHS Foundation Trust, Reading; Senior First
Officer, British Airways, London, UK
David J. Rainford MBE MBBS MRCS FRCP FFOM(Hon) FRAeS RAF(Rtd)
Air Commodore, Retired Consultant Physician and
Consultant Adviser in Renal Disease (Royal Air Force);
Formerly Defence Medical Postgraduate Dean, Consultant
Physician to the UK Civil Aviation Authority and Senior
Consultant Adviser in Medicine to the Royal Air Force of
Oman
Geoffrey Ewing Reid MBChB FRCPsych DAvMed MRAeS RAF
Latterly Consultant Adviser in Psychiatry RAF, Defence
Consultant Adviser in Psychiatry, Cirencester, UK
Jane E. Risdall MBBS MA(Cantab) MA(Lond) FFARCSI FRAeS
Surgeon Commander Royal Navy, Consultant in
Anaesthesia and Critical Care; Senior Lecturer, Academic
Department of Military Anaesthesia and Critical Care,
Royal Centre for Defence Medicine, Birmingham, UK
John Roberts BSc(Hon) MBBS DAvMed MFOM
Chief Medical Office and Head, NATS AeroMedical
Centres, Swanwick, UK
Graham M. Rood PhD MSc CEng FRAES MIMechE
Consultant, QinetiQ, Farnborough, UK
Ian D. Sargeant MBBS FRCS FRCS(Orth) DAvMed
Wing Commander; Department of Orthopaedics, Royal
Centre for Defence Medicine, Birmingham, UK; Consultant
Adviser in Orthopaedics to the Royal Air Force, UK
†Deceased.
17/11/2015 15:29

Robert A.H. Scott MBBS FRCS(Ed) FRCOphth DM
Wing Commander; Royal Air Force Consultant Adviser
in Ophthalmology, Royal Centre for Defence Medicine;
Consultant Ophthalmologist, University Hospital
Birmingham NHS Trust; Consultant Ophthalmologist,
Sandwell and West Birmingham NHS Trust; Senior
Lecturer in Ophthalmology, University of Birmingham
School of Medicine, Birmingham, UK
David K. Selvadurai MD FRCS FACS
Consultant Otolaryngologist, Director Auditory Implant
Service, St George’s Hospital, London, UK
J.R. Rollin Stott MA MB BChir DCH MRCP DIC DAvMed
Honorary Senior Lecturer in Aviation Medicine, Kings
College London; CAA Aeromedical Examiner, London, UK
Lauren J. Thomas CPsychol
Cranfield University, Cranfield, UK
Andrew Timperley BS MBChB FRCP DAvMed MRAeS RAF
Group Captain; Whittingham Professor of Aviation
Medicine, Royal Air Force Centre of Aviation Medicine,
Cambridge, UK
K17577_C000.indd 11
Contributors to the fifth edition  xi
Michael Tipton MSc PhD
Professor of Human and Applied Physiology, Extreme
Environments Laboratory, Department of Sport and
Exercise Science, University of Portsmouth, Portsmouth,
UK
Geoff Tothill MBBS FFTM RCPS(Glas) CertAvMed
Course Director, Aeromedical Retrieval, Department of
Occupational and Aviation Medicine, University of Otago,
Otago, NZ
Michael J.A. Trudgill MSc MBBCh MRCGP MFOM DAvMed Dip IMC
RCS(Ed) FAsMA FRAeS
Head, Aircrew Equipment Integration Group; Senior
Medical Officer, Consultant in Occupational Medicine,
Royal Air Force Centre of Aviation Medicine, Henlow, UK
Jane Ward BSc MBChB PhD
Senior Lecturer in Physiology, King’s College London,
London, UK
Gordon Williams MB FRCP FACC
Specialist Advisor, UK Civil Aviation Authority; Consultant
Cardiologist, York Teaching Hospitals NHS Trust, York, UK
Paul Wright MBBCh MSc BAO DAvMed MRAeS
Wing Commander, Royal Air Force Centre of Aviation
Medicine, Aviation Medicine Training Wing, Henlow, UK
17/11/2015 15:29
K17577_C000.indd 12 17/11/2015 15:29
 Air Vice Marshal Professor John Ernsting
CB OBE BSc MBBS PHD FRCP FFOM FRAES
21 April 1928 – 2 June 2009
John Ernsting’s (JE) contributions to aerospace physiol­
ogy and to the development of oxygen delivery systems
and aircrew protection have been enormous and without
parallel. In the best traditions of research, he achieved his
goals only at great personal risk, by subjecting himself to
the unknown. The safety of flight today owes him a great
deal, and he continued to work avidly in the field until the
day before he died.
Born in South East London, John qualified in medicine
at Guy’s Hospital and in 1954 was commissioned into the
Royal Air Force. Apart from a posting to the United States
School of Aviation Medicine, he spent his whole air force
K17577_C000.indd 13
career at the Royal Air Force Institute of Aviation Medicine
(IAM) at Farnborough. In his later career, he became
Commandant of IAM, Dean of Air Force Medicine and
Senior Consultant (RAF). On retirement from the RAF he
was appointed head of the Human Physiology and Aero­
space Medicine Group at Guy’s and St Thomas’ and King’s
College School of Biomedical Sciences, where he was already
a visiting professor.
It was at IAM that he made his greatest contributions
to the understanding of the physiology of high altitude
and developed systems for aircrew protection in this hos­
tile environment that underpin the equipment used in our
most modern aircraft. His achievements are too numer­
ous to list, but he received worldwide acclaim as the fore­
most expert in his field. In addition to his State Awards,
JE received the Louis H Bauer award from the Aerospace
Medicine Association, of which he was a Fellow, and was
elected President of the International Academy of Aerospace
Medicine (1995–1997). In May 2008 he was awarded the title
of honoris causa by Pontifica Universidade Católica do Rio
Grande do Sul, Porto Alegre, Brazil, in recognition of his
distinguished contribution to Aerospace Physiology, and he
was immensely proud that a research laboratory was dedi­
cated in his name, the John Ernsting Aerospace Physiology
Laboratory.
JE was committed not only to research but also to educa­
tion. He helped to develop the Diploma in Aviation Medicine
course and was involved as author or editor with the first
four editions of this textbook. It is therefore apt and appro­
priate that his enormous contributions be remembered by
its eponymous title, Ernsting’s Aviation and Space Medicine.
xiii
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K17577_C000.indd 14 17/11/2015 15:29
 Preface
This is the first edition of this book not to involve the late
John Ernsting, and we would like to express here our deep
appreciation of his dedication to this subject, of his encour­
agement over many years and of the infectious inspiration
of his enthusiasm which has now guided this book into its
fifth edition. The first edition was published in 1978. With
authorship drawn almost entirely from the RAF Institute of
Aviation Medicine at Farnborough, its aim was to prepare
students for the Diploma in Aviation Medicine of the Royal
College of Physicians. Since then the science and practice
of the speciality has broadened and deepened considerably.
What was once seen as a predominantly military medi­
cal discipline has, over the decades, become essential for
the safe operation of civilian aircraft, which carry millions
of passengers around the world every day. Medical practi­
tioners in aviation and space medicine need to be able to
call upon a variety of skills and a specific knowledge base
pertinent to flight. Nurses and scientists from a range of
backgrounds, including applied physiology and human fac­
tors, meet specific challenges when operating or research­
ing within the demanding environment of flight. It is our
ambition for this book to help them all. We hope that this
textbook will continue to be the cornerstone of prepara­
tion for postgraduate examinations in aviation medicine
K17577_C000.indd 15
and that it will also be an accessible source of reference for
practitioners in aerospace medicine around the world. In
this context we have sought to bring every element of this
book up to date and to add new sections addressing emerg­
ing fields of practice.
In this volume you will now find chapters on space
medicine and, for the first time, the aeromedical aspects
of remotely piloted vehicles. We have expanded the scope
of the description of aeromedical transfers of patients, and
all other chapters have been revised and updated. Each
edition of a book such as this builds on the expertise and
contributions of previous authors. We would therefore like
to express our thanks and acknowledgement to those who
have contributed to previous editions but whose names do
not appear on the list at the front of this edition. Their work
does, however, live on within these pages. We also welcome
new contributors from the UK and the US.
The preparation and publication of a large textbook
involves the input of many people, but we would like to
express our particular thanks and appreciation for the
support, encouragement and patience of Dr Jo Koster, the
Commissioning Editor. Jo has worked on the last three edi­
tions of the book and we have worked together with Jo on
the last two editions. We could not have done it without her.
xv
17/11/2015 15:29
 Acknowledgements

Each edition of a book such as this builds on the expertise and contributions of previous authors. We would therefore like to
express our sincere thanks to, and acknowledgement of, those who have contributed to previous editions but who have not
been involved directly in the updating of, or named within, this fifth edition. Their work does, however, live on within these
pages.

xvi

K17577_C000.indd 16 17/11/2015 15:29

 Abbreviations
A1AT alpha-1 antitrypsin
AAIB Air Accidents Investigation Branch
ABPM ambulatory blood pressure monitoring
ACE angiotensin-converting enzyme
ACEI angiotensin-converting enzyme inhibitor
ACI Airports Council International
ACM air combat manoeuvring
ACQ Asthma Control Questionnaire
ACR albumin:creatinine ratio
ACS acute coronary syndrome
ACSDG Aircraft Crash Survival Design Guide
ACT Asthma Control Test
ACTH adrenocorticotrophic hormone
ADH antidiuretic hormone
ADP adenosine diphosphate
ADPKD autosomal dominant polycystic kidney
disease
AE aeromedical evacuation
AEA aircrew equipment assembly
AED automatic external defibrillator
AEW airborne early warning
AF atrial fibrillation
AFB acid-fast bacilli
AFP alpha-fetoprotein
AFS after flight servicing
AGE arterial gas embolism
AGSM anti-G straining manoeuvre
AI articulation index
AIDS acquired immunodeficiency syndrome
AIS Abbreviated Injury Scale
AJCC American Joint Committee on Cancer
A-LOC almost loss of consciousness
AMC aeromedical centre
AME aeromedical examiner; authorized medical
examiner
AMP adenosine monophosphate
AMS Aero Medical Section
ANI asymptomatic neurocognitive impairment
ANP atrial natriuretic peptide
ANR active noise reduction
AOB auxiliary oxygen bottle
ARB angiotensin receptor blocker
ARED advanced resistive exercise device
ARM accident route matrix
K17577_C000.indd 17
ART antiretroviral therapy
AS ankylosing spondylitis
ASD atrial septal defect
ASDC Association of Sleep Disorders Centers
ASIC Air and Space Interoperability Council
AsMA Aerospace Medical Association
ASP Aircrew Services Package
ASW anti-submarine warfare
ATCO air traffic controller
ATD anthropomorphic test device
ATI air-transportable patient isolator
ATP ambient temperature and pressure;
adenosine triphosphate
ATPD atmospheric temperature and pressure,
dry
ATPS ambient temperature and pressure,
saturated with water vapour
AV atrio-ventricular
AVE aviation medical examiner
AVM arterio-venous malformation
AXR abdominal radiograph
BAC blood alcohol content
BBB blood-brain barrier
BCG bacillus Calmette–Guérin
BHL bilateral hilar lymphadenopathy
BOS backup oxygen system
BP atmospheric pressure
BPH benign prostatic hypertrophy
BPPV benign positional paroxysmal vertigo
BSA body surface area
BTPS body temperature and pressure, saturated
with water vapour
BTRU Barostatic Time Release Unit
CAA Civil Aviation Authority; contrast acuity
assessment
CABG coronary artery bypass graft
CAD cervical arterial dissection; colour vision
assessment and diagnosis
CAPSCA cooperative arrangement for the prevention
of spread of communicable disease through
air travel
CASCADE Concerted Action on Seroconversion to
AIDS and Death in Europe
casevac casualty evacuation
xvii
17/11/2015 15:29
 xviii Abbreviations

CBRN chemical, biological, radiological and ECS environmental conditioning system

nuclear EEG electroencephalography
CCB calcium channel blocker EFIS electronic flight instrumentation system
CDC Centers for Disease Control and Prevention eGFR estimated glomerular filtration rate
CEA carcinoembryonic antigen EGG electrogastrogram
CEP communication ear plug ELV exposure limit value
CFIT controlled flight into terrain EMG electromyography
CFS corrective flying spectacles eNOS endothelial nitric oxide synthase
CHB complete heart block ENT ear, nose and throat
CHIRP confidential human factors incident report­ EO emergency oxygen
ing programme EOG electro-oculogram
CIS clinically isolated syndrome; EP electrophysiological
Commonwealth of Independent States ER oestrogen receptor
CIVD cold-induced vasodilatation EVA extra-vehicular activity
CL contact lens FAA Federal Aviation Administration
CNS central nervous system FADEC fully automatic digital engine control
CO cardiac output; carbon monoxide FAST Fatigue Avoidance Scheduling Tool
COPD chronic obstructive pulmonary disease FBC full blood count
CPAP continuous positive airway pressure FCS Flight Control System
CPR cardiopulmonary resuscitation FCU flight control unit
CREEP container, restraint, environment, energy FEV1 forced expiratory volume in one minute
absorption and post-impact factors
FITS fighter index of thermal strain
CRM crew resource management
FL flight level
CRS corneal refractive surgery
FLIR forward-looking infrared
CRT cathode-ray tube
FMGS flight management guidance system
CSC centroserous chorioretinopathy
FR flame retardant
CSF cerebrospinal fluid
FRC functional residual capacity
CT computed tomography
FRMS Fatigue Risk Management System
CTI cavo-tricuspid isthmus
FVC forced vital capacity
CTPA computed tomography pulmonary
G acceleration
angiography
GBS Guillain–Barré syndrome
CV curriculum vitae
GCAS ground collision avoidance system
CVD cardiovascular disease
GCR galactic cosmic radiation
CVP central venous pressure
GCS ground control station
CVR cockpit voice recorder
GFR glomerular filtration rate
CXR chest X-ray
GH growth hormone
dB decibel
G-LOC G-induced loss of consciousness
δBP increased blood pressure
ΔP expiratory airflow GMC ground movement control
DCI decompression illness GP general practitioner
DCSAD Diagnostic Classification of Sleep and HAART highly active antiretroviral therapy
Arousal Disorders HAD HIV associated dementia
DEET diethyltoluamide HAND HIV associated neurocognitive disorder
DEP design eye position HbA normal adult haemoglobin
DLCO diffusing capacity of carbon monoxide HBPM home blood pressure monitoring
DMAC Diving Medical Advisory Committee hCG human chorionic gonadotrophin
DME Designated Medical Examiner HCM hypertrophic cardiomyopathy
DNA deoxyribonucleic acid HEPA high efficiency particulate air
DRI Dynamic Response Index HFACS human factors analysis and classification
DRT diagnostic rhyme test system
DS dioptre sphere HIV human immunodeficiency virus
DVT deep venous thrombosis HMD helmet-mounted display
EASA European Aviation Safety Agency HMI human-machine interface
ECCOR extracorporeal carbon dioxide removal HOCM hypertrophic obstructive cardiomyopathy
ECDC European Centre for Disease Control HP hectopascal; handling pilot
ECG electrocardiogram HPAI highly pathogenic avian influenza
ECMO extra-corporeal membrane oxygenation HPV hypoxic pulmonary vasoconstriction
HSI Human Systems Integration

K17577_C000.indd 18 17/11/2015 15:29


HSM head supported mass
HUD head-up display
IARV injury assessment reference value
IAS indicated air speed
IATA International Air Transport Association
ICAN International Committee on Air Navigation
ICAO International Civil Aviation Organization
ICL implantable contact lens
IED interictal epileptiform discharge
IFN-γ interferon gamma
IFR instrument flight rule
IGRA interferon gamma (IFN-γ) release assay
IHR International Health Regulation
IHST International Helicopter Safety Team
ILD interstitial lung disease
IMC instrument meteorological conditions
in Hg inches of mercury
INI integrase inhibitor
INR international normalized ratio
IOL intraocular lens
IOP intraocular pressure
IR infrared
IREQ required clothing insulation index
ISO International Organization of
Standardization
ISR/ISTAR intelligence, surveillance (targeting) and
reconnaissance
ISS International Space Station
JAA Joint Aviation Authorities
JAR Joint Aviation Requirement
LABA long-acting beta-2 bronchodilators
LAD left anterior descending
LASEK laser epithelial keratomileusis
LASER light amplification by the stimulated
emission of radiation
LASIK laser in situ keratomileusis
LBBB left bundle branch block
LBNP lower-body negative pressure
LDH lactate dehydrogenase
LEO low earth orbit
Leq loudness equivalent
LOSA Line Operations Safety Audit
LOX liquid oxygen
LRE launch and recovery element
LTK laser thermal keratoplasty
LVH left ventricular hypertrophy
MAA Military Aviation Authority
MAC Mycobacterium intracellulare complex
MAP Malaria Atlas Project
MAV micro air vehicle
mb millibar
MCA middle cerebral artery
MCE main (mission) control element
MCP micro-channel plate
MDC miniature detonating cord
MEDIF Medical Information Form
MEFV maximum effort flow-volume
K17577_C000.indd 19
Abbreviations xix
MERS-CoV Middle East respiratory syndrome
coronavirus
MG myasthenia gravis
MI myocardial infarction
MilAAIB Military Air Accident Investigation Branch
MMMF manmade mineral fibres
MND mild neurocognitive disorder
MOD Ministry of Defence
MP monitoring pilot
MPE maximum permissible exposure
MPI myocardial perfusion imaging
MRGB main rotor gear box
MRI magnetic resonance imaging
MRT modified rhyme test
MS multiple sclerosis
MSOC molecular sieve oxygen concentrator
MSW metres of seawater
MWT maintenance of wakefulness test
NANC non-adrenergic non-cholinergic
NASS National Accident Sampling System
NATO North Atlantic Treaty Organization
NCIN National Cancer Intelligence Network
nCoV novel coronavirus
NHP non-handling pilot
NICE UK National Institute for Health and
Clinical Excellence
NNRTI non-nucleoside reverse transcriptase
inhibitor
NO nitric oxide
NOAC new or novel oral anticoagulant
NOHD nominal ocular hazard distance
NOTECHS non-technical skills
NPI Nottingham Prognostic Index
NRDS neonatal respiratory distress syndrome
NRTI nucleoside reverse transcriptase inhibitor
NSCLC non–small-cell lung cancer
NSGCT non-seminomatous germ-cell tumour
NSTEMI non-ST elevation myocardial infarction
NTP normal temperature and pressure
NTS nucleus of the tractus solitarius
NTSB National Transportation Safety Board
NVH non-visible haematuria
OAG Official Airline Guide
OEA operational events analysis
OI orthostatic intolerance
OML operational multi-crew limitation
OPD obstructive pulmonary disease
OSA obstructive sleep apnoea
OSAS obstructive sleep apnoea syndrome
OSPL overall sound pressure level
OTC over the counter
Pa pascal
PaO2 arterial partial pressure of oxygen
PA pulmonary artery
PaO2 alveolar partial pressure of oxygen
PAPI Precision Approach Path Indicator
PB phonetically balanced
17/11/2015 15:29
 xx Abbreviations
PBA pressure breathing at 1 Gz for altitude
protection
PBG pressure breathing for Gz protection
PCI percutaneous coronary intervention
PCR protein:creatinine ratio; polymerase chain
reaction
PCRF parvicellular reticular formation
PD Parkinson’s disease
PEC personal equipment connector
PEF peak expiratory flow
PEFR peak expiratory flow rate
PET positron-emission tomography
PF pilot flying
PFO patent foramen ovale
PGL persistent generalised lymphadenopathy
PHEIC Public Health Emergency of International
Concern
PI protease inhibitor
PIC pilot in charge
PLMS periodic limb movement in sleep
PNdB perceived noise decibel
PNF pilot non-flying
PNL perceived noise level
POAG primary open angle glaucoma
PPB positive pressure breathing
PPE personal protective equipment
PPMS primary progressive multiple sclerosis
ppmv parts per million by volume
PRK photorefractive keratotomy
PSA prostate-specific antigen
PTA post-traumatic amnesia
PTE post-traumatic epilepsy
PTS permanent threshold shift
RAF CAM Royal Air Force Centre of Aviation
Medicine
RAST radioallergosorbent
RASTI rapid speech transmission index
RAW airway resistance
RBBB right bundle branch block
REM rapid eye movement
RF radiofrequency
RGC retinal ganglion cells
RK radial keratotomy
RLD restrictive lung/pulmonary disease
RLS restless legs syndrome
RMS root mean square
RNA ribonucleic acid
RPA/RPAS remotely piloted aircraft/systems
RRMS relapsing–remitting multiple sclerosis
R/T radiotelephone
RT-PCR reverse-transcriptase polymerase chain
reaction
RV residual volume
RVSM reduced vertical separation minimum
SA situational awareness; sinoatrial
SAFE System for Aircrew Fatigue Evaluation
SAFTE sleep, activity, fatigue and task-effectiveness
K17577_C000.indd 20
SAGAT situational awareness global assessment
technique
SAH subarachnoid haemorrhage
SAR search and rescue
SARPS Standards and Recommended Practices (of
the ICAO)
SARS severe acute respiratory syndrome
SART situational awareness rating technique
SAS space adaptation syndrome
SCD sudden cardiac death
SD spatial disorientation
SI service inquiry; International System of
Units
SIGN Scottish Intercollegiate Guidelines Network
SIL speech interference level
SIP Service Inquiry Panel
SN sinus node
SO2 oxygen saturation
SOL space-occupying lesion
SOP standard operating procedure
SPECT single photon emission computed
tomography
SPL sound pressure level
SPMS secondary progressive multiple sclerosis
SRATCOH Scheme for the Regulation of Air Traffic
Controllers’ Hours
SSRI selective serotonin reuptake inhibitor
STANAG standardized NATO agreement
STASS Short Term Air Supply System
STEMI ST elevation myocardial infarction
STEREO Solar-Terrestrial Relations Observatory
STI speech transmission index
STOL short takeoff and landing
STOVL short takeoff, vertical landing
STPD standard temperature and pressure, dry
SUNCT syndrome short-lasting unilateral neuralgiform
headache with conjunctival injection and
tearing
SVT supraventricular tachycardias
SWS slow-wave sleep
TAC trigeminal autonomic cephalgia
TB tuberculosis
TBI traumatic brain injury
TE thrombo-embolic
TECP tissue equivalent proportional counter
TEM threat and error management
TGA transient global amnesia
TIA transient ischaemic attack
TLC total lung capacity
TOE transoesophageal echo study
TPR total peripheral resistance
TRACON terminal radar approach control
TRT total rotor thrust
TRUCE training in unusual circumstances and
aircraft emergencies
TTS transdermal therapeutic system; temporary
threshold shift
17/11/2015 15:29

TU temporarily unfit
TUC time of useful consciousness
TURP transurethral resection of prostate
TV tidal volume
UAS unpiloted aerial systems
UAV unmanned aerial vehicle; uninhabited
aerial vehicle
UIA unruptured intracranial aneurysm
UPPP uvulopalatopharyngoplasty
URA unilateral renal agenesis
US ultrasonography
USSR Union of Soviet Socialist Republics
VC vital capacity
VCR visual control room
VDV vibration dose value
VFR visual flight rule
K17577_C000.indd 21
Abbreviations xxi
VGE venous gas embolus
VH visible haematuria
VIP vasoactive intestinal peptide
VMC visual meteorological conditions
VO2 total oxygen consumption of an individual
V/Q ventilation/perfusion
VSD ventricular septal defect
VSTOL vertical/short takeoff and landing
VT tidal volume
VTOL vertical takeoff and landing
WBTG wet-bulb globe temperature
WBV whole-body vibration
WHO World Health Organization
WHT white matter hyperintensity
WPW Wolff–Parkinson–White syndrome
YAG yttrium–aluminium–garnet
17/11/2015 15:29
K17577_C000.indd 22 17/11/2015 15:29
 Part     I
Aviation Physiology and Aircrew Systems

1 The Earth’s atmosphere 3

Revised by David P. Gradwell
2 Cardiovascular physiology 13
Revised by Jane Ward
3 Respiratory physiology 29
Revised by Jane Ward
4 Hypoxia and hyperventilation 49
Revised by David P. Gradwell
5 Prevention of hypoxia 65
Revised by David P. Gradwell
6 Oxygen systems, pressure cabin and clothing 79
David P. Gradwell and Alistair J.F. Macmillan
7 Long duration acceleration 131
Nicholas D.C. Green
8 Short duration acceleration 157
Matthew E. Lewis
9 Head injury and protection 165
Matthew E. Lewis
10 Restraint systems and escape from aircraft 175
Matthew E. Lewis
11 Human physiology in the thermal environment 189
Michael Tipton and Graeme Maidment
12 Thermal protection and survival 199
Michael J.A. Trudgill and Graeme Maidment
13 Vibration 213
J.R. Rollin Stott
14 Anthropometry and aircrew equipment integration 229
Michael J.A. Trudgill and Michael J. Harrigan
15 Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew 245
J. Lynn Caldwell
16 Optics and vision 263
Paul Wright and Robert A.H. Scott
17 Spatial orientation and disorientation in flight 281
J.R. Rollin Stott and Alan J. Benson

K17577_C001.indd 1 17/11/2015 15:29

K17577_C001.indd 2 17/11/2015 15:29

The Earth’s atmosphere
Revised by DAVID P. GRADWELL
Introduction 3
Development of the atmosphere 3
Structure of the atmosphere 4
Composition of the atmosphere 5
INTRODUCTION
All craft that venture into the air fly in, and sometimes
beyond, the Earth’s atmosphere. The nature of that atmo-
sphere influences how the craft is flown and has direct
consequences for the occupants. The physical and chemi-
cal properties of the environment that envelops the earth
induce physiological effects, and those effects can be delete-
rious or even hazardous to the aviator on ascent or descent.
It is for this reason that this book contains chapters on the
physiological, psychological and medical effects of flight.
However, before embarking on the study of those scientific
and clinical factors, it is appropriate to consider the nature
of that environment.
It is perhaps more than coincidence that the development
of a greater understanding of the physical and chemical
nature of the Earth’s atmosphere through the centuries has
association with early exploratory flights. Although there
had been accounts of the ill effects of high terrestrial alti-
tudes by the end of the sixteenth century, it was the inven-
tion of the mercury barometer by Torricelli in 1644  that
started a formal understanding of the presence of baromet-
ric pressure. The fundamental relationship between altitude
and pressure was first demonstrated in 1648, when Pascal
persuaded his brother-in-law to carry a mercury barometer
up the Puy-de-Dome in France and showed that the height
of the column of mercury fell on ascent and recovered to its
starting position on descent. Over the following two cen-
turies, the physical characteristics of the lower atmosphere
were enunciated and clearly described in Paul Bert’s classic
work, La Pression Barometrique, in 1878.
K17577_C001.indd 3
1
Physics of the atmosphere 6
Gas laws and conditions of measurement 9
Further reading 12
The chemical nature of air remained a mystery until the
eighteenth century, when Joseph Priestley discovered oxy-
gen but incorrectly termed it dephlogisticated air, leaving
it to the French chemist Lavoisier to clearly describe oxy-
gen and its exchange with carbon dioxide in 1777. In 1783,
the Montgolfier brothers demonstrated their hot air balloon
and, in the following century, advances in balloon technol-
ogy led to high altitude ascents to heights above 25 000 feet
and to the first recorded altitude-induced deaths during the
Zenith expeditions of 1875. Thus, understanding the nature
of the atmosphere and an awareness of its hazards have been
fundamental to achieving safe flight.
The form and function of the atmosphere are funda-
mental to the operation of all aircraft – military and civil-
ian, fixed- and rotary-wing. This chapter considers those
physical and chemical properties of our atmosphere and
the principles of internationally accepted standards for its
composition and behaviour. It also provides a description
of the elementary gas laws and the means of measurement
adopted under differing conditions.
DEVELOPMENT OF THE ATMOSPHERE
The primitive atmosphere is believed not to have had the
same gaseous composition as is present today. There is an
interaction between the atmosphere and the land and sea
masses – the lithosphere and hydrosphere, respectively – that
it covers. Water from the seas is drawn into the atmosphere
as water vapour, transported across considerable distances
and then returned to earth as freshwater precipitation. As
it returns to the sea, water modifies the Earth’s surface
17/11/2015 15:29
 4 The Earth’s atmosphere

through erosion and provides essential support to life on
Earth. The other crucial element required for life is the pres-
ence of oxygen molecules, essential for the generation of
energy and without which organisms cannot survive. The
part of our planet in which life can exist naturally is termed
the biosphere. The biosphere is a relatively restricted zone of
the land, sea masses and the air above them. Human physi-
ological processes allow life to exist in many, but not all,
regions and altitudes of the Earth’s surface. Unsupported
exposure to environmental conditions outside this zone is
hazardous and potentially fatal.
The presence of life itself has an influence on the com-
position of the atmosphere, both directly and indirectly,
and so once life evolved on the planet its existence modi-
fied the atmosphere and may be continuing to do so. The
atmosphere, however, serves other functions, too. It acts as
a shield against the potentially harmful effects of cosmic
radiation reaching the Earth and as a thermal protective
layer over the Earth’s surface. Depletion of the atmosphere’s
protective shield is already identified as a serious hazard to
organisms living beneath such a defect.
STRUCTURE OF THE ATMOSPHERE
The gases of the atmosphere are rarely, if ever, absolutely
constant in position, temperature or pressure, and the rota-
tion of the Earth and its gravitational influence have pro-
found effects on the nature of the atmosphere. However, in
practice, it is possible to divide the structure of the atmo-
sphere in a relatively simple manner, commonly described
of the stratosphere are now recognized (Figure  1.1). In a
similar manner, atmospheric pressure measured at high
terrestrial altitudes shows some deviation from the pattern
described later. This is affected particularly by meteoro-
logical conditions and the seasons. Even mean sea level is
not constant, as high barometric pressure over a maritime
region can ‘push down’ on the surface of the water, lowering
mean sea level. The ascent of Mount Everest without sup-
plemental oxygen took advantage of such meteorological
effects, elevated local barometric pressure causing a ‘reduc-
tion’ in the physiologically effective altitude. However, the
physical relationships described below are reasonably accu-
rate and explain the general physiological effects observed
at altitude.
Troposphere
The troposphere is characterized by a relatively consistent
fall of temperature with increasing altitude, the presence
of water vapour and the presence of large-scale air turbu-
lence and movements, which are responsible for many of
the changes in the weather. The fall of temperature with
altitude is termed the temperature lapse rate and depends
largely on local conditions. The mean lapse rate in still air is
approximately 1.98°C per 1000 feet of ascent. The decline in
temperature ceases at the tropopause, the altitude of which
varies with latitude and time of year. This variation arises as
a consequence of the effect of solar heating of atmospheric
Exosphere

as a series of concentric ‘shells’ around the Earth. These

435 miles
shells are of varying depths and are not the same thick-
Thermosphere

ness at all points over the surface of the planet. Each shell Altitude
or, more properly, sphere, has its own distinctive qualities; (feet)
300000
the point at which one set of qualities gives way to another
is termed a pause. One of the most valuable and widely
used descriptive approaches is that based on the thermal 250000
Mesosphere

features of each region. The successive layers of the atmo-

sphere from the surface of the Earth outwards are the tro-
posphere, the stratosphere, the mesosphere, the thermosphere 200000
and the exosphere. The level at which the thermal behav-
iour of the atmosphere in the troposphere changes to that Stratopause
of the stratosphere is termed the tropopause. At the outer 150000
region of the stratosphere, the stratopause marks the change
Stratosphere

to the mesosphere. Since the depths of the spheres vary at

Ozonosphere

100000
different points over the Earth, particularly with latitude,
the altitudes at which these transitions from one part of
the atmosphere to another occur also vary. These changes
50000
with latitude and thermal region, such as the Poles and the Tropopause
Troposphere

Equator, are influenced further by the effects of the seasons.

This description of the layered character of the atmosphere 0
was established before accurate measurements were avail- –60 –40 –20 0 20 0 5 10
Temperature (°C) [Ozone]
able, and it is now apparent that some of the distinctions (ppmv)
used to delineate atmospheric regions are not as constant as
thought previously. For example, temperature does not fall at Figure 1.1  Relationship between temperature, altitude
a truly constant rate on ascent through the troposphere and and the layers of the atmosphere, including the ozono-
does not remain constant in the stratosphere. Subdivisions sphere. ppmv, parts per million by volume.

K17577_C001.indd 4 17/11/2015 15:29


gases. Thus, the atmosphere in equatorial regions receives
more solar energy; the air, therefore, is hotter and more
expanded than at polar regions. As a result, the altitude of
the tropopause varies from approximately 58 000 feet at the
equator to 26 000 feet at the poles. The temperature gradient,
therefore, can range from an average sea-level value of 15°C,
to approximately −83°C at the tropopause over the equator,
to −53°C over the poles. This causes a level of instability in
the atmosphere, which contributes to the generation of the
weather patterns observed.
Stratosphere
The stratosphere is the next outer layer or strata of the atmo-
sphere. It was once thought to be characterized by a fairly
uniform temperature of −56°C and an almost complete
absence of water vapour. It extends from the tropopause to
the stratopause at an altitude of about 158 000 feet (30 miles,
50 km). It is now known to demonstrate an overall increase
in temperature, with only the lower part of the stratosphere
– the isothermal layer – being at a constant temperature.
Thereafter, temperature increases with altitude from about
90 000 feet to reach a maximum of −3°C at the stratopause.
The progressive rise in temperature is related to the other
important feature of the stratosphere, the presence of ozone
(see below). This region is termed the ozonosphere and
extends from an altitude of about 40 000 feet to 140 000 feet.
The ozonosphere is responsible for protecting the Earth
from most of the ultraviolet radiation from the sun. The
breakdown of ozone in this region into free ions and molec-
ular oxygen releases heat into the atmosphere.
Mesosphere
The next strata, the mesosphere, meaning ‘middle region’, is
characterized by a rapid decline in temperature, from −3°C
at its base at the stratopause to about −110°C at an altitude of
290 000 feet (55 miles, 85 km), making it the coldest layer of
the atmosphere and at its most extreme at the poles.
Thermosphere
The thermosphere is the essentially uppermost region of the
true atmosphere. It is characterized by a continuous increase
in temperature to values that depend on the activity of the
sun. Temperatures can exceed 1700°C during days of maxi-
mum solar activity but may fall to 227°C during nights of
solar calm. In air of such low density, however, temperature
has no thermal significance for the air itself, although it does
for any body within it. The upper limit of the thermosphere
lies at an altitude of about 372  miles (600  km), i.e. at the
extreme edge of the atmosphere. Since most of the particles
within this layer are charged, it is also known as the iono-
sphere. The precise structure of the ionosphere varies with
the energy input from the sun and is affected markedly by
the 11-year cycle of solar-flare activity. The ionosphere acts
as a reflector for long-wavelength electromagnetic radiation,
K17577_C001.indd 5
Composition of the atmosphere  5
a phenomenon that is used to reflect radio communication
between distant points on the Earth’s surface.
Exosphere
At the very edge of the Earth’s atmosphere and, thus, at the
beginning of true space, is a final sphere, the exosphere.
There is no pause at the upper reaches of this sphere, but it
becomes progressively indistinguishable from space and its
composition indistinguishable from that of interplanetary
gases. Within this sphere, collisions between particles are
so rare as to be considered not to occur at all, and gas atoms
may be regarded as having free-space trajectories. The
principal components are hydrogen and helium, but even
these are present at very low concentrations. The exosphere
can be considered as an isothermal layer that extends into
deep space.
COMPOSITION OF THE ATMOSPHERE
The chemical composition of the atmosphere is remark-
ably constant between sea level and an altitude of about
300 000 feet. Air is a mixture of nitrogen, oxygen and argon,
together with traces of carbon dioxide and certain rare
gases such as neon and helium. Water vapour is present in
variable amounts, but by convention the composition of
atmospheric gases assumes it to be dry. Table  1.1  lists the
constituents of dry air in percentages by volume according
to the ICAO 1964 standard.
The composition of air close to the surface of the Earth
may be varied somewhat by a number of factors, including
human activity, such as factory effluent and engine exhausts,
but also natural phenomena, such as volcanic eruptions and
geysers. There may be significant increases in the concen-
tration of carbon dioxide in the air near such activity, and
some more modern standards record a slightly higher level
of carbon dioxide. There may also be measurable levels of
toxic contaminants such as carbon monoxide and meth-
ane. The lower regions of the atmosphere, up to an altitude
of about 30 000 feet, i.e. the troposphere, may also contain
significant quantities of water vapour. The concentration
of water within a given mass of air depends largely on its
Table 1.1  ICAO (1964) ISA composition of the
atmosphere
Concentration in dry air
Gas (%  by volume)
Nitrogen 78.09
Oxygen 20.95
Argon 0.93
Carbon dioxide 0.03
Neon 1.82 × 10−3
Helium 5.24 × 10−4
Krypton 1.14 × 10−4
Hydrogen 5.00 × 10−5
Xenon 8.70 × 10−6
17/11/2015 15:29
 6 The Earth’s atmosphere
location (i.e. whether it is, or has recently been, located over
an area of water) and its temperature. The higher the tem-
perature of the mass of air, the greater will be its capacity for
water vapour. For many purposes, dry air may be regarded
as a mixture consisting of 21  per cent oxygen and 79  per
cent nitrogen, although, more accurately, almost one per
cent is argon and the rare gases. The oxygen that is such an
essential component of our atmosphere is derived from the
photosynthetic processes of plants.
Ozone (O3), the triatomic form of oxygen, is a further
important constituent of the atmosphere. However, as noted
above, it is present in significant concentrations only within
the ozonosphere. It is a blue, unstable gas formed by the
irradiation of molecular oxygen in the upper atmosphere by
short-wavelength (200  nm) ultraviolet light from the sun.
The ultraviolet radiation is absorbed and the oxygen mol-
ecules are split into free atoms, which then either recombine
with each other to reform molecular oxygen or combine with
other oxygen molecules to form ozone. The amount of ozone
formed at a given altitude thus depends on the concentration
of oxygen molecules and the intensity of ultraviolet radia-
tion. Above about 350 000  feet, ultraviolet radiation is so
intense that all molecular oxygen is dissociated into oxygen
atoms; below this altitude, molecular oxygen is more abun-
dant and the ultraviolet radiation less intense, so that con-
ditions for ozone production are created. Consequently, the
concentration of ozone increases progressively as altitude is
reduced below about 140 000 feet, reaching a maximum level
of approximately 10 parts per million by volume (ppmv) at
100 000 feet (Figure 1.1). Below this altitude, ultraviolet radi-
ation is much less intense, as a consequence of atmospheric
absorption, and oxygen molecules are more numerous, so
the concentration of ozone falls progressively to a value of
less than 1 ppmv at altitudes below 40 000 feet and to about
0.03 ppmv at sea level. Furthermore, at these lower altitudes,
ozone is dissociated to molecular oxygen by longer-wave-
length (210–300 nm) ultraviolet light.
Ozone is a very strong oxidant and is highly toxic, exert-
ing its clinical effects primarily upon the respiratory tract.
Although in the early part of the twentieth century some
clinicians believed that ozone might assist in the treat-
ment of various diseases, acute exposure to concentrations
of 0.6–0.8 ppmv for two hours is sufficient to reduce vital
capacity and forced expiratory volume and to cause a fall
in diffusing capacity for carbon monoxide, presumably as
a consequence of alveolar oedema. Exposure to 1 ppmv is
sufficient to cause lung irritation, while 10 ppmv can induce
fatal pulmonary oedema.
Some military aircraft operate within the ozonosphere,
but their occupants generally will have personal oxygen
systems, providing a high concentration of oxygen in the
inspired breathing gas. In aircraft in which the cabin envi-
ronment is pressurized so as to make it suitable as the primary
means of protection against hypoxia at high altitudes, there
would be a potential risk of the ozone concentration in cabin
air being unacceptably high and giving rise to respiratory
irritation. However, at normal engine power settings, the air
K17577_C001.indd 6
entering the cabin will have passed through the engine com-
pressors before reaching the cabin-conditioning system and
therefore have been heated to high temperatures. As ozone is
thermally unstable, this potentially toxic gas is broken down
to molecular oxygen. Only at flight-idle engine power could
ozone pass unaltered through the cabin-conditioning sys-
tem in any significant amount and, inevitably, at such power
levels the aircraft will be descending out of the ozonosphere.
PHYSICS OF THE ATMOSPHERE
Density and pressure
As described above, the overall depth of the atmosphere var-
ies with latitude and is the result of two opposing influences.
The sun heats the atmospheric gases; the more directly this
acts, the greater the effect seen. At the outer reaches of the
atmosphere, gases expand into the vacuum of space, but this
effect is counteracted by the gravitational attraction exerted
by the Earth, tending to draw the gases towards its surface.
Air density, i.e. mass per unit volume, in the atmosphere is
proportional to ambient pressure, i.e. force per unit area at
a specific altitude. Atmospheric pressure falls progressively
with ascent from the surface of the Earth; indeed, because
gas is compressible, density and pressure both fall in an
approximately exponential manner with vertical distance
(altitude) from the Earth’s surface, although local variations
in temperature at altitude bring about some deviations from
a true exponential decline. However, the physiologically
significant factor in inspired atmospheric air is its pressure;
therefore, in aviation medicine, it is pressure rather than
density that is used when considering the consequences of
ascent to altitude.
The pressure exerted at sea level by the weight of the atmo-
sphere is 101.3 kPa (14.7 lb/in2). This atmospheric pressure
will support a column of mercury (Hg) in an evacuated tube
to a height of approximately 760 mm. As Figure 1.2 shows,
this pressure is halved to 50.7 kPa (380 mmHg) at an alti-
tude of 18 000  feet and reduced to one-quarter (25  kPa,
190 mmHg) at an altitude of 33 700 feet. At 100 000 feet, the
atmospheric pressure is one-hundredth of that at sea level.
At the upper reaches of the atmosphere, the gases are
so expanded that collisions between molecules occur with
decreasing frequency. By an altitude of about 262 000  feet
(50 miles, 80 km) (the von Karman line), the pressure exerted
by atmospheric gas has fallen to such a degree that aerody-
namic forces are no longer effective and manoeuvrability of
craft must be achieved by rockets or reaction jets. At even
greater altitudes, the density of the atmosphere is so low that
particles travel considerable distances without colliding
with each other at all. In the exosphere, as described above,
some lighter particles travelling at high velocity may escape
from the atmosphere completely and move into space. This
characterizes the very edge of the Earth’s atmosphere. Even
so, the influence of the Earth’s gravitational force remains
strong, and only at an altitude of 1700 miles (2735 km) has it
fallen to half its sea-level value.
17/11/2015 15:30

800
600
Pressure = 380 mmHg
Pressure (mmHg)
at 18000 feet
400
200
0 collide with atoms within it at altitudes between 60 000 and
0 20000 40000 60000 80000
Altitude (feet)
Figure 1.2  Exponential relationship between pressure
exerted by the atmosphere and altitude.
Temperature
The temperature of the atmosphere varies markedly with
altitude (Figure 1.1), but the relationship is not a simple one.
For any given altitude, there are considerable geographical
and temporal differences in temperature. These could be
predicted from the observations on the influence of solar
heating noted above, but there are several mechanisms
involved in this process. Although some solar radiation
is reflected away into space by the outermost layers of the
atmosphere and some, particularly ultraviolet radiation, is
absorbed in the upper layers, the bulk of the infrared radia-
tion from the sun penetrates the atmosphere and reaches
the Earth’s surface. As the ground itself is warmed by this
process, it warms the air immediately above it by radiation
and conduction. The ground radiation is at a different fre-
quency from solar radiation but still in the infrared part of
the spectrum. This radiation is absorbed by carbon dioxide
and water vapour in the lower atmosphere; in turn, these
lower layers re-radiate part of the infrared energy. Some
returns to the surface of the Earth to be radiated yet again,
while the remainder passes up to be absorbed in the higher
layers of the atmosphere. Thus, the atmosphere has the effect
of creating a warmer environment on Earth than would
occur simply as a result of solar heating in the absence of
the atmosphere. This blanketing influence is termed the
greenhouse effect.
The thermal changes that occur at or near the surface
of the Earth create convection currents in the lower atmo-
sphere, contributing to the circulation of weather patterns
and influencing climate. Since the heating of the lower
atmosphere is influenced strongly by solar infrared heating
of the Earth’s surface, the greater the distance above the sur-
face, the lower the expected temperature. Thus, there is nor-
mally a progressive decline in temperature with increasing
altitude, although local inversions and variations do occur.
This progressive fall in temperature continues until the tro-
popause is reached. The thermal patterns described previ-
ously have the effect of inhibiting further convection and
thereby tend to limit weather patterns to the troposphere.
K17577_C001.indd 7
Physics of the atmosphere  7
Ionizing radiation
Ionizing radiation falls on the Earth from space in a con-
tinuous stream. This high-energy subatomic particulate
radiation originates either from our own sun (solar cosmic
radiation) or from other stars (galactic cosmic radiation). It
consists of protons (79 per cent), alpha particles (20 per cent)
and the nuclei of heavier atoms (one per cent). The radia-
tion enters the atmosphere at high velocity, in some cases
approaching that of light. As the ionizing radiation enters
the upper regions of the atmosphere, the primary particles
100000
120 000  feet to produce a secondary radiation of protons,
electrons, neutrons, mesons and gamma rays. Such second-
ary radiation has considerably less energy than its precur-
sor, but it is capable of intense ionization. Secondary rays
penetrate the lower regions of the atmosphere, but although
some reach the surface of the Earth, their ionizing power
diminishes rapidly at altitudes below 50 000 feet, as further
collisions occur with atmospheric molecules as atmospheric
density increases. At sea level, the ionizing effect of cosmic
radiation is about only one-seventieth of that encountered
at an altitude of 70 000 feet.
The potential to receive higher doses of ionizing radiation
at high altitude has some implications for high-flying aircraft
and manned spacecraft. Since these craft operate outside the
protective effect of most, or all, of the Earth’s atmosphere,
the dose of cosmic radiation increases. Manned spaceflight,
therefore, exposes astronauts to some additional degree of
radiation hazard. Although the shell of the craft provides
some element of shielding in current spacecraft, it is con-
siderably less effective than the natural shielding provided
by the atmosphere. With longer endurance spaceflights
being conducted in the International Space Station, and the
potential for a manned mission to Mars, there is an inevita-
ble cumulative risk arising from increased received doses of
ionizing radiation. During extra-vehicular activity (space-
walks), this problem is exacerbated, since the suits worn by
astronauts are even less effective than the structure of the
spacecraft in providing a shield against ionizing radiation.
Standard atmospheres
The introduction of flight instrumentation that could indi-
cate the height of an aircraft or balloon in terms of altitude
and barometric pressure made it essential that a reference
standard was introduced. This type of standard can be
used as the basis for calibration of flight instruments, to
allow accurate comparisons to be made between the per-
formance of various aircraft and aircraft systems, and is
crucially important in establishing altitude separation
in busy commercial airways. In a little over 20  years of
heavier-than-air flight, but coming after the rapid advances
in aircraft design during the First World War and with
the development of the first commercial air services, the
International Committee on Air Navigation (ICAN) drew
up the first internationally accepted standard atmosphere
17/11/2015 15:30
 8 The Earth’s atmosphere

in 1924. This used simple laws to define the relationship Table 1.2  International Civil Aviation Organization (ICAO)
between pressure and altitude. In the years that followed, a (1964) international standard atmosphere
number of different standards were prepared and adopted
Altitude Pressure
both nationally and internationally. The International Temperature
Civil Aviation Organization (ICAO) standard (1964) and ft m mmHg lb/in2 (°C)
the US Standard Atmosphere (1976) are the most widely 0 0 760 14.70 +15.0
known. Even as recently as 1986, an updated standard – 1000 305 733 14.17 +13.0
the Committee on Space Research international reference 2000 610 706 13.67 +11.0
atmosphere – was published. Although there are differ- 3000 914 681 13.17 +9.1
ences between standards, these tend to be associated with
4000 1219 656 12.69 +7.1
alternative approaches to the temperature–altitude con-
5000 1525 632 12.23 +5.1
vention employed in their construction, especially with
6000 1829 609 11.78 +3.1
respect to the upper atmosphere, and they are very simi-
lar (and, indeed, identical in their most recent versions) 7000 2134 586 11.34 +1.1
for altitudes up to 65 000  feet. For the purposes of both 8000 2438 565 10.92 −0.9
military and civil aviation, the ICAO (1964) standard has 9000 2743 543 10.50 −2.8
been adopted. 10 000 3048 523 10.11 −4.8
11 000 3353 503 9.72 −6.8
INTERNATIONAL CIVIL AVIATION ORGANIZATION 12 000 3658 483 9.35 −8.8
STANDARD ATMOSPHERE 13 000 3962 465 8.98 −10.8
The 1964 ICAO standard atmosphere closely represents the 14 000 4267 447 8.63 −12.7
pressure and temperature characteristics of the real atmo- 15 000 4572 429 8.29 −14.7
sphere at the temperate latitude of 45° North. The relation- 16 000 4879 412 7.97 −16.7
ship between pressure and altitude defined by this standard, 17 000 5182 395 7.64 −18.7
and listed in an abbreviated form in Table 1.2, is based upon 18 000 5486 380 7.34 −20.7
the following ‘ideal’ assumptions:
19 000 5791 364 7.04 −22.6
20 000 6096 349 6.75 −24.6
●● The air is dry and devoid of dust and has a stated com-
21 000 6401 335 6.48 −26.6
position (that given in Table 1.1).
●● The atmospheric pressure at mean sea level is 22 000 6706 321 6.21 −28.6
760 mmHg (101.3 kPa). 23 000 7010 307 5.95 −30.6
●● The atmospheric density at mean sea level is 1.225 kg/m3. 24 000 7315 294 5.70 −32.6
●● The relative molecular mass of air at mean sea level is 25 000 7620 282 5.45 −34.5
28.9644. 26 000 7925 270 5.22 −36.5
●● Acceleration due to gravity is 9.80665 m/s2 and 27 000 8230 258 4.99 −38.5
is constant. 28 000 8534 247 4.78 −40.5
●● The temperature–altitude profile is as follows: 29 000 8839 236 4.57 −42.5
●● Temperature at mean sea level: +15°C. 30 000 9144 226 4.36 −44.4
●● Mean temperature lapse rate: −1.98°C per 1000 feet 31 000 9449 215 4.17 −46.4
from mean sea level to 36 089 feet. 32 000 9754 206 3.98 −48.4
●● Height of tropopause: 36 089 feet above mean 33 000 10 058 196 3.80 −50.6
sea level.
34 000 10 363 187 3.63 −52.4
●● Temperature of isothermal layer of stratosphere,
35 000 10 668 179 3.46 −54.2
from 36 089 to 65 616 feet: −56.5°C.
36 000 10 973 170 3.30 −56.3
●● Temperature rises progressively above 65 616 feet to
−46°C at 100 000 feet. 37 000 11 278 162 3.14 −56.5
38 000 11 582 155 3.00 −56.5
A given standard atmosphere defines the variation of 39 000 11 887 147 2.95 −56.5
pressure with altitude for a given relationship between tem- 40 000 12 192 141 2.72 −56.5
perature and altitude. In reality, as noted above, there are 41 000 12 497 134 2.59 −56.5
considerable variations in the temperature profile, both 42 000 12 802 128 2.47 −56.5
with season of the year and with latitude. Table  1.3  illus- 43 000 13 107 122 2.36 −56.5
trates this by comparing the ICAO standard with measured 44 000 13 411 116 2.24 −56.5
maximum and minimum temperatures at various altitudes. 45 000 13 716 111 2.14 −56.5
These temperature variations are of practical importance 46 000 14 021 106 2.04 −56.5
to both physiologists and aeronautical engineers. Thus, 47 000 14 326 101 1.95 −56.5
the physiological disturbances induced by exposure to low

K17577_C001.indd 8 17/11/2015 15:30

 Gas laws and conditions of measurement  9

Table 1.2 (Continued)  International Civil Aviation Table 1.3  Worldwide maximum and minimum recorded
Organization (ICAO) (1964) international standard air temperatures at various altitudes (frequency of
atmosphere occurrence of 10 days in one year)

Altitude Pressure Temperature (°C)

Temperature
ft m mmHg lb/in 2 (°C) Altitude ICAO (1964) Maximum Minimum
48 000 14 630 96.0 1.85 −56.5 (ft) standard recorded recorded
49 000 14 935 91.5 1.77 −56.5 0 +15.0 +50 −26
50 000 15 240 87.3 1.68 −56.5 10 000 −4.8 +16 −34
51 000 15 545 83.2 1.61 −56.5 20 000 −25.6 −3 −48
52 000 15 850 79.3 1.53 −56.5 30 000 −44.4 −21 −62
53 000 16 155 75.6 1.46 −56.5 40 000 −56.5 −40 −68
54 000 16 459 72.1 1.39 −56.5 50 000 −56.5 −40 −78
55 000 16 764 68.8 1.32 −56.5 60 000 −56.5 −40 −86
56 000 17 069 65.5 1.27 −56.5 80 000 −52.1 −40 −86
57 000 17 374 62.4 1.21 −56.5 100 000 −46.0 −30 −90
58 000 17 679 59.5 1.15 −56.5 ICAO, International Civil Aviation Organization.
59 000 17 983 56.8 1.10 −56.5
60 000 18 288 54.1 1.04 −56.5 Boyle’s law
65 000 19 812 42.3 0.828 −56.5
70 000 21 336 33.3 0.644 −55.2 Boyle’s law states that measured at a constant tempera-
75 000 22 860 26.2 0.507 −53.6 ture, the volume of a fixed mass of an ideal gas is inversely
80 000 24 384 20.7 0.401 −52.1 proportional to the pressure to which it is subjected.
85 000 25 908 16.4 0.317 −50.6 Expressed mathematically,
90 000 27 432 13.0 0.251 −49.1
1
95 000 28 956 10.3 0.199 −47.5 P∝
100 000 30 480 8.2 0.158 −46.0 V

pressure in a hypobaric chamber are related to the pres-
sure–altitude tables uncorrected for temperature, while the
aerodynamic behaviour imparted to an airframe during its
passage through the air is determined by the density alti-
tude. Since density altitude is pressure–altitude corrected
for the difference between the observed temperature and
the temperature adopted by the standard atmosphere, it
may therefore be regarded as the ‘real’ or ‘true’ altitude.
GAS LAWS AND CONDITIONS OF
MEASUREMENT
The physical laws that govern the behaviour of gases in iso-
lation, as components of gaseous mixtures and dissolved
in liquids, have a direct bearing on the understanding of
the mechanisms whereby changes in altitude affect human
physiology. The laws of particular relevance to physiology
include Boyle’s law and Charles’s law, which are concerned
with the relationships between pressure, temperature and
volume of an ideal (hypothetical) gas, but they also extend
to the behaviour of the individual components making
up a mixture of gases (Dalton’s law) and the behaviour of
gases in solution (Henry’s law and the laws of gaseous dif-
fusion). The physical principles of gauge and absolute (abs)
pressures are also pertinent, as is an understanding of the
conditions of measurement applicable to atmospheric and
respired gases.
and, therefore,
P1 V2
=
P2 V1
where P1 is the initial pressure, P2 is the final pressure,
V1 is the initial volume and V2 is the final volume.
It should be noted that the pressure here is expressed
in absolute terms and not as a differential (gauge) pres-
sure (see below). The law is modified by the presence of
water vapour; therefore, since the gases in body cavities
may be regarded as being saturated with water vapour at
a constant (body) temperature, the equation becomes, for
physiological purposes:
( P1 − PH2O ) V2
=
( P2 − PH2O ) V1
where PH2O is saturated water vapour pressure at body
temperature. Since body temperature is constant, so, too, is
PH2O.
Charles’s law
Charles’s law states that the volume of a fixed mass of gas is
directly proportional to its absolute temperature, measured
at a constant pressure. The absolute temperature of a gas,

K17577_C001.indd 9 17/11/2015 15:30

 10 The Earth’s atmosphere
which is measured in Kelvin, is obtained by adding 273 to
its Celsius temperature, since absolute zero is −273°C. (At
absolute zero, molecular motion ceases and, theoretically,
gases then have no volume.) Charles’s law may be expressed
mathematically, thus:
V ∝ T
and, therefore,
V = constant × T
or
V1 T1 (t1 + 273)
= =
V2 T2 (t2 + 273)
where V1 is the initial volume, V2 is the final volume, T1 is
the initial absolute temperature and T2 is the final absolute
temperature (absolute temperature being the sum of the
temperature t1 and t2 in degrees Celsius plus 273).
UNIVERSAL GAS LAW
By combining Boyle’s and Charles’s laws, a universal
or general gas law can be derived, as described by the
following equation:
PV PV
1 1
= 2 2
T1 T2
where P1, V1 and T1 refer to the pressure, volume and tem-
perature (in kelvins) of a mass of gas in one set of conditions
and P2, V2 and T2 describe them in a second set of conditions.
Dalton’s law
Dalton’s law of partial pressures states that the pres-
sure exerted by a mixture of gases is equal to the sum of
the pressures that each would exert if it alone occupied
the space filled by the mixture. The law may be expressed
mathematically thus:
Pt = P1 + P2 + P3 … Pn
where Pt is the total pressure of the mixture and P1, P2,
P3 … Pn are the partial pressures of each component.
It follows that the partial pressure of any gas in a mixture
is given by the relationship
Px = Fx × Pt
where Px is the partial pressure of gas x, Fx is the frac-
tional concentration of gas x in the mixture and Pt is the
total pressure of the gas mixture. Thus, for example, the
partial pressure of oxygen (Po2) in the dry atmosphere at
mean sea-level pressure is
K17577_C001.indd 10
20.95
Po 2 = × 760 = 159.2 mmHg
100
Henry’s law
Henry’s law states that the mass of gas that will dissolve in
a liquid (and with which it does not combine chemically) at
a given temperature is directly proportional to the partial
pressure of the gas above the liquid and the solubility coef-
ficient of the gas in the particular liquid. At equilibrium,
the partial pressure of the gas in the liquid phase will be
the same as that of the gas directly above the liquid. Thus,
if the partial pressure of a gas in a liquid is reduced, then
the amount of that gas that can be held in solution will
be reduced in proportion. A simple example of the way in
which Henry’s law works is seen when a bottle of carbon-
ated water is opened. The opening of the bottle causes a
sudden reduction in pressure in the gas above the liquid,
and gas in the liquid comes out of solution, as evidenced
by the production of bubbles in the liquid. This behaviour
is believed to be the basis of bubble formation (leading to
decompression sickness) in body fluids on abrupt exposure
to a significant reduction in environmental pressure.
Laws of gaseous diffusion
Diffusion is the process whereby molecules move from
regions of higher concentration to those of lower concentra-
tion. In gaseous diffusion, the molecules of one gas inter-
mingle with those of another. The rate of diffusion of a single
gas through a liquid or gaseous mixture is proportional to
the difference between the partial pressures of the gas at the
two points and inversely proportional to the square root of its
molecular weight (Graham’s law). In a liquid, the rate of diffu-
sion is proportional to the solubility of the gas within the liq-
uid, such that the more soluble the gas, the faster its diffusion.
Fick’s law describes the diffusion of a gas through a tissue
medium. When considering the effect of Fick’s law in the
body, the diffusion rate of a gas across a fluid membrane is
proportional to the difference in partial pressure (as above),
proportional to the area of the membrane and inversely pro-
portional to the thickness of the membrane. Combined with
the diffusion rate determined by Graham’s law, Fick’s law
provides the means for calculating exchange rates of gases
across membranes. The total membrane surface area of the
lung alveoli (the alveolar–capillary membrane) in adults may
be of the order of 100 m2 and have a thickness of less than
one-millionth of 1 m, and so it is a very effective gas-exchange
interface. Fick’s law can be expressed mathematically thus:
⎛ ⎞
V̇gas ∝ ⎜ A ⎟ D(P1 − P2)
⎝T ⎠
and,
Sol
D∝
( MW )
17/11/2015 15:30

where V̇gas is the rate at which gas is transferred, A is the
surface area of the tissue, T is the thickness of the tissue, P1 −
P2 is the difference in gas partial pressure across the tissue,
D is the diffusion constant, Sol is the solubility of the gas,
and MW is the molecular weight of the gas.
Conditions of measurement
MEASUREMENT OF PRESSURE
Pressure may be defined as perpendicular force per unit
area. A column of liquid or gas, therefore, will exert a pres-
sure that is proportional to the height of the column, the
density of the material within it and the acceleration due to
gravity. Accordingly, atmospheric pressure is a reflection of
the force applied by the mass of a column of air that, at sea
level, will exert a pressure on the Earth’s surface of 1.033 kg/
cm2 (14.7 lb/in2, 760 mmHg, 1 atmosphere, 1 bar, 101.3 kPa).
The absolute pressure of a gas or (confined) liquid is
the total pressure it exerts and includes the effect of atmo-
spheric pressure. Thus, an absolute pressure of zero corre-
sponds to a complete vacuum (as is found in deep space).
Pressure-measuring devices, such as pneumatic tyre pres-
sure gauges, however, respond to the pressure present in
excess of any atmospheric component. So, for example,
a tyre pressure gauge may indicate a pressure of 30  lb/
in2  within a tyre – which is termed the gauge pressure –
but the absolute pressure exerted by the air within the tyre
must include the local atmospheric component and thus
at sea level will be 44.7 lb/in2. The gauge reading given by
such an instrument therefore is the difference between two
pressures, and so the instrument will register zero when-
ever the pressure applied to the measuring point equals
that of its surroundings. The total or absolute pressure is
the algebraic sum of the gauge and the local (i.e. ambient)
atmospheric pressures, i.e.
absolute pressure = gauge pressure + local atmospheric
pressure
Pressures less than atmospheric pressure will produce
negative gauge pressures, and these correspond to partial
vacuums. An absolute pressure, however, cannot be less
than zero.
In physiology, the distinction between absolute and gauge
pressures is important. In the case of a diver, for example,
the individual is already under a pressure of 1 atmosphere
(1 bar) at sea level before descending; a dive to a depth of
30 m will produce a gauge reading of 3 bars (3 atmospheres),
but the absolute pressure will be 4 bars. In aviation physiol-
ogy, this concept is of particular relevance when considering
cabin-pressurization schedules (see Chapter 6). The absolute
pressure within the cabin of an aircraft equals the sum of
the atmospheric pressure at its external surface (measured
by static probe) and the cabin differential pressure; the cabin
differential pressure is the difference between the absolute
pressure within the aircraft and that of the atmosphere out-
side it. Thus:
K17577_C001.indd 11
Gas laws and conditions of measurement  11
cabin differential = internal cabin − atmospheric
pressure pressure (abs) pressure (abs)
and so,
cabin absolute = cabin differential + atmospheric
pressure pressure pressure (abs)
As an example, the atmospheric pressure surround-
ing an aircraft flying at 25 000 feet is 38 kPa (282 mmHg,
5.5  lb/in2  abs). If the cabin differential pressure is 31  kPa
(252 mmHg,4.5 lb/in2 g), then the absolute pressure within
the cabin will be the sum of these, i.e. 69 kPa (514 mmHg,
10.0  lb/in2), and the cabin altitude will be just over
10 000 feet.
MEASUREMENT OF GAS VOLUMES
The gas laws have a great influence on respiratory function.
The brief description of the laws governing the behaviour
of gases implies that changes in temperature and pres-
sure will have profound effects on the numerical values of
any variables studied. Therefore, it is important that rela-
tionships between the various conditions of measurement
are understood.
It is generally accepted that body temperature, includ-
ing that of the lungs, is constant and that water vapour
when present, as in the lungs, is at its saturation pressure.
The values commonly used are a temperature of 37°C and
the saturated water vapour pressure at that temperature,
i.e. 47  mmHg (6.3  kPa). The gas in the lungs under these
conditions is stated to be at body temperature and pressure,
saturated with water vapour (BTPS). The volumes of gases
within the lungs are usually defined at BTPS conditions.
Under most circumstances, however, ambient air is at a
lower temperature than gas in the lungs and, furthermore,
contains less water vapour. This is not only because atmo-
spheric air is not usually saturated with water vapour but
also because, at a lower temperature, the saturated water
vapour pressure is lower. If measurements are made under
these conditions, then they are said to be at ambient tem-
perature and pressure (ATP). If, however, respiratory mea-
surements are made via a spirometer, or if gas is collected
in a bag, then the air is regarded as saturated with water
vapour and the conditions of measurement are termed
ambient temperature and pressure, saturated with water
vapour (ATPS).
Ambient air is heated and humidified as it passes
through the upper respiratory tract, and consequently it
expands in accordance with Charles’s law and by virtue
of water molecules evaporating within the airway. The
physiological importance of this is that the volume of gas
inspired (as measured by a spirometer or similar device)
is less than the volume of gas taking part in respiratory
exchange. The shortfall may be on the order of 10 per cent
in temperate climates, and a correction from ATPS to BTPS,
therefore, is necessary. The correction may be expressed
mathematically thus:
17/11/2015 15:30
 12 The Earth’s atmosphere
⎡ (275 + 37) ⎤ ⎡ (PB − PH O) ⎤
V̇BTPS = V̇ATPS × ⎢ ⎥ × ⎢
⎣ 273 + ta ⎦ ⎣ (PB − 47) ⎦
where ta is the ambient temperature in degrees Celsius,
P B is the barometric pressure in millimetres of mercury,
P H2O is the saturated water vapour pressure at ta, and 47 is
the saturated water vapour pressure at body temperature, in
millimetres of mercury.
The first fraction in this equation is the term describ-
ing expansion due to heat. The second fraction is the term
describing the volume increase as a consequence of added
water vapour. The product, therefore, is the factor by which
the ATPS volume must be multiplied to give the lung vol-
ume at BTPS.
When dealing with metabolic physiology, however, dif-
ferent requirements exist. In this case, it is the number of
molecules of oxygen used and of carbon dioxide produced
that are of interest, rather than the volume that they happen
to be occupying at the time of measurement. It is essential,
therefore, to express oxygen and carbon dioxide volumes
under the precisely defined standard conditions, i.e. at stan-
dard temperature and pressure, dry (STPD). Standard tem-
perature is 273 K (0°C) and standard pressure is 760 mmHg
(101.3 kPa). When defined in this way, the number of mole-
cules contained within the STPD volume can be calculated,
since under these conditions, gases comply with Avogadro’s
law, i.e. 1 gram-mole of a gas will have a volume of 22.4 L
(STPD).
The correction from ATPS measurement to STPD
conditions is:
⎡ 273 ⎤ ⎡ (Pb − PH O) ⎤
V̇STPD = V̇ATPS × ⎢ ⎥ × ⎢
⎣ (273 + ta) ⎦ ⎣ 760 ⎦
Finally, in the context of breathing system definition
(see Chapter 6), two further conditions of measurement are
encountered that are of particular use to life-support engi-
neers. Thus, system specifications may often quote gas volumes
under atmospheric temperature and pressure, dry (ATPD) con-
ditions, while consumption figures are quoted under normal
temperature and pressure (NTP) conditions. In the UK, tem-
perature and pressure under ATPD conditions are considered
to be +15°C and the absolute pressure of gas within the site
under study (e.g. within a mask delivery hose). Similarly, the
temperature and pressure under NTP conditions are +15°C
and 760 mmHg (101.3 kPa) absolute, respectively.
The need to express quantities of gas under NTP condi-
tions is a reflection of the expansile behaviour of gases on
exposure to low environmental pressures; that is, once at
altitude, the volume flow of a gas is not the same as its mass
flow, the difference increasing with altitude. As an example,
a mass flow of 4 L (NTP)/min will provide a volume flow of
about 8 L (ATPD)/min at an altitude of 18 000 feet, where
atmospheric pressure is half its sea-level value and expan-
sion has occurred in accordance with Boyle’s law. In fact,
K17577_C001.indd 12
the volume flow of a gas is never the same as its mass flow,
2
⎥ even at sea level, although the magnitude of the difference
increases with altitude. This has particular relevance for
respiratory physiology at altitude, since respiration is a vol-
ume flow phenomenon.
SUMMARY
●● The Earth’s atmosphere is composed of air
containing nitrogen, oxygen, argon, carbon
dioxide and rare gases plus varying amounts
of water vapour. Thus, it provides oxygen for
respiration and offers protection against cosmic
radiation. The atmosphere has been character-
ized as having a number of concentric spheres,
defined by their physical properties. The pressure
of the atmosphere falls in an exponential decline
with ascent from sea level. Temperature initially
falls at a constant lapse rate as far as the edge of
the troposphere.
●● International Standard Atmospheres have been
defined to assist safe operation of aircraft by
providing common physical properties; the
most widely used being the International Civil
Aviation Organisation (1964).
●● Human physiology is strongly influenced by the
application of the fundamental Gas Laws, which
define the relationship between pressure, volume
and temperature of gases and their movement in
gaseous or liquid phases. Physiological measure-
ments have to take account of the varied condi-
2
⎥
tions in which they are made and corrected to
known standards.
FURTHER READING
Andrews DG. An Introduction to Atmospheric Physics.
Cambridge: Cambridge University Press, 2000.
Bert P. La Pression Barometrique. Masson Paris, 1878.
English translation: Hitchcock MA and FA. Columbus,
OH: College Book Company, 1943.
Goody RM. Principles of Atmospheric Physics and
Chemistry. Oxford: Oxford University Press, 1995.
International Civil Aviation Organization. Manual of the ICAO
Standard Atmosphere, 2nd edn. Montreal: ICAO, 1964.
Lumb AB. Nunn’s Applied Respiratory Physiology. Oxford:
Butterworth−Heinemann, 2000.
Meteorological Office. Handbook of Aviation
Meteorology. London: HM Stationery Office, 1971.
West JB. Respiratory Physiology: The Essentials, 9th edn.
Philadelphia: Lippincott, Williams and Wilkins, 2012.
West JB, Schoene RB, Luks AM, Milledge JS. High
Altitude Medicine and Physiology, 5th edn. Boca
Raton, FL: CRC Press, 2013.
17/11/2015 15:30

Cardiovascular physiology
Revised by JANE WARD
Overview of the cardiovascular system 13
Measurement of cardiovascular pressures in the body 14
Factors affecting pressures in blood vessels 14
Factors affecting resistance 16
Fluid exchange in the capillaries: the Starling principle 18
Pulmonary circulation 19
Control of cardiac output 20
Reflex control of the cardiovascular system 20
Arterial chemoreceptors, lung receptors and
responses to hypoxia 22
Pain and reflexes from skeletal muscle 22
OVERVIEW OF THE CARDIOVASCULAR
SYSTEM
The human cardiovascular system consists of the sys-
temic circulation in series with the pulmonary circulation
(Figure 2.1). In the systemic circulation, blood is ejected by
the left ventricle into the aorta. Nearly all this blood, hav-
ing passed through the various vascular beds of the different
organs and tissues, finds its way back via the systemic veins
to the right side of the heart, to be pumped through the pul-
monary circulation for gas exchange. This series arrange-
ment of the systemic and pulmonary circulations means that
the output of the right heart, measured in litres/minute (L/
min), must be almost identical to the output of the left heart.
In normal people, a small difference exists because of some
anomalies in the anatomy of the normal circulation, e.g. the
bronchial venous drainage as shown in Figure 2.1. Normally,
the blood flow through such right-to-left-shunt pathways is
less than three per cent of the cardiac output (CO).
In young people, the walls of the aorta and large arteries
contain large amounts of elastin, making them very disten-
sible. During ventricular systole, the aorta and other elastic
arteries stretch, accommodating more blood and reducing
systolic pressure. During diastole, they recoil, maintaining
K17577_C002.indd 13
2
Reflexes contributing to the diving response 22
Reflexes from the urinary bladder 22
Defence or alerting response 23
Interaction between cardiovascular and respiratory
reflexes 23
Cardiovascular responses to changing posture 23
Vasovagal fainting 25
The Valsalva manoeuvre 25
Cardiovascular response to exercise 26
Further reading 27
flow during ventricular relaxation and raising diastolic
pressure. The difference between systolic and diastolic arte-
rial pressure (pulse pressure) increases with age as the arter-
ies become less elastic.
The capillary beds of most tissues and organs in the sys-
temic circulation are in parallel with each other. The large
arteries divide into smaller muscular arteries, which in turn
lead to the muscular arterioles and pre-capillary sphinc-
ters, which supply the thin-walled capillaries where gas and
nutrient exchange occur. The blood emerging from the cap-
illaries passes through venules and veins, finally entering
the right atrium via the inferior and superior vena cava and
the coronary sinus.
In a few places in the body, two capillary beds that are func-
tionally linked are in series with each other. In the hepatic
portal system, the blood draining from gastro­intestinal cap-
illary beds passes via the portal vein to the liver, where the
products of digestion are processed. In the kidney, the blood
from the glomerular capillaries drains into efferent arterioles
that supply the capillaries of the renal tubules. The potential
disadvantage of portal systems is reduced oxygen delivery
to the downstream vascular bed. In the liver, an adequate
oxygen supply is maintained via the hepatic artery. In the
kidney, blood flow is normally very high relative to oxygen
13
17/11/2015 15:31
 14  Cardiovascular physiology

Head and neck

Arms

Pulmonary
Superior arteries
Lungs Pulmonary
vena cava vein

Bronchi

RA LA
*
Coronary Aorta
Inferior RV LV
sinus
vena cava *

Liver Gastrointestinal tract

Hepatic portal vein
Hepatic artery

Aorta
Kidney
Tubules Glomerulus

Other
(bladder, reproductive
organs, etc.)

Legs

Figure 2.1  Schematic overview of the main features of the human cardiovascular system. The white boxes represent the
main organs and tissues of the systemic circulation, which are in parallel with each other and supplied by the left ven-
tricle (LV) via the aorta. The stippled box is the pulmonary circulation, which is supplied by the right ventricle (RV) via the
pulmonary arteries. The grey lines represent vessels carrying well-oxygenated blood, and the black lines represent vessels
containing blood with a low oxygen content. Some deoxygenated blood from the bronchial circulation and a small amount
from the left ventricular muscle join the oxygenated blood on the left side of the heart. These normal right-to-left shunts
are shown by asterisks.

consumption and provides an adequate oxygen delivery to
both capillary beds. However, tubular necrosis can occur
when blood flow to the kidney is reduced in haemorrhage.
Typical resting blood flows to the different organs of the
body are given in Table 2.1, which compares the circulation
at rest and in strenuous exercise.
MEASUREMENT OF CARDIOVASCULAR
PRESSURES IN THE BODY
Pressures in the body are usually referred to atmospheric
pressure, with pressures above atmospheric being positive
and those below being negative. The International System
of Units (SI) unit of pressure is the pascal (Pa) but blood
pressures are still usually expressed in millimetres of mer-
cury (mmHg), i.e. the height of a column of mercury that
the pressure would support. Low pressures, such as central
venous pressure, are also measured in centimetres of water
(cmH2O). Sometimes, especially when considering the
effects of posture on blood pressure, it is helpful to know
the pressure exerted by the weight of a column of blood
expressed in conventional units:
1 cm blood = 1.06 cmH2O = 0.78 mmHg = 0.104 kPa
FACTORS AFFECTING PRESSURES IN
BLOOD VESSELS
Several factors play a part in determining the pressure in
any vessel in the circulation. First, blood is an incompress-
ible liquid completely filling a system of elastic vessels. If
the heart is stopped suddenly, then blood continues to flow
from arteries to veins, causing arterial pressure to fall and
central venous pressure to rise until, after a few seconds,
pressure becomes equal throughout the circulation. This
pressure – the mean circulatory filling pressure – is depen-
dent on the blood volume contained within the circulation
and the vascular capacity, which is especially affected by
venous smooth muscle tone. Mean circulatory filling pres-
sure is normally about 7 mmHg.

K17577_C002.indd 14 17/11/2015 15:31

 Factors affecting pressures in blood vessels  15

Table 2.1  Typical physiological values in healthy 20-year-old man at rest and in maximal exercise. Actual values, especially
those in maximal exercise will vary considerably depending on the subject’s level of physical fitness and training and on
environmental conditions. Blood flows for the important organs are shown both in absolute values and as a percentage of
the cardiac output.

Max ex
Rest (R) Maximal exercise (max ex) R
Heart rate (bpm) 70 200 2.9
Stroke volume (mL) 75 90 1.2
CO (mL/min) 5250 18 000 3.4
a O2 content (mL/mL) 0.2 0.2 1.0
v O2 content (mL/mL) 0.152 0.033 0.23
(a–v) O2 content (mL/mL) 0.048 0.167 3.5
O2 consumption (mL/min) 250 3000 12
Blood flow (mL/min, % CO):
Skeletal muscle 790 (15%) 13,000 (72%) 16.5
Skin 320 (6%) 1,260 (7%) 3.9
Heart 260 (5%) 900 (5%) 3.5
Brain 790 (15%) 790 (4%) 1
Gastrointestinal tract 1300 (25%) 900 (5%) 0.7
Kidneys 1050 (20%) 540 (3%) 0.5
a, arterial; v, mixed venous; CO, cardiac output.

Second, contraction of the heart generates pressure. or group of vessels is proportional to the pressure difference
Left ventricular contraction generates a mean pressure in across them, i.e. arterial pressure minus venous pressure
the aorta of about 90–100 mmHg. As blood flows through (Pa − Pv):
the systemic vessels back to the right atrium, the pressure
falls progressively in a way that depends on the resistance ( Pa – Pv )
F=
of the vessels. R

Finally, the effects of gravity modify pressures within
vessels. In an open container filled with a liquid, the pres-
where R is the resistance to flow.
sure at the surface is atmospheric or ‘zero’ and increases
For the whole systemic circulation, flow is cardiac output
with distance below the surface because of the weight of
(CO) and resistance is the total peripheral resistance (TPR).
the liquid. If the liquid has a density ρ (measured in grams
per millilitre), then h metres below the surface the pressure The pressure difference is the mean arterial blood pressure
(BP) in the ascending aorta minus the central venous pres-
increases by ρgh (measured in kilopascals), where g is the
sure (CVP). CVP is the pressure in the right atrium and the
acceleration due to gravity (9.81m/s−2). Alternatively, h cen-
great veins close to the heart.
timetres below the surface, the pressure is increased by ρh
Therefore:
cmH2O or 0.74ρh mmHg.
The human circulatory system is a closed, completely
liquid-filled system. In life, end-diastolic pressure in the (BP – CVP)
CO =
right ventricle is close to atmospheric and is little affected TPR
by posture. Changing posture from supine to upright
increases the pressure in vessels h cm below the heart Since in health CVP is close to atmospheric pressure, this
and reduces the pressure h cm above it by ρgh kPa or equation is often simplified to:
0.74ρh mmHg or 0.78h mmHg, since the density of blood
is about 1.06g/cm3. BP
CO ≈
TPR
Blood flow and vascular resistance
Fluid flows from a region of high pressure to a region of low Poiseuille studied the factors affecting laminar flow of
pressure, and the flow rate is affected by the resistance to Newtonian (constant viscosity) fluids moving along straight
flow offered by the tube(s) or vessel(s) through which the smooth-walled tubes and determined that:
fluid is flowing. Blood flow is usually laminar, with layers
8hl
of blood moving in an orderly, streamlined fashion parallel R=
to the walls of the vessels. Laminar flow F through a vessel πr4

K17577_C002.indd 15 17/11/2015 15:31

 16  Cardiovascular physiology
where R is the resistance, η is the viscosity of the fluid
flowing through the tube, l is the length of the tube and r is
the radius of the tube.
The human vascular system is complex and blood is non-
Newtonian, as its viscosity is not constant but is reduced
when flowing through vessels with diameters less than
1  mm. Nevertheless, the main principles of Poiseuille’s
equation apply to the human circulation. The radius of a
vessel markedly affects its resistance to flow, with a halving
of radius leading to a 16-fold increase in resistance. Most
moment-to-moment control of blood flow through vas-
cular beds is brought about by alterations in the radius of
the smaller arteries and arterioles upstream of the vascular
beds, and this vasoconstriction or vasodilation has a marked
effect on the local vascular resistance and flow. Widespread
vasoconstriction or vasodilation affecting many different
vascular beds at the same time can markedly increase or
decrease total peripheral resistance.
Red blood cells are the main blood component affect-
ing its viscosity, which nearly doubles when haematocrit
increases from its normal value of about 45  per cent to
60 per cent in polycythaemia. Polycythaemia often develops
as a response to chronic hypoxia, for example, at altitude
or in chronic respiratory failure. The increased viscosity
increases the work of the heart and partly offsets the benefi-
cial effect of the increased arterial oxygen content.
In a healthy young person, a typical pressure in the
ascending aorta is 120/80 mmHg, with a mean pressure of
about 93  mmHg. The way in which pressure falls around
the systemic circulation is determined by the distribution
of resistance in the circulation. What determines this is
the total resistance of all the blood vessels at each level of
branching. Moving peripherally from aorta to capillaries,
the resistance of individual vessels rises as the radius falls;
however, at each level of branching, there are progressively
more vessels in parallel with each other, which lowers their
combined resistance. In the systemic circulation, the net
effect of these opposing factors is such that the main resis-
tance is located at the level of the arterioles and the largest
pressure drop occurs across these vessels.
The large radius of the aorta ensures its resistance is low, as
is the total resistance of vessels at the next few branching lev-
els, so the pressure drop along the aorta and arteries is small.
Mean pressure in a foot artery is only a few millimetres of mer-
cury below that in the arch of the aorta in the supine subject.
The parallel arrangement of systemic vascular beds per-
mits separate control of blood flow to different organs and
tissues through alterations in arteriolar resistance brought
about by both local and centrally integrated reflex mecha-
nisms. As vascular beds are in parallel with each other,
removing one of them, for example, by amputating a limb,
increases total peripheral resistance.
FACTORS AFFECTING RESISTANCE
Vascular smooth muscle is subject to many different influ-
ences that can either increase or decrease its tone. Some of
K17577_C002.indd 16
these mechanisms operate locally and change blood flow
appropriately to meet the local tissue needs; others, medi-
ated by nerves, adjust peripheral resistance and/or capaci-
tance to meet the needs of the body as a whole, for example,
in order to maintain arterial blood pressure or core tem-
perature. Control is hierarchical, with nervous control
mechanisms able to override local mechanisms when the
need arises.
Autoregulation
A sudden increase in perfusion pressure increases blood
flow, but in most tissues the flow falls again over the next
minute or two as the arterioles constrict. This ability of a
tissue to maintain a fairly constant blood flow in the face
of alterations in perfusion pressure is known as autoregu-
lation. The mechanism is partly myogenic, with the vas-
cular smooth muscle responding to increased stretch by
contracting, and partly metabolic, with increased pressure
leading to increased washout of vasodilator metabolites. All
vascular beds, except the pulmonary circulation, exhibit
some degree of autoregulation, but the mechanism is espe-
cially well developed in the renal and cerebral circulations,
where flow stays remarkably constant at perfusion pressures
between about 60 and 160 mmHg in a normotensive person.
Local metabolites
The vasodilator properties of metabolites have an important
role in matching blood flow to metabolic activity in many
tissues. Increased acidity, increased CO2, increased adenos-
ine, increased K+, increased osmolality, increased phosphate
and decreased O2  all contribute to metabolic vasodila-
tion, but the relative importance of these factors differs in
different tissues.
Endothelial factors
The endothelial cells lining the blood vessels produce both
vasodilator and vasoconstrictor substances. Nitric oxide
(NO) is produced continuously by the enzyme endothelial
nitric oxide synthase (eNOS) in normal subjects. In health,
this basal NO production leads to a tonic reduction in
total peripheral resistance. NO production increases when
vessels are exposed to increased shear stress, causing the
flow-mediated vasodilation of arteries that often follows
metabolite-mediated dilation of more peripheral vessels.
It allows blood flow to rise higher than would be possible
otherwise. The vasodilation that accompanies inflamma-
tion also involves NO production, but in this case it follows
induction of a form of NOS not normally found in the endo-
thelium (inducible NOS, iNOS).
Other vasodilator substances produced by the endothe-
lium include prostacyclin and endothelial-derived hyper-
polarizing factor. Endothelin is a vasoconstrictor produced
by the endothelium that also has an effect on basal vascular
resistance in health. It is likely that alterations in the balance
17/11/2015 15:31

between endothelial vasodilator and vasoconstrictor sub-
stances are important in many common diseases, such as
hypertension, pre-eclampsia and diabetes.
Hormones
The catecholamines adrenaline (epinephrine) and nor-
adrenaline (norepinephrine) are released into the blood
from the adrenal gland when its preganglionic sympathetic
fibres are stimulated. Noradrenaline is also the transmitter
released by most postganglionic sympathetic nerves. Both
noradrenaline and adrenaline stimulate alpha-receptors
in most tissues to cause vasoconstriction and beta1-recep-
tors in the heart to increase heart rate and contractility.
Circulating adrenaline can also stimulate beta 2-receptors
in skeletal and cardiac muscle vessels to cause vasodilation.
This effect dominates if adrenaline is infused, so that total
peripheral resistance falls, cardiac output rises and blood
pressure rises a little. In contrast, infused noradrenaline
causes a marked increase in total peripheral resistance and
blood pressure, which activates the arterial baroreceptor
reflex. The reflex effects override the direct effects of nor-
adrenaline on the heart, leading to bradycardia, reduced
contractility and reduced cardiac output.
Antidiuretic hormone (ADH) from the posterior pitu-
itary increases water reabsorption in the distal nephron,
reducing urine output. It can also cause vasoconstriction,
as indicated by its alternative name vasopressin, although
higher concentrations are needed for this than for its antidi-
uretic action. In health, the release of ADH is controlled by
plasma osmolality sensed by osmoreceptors in the hypo-
thalamus. ADH release is also stimulated by hypovolae-
mia, via a reduction in firing of the cardiopulmonary and
arterial baroreceptors. Following haemorrhage, its antidi-
uretic effect contributes to the restoration of extracellu-
lar fluid volume, and the vasoconstriction helps support
blood pressure.
The renin–angiotensin–aldosterone system is also
involved in the responses to haemorrhage, helping to restore
circulating blood volume. Renin secretion from juxtaglo-
merular cells of the kidney is increased in hypovolaemia by
several mechanisms, including increased renal sympathetic
stimulation. Renin acts on plasma angiotensinogen to form
angiotensin I, which is converted to angiotensin II by the
action of angiotensin-converting enzyme. Angiotensin II
stimulates adrenal cortical aldosterone secretion, leading to
increased salt and water retention by the kidney; in addi-
tion, angiotensin II is a potent vasoconstrictor.
Autocoids (local hormones) and other
vasoactive substances
Many substances produced during inflammation act locally
as vasodilators, including histamine, bradykinin, platelet-
activating factor and prostaglandin E2. Bradykinin is also
produced by sweat glands and may contribute to the skin
vasodilation that occurs when core temperature rises.
K17577_C002.indd 17
Factors affecting resistance  17
Serotonin and thromboxane A2  released from platelets
cause local vasoconstriction.
Nervous control of the blood vessels
At times, blood flow to a tissue needs to be adjusted to
serve not its own needs but those of the body as a whole.
This control is mediated mostly by nerves. Blood flow to
the skin increases to many times that needed for its own
metabolism as part of thermoregulatory response to heat
stress. In haemorrhage, blood flow in the splanchnic, renal
and cutaneous circulation is reduced below that required by
local metabolic needs. The increased vascular resistance in
these tissues helps to maintain blood pressure and, hence,
coronary and cerebral blood flow. The reflexes that are inte-
grated to override local mechanisms are described later in
this chapter.
The most important nerves controlling blood ves-
sels throughout the body are sympathetic vasoconstrictor
nerves. These innervate small arteries and arterioles, the
constriction of which increases vascular resistance and
reduces tissue blood flow and secondarily leads to a local fall
in capillary and venous pressure. Veins are also innervated
by sympathetic nerves; this innervation is sparse in skeletal
muscle and more important in the splanchnic circulation.
Sympathetic activity can reduce vascular capacitance both
by reducing the flow into the veins secondary to arteriolar
constriction and also by active venoconstriction.
Presympathetic nerves originate in the ventrolateral
medulla; their discharge is modulated by many cardio-
vascular and respiratory reflexes that are integrated in the
brainstem. The bulbospinal fibres synapse with pregangli-
onic sympathetic fibres in the intermediolateral column of
the spinal cord. Preganglionic sympathetic nerves emerge
from the thoracic and upper lumbar segments (T1–L3) of
the spinal cord, and most synapse with the postgangli-
onic sympathetic nerves in the ganglia of the sympathetic
chain. Some preganglionic fibres pass without synapsing
to the adrenal medulla, where they stimulate the release of
adrenaline and, to a lesser extent, noradrenaline. The trans-
mitter in the ganglia and adrenal medulla is acetylcholine;
between postganglionic vaso­constrictor fibres and vascular
smooth muscle, the transmitter is noradrenaline acting on
alpha-adrenergic receptors. Sympathetic vasoconstrictor
nerves have a resting tone, which means that they are dis-
charging continuously under normal conditions; vasodila-
tion and venodilatation are mediated by a reduction of their
ongoing discharge.
Other nerves innervating blood vessels
Most blood vessels are innervated only by sympathetic
vasoconstrictor nerves, but some, for example, those in the
salivary glands and erectile tissue of the penis, also receive a
parasympathetic vasodilator innervation. The transmitters
released from the postganglionic parasympathetic nerves
are acetylcholine and vasoactive intestinal peptide (VIP),
17/11/2015 15:31
 18  Cardiovascular physiology
substance P or NO; these are often referred to as non-adren-
ergic non-cholinergic (NANC) transmitters.
Vasodilation can also occur when nociceptive C-fibres
are stimulated. Collaterals from these nerves release vaso-
dilator neuropeptides such as substance P. This ‘axon reflex’
occurs when C-fibre stimulation activates these collaterals
without involving the central nervous system. It is respon-
sible for the red flare surrounding a sting or injury and,
together with the local redness and wheal (oedema) at the
site of injury, forms part of the triple response described
by Lewis.
Some special features of different systemic
vascular beds
The mechanisms described above operate in all systemic
circulations but their relative importance differs in differ-
ent tissues and circumstances. Special features of the renal,
coronary, cerebral, skeletal muscle and cutaneous circula-
tions are outlined below.
RENAL CIRCULATION
The blood flow needed by the kidney for its filtration func-
tion is very high and it receives 20  per cent of the resting
cardiac output; this exceeds the blood flow needed for its
oxygen requirements, so oxygen extraction is low and renal
venous oxygen saturation is higher than mixed venous
oxygen saturation (the average venous oxygen saturation).
Renal blood flow shows very good autoregulation but it also
has a rich sympathetic nerve supply and reflex vasocon-
striction can cause a marked fall in renal blood flow during
haemorrhage or heavy exercise.
CORONARY CIRCULATION
Blood flow to the left ventricular wall is restricted during
systole as blood vessels are compressed by the contract-
ing muscle. At rest, coronary blood flow is low relative
to myocardial oxygen consumption, oxygen extraction
is very high and coronary venous oxygen saturation is
very low. In exercise, coronary blood flow increases by
metabolic vasodilatation; as oxygen extraction is already
near maximal, coronary blood flow rises in direct pro-
portion to oxygen consumption to meet the increased
metabolic needs.
CEREBRAL CIRCULATION
Total cerebral blood flow is not very variable, although
local increases in cerebral activity do increase local blood
flow. The cerebral vessels are sensitive to local O2 and espe-
cially local CO2; when arterial Pco2  is lowered by hyper-
ventilation, the vasoconstriction can be severe enough to
lead to visual disturbance and light-headedness. The cere-
bral circulation shows good autoregulation; despite this
cerebral blood flow does fall a little on standing. Although
their blood vessels do have autonomic innervation, ner-
vous control is not very strong in either the cerebral or
coronary circulation.
K17577_C002.indd 18
SKELETAL MUSCLE CIRCULATION
Accumulation of local metabolites acting directly on arte-
rioles is the main mechanism of the vasodilation in exer-
cising skeletal muscle. In other circumstance, for example,
on standing or during haemorrhage, reflex control via sym-
pathetic vasoconstrictor determines skeletal muscle blood
flow to help maintain blood pressure.
CUTANEOUS CIRCULATION
Nervous control, via sympathetic vasoconstrictor nerves to
arterioles and the special arteriovenous anastomoses found
in the skin of the extremities, is a most important regula-
tor of skin blood flow. Reflexes from the hypothalamic
thermoregulatory centres act to increase or decrease skin
blood flow to increase or reduce heat loss. These responses
to thermal stress are discussed fully in Chapter 12. During
heat exposure, the large increase in cutaneous blood flow
can have important effects on the ability to meet the cardio-
vascular demands of exercise.
Veins and capacitance vessels
The veins tend to be large in diameter and, as a group, veins
offer little resistance to flow. They are much thinner-walled
than the arteries and have a large internal volume. At any
one time, usually about 60–70  per cent of the total blood
volume is in the veins, which are, therefore, often known as
‘capacitance vessels’. The internal volume of the veins can
vary greatly. When pressures within the veins are low, the
veins collapse; when pressures rise, the veins become circu-
lar in cross-section, with a considerable increase in volume.
If blood volume expands, veins exhibit stress relaxation, so
that the initial rise in venous pressure gradually lessens.
In haemorrhage, the reverse occurs, helping to lessen the
fall in venous pressures. In addition, sympathetic nerves
innervate veins, especially those in the abdomen, permit-
ting active control of their capacity. This gives them a role
in the maintenance of central venous pressures and venous
return to the heart, for example, during standing. Limb
veins contain semilunar valves. Contraction of the muscles
that surround the deep veins of the leg raises venous pres-
sure, which drives the blood towards the heart. Backflow is
prevented by the presence of the valves. This is known as
skeletal muscle pumping. Venous return to the heart is also
increased during inspiration, when the fall in intrathoracic
pressure helps to suck blood back to the heart.
FLUID EXCHANGE IN THE CAPILLARIES:
THE STARLING PRINCIPLE
Capillaries are the exchange vessels where fluids, gases,
nutrients and products of metabolism move between the
blood and the interstitium. The direction and magnitude
of the fluid movement across the capillary at any point
depends on the balance between hydrostatic and osmotic
pressures across the capillary; this is the Starling principle
of fluid exchange (Figure 2.2).
17/11/2015 15:31
 Pulmonary circulation  19

Effective Effective Effective Effective

∆HP = 36.5 ∆COP = 13.5 ∆HP = 16.5 ∆COP = 13.5 ∆HP = 16.5 ∆COP = 13.5 ∆HP = 6.5 ∆COP = 13.5
(90% × 15) (90% × 15) (90% × 15) (90% × 15)

–1.5 10 –1.5 10 –1.5 10 –1.5 10

15 25 5 25
35 25 15 25

23 mmHg Net filtration or 3 mmHg 3 mmHg Net filtration or 7 mmHg

filtration absorption filtration filtration absorption absorption
pressure pressure
Arterial end Venous end Arterial end Venous end

(a) (b)

Figure 2.2  Starling principle. Hydrostatic pressure (HP) in capillaries depends on the degree of vasoconstriction and the
position of the vascular bed above or below the heart. Tissue colloid osmotic pressure (COP) and local vessel permeability
to proteins also vary in different tissues. (a) Situation in a typical capillary at heart level. Hydrostatic and colloid osmotic
pressures (mmHg) inside and outside the capillary are shown above, and the net filtration or absorption pressures are
shown below. (b) Situation soon after the onset of vasoconstriction, which lowers the capillary hydrostatic pressures. Net
reabsorption now occurs along most of the capillary, although this will not be sustained indefinitely, because the move-
ment of fluid from interstitium to capillary will increase interstitial and reduce blood COP.

The main force driving fluid out of the capillaries is the
hydrostatic pressure difference between the capillary and
the interstitium. Capillary hydrostatic pressure falls along
the capillary, with values at the arterial end depending on
the vascular tone and the height above or below the heart.
Interstitial fluid pressure is usually close to zero and in
many tissues a few millimetres of mercury below atmo-
spheric pressure. Hydrostatic pressure values for a typical
tissue at heart level are given in Figure 2.2a (black arrows).
The osmotic pressure difference opposes filtration and is
due to the difference in concentration of plasma proteins
across the capillary. Plasma colloid osmotic pressure is
about 25  mmHg; interstitial colloid osmotic pressure is
variable but about 10 mmHg (white arrows). Even this col-
loid osmotic pressure difference of 15  mmHg across the
capillary wall is only about 90  per cent exerted, because
the capillary is an imperfect (slightly leaky) semipermeable
membrane. It can be seen from Figure  2.2a that when all
these different forces are taken into account, there is nor-
mally net filtration occurring along the entire length of the
capillary in most tissues. This filtered fluid returns to the
circulation via the lymphatic vessels. Oedema occurs when
net filtration exceeds lymphatic drainage; this may occur
if the Starling forces are altered, e.g. by a rise in capillary
pressure or a fall in plasma protein concentration; it will
also occur if the lymphatics are blocked, for example, by
tumour, parasites or post-radiotherapy scarring. Net reab-
sorption of fluid into capillaries may occur transiently
in many tissues following haemorrhage (Figure  2.2b),
because reflex vasoconstriction causes a fall in capillary
pressure. This fluid movement from interstitium to blood
vessel can increase circulating fluid volume by several
hundred millilitres.
PULMONARY CIRCULATION
A typical pulmonary artery pressure in health is 25/8 mmHg
(3.3/1.1  kPa), with a mean pressure of about 15  mmHg
(2  kPa). This pressure is only about 10  mmHg above left
atrial pressure, but this pressure difference is enough to
drive the cardiac output through the pulmonary circulation
because pulmonary vascular resistance is less than one-
sixth of systemic vascular resistance.
Autoregulation does not occur in the pulmonary circula-
tion, where holding flow constant would be unhelpful. Thus,
in exercise, when increased venous return increases pulmo-
nary artery pressure, pulmonary blood flow and, therefore,
cardiac output are allowed to increase.
Nervous control of the pulmonary circulation is much
less important than in the systemic circulation. Pulmonary
vessels constrict in response to local hypoxia, in contrast to
the vasodilation seen in systemic vascular beds. Hypoxic
vasoconstriction helps to reduce ventilation/perfusion
mismatching in the lungs by diverting blood flow from
poorly ventilated to better ventilated areas. When hypoxia
is global, e.g. at altitude or in the presence of respiratory
failure, hypoxic vasoconstriction is less helpful and simply
increases pulmonary vascular resistance and can lead to
right heart strain and failure.
Pulmonary capillary hydrostatic pressure at about
10  mmHg is lower than systemic capillary pressure, but
there is still net filtration and lymph formation, because

K17577_C002.indd 19 17/11/2015 15:31

 20  Cardiovascular physiology
pulmonary interstitial protein concentration is unusu-
ally high, with an interstitial colloid osmotic pressure of
16–20 mmHg.
CONTROL OF CARDIAC OUTPUT
Cardiac output is the product of stroke volume and heart
rate. These are determined by nervous and other factors
described in this section. The heart is supplied by parasym-
pathetic nerves travelling in the vagus (X cranial nerve) and
sympathetic nerves from the upper thoracic spinal cord (T1–
T5). Both sympathetic and parasympathetic nerves inner-
vate the sinoatrial (SA) node, the atrioventricular node and
the atria, releasing noradrenaline and acetylcholine to act
on beta1-adrenergic and muscarinic receptors, respectively.
The ventricular myocardium has a rich sympathetic inner-
vation, but parasympathetic innervation is sparse.
In a healthy young person at rest, there is both tonic
parasympathetic and sympathetic discharge to the SA node,
but the parasympathetic discharge dominates, keeping the
heart rate below its intrinsic rate of about 100  beats/min.
Heart rate is also affected by temperature, rising during
fever and falling in hypothermia.
Stroke volume is affected by end-diastolic volume (the
preload), the contractility of the heart and the arterial blood
pressure (the afterload). The Frank–Starling law of the heart
states that the energy of contraction is dependent on the ini-
tial length of the cardiac muscle fibre. Venous return and
heart rate both affect ventricular end-diastolic volume and,
hence, the initial length of the cardiac muscle fibres at the
start of ventricular systole. Increased venous return tends
to increase end-diastolic volume, and increased heart rate
tends to reduce it by reducing the time available for diastolic
filling. The Frank–Starling mechanism helps the heart to
respond to changes in preload and ensures that the outputs
of the right and left heart are matched.
Changes in cardiac contractility or inotropic state refer
to the changes in the energy of contraction at a given end-
diastolic length. An increased contractility or positive ino-
tropic effect means an increase in energy of contraction
caused by anything other than the Frank–Starling mecha-
nism. Sympathetic stimulation, adrenaline and drugs such
as digoxin increase cardiac contractility, while myocar-
dial ischaemia and heart failure reduce cardiac contractil-
ity. A rise in heart rate can also increase contractility (the
Bowditch effect), as can an increased aortic blood pressure
(the Anrep effect). Although parasympathetic vagal inner-
vation of the ventricular myocardium is sparse, there is
some evidence that vagal stimulation may reduce ventric-
ular contractility directly as well as secondary to a fall in
heart rate.
The immediate effect of a rise in mean arterial pressure
is to increase the afterload on the ventricle and to reduce the
stroke volume that can be achieved with a given energy of
contraction. However, a rise in blood pressure can also have
indirect effects on the heart that also affect stroke volume.
As mentioned above, increased afterload is followed in a few
K17577_C002.indd 20
beats by an increased cardiac contractility, but in the intact
circulation activation of the arterial baroreceptor reflex will
lead to a reflex fall in both heart rate and contractility.
REFLEX CONTROL OF THE
CARDIOVASCULAR SYSTEM
Arterial baroreceptors in the carotid sinus
and aortic arch
The main arterial baroreceptors are located in the carotid
sinus at the bifurcation of the common carotid artery and
the arch of the aorta, with afferents in the glossopharyngeal
and vagus nerves, respectively. These afferents synapse in
the nucleus of the tractus solitarius (NTS) of the dorsome-
dial medulla. Individual baroreceptors respond to a rela-
tively narrow range of pressures, with firing rising from zero
to maximum as pressure increases by 20–30  mmHg from
the threshold. As pressure in the carotid sinus increases,
there is an increased firing of individual baroreceptors and
a progressive recruitment of baroreceptors with higher
thresholds, to give the sigmoid response curve of the whole
nerve, where firing starts at about 50 mmHg and reaches a
maximum at about 180 mmHg. Carotid baroreceptor firing
is affected by pulse pressure as well as by mean blood pres-
sure. This is important in situations such as haemorrhage or
standing, where a fall in stroke volume and pulse pressure
reduces carotid sinus baroreceptor firing, even if mean pres-
sure is unchanged.
A rise in mean blood pressure or pulse pressure increases
arterial baroreceptor discharge and leads to increased car-
diac vagal stimulation and reduced sympathetic stimulation
to the heart and vasculature. Together, they reduce heart
rate and cardiac contractility and lead to vasodilatation
and venodilatation. Arterial baroreceptors discharge toni-
cally under normal conditions, so that a fall in mean arte-
rial blood pressure or pulse pressure reduces firing, giving a
reflex tachycardia, increased cardiac contractility, vasocon-
striction and venoconstriction.
The arterial baroreceptor control of vascular beds is vari-
able, with strong control in the skeletal muscle and splanch-
nic and renal vascular beds and little effect in the coronary
and cerebral circulation. Arterial baroreceptor control of
the cutaneous circulation is weak, and the skin vasocon-
striction and pallor in haemorrhage is probably mediated
by other mechanisms, such as the rise in circulating vaso-
pressin and angiotensin.
The aortic arch baroreceptors are qualitatively similar in
their reflex response to the carotid sinus baroreceptors, but
the aortic baroreceptor reflex has a stronger reflex effect on
heart rate and a weaker effect on vascular resistance than
carotid sinus reflex. They are also less sensitive to changes
in pulse pressure. The aortic baroreceptors are close to
heart level; therefore, the pressure that they are exposed
to changes little as posture alters, whereas pressure in the
carotid sinus falls when moving from supine to upright.
17/11/2015 15:31

Set point and gain of the arterial
baroreceptor reflex
The relationship between carotid sinus pressure and the
reflex effects on blood pressure and heart rate is not fixed
but can be altered by many factors acting peripherally at
the carotid sinus or centrally by inputs to the brainstem.
Exercise, activation of the defence response (see below)
and a sustained increase in arterial blood pressure can all
raise the blood pressure that the arterial baroreceptor reflex
operates to maintain, whereas in sleep the operating point
is lowered.
Long-term control of blood pressure
It is usually stated that the arterial baroreceptor reflex con-
trols moment-to-moment changes in blood pressure but
does not determine the mean level of blood pressure in the
long term. In support of this view is the fairly rapid reset-
ting of the reflex that occurs when carotid sinus pressure is
maintained at a new level. Moreover, although hypertension
occurs immediately after arterial baroreceptor denervation
in animals, mean blood pressure returns to near-normal
values over the following weeks. Long-term blood pressure
control is thought to involve the control of blood volume via
the kidney, and this probably involves the cardiopulmonary
baroreceptors. However, new experimental approaches have
raised the possibility that arterial baroreceptors do have a
role in long-term regulation of blood pressure in humans.
Cardiopulmonary receptors
In addition to the aortic baroreceptors, there are many
other receptors within the thorax that have reflex effects
on the cardiovascular system, including mechanoreceptors
in blood vessels and the chambers of the heart, chemore-
ceptors in the heart, and several groups of airway and lung
receptors. The afferents from most of these receptors pass in
the vagus to the brainstem, but there are also some afferent
fibres from the heart that travel in the nerves containing the
cardiac sympathetic efferent fibres.
In humans, it is difficult to devise ways of stimulating
these receptors discretely; consequently, those that respond
to pressure or stretch are often referred to together as the
cardiopulmonary baroreceptors. One technique used
to study these receptors is lower-body negative pressure
(LBNP), in which suction is applied around the legs and
lower abdomen. This distends the veins of the lower body,
producing venous pooling, reducing central venous pres-
sures and mimicking the effects of gravitational stress. If
low suction pressures such as 10 mmHg are used, there is
a small fall in central venous pressure without a significant
change in mean arterial blood pressure or pulse pressure.
The forearm vasoconstriction seen with this mild LBNP is
considered to be due to unloading of a subgroup of cardio-
pulmonary receptors often referred to as low-pressure recep-
tors. Passively raising the legs of supine human subjects has
K17577_C002.indd 21
Reflex control of the cardiovascular system  21
the opposite effect, increasing central venous pressures and
leading to forearm vasodilation.
Our knowledge of the effects of discretely stimulating
the different groups of cardiopulmonary receptors is based
largely on animal experiments, and these are outlined in
the following section. It is likely that similar receptors and
reflexes exist in humans and that they contribute to the
responses seen when cardiopulmonary baroreceptors are
stimulated or unloaded. However, it is also likely that there
is considerable species difference in the strength and impor-
tance of these reflexes.
Atrial receptors
Receptors with large myelinated afferents are found in both
the right and left atrium close to their junction with the
veins; their firing increases when atrial volume increases.
The reflex effects of discretely stimulating these venoatrial
receptors are a tachycardia and an increased urine flow. The
tachycardia is mediated largely through sympathetic effer-
ent nerves, but there is no effect on contractility. Several
mechanisms contribute to the diuresis, including reduced
sympathetic discharge to the kidney and reduced renin and
vasopressin secretion. The tachycardia that occurs in dogs
following a rapid saline infusion (the Bainbridge reflex) is
probably due to stimulation of these venoatrial receptors.
This reflex is probably much less potent in humans.
Distension of the atria also produces diuresis and natri-
uresis by increased secretion of the hormone atrial natri-
uretic peptide from specialized atrial cells in response to
stretch. It seems likely that the atria contribute to the con-
trol of blood volume by both of these mechanisms.
Coronary artery baroreceptors
In recent years, it has been recognized that the coronary
arteries contain important baroreceptors and that these
work alongside the better-known carotid sinus and aortic
arch arterial baroreceptors to help control arterial blood
pressure. The coronary baroreceptors appear to be as potent
in their reflex vascular effects as the carotid sinus barore-
ceptors. They differ from the carotid sinus and aortic arch
baroreceptors in that they operate over a lower range of
pressures and that they have little effect on heart rate.
Ventricular receptors
Ventricular receptors with vagal afferents can be stimulated
by either mechanical or chemical stimuli and many recep-
tors respond to both. The left ventricle seems to be a more
important source of these receptors than the right ventricle.
Stimulation of ventricular receptors with unmyelinated
vagal afferents can produce a profound depressor reflex, with
increased parasympathetic drive to the heart and reduced
sympathetic drive to both the heart and the blood vessels.
This reflex, known as the Bezold–Jarisch reflex, is usually
provoked experimentally by coronary artery infusion of
17/11/2015 15:31
 22  Cardiovascular physiology
foreign substances such as veratridine; it may be activated in
life by substances produced during myocardial ischaemia,
such as adenosine, bradykinin or prostaglandins.
There are also mechanosensitive and chemosensitive
afferents that run with the sympathetic nerves and whose
reflex effects are excitatory; their stimulation leads to
tachycardia and vasoconstriction. The different types of
receptors are distributed unevenly within the left ventricle,
which may explain the finding that bradycardia and hypo-
tension are more common following posterior and inferior
left ventricular wall myocardial ischaemia and tachycar-
dia and hypertension are more common with anterior
wall ischaemia.
With care taken to prevent changes in coronary artery
pressure, it seems that the responses (bradycardia and sys-
temic vasodilation) to left ventricular mechanoreceptor
stimulation are small and apparent only at high left ventric-
ular distension pressures associated with large increases in
left ventricular end-diastolic pressure.
In view of the fact that the stimuli needed to give reflex
effects from ventricular receptors are either very high pres-
sures or substances produced by ischaemic myocardium, it
seems likely that these receptors are more concerned with
responses seen in pathological situations than in normal
day-to-day regulation of the circulation.
ARTERIAL CHEMORECEPTORS, LUNG
RECEPTORS AND RESPONSES TO
HYPOXIA
Carotid body chemoreceptor stimulation increases ventila-
tion and also has reflex effects on the cardiovascular system.
The cardiovascular effects are complicated because in addi-
tion to the primary reflex effects of carotid body stimulation
(bradycardia and vasoconstriction), there are secondary
reflex effects (tachycardia and vasodilation) from activation
of pulmonary stretch receptors as ventilation increases. In
addition, carotid chemoreceptor stimulation can activate
the defence areas of the brain (see below), with marked
cardiovascular effects.
When the whole body is exposed to hypoxia, in addition
to these direct and indirect reflex responses to peripheral
chemoreceptor stimulation, there are also local effects of
hypoxia on the heart and blood vessels. The local effects
probably involve the release of adenosine, which in the
heart leads to bradycardia and in many tissues to vasodila-
tion. The usual cardiovascular responses to acute hypoxia
observed in humans, which are the net result of all these
different mechanisms, are discussed in Chapter 4.
PAIN AND REFLEXES FROM SKELETAL
MUSCLE
There are numerous other afferent inputs that have reflex
cardiovascular effects. Reflexes from mechanorecep-
tors and chemoreceptors in skeletal muscle play a part
K17577_C002.indd 22
in the cardiovascular responses to exercise (see below).
Stimulation of pain receptors in many locations can give
rise to an increase in heart rate and blood pressure.
REFLEXES CONTRIBUTING TO THE
DIVING RESPONSE
Stimulation of the face around the eyes and nose with cold
water can stimulate receptors whose afferents travel in
the ophthalmic and maxillary divisions of the trigeminal
nerve. This can lead to reflex apnoea, bradycardia and vaso-
constriction, which contribute to ‘the diving response’. The
cardiovascular responses are enhanced by the reflex effects
of peripheral chemoreceptor stimulation as the arterial par-
tial pressure of oxygen (Po2) falls and the arterial partial
pressure of carbon dioxide (Pco2) rises during the period of
apnoea. These responses are especially strong in diving ani-
mals such as seals and are thought to have an oxygen-con-
serving role, by reducing the work of the heart and directing
the reduced cardiac output to the brain.
The diving response also occurs in humans, but it is
usually less intense, partly because humans usually inhale
before diving into water and with stretched lungs the reflex
tachycardia from stimulation of the lung airway receptors
opposes the bradycardia from the facial and peripheral che-
moreceptor reflexes. Occasionally, however, an excessive
bradycardia occurs, particularly if an unexpected immer-
sion occurs during expiration, and this may contribute to
some accidental deaths in water. A similar pattern of reflex
responses can be elicited by stimulating the inside of the
nose or larynx, and this may contribute to the vagally medi-
ated asystole that occasionally complicates laryngeal intu-
bation during the induction of anaesthesia.
The reflex effects of cold water applied to other regions of
the body are very different. Immersion of the body in cold
water to the neck, excluding the face, gives rise to hyperven-
tilation and tachycardia.
REFLEXES FROM THE URINARY BLADDER
Distension of the urinary bladder can cause reflex tachy-
cardia, vasoconstriction and increased blood pressure. In
normal healthy humans, the rise in blood pressure is usu-
ally moderate because of the buffering action of the arte-
rial baroreceptor reflexes. Rapid emptying of a distended
bladder can cause sudden loss of this pressor reflex, which,
if the depressor reflex from the arterial baroreceptors per-
sists for a while, may cause a transient fall in blood pres-
sure. Occasionally, this is large enough to cause fainting.
This ‘micturition syncope’ is not uncommon in otherwise
healthy young men and is especially likely when a very full
bladder is emptied rapidly at night after drinking alcohol.
Its main importance is that it may be confused with more
serious causes of syncope, especially since, unlike the more
familiar postural fainting, it often occurs suddenly with
little warning that consciousness is about to be lost.
17/11/2015 15:31

DEFENCE OR ALERTING RESPONSE
In both humans and animals, novel or threatening stimuli
can provoke behavioural responses. These can range from
signs of increased alertness, such as ear-pricking in response
to an unexpected sound, to full-blown rage when faced with
a threatening situation. These alerting or defence responses
are accompanied by a particular pattern of cardiovascular
response as well as increased ventilation, piloerection and
dilation of the pupils.
The cardiovascular responses include tachycardia,
hypertension, vasoconstriction in the kidney, splanchnic
and many other vascular beds, and vasodilatation in skel-
etal muscle. The skeletal muscle vasodilatation has sev-
eral efferent mechanisms, including reduced sympathetic
discharge and increased circulating adrenaline acting on
beta2-receptors. In some animals such as the cat, there is
also activation of cholinergic vasodilator nerves to skeletal
muscle, but there is little evidence for the existence of such
nerves in humans.
The regions of the brain that integrate these responses
are known as the defence areas and include parts of the
hypothalamus, periaqueductal grey and amygdala. The
natural stimuli that provoke these responses vary with spe-
cies and the individual, depending on the emotional signif-
icance of the stimulus. A telephone ringing in a quiet room
may be a mild alerting stimulus to one individual or an
intense stimulus to someone awaiting bad news. In experi-
ments on humans, mental arithmetic often proves to be an
effective stimulus.
Hypoxia also activates the defence areas of the brain
via peripheral chemoreceptor stimulation. It is probably
the mechanism of the repeated awakening from sleep that
occurs during hypoxic episodes in patients with obstructive
sleep apnoea and it may be involved in the development of
the chronic hypertension that is common in these patients.
INTERACTION BETWEEN
CARDIOVASCULAR AND RESPIRATORY
REFLEXES
Respiratory modulation of the arterial
baroreceptor reflex and sinus arrhythmia
Sinus arrhythmia is the speeding up and slowing down
of heart rate that occurs with inspiration and expiration
respectively, in normal individuals. In inspiration, the car-
diac vagal motor neurons in the brainstem are inhibited
both by central inspiratory activity and also by afferent
input from the pulmonary stretch receptors; as a conse-
quence, heart rate rises. The responses to arterial barorecep-
tor reflex stimulation are also inhibited during inspiration.
The inspiratory increase in heart rate can occur only if
there is tonic vagal activity to inhibit. With increasing age,
cardiac vagal tone declines and sinus arrhythmia becomes
less pronounced.
K17577_C002.indd 23
Cardiovascular responses to changing posture  23
CARDIOVASCULAR RESPONSES TO
CHANGING POSTURE
In the upright posture, the weight of the column of blood
below the heart raises both arterial and venous pressures
in the feet (Figure  2.3). When standing completely still,
the pressure rise in arteries and veins is similar (about
90  mmHg) and, hence, the pressure difference across the
foot capillary bed is unchanged by the direct effect of grav-
ity. If blood vessels were rigid, blood flow in the foot would
be unaffected by changing posture. However, the pressure
difference between the inside of the vessels and the outside
is increased; this is particularly important in the veins,
which are easily distended by an increased transmural pres-
sure. Within the first minute of standing, there is a shift of
about 500 ml of blood from the thorax to the vessels below
the heart, especially to those in the lower legs. When walk-
ing, skeletal muscle pumping reduces, but does not abolish,
the postural increase in lower-leg venous pressures.
This venous pooling reduces venous return to the heart
on standing, leading to a fall in stroke volume and cardiac
output by the Frank–Starling mechanism. Despite this,
blood pressure does not usually fall, even when skeletal
muscle pumping is prevented by moving the subject pas-
sively from supine to upright on a tilt table. Several differ-
ent reflexes and responses contribute to the maintenance of
blood pressure following the move from supine to upright.
In the upright position, there is reduced stimulation of
the carotid sinus baroreceptors, even if mean blood pres-
sure does not fall. At the carotid sinus, about 25 cm above
the heart, the effect of gravity reduces blood pressure by
about 20  mmHg (2.7  kPa). In addition, the carotid sinus
baroreceptors are sensitive to pulse pressure, which falls
on standing, because of the reduced stroke volume. The
unloading of the carotid sinus baroreceptors leads to a
reflex increase in heart rate, cardiac contractility and
peripheral vasoconstriction.
The fall in central blood volume will also unload the
cardiopulmonary baroreceptors, and the reflex responses,
such as skeletal muscle vasoconstriction, will contribute to
the rise in peripheral resistance. Reflexes from the vestibu-
lar system in response to a change in posture may also be
important. Activation of the otolith organs of the vestibu-
lar system leads to reflex sympathetic activation. This ves-
tibulosympathetic reflex may act in a feed-forward manner,
causing a rapid increase in vascular resistance on standing
that is then modulated by negative feedback from the arte-
rial baroreceptor reflex.
Together, these reflexes usually maintain blood pres-
sure during standing. The reflex tachycardia and increased
contractility are not very effective in the face of a reduced
venous return, and cardiac output falls by about 20–25 per
cent on standing. A fall in mean blood pressure at heart
level is prevented by matching this fall in cardiac out-
put by a similar 20–25  per cent reflex increase in total
peripheral resistance.
17/11/2015 15:31
 24  Cardiovascular physiology

10 mmHg Venous pressures 3 mmHg 10 mmHg

(a)

90 mmHg Arterial pressures 93 mmHg 90 mmHg

50 (=90–40) mmHg
Dural sinus –10 mmHg Top of head
68 (=91–23) mmHg
Eye

72 (=92–20) mmHg

50 cm
Carotid

30 cm
0 mmHg sinus
Neck veins

25 cm
0 mmHg

Right atrium 3(=3+0) mmHg 93 (=93+0) mmHg

Aorta at
heart

170 cm
120 cm
Foot vein 100 (=10+ 90) mmHg 180 (=90+90) mmHg

(b)
Venous pressures Arterial pressures

Figure 2.3  Pressures in arteries (solid lines) and veins (dotted lines) in the supine (a) and upright (b) postures. In the supine
subject, mean pressures in all arteries are close to those at heart level (in this person, 93 mmHg), falling by a few millime-
tres of mercury from heart to periphery. Similarly, venous pressures in peripheral veins are a few millimetres of mercury
above central venous pressure. In the upright posture, the mean pressure in any artery is the mean pressure at that point
in the supine position plus or minus the pressure due to the weight of the column of blood below or above the heart.
Pressures in the veins below the heart are also increased when standing still, by the weight of the column of blood below
the heart. In veins above the heart, venous pressure also falls, but the fall is less than predicted from the height above the
heart because of collapse of the neck veins, in which the fall is limited to 0 mmHg.

Effect of posture on capillary fluid balance
The rise in foot arterial and venous pressures means that
capillary hydrostatic pressure and the net filtration pres-
sure inevitably also rise on standing. Prolonged stand-
ing makes normal feet swell, and foot and ankle oedema
occurs readily in the presence of any factors increasing
filtration. Increased filtration can reduce circulating blood
volume and further impair venous return to the heart.
Mechanisms that help to reduce the rise in capillary pres-
sure include skeletal-muscle pumping, as this lowers
venous pressure. The sympathetically mediated arteriolar
vasoconstriction that occurs as part of the reflex responses
to posture also reduces the rise in capillary pressure.
An additional local mechanism operates that does not
involve the central nervous system and causes arteriolar
constriction only in vascular beds below heart level. This
venoarteriolar response is thought to be triggered by local
venous distension and probably involves local sympathetic
nerve networks.
Effect of posture on blood vessels above
the heart and on cerebral blood flow
For each cm above heart level, pressure within an artery is
reduced by about 0.78  mmHg (0.1  kPa). Consequently, in
an upright person, the pressure in the arteries at the top
of the head is about 40  mmHg (5.3  kPa) and at eye level
about 23  mmHg (3  kPa) below that in the aorta at heart
level (Figure 2.3). Venous pressures above the heart, which
are low in the supine position, are also affected by grav-
ity. The internal jugular veins in the neck are exposed to
atmospheric pressure on the outside; as pressure within
them falls on standing, they collapse, which limits the fall

K17577_C002.indd 24 17/11/2015 15:31

 The Valsalva manoeuvre  25

of pressure within them to 0 mmHg. Within the skull, veins
do not collapse, and the pressure within the dural sinuses
on top of the head is typically about –10 mmHg (–1.3 kPa).
As venous pressure in the head falls less than arterial
pressure, the cerebral perfusion pressure (arterial minus
venous pressure) falls on standing. As a result, cerebral
blood flow falls despite autoregulation but in normal stand-
ing, not enough to impair cerebral oxygen consumption.
VASOVAGAL FAINTING
Prolonged standing may cause fainting (syncope) even in
healthy subjects. Blood pressure is initially maintained well
on standing by the increased total peripheral resistance,
but eventually, in the face of a progressively falling venous
return and cardiac output, mean blood pressure begins to
fall. At some point, the reflex vasoconstriction and tachy-
cardia are suddenly replaced by a vagally mediated bra-
dycardia and widespread vasodilation as sympathetic
discharge to many vascular beds is withdrawn (Figure 2.4).
At this point, blood pressure and cerebral blood flow fall
precipitously and syncope occurs. Usually the subject ends
up lying down and in this position venous return, cardiac
output and consciousness are restored rapidly. Brain dam-
age can occur if the subject is prevented from falling, per-
haps by support from a ‘helpful’ bystander. Typically in the
period before consciousness is lost (presyncope), the subject
complains of nausea and light-headedness, looks very pale
and may yawn or sigh.
The peripheral vasodilation seems to be the most impor-
tant aspect of this vasovagal syncope in most people, and
cardiac pacing is usually ineffective in patients with recur-
rent postural syncope. The mechanism that triggers the bra-
dycardia and vasodilation is unknown. The hypothesis that
reflexes from ventricular receptors might initiate it has not
been supported by experimental and clinical evidence.
Vasovagal syncope may also occur in haemorrhage, heat
exposure, positive-pressure breathing, hypoxia and in the
presence of strong emotional stimuli; these situations are
additive in their effects. A person who has lost a litre of
blood may maintain a normal blood pressure lying down
but faint quickly on standing.
THE VALSALVA MANOEUVRE
The Valsalva manoeuvre occurs when forced expiration
is attempted but airflow is prevented by breathing against
a closed glottis or, experimentally, against a manometer
to measure the raised intrathoracic pressure generated
(Figure 2.5).
A characteristic sequence of blood pressure and heart
rate changes occur in normal subjects:
Phase 1: There is an immediate rise in arterial blood pres-
sure caused by the direct effects of the raised intra-
thoracic pressure compressing the aorta. A brief fall
in heart rate may result from activation of the arterial
baroreceptor reflex.

6
CO2 (%)

4
2
0

200
180
BP (mmHg)

160
140
120
100
80

120
HR (b.p.m.)

100
80
60
40
20
20
volume (L)

15
10
5
0
1500 1550 1600 1650 1700 1750 1800 1850 1900

Figure 2.4  Vasovagal faint in a healthy young volunteer subjected to combination of head-up tilt and lower-body negative
pressure. Note the initial gradual fall in blood pressure (BP) and a rise in heart rate (HR), followed by a sudden marked fall
in both. At the event mark, the subject was returned to the horizontal and suction switched off. Traces from above down
are expired % CO2, finger arterial blood pressure, heart rate and cumulative inspired volume.

K17577_C002.indd 25 17/11/2015 15:31

 26  Cardiovascular physiology

Phase 2: The raised intrathoracic pressure impairs venous
return to the thorax, which reduces cardiac output,
pulse pressure and blood pressure. The arterial barore-
ceptors are unloaded, leading to reflex tachycardia and
peripheral vasoconstriction, which in normal people
limits the fall in blood pressure.
Phase 3: At the end of the forced expiration, the sud-
den fall in intrathoracic pressure is transmitted to the
aorta, causing aortic pressure to fall and a further reflex
speeding up of heart rate.
Phase 4: The fall in intrathoracic pressure causes a sudden
large increase in venous return, as the blood that has
been accumulating in the abdomen, head and arms can
now enter the thorax. This increases cardiac output and
blood pressure and results in an arterial baroreceptor
reflex mediated bradycardia.
CARDIOVASCULAR RESPONSE TO
EXERCISE
In dynamic exercise such as running, the oxygen consump-
tion increases linearly as work rate increases progressively,
150
Blood Pressure (mmHg)
until a maximum is reached. Once maximum O2 consump-
tion (V̇O 2max) is reached, a small further increase in work
can be performed by an increase in anaerobic work, but
essentially, the rate of working of an individual is deter-
mined by his or her (V̇O 2max). Oxygen consumption (V̇O 2)
is equal to the product of the cardiac output (CO) and the
average oxygen extraction as the blood passes through the
tissues, i.e.
V̇O2 = CO × (arterial oxygen content –
mixed venous oxygen content)
Both cardiac output and oxygen extraction increase as
work rate increases in exercise. Arterial oxygen content
remains constant at the resting value, and the maximum
oxygen extraction is limited by the minimum venous oxy-
gen content that can be achieved. This is limited by the need
to maintain a capillary Po2  sufficient to drive oxygen dif-
fusion and is similar in different people. Consequently, the
maximum oxygen consumption in normal people is deter-
mined largely by the maximum cardiac output that they
can generate.
In health, cardiac output is increased during exercise by
an increase in both heart rate and stroke volume, of which
the increased heart rate is quantitatively the most impor-
tant (see Table  2.1). The maximum heart rate is reduced

with age, being approximately equal to 220  minus the

age in years, and the increase in stroke volume becomes
100

proportionally larger.
50
In dynamic exercise, there is also some redistribution
of blood flow, with vasoconstriction in non-active skel-
etal muscle and the splanchnic and renal circulations. Skin
vasoconstriction occurs initially, but as the core tempera-
80
ture rises, thermoregulatory control mechanisms lead to
Mouth Pressure (mmHg)

60 increased cutaneous blood flow. In active skeletal muscle,

40
there is vasodilation caused by increased local metabolite
concentration. Overall, there is a fall in total peripheral
20 resistance. The blood flow in different tissues as a propor-
0
tion of cardiac output is very different from that at rest (see
Table  2.1). The net effect of the rise in cardiac output and
–20
fall in total peripheral resistance is a moderate rise in blood
100 pressure, which increases with increasing exercise intensity.
Diastolic blood pressure rises less than systolic blood pres-
Heart Rate (BPM)

80 sure and in some subjects may even fall a little.

60
20 seconds
40
530 540 550
Figure 2.5  Heart-rate (HR) and blood-pressure (BP)
responses to a Valsalva manoeuvre in a healthy 20-year-
old man. The subject breathed with an open glottis into
a closed tube and was asked to maintain a pressure of
40 mmHg (middle trace). Finger blood pressure (top trace)
was measured non-invasively using a Finapres, and the
heart rate was derived beat by beat from the blood-pres-
sure trace. The numbers represent the four phases of the
Valsalva manoeuvre, as described in the text.
The mechanisms that initiate and maintain the cardio-
vascular response to exercise are not resolved completely,
but there is evidence that both central command and
560 570 reflexes from the exercising muscles play a part. Central
command refers to inputs from locomotor areas of the brain
to the brainstem cardiovascular control areas, which are
initiated in parallel with the motor output to the muscles.
Reflexes from both chemoreceptors and mechanoreceptors
in skeletal muscle can cause reflex increases in heart rate
and blood pressure in response to muscle activity. All these
responses are moderated by the arterial baroreceptor reflex,
the operating point of which is reset to a higher pressure
and heart rate in exercise.

K17577_C002.indd 26 17/11/2015 15:31

 Further reading  27

In isometric exercise, such as weightlifting, heart rate

140
and blood pressure also rise, but the pattern is different.
With forces that are 20  per cent or more of maximum 120

Heart rate (b.p.m)

voluntary contraction, the heart rate and blood pressure 100
increase progressively during the contraction (Figure 2.6).
80
The rise in diastolic pressure is greater and, relative to the
oxygen consumption, the increase in mean blood pressure 60
is larger, than in dynamic exercise. In isometric exercise, 40
the continuous contraction restricts blood flow and means
that the accumulation of muscle metabolites is greater than
in dynamic exercise, which leads to increased activation of 300
muscle chemoreceptor reflexes.
250

BP (mmHg)
200

150

SUMMARY 100

●● Cardiac output, CO, = arterial – central venous

pressure/total peripheral resistance. Arterial
blood pressure is increased by a rise in cardiac
output and/or total peripheral resistance. Blood
flow (F) to an organ or tissue = ΔP/R, where ΔP
is arterial – venous pressure and R is the local
vascular resistance.
●● Tissue blood flow is normally controlled by
altering R, by constricting or dilating the
arterioles. Local factors (such as metabolites
or autocoids) produce changes which tend to
adjust tissue blood flow to meet local needs but
these can be overridden by reflexes via auto-
nomic (mostly sympathetic) nerves to vascular
smooth muscle.
●● Stimulation of a wide variety of receptors in
the body can provoke cardiovascular reflex
effects. These may override local effects for
example to control blood pressure during
changes in posture or during haemorrhage or to
accomplish thermoregulation.
●● The most important receptors are the arterial
baroreceptors in the carotid sinus and aortic
arch; they control blood pressure by a negative
feedback reflex acting on the heart, arterioles
and veins.
●● Other receptors giving rise to important cardio-
vascular reflex effects include cardiopulmonary
receptors, arterial chemoreceptors, temperature
and pain receptors, and receptors in muscles,
joints, the face, nose, the vestibular system of the
ear, bladder and other hollow viscera.
●● Activation of the defence areas and locomotor
areas of the brain contribution to the patterns
of cardiovascular and respiratory responses
seen in the ‘alerting response’ and during
exercise, respectively.
400
300
Force (N)
200
100
0
150 seconds
–100
500 600 700 800
Figure 2.6  Effects of isometric exercise on blood pressure
and heart rate. A healthy 20-year-old male subject performed
an isometric contraction of his left quadriceps muscle using
30 per cent of his maximum voluntary contraction force (lower
trace), which he maintained for 150 seconds. Heart rate (top
trace) and systolic and diastolic finger arterial blood pressure
(middle trace) rose progressively during the contraction.
ACKNOWLEDGEMENT
Revised and updated from the corresponding contribution
to the Fourth Edition written by the late John Ernsting, Jane
Ward and Olga M. Rutherford.
FURTHER READING
Aaronson PI, Ward JPT, Connolly MJ. The Cardiovascular
System at a Glance, 4th edn. Oxford: Blackwell, 2012.
Levick JR. An Introduction to Cardiovascular Physiology,
5th edn. London: Hodder Arnold, 2010.
Advanced reading
Astrand PO, Rodahl K, Dahl HA, Stromme SB. Textbook
of Work Physiology, 4th edn. Champaign, IL: Human
Kinetics, 2003.
Coote JH. Cardiovascular Responses to Exercise: Central
and Reflex Contributions. In: Jordan D, Marshall J
(eds). Cardiovascular Regulation. London: Portland
Press, 1995: 93–111.

K17577_C002.indd 27 17/11/2015 15:31

 28  Cardiovascular physiology

Marshall JM. Cardiovascular Changes Associated with Behav­ West JB, Schoene RB, Luks AM, Milledge JS. High
ioural Alerting. In: Jordan D, Marshall J (eds). Cardiovascular Altitude Medicine and Physiology, 5th edn. Boca
Regulation. London: Portland Press, 1995: 37–59. Raton, FL: CRC Press, 2012.

K17577_C002.indd 28 17/11/2015 15:31


Respiratory physiology
Revised by JANE WARD
Tissue respiration 29
Lung functions, structure and mechanics 31
Gas diffusion and transport in the blood 37
TISSUE RESPIRATION
Cellular metabolism
In all known organisms, adenosine triphosphate (ATP) acts
as the main energy-carrying molecule. The chemical energy
is held in the energy-rich bonds of ATP and released when,
during hydrolysis of the terminal phosphate bond of ATP
to produce adenosine diphosphate (ADP), the phosphate
is transferred to another molecule. The energy released is
used for pumping ions against electrochemical gradients,
the beating of cilia, biosynthetic reactions, the contraction
of muscles and almost all other energy requiring processes
in cells. At any one time, the ATP present in the cells of the
body is only sufficient for a few seconds of energy usage and
it must be continuously re-synthesized from ADP. Synthesis
of ATP involves oxidation of energy rich dietary substrates
(carbohydrates, fatty acids and proteins). Some of these
ATP-producing reactions require oxygen and some do not.
Those that do not use oxygen (‘anaerobic’) can take place
outside the mitochondria in the cytosol but are not very effi-
cient in terms of the amount of ATP produced from each
molecule of substrate. For example, in anaerobic metabo-
lism, the pyruvic acid formed by the initial step in the
breakdown of glucose is further metabolised to lactic acid,
producing just two molecules of ATP from each molecule of
glucose. The overall reaction for this anaerobic glycolysis is:
C6H12O6 + 2 ADP + 2 Pi → 2 lactate + 2H+ + 2 ATP
When the oxygen supply is adequate, the electron
transport chain in the mitochondria functions properly,
K17577_C003.indd 29
3
Control of pulmonary ventilation 45
Further reading 47
oxidative phosphorylation takes place and the glucose is
completely oxidized to carbon dioxide and water producing
many more molecules of ATP (about 38) per glucose mol-
ecule. The overall reaction in the presence of aerobic respi-
ration is summarized by the equation:
C6H12O6 + 38 ADP + 38 Pi + 6O2 → 6 CO2 + 6 H2O + 38 ATP
Anaerobic glycolysis will occur whenever the mitochon-
dria have an inadequate oxygen supply, for example, in
skeletal muscle cells during heavy exercise. As the intensity
of exercise increases, a point is reached where the exercis-
ing muscle cells farthest from the nearest capillary have an
inadequate oxygen supply and lactate production begins.
As work rate increases beyond this ‘anaerobic threshold’,
more and more cells produce lactic acid, which accumu-
lates in the muscle as well as passing into the bloodstream.
In the heart it can be taken up and converted back to
pyruvate, which enters the aerobic respiration pathways in
the mitochondria. In the liver, especially during the recov-
ery period after exercise, lactic acid is converted to glucose
and glycogen.
ATP production in the mitochondria is carefully con-
trolled to match requirements, which can vary 100-fold
between the complete rest of sleep and heavy dynamic exer-
cise. In humans, oxidative phosphorylation is essential to
maintain an adequate ATP supply; the critical minimum
value of the mitochondrial Po2 required is 0.5–3.0 mmHg
(0.07–0.4  kPa). The speed at which loss of function and
eventually irreversible tissue damage occurs when the oxy-
gen supply is lost completely, varies from tissue to tissue.
In the brain loss of function occurs within 5–8 seconds of
29
17/11/2015 15:32
 30  Respiratory physiology

a sudden loss of oxygen supply and permanent brain dam- Table 3.1  Partition of oxygen consumption in a normal
age occurs after a few minutes. Limbs, on the other hand, subject (body weight 70 kg) at rest
can lose their oxygen supply for 40 minutes or more without
Oxygen consumption
permanent damage.
Although oxygen is vital for life, in high concentrations mL (STPD)/
it can be toxic because of the production of reactive oxygen Organ/region min % total
species. The progressive reduction of Po2 that occurs from Brain 47 19
the atmosphere to the mitochondria (the oxygen cascade, see Heart 28 11
Figure 3.7) was once viewed as an unfortunate inefficiency Kidney 18 7
but it is now thought to protect the tissues from excessively Splanchnic region 62 25
high Po2. Although this stepping down of Po2 may be ben-
Skeletal muscle 75 30
eficial at sea level, it becomes unhelpful in the low Po2 envi-
Skin 5 2
ronment at high altitude.
Other organs 15 6
More than 90  per cent of the oxygen consumed at rest
by the tissues is used in oxidative phosphorylation in the Total 250 100
mitochondria, which is unaffected by tissue Po2 until it falls The oxygen consumed by the respiratory muscles, which is
included in the figure for skeletal muscles, amounts to 5 mL/min
below 3 mmHg. The remainder is used in a variety of other
or 2% of the total.
pathways, especially those catalysed by the cytochrome
P450  enzymes, by which steroids are synthesized from
Table 3.2  Total oxygen consumption during various
fatty acids by oxygenation or substances detoxified or made
activities for an average-sized young man
more soluble. Some of these other reactions are significantly
slowed if Po2 falls below 60 mmHg (8 kPa). Total oxygen
consumption
Tissue oxygen requirements Activity (L [STPD]/min)
Sleep 0.24
The rate of oxygen consumption varies with the tissue and
Lying down, fully relaxed 0.24
its activity. The distribution of the total oxygen consump-
Lying down, moderately relaxed 0.28
tion of a resting man is summarized in Table 3.1. The total
Sitting at rest 0.34
oxygen consumption of an individual (VO2) of a healthy
young man at rest is 133  mL (standard temperature and Standing relaxed 0.36
pressure, dry, STPD)/min/m2  of body surface, increasing Walking (5 km/h) 0.85
considerably during physical activity. Typical values of Running (10 km/h) 2.8
VO2 for various activities are presented in Table 3.2. Flying an aircraft
Level flight 0.34
Blood–tissue gas exchange Light aircraft in rough air 0.54
Taxiing 0.58
Gas exchange between tissue capillaries and tissue cells is Aerobatics 0.65
by simple diffusion driven by partial pressure gradients. Air-combat manoeuvring 1.00
The Po2  of cells within the tissue varies with their posi-
tion in relation to the nearest capillary (Figure  3.1). The
points within a tissue where the Po2  is a minimum are oxygen consumption resulti ng in lethal corners in
the first to suffer if oxygen supply fails to match oxygen which anaerobic respiration takes place. Lethal cor-
requirements. In the example given, when capillary Po2 is ners also develop in resting tissues when oxygen supply
reduced to 20  mmHg (Figure  3.1, curve B) oxygen sup- is impaired. The border zones between major cerebral
ply is critical, as tissue Po2  falls to just 2  mmHg midway arterial territories are especially vulnerable during pro-
between the two capillaries, which is only just adequate longed hypotension and this can result in cerebral
to maintain aerobic metabolism. Any further lowering of infarcts in these ‘watershed’ territories. Tissue oedema
capillary Po2 (Figure 3.1, curve C) will result in anaerobic can also lead to lethal corners because of the lengthened
respiration in this region. Such regions are termed ‘lethal diffusion distances.
corners’. The supply of oxygen to a tissue is almost always more
When a tissue’s oxygen consumption increases, accu- critical than the removal of carbon dioxide, since (i) accu-
mulation of local metabolites causes vasodilatation and mulation of carbon dioxide causes less disruption of tissue
capillary recruitment. This increases blood flow and function than hypoxia; (ii) carbon dioxide diffuses about
reduces diffusion distances, maintaining mean capil- 20  times more rapidly than oxygen for the same partial
lary and tissue Po2  until at heavy levels of exercise the pressure gradient and (iii) the tissue storage capacity for
increased blood flow fails to keep up with the increased carbon dioxide is much greater than for oxygen.

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Capillaries
60
Oxygen tension (mmHg)
40
A Circulating noradrenaline (norepinephrine), sero-
20
B monophosphate (ATP, ADP and AMP), some prosta-
C
0 0
Distance from capillary
Anaerobic tissue
Figure 3.1  Cross-section of a simple model of the distri-
bution of tissue oxygen tension in which symmetrically
arranged parallel capillaries carry blood in one direction
through a tissue with uniform oxygen consumption. The
solid curves (A, B, C) depict the magnitude of the oxygen
tension with distance from a capillary. The tension falls to
a minimum at a point midway between the two capillaries.
When the oxygen tension in the capillary blood is high
(A), the oxygen tension everywhere in the tissue exceeds
15 mmHg (2 kPa). When the capillary oxygen tension
is reduced to about 20 mmHg (2.7 kPa) (B), the oxygen
tension in the tissue midway between the capillaries falls
to about 2 mmHg (0.27 kPa), whereas when the capillary
oxygen tension falls to about 10 mmHg (1.33 kPa) (C), the
oxygen tension of a significant part of the tissue is zero.
LUNG FUNCTIONS, STRUCTURE AND
MECHANICS
Non-respiratory functions of the lungs
The main role of the lungs is gas exchange but there are
other important functions:
1. Filtration of microthrombi.
The lungs receive the whole systemic venous return
and any microthrombi formed in peripheral veins are
trapped and rapidly broken down in the pulmonary
microcirculation. This prevents their passage to the
systemic vascular beds, where even small emboli can
cause serious problems such as myocardial or cerebral
infarction. This filtration function is not foolproof;
a large embolus or multiple small emboli may cause
cardiovascular collapse, severe ventilation-perfusion
mismatch or neutrophil activation leading to acute
lung injury. About 25 per cent of people have a pat-
ent foramen ovale (PFO) which may open when right
atrial pressure is raised by coughing or the Valsalva
manoeuvre; emboli or gas bubbles (formed in the tissues
in decompression illness) can then bypass the lungs to
reach the systemic circulation.
K17577_C003.indd 31
Lung functions, structure and mechanics  31
2 . Metabolic functions.
As the blood passes through the lungs some substances
are deactivated and others activated. Angiotensin I is
60 activated to angiotensin II, by the pulmonary endothe-
lial angiotensin-converting enzyme (ACE). Bradykinin
is broken down by ACE and loss of this function is
40 probably responsible for the persistent dry cough that is
a common side effect of ACE inhibitor drugs.
20
tonin (5-hydroxytyptamine), adenosine tri-, di- and
glandins (PGE1, PGE2, and PGF2α), endothelin 1 and
3 (ET1, ET3), leukotrienes and thromboxane are taken
up by the pulmonary endothelium and broken down
or inactivated. Other vasoactive substances, such as
PGI2, PGA2, adrenaline, vasopressin and histamine are
unaffected by passage through the pulmonary circula-
tion. Many basic drugs (propranolol, chlorpromazine,
nortriptyline, fluphenazine, amphetamine) accumulate
in the lungs; chlorpromazine is also metabolized there.
3. Blood reservoir.
The pulmonary circulation acts as a blood reservoir,
helping to ensure a continuous blood supply to the
left side of the heart despite acute changes in venous
return. In the supine position the lungs normally
contain about 500 ml of blood and this falls by about
30 per cent to 350 ml on standing. It can decrease
further, to about 250 mL, during a forced expiration or
during haemorrhage.
Respiratory system structure
Adult male lungs contain about 300  million alveoli, each
about 0.3  mm in diameter. Gases are exchanged across
the very thin (about 0.5 μm) alveolar-capillary membrane,
which has a total area of 50–100  m2. The large area and
thinness of the alveolar-capillary membrane serve to min-
imize the resistance to gas diffusion between the gas and
blood phases.
Air is conducted through a branching system of air-
ways. Each new generation of airways has approximately
double the number of airways as the previous one. A typical
man has about 23 levels of division or ‘airway generations’.
Traditionally, the trachea is referred to as ‘generation 0’, the
right and left main bronchi as ‘generation 1’, the lobar, seg-
mental and other bronchi are generations 2–11. Generations
12–16 are known as bronchioles; the key feature distinguish-
ing them from bronchi is that they lack cartilage in their
walls. Their support comes instead from the outward pull on
their walls of the surrounding lung tissue (like the support a
traditional tent gets from guy ropes). The final generation of
bronchioles, the ‘terminal bronchioles’, divide into respira-
tory bronchioles, which are the first generation of airways to
have alveoli. The final division is the alveolar ducts (genera-
tion 23), which are lined completely with alveoli.
Respiratory muscles generate pressure gradients between
the mouth and the alveoli and this produces bulk flow of
17/11/2015 15:32
 32  Respiratory physiology

gas. Beyond the terminal bronchioles the combined cross-
sectional area of the airways increases rapidly and the for-
ward velocity of the gas becomes very low. Between the
terminal bronchioles and alveolus (a distance of < 5 mm),
gases move by diffusion, with virtually no bulk flow.
The pulmonary arteries run into the lung tissue along-
side the branching airways, subdividing by way of arteri-
oles to feed the capillary beds that surround the alveoli.
The network of capillaries is very dense and there is an
almost continuous sheet of blood over the alveolar wall.
The large area of alveolar–capillary membrane is vulner-
able to inhaled particles. Large particles are filtered out in
the nose. Smaller particles reaching the conducting air-
ways are trapped in the mucus secreted by the seromucus
glands and goblet cells and swept by the coordinated beat-
ing of the epithelial cilia (the ‘mucociliary escalator’) to the
epiglottis where they are either swallowed or coughed out.
Particles small enough to reach the alveoli are engulfed by
macrophages, which then pass into the blood or lymphat-
ics. The lungs are protected from the proteases released
from dead bacteria and macrophages by the mucociliary
escalator and by alpha-1  antitrypsin (A1AT), a protease
inhibitor produced by the liver. Deficiency of A1AT is asso-
ciated with early onset emphysema, especially when com-
bined with smoking.
Anatomical, alveolar and physiological dead
space
The respiratory passages can be divided into two regions,
the conducting airways (with no alveoli) and the respiratory
zone. The conducting airways comprise the nose, mouth,
pharynx, larynx, trachea and the pulmonary airways up to
the terminal bronchioles. They form the ‘anatomical dead
space’: the region that because of normal human anatomy is
ventilated but wasted (or ‘dead’) in terms of gas exchange.
Its volume is about 150  mL in an average adult, increas-
ing a little during deep breaths as the airways expand. The
respiratory bronchioles and alveolar ducts and sacs form the
‘respiratory zone’ where gas exchange occurs.
In diseases, such as pulmonary embolism, there may also
be alveolar regions that are ventilated but which have no,
temperature and pressure. For consistency, lung volumes
are corrected from the volume measured at ambient tem-
perature and pressure, saturated with water vapour (volume
ATPS) to the volume that they would occupy in the body
(volume BTPS, i.e. body temperature and pressure, satu-
rated). Measured values must be compared with the pre-
dicted values for healthy subjects of the same gender, height
and age based on population studies. Typical lung volumes
for a healthy 170  cm (67  inches) tall 20-year-old man are
illustrated in Figure 3.2 and explained below:
●● The tidal volume (VT) is the volume of gas breathed in
or out; it is about 0.5 L at rest but larger in exercise.
●● The total lung capacity (TLC) is the total volume of gas
in the lungs at the end of a maximal inspiration (about
6.5 L in this subject).
●● The residual volume (RV) is the volume left in the lungs
after a maximum forced expiration (about 1.4 L in this
subject).
●● The vital capacity (VC) is the subject’s maximum tidal
volume, TLC - RV (about 5.1 L in this subject).
●● The functional residual capacity (FRC) is the volume of
gas in the lungs at the end of a normal expiration (about
3 L in this subject).
●● The expiratory reserve volume is the volume that can
be exhaled using a maximum expiration starting from
the end of a normal breath out, FRC - RV (about 1.6 L in
this subject).
●● The inspiratory reserve volume is the volume that
can be inhaled using maximum inspiratory effort
starting from the end of a normal inspiration, TLC −
(FRC + TV) (about 3 L in this subject).
Pulmonary ventilation (or ‘minute volume’) is the L/min
of gas entering or leaving the lungs.
Maximum
6 inspiration
Inspiratory
5 reserve
Vital volume
Lung gas volume [L(BPTS)]

or inadequate, perfusion with blood; such regions produce capacity

‘alveolar dead space’ with no, or inadequate, gas exchange. 4
The sum of anatomical dead space and alveolar dead space is End of quiet
Total lung inspiration
the ‘physiological dead space’. ‘Physiological’ in this context capacity Tidal volume
means ‘functional’, as opposed to ‘normal’. If physiological 3
End of quiet
dead space is 300 mL, it means that the respiratory system Expiratory expiration
reserve
behaves as if there were 300 mL that were not taking part in 2 volume
gas exchange. In healthy young people, there is no alveolar Functional Maximum
residual expiration
dead space and physiological dead space equals anatomical capacity
dead space. 1 Residual
volume

Lung volumes and ventilation 0

Lung volume measurements help in the diagnosis and mon- Figure 3.2  Subdivisions of the total lung capacity, with
itoring of lung diseases. Gas volumes are affected by the normal values for a young male (height 1.7 m).

K17577_C003.indd 32 17/11/2015 15:32


Alveolar ventilation is the L/min of gas entering or leav-
ing the alveolar or respiratory zone, which takes part in
gas exchange.
At rest, tidal volume is about 500  mL and respiratory
frequency about 15  breathes per minute, giving a resting
ventilation of about 7500 mL/min. Resting alveolar ventila-
tion ((tidal volume - dead space volume) × respiratory fre-
quency) is about 5250 mL/min.
Respiratory muscle function, intrapleural,
alveolar and airway pressure
Inspiratory muscles all work by increasing the volume of the
chest. This lowers pressure in the sealed intrapleural space,
increasing the outward distending pressure gradient across
the alveoli walls. The alveoli expand, lowering alveolar pres-
sure and creating the pressure gradient between the mouth
and alveoli that generates inspiratory airflow.
At FRC, the opposing inward recoil of the lungs and
outward recoil of the chest wall create a sub-atmospheric
intrapleural pressure; this becomes more negative during
inspiration and less negative during expiration oscillat-
ing between about –4 and –6 mmHg (–0.5 and –0.75 kPa)
during quiet breathing. The alveolar pressure generated
by these changes in intrapleural pressure oscillates above
and below atmospheric pressure (0 mmHg/kPa); it is nega-
tive during inspiration, positive in expiration and zero
when no air flows at the end of both inspiration and expi-
ration. The main inspiratory muscle is the diaphragm,
which is innervated by the phrenic nerves from cervical
roots C3,4,5. Contraction of the diaphragm flattens the
dome, increasing the expansion of the chest in cranial cau-
dal direction; intra-abdominal pressure increases, push-
ing the lower ribs out. The intercostal muscles help stiffen
the intercostal spaces preventing them being sucked in as
intrapleural pressure falls during inspiration or ballooned
out in forced expiration. The intercostal muscles that have
fibres running caudally and anteriorly (mostly the external
intercostals) help to raise the ribs in normal inspiration.
The scalene muscles (C3–C8) raise the upper two ribs and
are also active in normal inspiration. Cervical cord inju-
ries above C3  will leave all respiratory muscles paralyzed
and survival will require mechanical ventilation. Injuries
below C5  will spare the phrenic nerves and ventilation is
usually adequate.
The expansion of the chest caused by the movement of
the ribs is known as ‘thoracic breathing’. As the diaphragm
moves down the increase in intra-abdominal pressure
pushes the abdominal wall outward; diaphragmatic breath-
ing is often called ‘abdominal breathing’. In normal breath-
ing, the chest and abdominal walls move in and out together.
Phrenic nerve injury will weaken or paralyze the dia-
phragm. It is possible to maintain resting ventilation with
the remaining inspiratory muscles but symptoms, such as
breathlessness on exertion, immersion in water and/or when
lying down (orthopnoea), will usually occur. When intra-
thoracic pressure falls in inspiration, the flaccid diaphragm
K17577_C003.indd 33
Lung functions, structure and mechanics  33
will be sucked up into the chest and the abdominal wall will
move in. This ‘paradoxical movement’ of the abdominal and
chest wall is a sign of paralysis of the diaphragm.
In newborn babies, the ribs are horizontal, impairing
thoracic breathing and increasing the reliance on diaphrag-
matic breathing. The hyperinflation of severe emphysema
also leads to more horizontal ribs, impairing thoracic
breathing; in addition it flattens the diaphragm, impairing
its effectiveness as an inspiratory muscle.
In quiet breathing, expiration is passive and the lungs and
chest wall return to FRC by elastic recoil. The abdominal
muscles contract when forced expiration is needed in exer-
cise, coughing or sneezing. This increases intra-abdominal
pressure and speeds up the return of the relaxed diaphragm
into the chest, raising intrapleural and alveolar pressure.
Intrapleural pressure can rise to +40 mmHg (+5.3 kPa) in
maximal forced expiration.
Elastic and airway resistance to breathing
The inspiratory muscles work against two main forms of
resistance: the elastic resistance to stretch (stiffness) offered
by the lungs and chest wall and the airway resistance (R AW).
Increases in either of these resistances increase the work
of breathing and produce symptoms such as dyspnoea
(breathlessness).
Elastic resistance, lung compliance and
surfactant
The lungs and the chest wall both contribute to the elastic
resistance of the respiratory system but abnormalities of the
chest wall stiffness (such as kyphosis and chest wall scar-
ring) are uncommon and usually obvious when present.
Stiff lungs have high elastic resistance and low lung compli-
ance (stretchiness); they also recoil more forcefully to their
original size when the stretching force is removed.
Structural proteins like collagen and elastin produce
about half of the elastic resistance of the lungs, with the
other half arising in the surface tension forces at the air-
fluid interfaces in the alveoli. The surface tension in the
curved air-fluid interface of a bubble or alveolus resolves
partly inwards raising the pressure, P, in the bubble or
alveolus; the smaller the radius, R, of the bubble, the greater
is its curvature and the more the surface tension resolves
inwards. This is described by Laplace’s law, P = 2T/R, where
T is the surface tension of the lining liquid. Alveolar fluid
surface tension, T, would be much higher if the fluid was
water or saline; its surface tension is kept low by surfactant
produced by the alveolar type 2 pneumocytes. Surfactant is
a complex mixture of substances composed of 90 per cent
lipids, mostly phospholipids, and about 10 per cent surfac-
tant specific proteins. The proteins have host defence prop-
erties as well as contributing to the surface tension lowering
action of the phospholipids.
Surfactant produces a general decrease in the stiff-
ness of the lungs (increased compliance) and, in addition,
17/11/2015 15:32
 34  Respiratory physiology
it contributes to alveolar stability. Laplace’s law predicts
that during expiration alveolar pressure would rise pro-
gressively, accelerating expiration and reducing FRC.
However, surfactant floats on the surface of the alveolar
fluid, becoming more concentrated there and more effec-
tive at lowering surface tension as the alveoli shrink. This
fall in T offsets the effects of the fall in R and helps prevent
alveoli from collapsing completely in expiration, maintain-
ing a good FRC. A good FRC aids re-inflation and allows
gas exchange to continue throughout the respiratory cycle.
Surfactant deficiency occurs in neonatal respiratory dis-
tress syndrome, NRDS. Type 2  pneumocytes only begin
to function properly in the last trimester of pregnancy, so
NRDS is especially common in premature babies. It has
the effects predicted from the above discussion: the lungs
are stiff and the work of breathing is increased, there are
areas of atelectasis (airless alveoli), FRC is reduced and gas
exchange impaired.
In lung fibrosis, elastic resistance is increased because of
the stiffness of the fibrous tissue laid down as the end result
of a variety of chronic inflammatory disease processes. In
contrast, in emphysema there is loss of lung elastin and
collagen and a reduced area of air-fluid interface; the lungs
become less stiff (more compliant) than normal.
Functional residual capacity and elastic forces
In the respiratory system one elastic structure, the lungs,
is sealed inside another elastic structure, the chest wall.
The natural resting size of an elastic body is that to which
it recoils when no external forces act on it; for the lungs this
is much smaller, and for the chest wall larger, than FRC.
At end of a normal expiration, the inspiratory and expira-
tory muscles are relaxed and FRC is determined solely by
the elastic recoils of the lungs and chest wall. The oppos-
ing recoils of the lungs (inwards) and chest wall (outwards)
create a subatmospheric intrapleural pressure preventing
further recoil of either. At thoracotomy air enters the intra-
pleural space and the subatmospheric pressure is lost; the
lungs collapse down to their small natural resting volume
and the chest wall springs outwards.
If the lungs are unusually stiff, as in lung fibrosis or
NRDS, the FRC will be low because of the increased inward
recoil of the lungs. If the lungs are abnormally stretchy,
FRC will be high because the inward recoil of the lungs
is reduced; this contributes to the ‘barrel chest’ of severe
emphysema. In contrast, respiratory muscle weakness has
no effect on FRC.
Assessing the stiffness of the lungs
Clinically, stiffness is expressed as lung compliance, CL
(‘stretchiness’), which is the inverse of elastic resistance
(‘stiffness’). Stiff lungs have low compliance. Lung compli-
ance, CL=ΔV/ ΔP where ΔV is the change in lung volume and
ΔP is the change in pressure gradient across the lung causing
it to distend. P = alveolar pressure – intrapleural pressure.
K17577_C003.indd 34
Lung compliance can be measured but it requires intra-
pleural pressure to be assessed from oesophageal pres-
sure, which is not very pleasant or convenient. Fortunately,
abnormal lung stiffness can usually be deduced from lung
volume measurements. (see Lung function tests, p. 35).
Airway resistance, R AW
In most airways, most of the time, airflow is laminar, flowing
in smooth layers parallel to the walls of the airways. Turbulent
flow, which is less efficient, can occur in the trachea at high
ventilation rates causing harsh, noisy breath sounds.
With laminar flow through a smooth tube, F = ΔP/R where
F is the airflow rate, ΔP is the pressure gradient between the
tube ends and R is the resistance of the tube. Poiseuille dis-
covered that the resistance to flow was directly proportional
to the length, L, of the tube, the viscosity of the liquid, η and
inversely proportional to the fourth power of radius, r:
R = 8ηL/πr4 Poiseuille’s law
The key findings apply to lung airways, even though they are
more complex. In particular, changes in radius have a very
large effect; halving an airway’s radius increases its resis-
tance to airflow 16-fold.
For the respiratory system as a whole, F = ΔP/R AW, where
F is the airflow (measured at the mouth), ΔP is the pressure
gradient from mouth to alveolus and R AW is airway resistance
(the net resistance [R] of all the airways [AW]). The nose
contributes about two thirds of the total airway resistance.
Switching to mouth breathing lowers R AW, with all the extra-
thoracic airways then contributing about 1/3rd and the lung
airways 2/3rd of the total. In the lungs, airflow is divided
amongst the parallel airways of each airway generation.
Although, peripherally, the narrow individual airways each
have a high resistance, the number of parallel airways in the
whole generation is high and this lowers their net resistance.
Within normal lungs, the generations with the highest net
resistance are generations 3–5 (medium-sized bronchi). In
healthy young people the airways less than 2 mm in diameter
contribute only 10 per cent of the total R AW. These airways
(preferentially damaged by smoking) are known as the ‘silent
zone’ because a lot of damage must accumulate in this region
before it can be detected by measuring R AW.
Factors affecting airway resistance
Airway resistance can be affected by factors within the air-
way walls or by forces acting across the airway wall, such
as compression from a lung tumour or lymph nodes or
the ‘dynamic compression of airways’ that occurs during
forced expiration.
The airway mucosa and smooth muscle
Airway smooth muscle is supplied with bronchocon-
strictor parasympathetic vagal nerve fibres that form the
17/11/2015 15:32

efferent limb of the reflexes affecting bronchial smooth
muscle tone. Stimulation of airway irritant receptors
causes bronchoconstriction. Activation of slowly adapt-
ing pulmonary stretch receptors inhibits parasympathetic
bronchoconstrictor activity.
The airways are also innervated by excitatory and inhibi-
tory non-adrenergic, non-cholinergic (NANC) nerves
whose role in health and disease is still the subject of much
research and debate.
In humans there is no significant sympathetic inner-
vation of bronchial smooth muscle. Airways contain
β2-adrenergic receptors; their activation by adrenaline and
drugs such as salbutamol, causes bronchodilatation. Non-
selective beta-blockers such as propranolol cause a small
increase in airway resistance in normal subjects and a larger
increase in most asthmatics.
Bronchoconstriction and inflammation are also caused
by substances released from mast cells and eosinophils,
such as histamine, serotonin, prostaglandins (PGD2), leu-
kotrienes (C 4  and D4) and cytokines such as interleukins
(IL-5  and IL-13). In asthma, mast cells are triggered to
release inflammatory and bronchoconstrictor substances
by IgE produced in response to common antigens (house
dust mites, pollen, etc.). Abnormally high R AW may be epi-
sodic and completely reversible, as in many young asthmat-
ics where the narrowing is due to a combination of mucosal
inflammation and bronchoconstriction in hyperrespon-
sive airways. In chronic asthma, airway remodelling with
increased smooth muscle content often gives a degree of
irreversibility to the airway narrowing. The airway obstruc-
tion of chronic bronchitis and emphysema is largely irre-
versible. In chronic bronchitis the main mechanism is
mucosal gland hypertrophy; in emphysema loss of support
from the surrounding lung tissue makes the airways more
susceptible to dynamic compression.
Dynamic compression of airways
At FRC, during inspiration and during quiet expiration,
intrapleural pressure is subatmospheric and negative com-
pared to airway pressure, creating a distending force help-
ing to hold the intrathoracic airways open. During forced
expiration, intrapleural and alveolar pressure rise above
atmospheric, increasing the alveolar–mouth pressure gra-
dient (ΔP) driving expiratory airflow. As air flows, airway
pressure falls progressively from alveolus to mouth; at some
point airway pressure equals intrapleural pressure and
beyond this point the transmural pressure gradient reverses
causing airway collapse. Pressure builds up behind the col-
lapsed airway, flow restarts and pressure falls again; the air-
way will flutter open and closed.
This dynamic compression of airways occurs in normal
people and limits airflow towards the end of a forced expira-
tion when lung volumes are small. During a forced expira-
tion from TLC, the peak expiratory airflow (PEFR) occurs
near the start and is ‘effort dependent’; a true maximum
PEFR requires maximum effort. At low lung volumes the
K17577_C003.indd 35
Lung functions, structure and mechanics  35
airflow (=ΔP/R AW) is ‘effort independent’; any increase in ΔP
caused by increased expiratory effort is offset by an increase
in R AW caused by dynamic compression so that flow fails
to rise. Dynamic compression of airways is more marked
in the presence of obstructive airway disease; in severe air-
way obstruction even normal expiration is affected, making
expiration abnormally slow.
Lung function tests
R AW can be measured using a body plethysmograph found in
specialist hospital lung function laboratories. As with lung
compliance, abnormalities of airway resistance are usually
deduced from the more readily available lung function tests
based on forced expiratory manoeuvres. These tests help
determine whether common symptoms like breathlessness
are likely to be due to respiratory disease and, if so, what
sort of respiratory disease.
Diseases affecting lung mechanics are divided into
restrictive and obstructive pulmonary disease:
Restrictive lung/pulmonary disease (RLD) means restricted
expansion of the lungs during inspiration. The key
feature is a low TLC. There are three mechanisms:
1. Reduced lung compliance (lung fibrosis, NRDS).
2. Reduced inspiratory muscle power (muscular
­dystrophy, cervical cord injury, phrenic nerve palsy).
3. Reduced chest wall compliance (kyphoscoliosis or
extensive chest wall scarring following burns).
Obstructive pulmonary disease (OPD) means there is obstruc-
tion to airflow. The key feature is slow airflow, especially
during forced expiration. OPD can be either reversible,
as in asthma, or chronic with the airway obstruction
changing little, either spontaneously or with drugs. The
main pathology of chronic obstructive pulmonary disease
(COPD) is bronchitis and/or emphysema.
FORCED EXPIRATORY TESTS
For forced expiratory spirometry the subject takes a maxi-
mum breath in to TLC and breathes out as hard and fast as
possible into a spirometer (volume measuring device) until
RV is reached. The bellows spirometer measures volume
directly, whereas electronic spirometers measure flow, with
volume obtained by electrical integration of the flow signal.
Flow-measuring spirometers are more portable and they
permit maximum flow-volume plots to be produced as well
as volume–time plots.
Typical volume-time spirograms for a healthy 170  cm
20-year-old man and for patients with OPD and RLD are
shown in Figure 3.3a with the maximum flow-volume spi-
rograms in Figure 3.3b. The most important measurements
from the volume-time trace (Figure 3.3a) are the forced expi-
ratory volume in one second, FEV1, the forced vital capac-
ity, FVC, and the forced expiratory ratio, FER; FER = FEV1/
FVC. Volumes are corrected to volumes BPTS and compared
with the predicted values for the subject’s age, gender and
height. FEV1 is the best screening test for respiratory disease;
17/11/2015 15:32
 36  Respiratory physiology

it is reduced in both obstructive and restrictive lung disease.
FER is reduced (< 0.7) in the presence of obstructive pulmo-
nary disease. A normal or high FER with low FEV1 and FVC
is suggestive of restrictive lung disease. If FER is low, the test
is usually repeated following administration of a β2-agonist,
such as salbutamol; an increase in FEV1 of ≥ 200  mL or
12 per cent is suggestive of asthma.
Maximum effort flow-volume (MEFV) loops (Figure 3.3b)
can give useful supportive information; a concave expi-
ratory trace (thick black line) suggests intrathoracic air-
way obstruction, as in COPD. Fixed extrathoracic airway
obstruction, as in tracheal stenosis, gives a loop where
both inspiratory and expiratory airflow have flat tops (thin
dashed  line). In  restrictive lung disease, the shape is nor-
mal but the flows and volumes achieved are reduced (thick
dashed line).
Peak expiratory flow rate (PEFR, L/min) can be read from
the maximum flow-volume trace or a dedicated peak flow
meter. PEFR is both volume and effort dependent. PEFR is
useful as a screening test for respiratory disease (although
less sensitive than FEV1) and for monitoring asthma; it can-
not reliably distinguish between obstructive and restrictive
pulmonary disease as both can lower it.
6
N
5 OAD: Obstructive airway disease.
4 or reduced. The key feature is the
Volume, L BTPS
OTHER LUNG FUNCTION TESTS
Residual volume, total lung capacity and functional residual
capacity can be measured by helium dilution or body
plethysmography. In lung fibrosis, the reduced VC is
associated with a reduced TLC, FRC and RV. In emphy-
sema a reduced VC is associated with an increased TLC,
FRC and RV. In respiratory muscle weakness TLC is
low, FRC normal and RV high if the expiratory muscles
are also affected.
Carbon monoxide transfer factor, TLCO (CO diffusing
capacity, DLCO), assesses the ease at which CO is
transferred across the alveolar capillary membrane. The
main factors that affect TLCO are the total surface area
of the alveolar-capillary membrane and its thickness
but it is also affected by haemoglobin concentration. It
is sensitive but not specific for any one disease. TLCO is
low in emphysema (reduced area), pulmonary oedema
(increased thickness of the diffusion pathway), in pul-
monary vascular occlusive disease (reduced area) and in
lung fibrosis (reduced area and increased thickness). It is
often low in respiratory muscle weakness because small
lungs have a reduced surface area. The effect of lung
volume on TLCO can be allowed for by calculating the
N: Normal respiratory system.
FEV1 is reduced, FVC may be normal

OAD reduced ratio FEV1/FVC (FER). *True

FVC was not reached as the volume
3 was still rising at 6s; FER will be
RLD
overestimated. Modern bellows
2 spirometers record 12s expirations to
allow a plateau to be reached.
FVC (see *)

1 RLD: Restrictive lung disease.

FEV1

FEV1 is low and the percentage

0 reduction in FVC is similar or larger.
(a) 0 2 4 6 FER is normal or higher than predicted.

Time, s

600

Normal
Obstructive airway disease affecting small
300 airways. Forced expiratory airflow falls
Expiratory

rapidly after the peak to give a concave

MEFV curve.
Airflow, L/min

Fixed upper airway obstruction (e.g.

0 tracheal stenosis). The MEFV curve is
flat-topped, affecting both inspiration and
Inspiratory

expiration.
Restrictive lung disease. The MEFV curve
300 has a normal shape. The low peak flow
rates are related to low volume.

6 4 2 0
(b) 600
Lung volume, L

Figure 3.3  (a) Forced expiratory volume against time for three 20 year-old men of the same height (170 cm). (b) Maximum
effort flow-volume (MEFV) curves.

K17577_C003.indd 36 17/11/2015 15:32


diffusion coefficient, KCO; KCO = TLCO/alveolar vol-
ume. When restrictive disease is caused by lung fibrosis
both TLCO and KCO are reduced whereas in respiratory
muscle weakness KCO is normal.
Other specific investigations are sometimes needed.
Computerized tomography (CT) may be used to assess the
extent of emphysema. Radiological screening of the dia-
phragm during sniffing is used when diaphragmatic paraly-
sis is suspected; a paralyzed diaphragm moves up instead
of down during sniffing. Arterial Po2, Pco2, pH and oxy-
gen saturation are used to detect and assess the severity of
respiratory failure.
GAS DIFFUSION AND TRANSPORT IN THE
BLOOD
DRY AND MOIST INSPIRED Po2 AND Pco2
The air we breathe in contains mostly oxygen and nitrogen.
Nitrogen is physiologically inert and in respiratory physi-
ology the term ‘nitrogen’ is shorthand for ‘nitrogen and
the other inert gases (mostly argon)’. The concentration of
CO2 in air is low enough (0.04 per cent) for inspired Pco2 to
be taken to be 0 mm Hg/kPa.
The fractional concentration of oxygen in dry air (Fio2)
is 0.2095  and therefore at sea level (barometric pressure,
PB = 760 mmHg) the partial pressure of oxygen in dry air
(Fio2  × PB) is about 159  mmHg (21.2  kPa). Air contains a
variable amount of water vapour but as it passes through
the upper airways it is warmed to 37°C and fully saturated
with water vapour; saturated water vapour pressure at 37°C
is 47 mmHg (6.3 kPa). The added water vapour dilutes all
the other gases; the total pressure that they share falls from
PB to PB – 47 mmHg (PB – 6.3 kPa).
The Po2  of air in the trachea during inspiration is the
moist inspired Po2 (Pio2) and can be calculated from:
Pio2 = Fio2 × (PB – 47) mmHg (or Fio2 × (PB – 6.3) kPa)
The Pio2 is less than the dry Po2 by just under 10 mmHg
(1.3 kPa) whatever the altitude. The effect of adding mois-
ture is proportionally larger at high altitude; at sea level
Pio2 falls by about 6 per cent (159 mmHg dry to 149 mmHg
saturated at 37°C) whereas on the summit of Everest (PB =
252 mmHg) the equivalent fall is 19 per cent (53 mmHg dry
to 43 mmHg saturated at 37°C).
Alveolar Po2 and Pco2 (Pao2 and Paco2)
At sea level a healthy young person has a Pao2  of about
100 mmHg (13.3 kPa) and Paco2 of about 40 mmHg (5.3 kPa).
As gas exchange only takes place in the alveolar region,
O2 consumption is equal to the product of alveolar ventila-
tion and the difference in fractional concentration of oxygen
between moist inspired (Fio2) and alveolar air (Fao2):
K17577_C003.indd 37
Gas diffusion and transport in the blood  37
O2 consumption = alveolar ventilation × (Fio2 – Fao2)
(inspired) Equation 1
The equivalent equation for CO2  is simpler because
Fico2 = 0 when breathing air:
CO2 production = alveolar ventilation (expired) × Faco2
 Equation 2
Dividing Equation 2 by Equation 1:
CO2 production
= respiratory gas exchange ratio,
O2 consumption
Faco2
R≈
Fio2 – Fao2
Rearranging gives:
Faco2
Fao2 ≈ Fio2 –
R
Multiplying by barometric pressure, PB, to give partial
pressures. P:
Paco2
Pao2 ≈ Pio2 –
R
Arterial Pco2 (Paco2) is close to alveolar Pco2 (Paco2) in
both health and disease (CO2  diffuses easily and is much
less affected than O2  by ventilation-perfusion mismatch-
ing), so we can replace Paco2 with Paco2:
Paco2
Pao2 ≈ Pio2 –  Simplified alveolar air equation
R
This is a simple version of the alveolar air (or gas) equa-
tion. It is approximate because when equation 2 was divided
by equation 1, the alveolar ventilations were cancelled out,
although, they are not identical; usually more oxygen is
taken up than carbon dioxide is exhaled. The error is usually
small enough that this version of the equation is adequate
for estimating alveolar Po2  knowing the inspired Po2  and
arterial Pco2. In many situations R is not actually measured
but assumed to be the typical value of 0.8.
The general form of the alveolar gas equation is:
Pao2 = Pio2 – Paco2 (Fio2 + [1 – Fio2] / R)
Note, that in two special circumstances, when pure oxy-
gen is being breathed (Fio2 = 1) or when R = 1, the alveolar
air equation simplifies to: Pao2 = Pio2 – Paco2 .
Pao2  calculated from the alveolar air equation, is the
Po2 in the gas exchanging alveolar regions or ‘ideal alveo-
lar gas’. Ideal alveolar Po2  differs from the end-expiratory
(‘end-tidal’) alveolar Po2, which may be contaminated with
gas from any alveolar dead space present.
The alveolar gas equation is useful in several situations.
It allows us to consider the effects of altitude and changing
19/11/2015 06:44
 38  Respiratory physiology
alveolar ventilation on Pao2 . It is also used to calculate the
‘A-a Po2  gradient’, which is the difference between ideal
alveolar (A) and arterial Po2  (a). This helps quantify the
degree of right to left shunting (pure or with ventilation-
perfusion mismatching); the more there is, the larger the
A-a Po2 gradient.
Diffusion across the alveolar capillary
membrane
Oxygen diffusion across the alveolar–capillary membrane
is driven by the partial pressure gradient between alveolar
air and pulmonary capillary blood. At rest, breathing air
at sea level, the pressure gradient is 60  mmHg (8  kPa) at
the start of the pulmonary capillary (mixed venous Po2 is
40 mm Hg, 5.3 kPa; alveolar Po2 is 100 mmHg, 13.3 kPa)
(Figure 3.4) and oxygen diffuses very rapidly into the blood
and loads onto haemoglobin in the red blood cells; once
all the binding sites are full (oxygen saturation ≈ 100  per
cent) the Po2 of the blood rises rapidly. Approximately 0.2–
0.25  seconds after entering the pulmonary capillary (one-
third of the way along the capillary in a resting person) the
Po2 of the blood and alveolar gas are equal (Figure 3.4) and
no further oxygen diffuses into the blood. In heavy exercise,
as cardiac output increases, the average time in the pul-
monary capillary is reduced to from 0.75 s to about 0.25 s,
which at sea level, is usually just enough time for pulmonary
end-capillary Po2 to reach alveolar Po2.
High altitude reduces alveolar Po2  and hence the
Po2  gradient for diffusion. Also, when alveolar Po2, and
hence pulmonary end–capillary blood Po2, are low (< about
50 mmHg, 6.7 kPa) the haemoglobin remains unsaturated
(Figure 3.5 and next section) so that oxygen is still loading
onto it as alveolar Po2 is approached. The reduced diffusion
gradient and continued loading of oxygen both reduce the
rate of rise of pulmonary capillary Po2 as shown in the lower
curve of Figure  3.4  which illustrates the situation when
alveolar Po2 is lowered to 40 mmHg (5.3 kPa). At rest, Po2 in
the blood still rises to this alveolar Po2 before it leaves the
pulmonary capillary. During exercise there may be insuffi-
cient time in the pulmonary capillary for the blood to equil-
ibrate with alveolar gas and this will worsen the already low
arterial Po2.
Carriage of oxygen in the blood
DISSOLVED OXYGEN AND Po2
Oxygen is carried in the blood in physical solution and in
chemical combination with haemoglobin. The Po2 in a liquid
is equal to the Po2 of a gas mixture with which it is in equi-
librium. As blood passes through the pulmonary capillaries
it normally comes into equilibrium with the alveolar gas, so
that pulmonary end–capillary Po2 = alveolar Po2 (Pao2). In
health, at sea level, this is about 100 mmHg (13.3 kPa).
The quantity of gas in simple solution per litre = the par-
tial pressure of the gas × the solubility of the gas in the liquid.
K17577_C003.indd 38
Alveolar PO2 = 103 mmHg
100
Blood PO2
80
Oxygen tension (mmHg)
60
Alveolar PO2 = 40 mmHg
40
Blood PO2
20
Exercise Rest
0
0 0.25 0.50 0.75
Time in pulmonary capillary (s)
Figure 3.4  Time course of the oxygen tension of the
blood as it flows through a typical pulmonary capil-
lary with a normal alveolar oxygen tension (103 mmHg,
13.7 kPa) and during hypoxia (alveolar oxygen tension
40 mmHg, 5.3 kPa). With the higher alveolar oxygen ten-
sion, the oxygen tension of the blood rises very rapidly,
reaching that of alveolar gas before it has traversed more
than one-third of the length of the capillary. Equilibration
of oxygen tension between blood and alveolar gas takes
longer at the lower alveolar oxygen tension. Typically,
blood transverses the pulmonary capillary in 0.75 seconds
at rest and 0.25 seconds in moderate exercise.
The solubility of oxygen is low (0.03 mL/L blood/ mmHg,
0.225 mL/L blood/kPa ); only about three of the 200 mL of
oxygen in each litre of arterial blood at sea level are in sim-
ple solution. Even when the arterial Po2 is raised to about
650 mmHg (86.6 kPa) by breathing 100 per cent oxygen at
one atmosphere, the quantity of oxygen in physical solution
delivered to the tissues each minute is only about 40 per cent
of resting oxygen consumption.
Diffusion of oxygen is determined by the Po2  gradient
and not the oxygen concentration gradient. This is espe-
cially important when dealing with diffusion across differ-
ent ‘phases’ for example between a gas phase (alveolar air)
and plasma or between plasma and lipid. The dissolved oxy-
gen is in a dynamic equilibrium with oxygen bound to hae-
moglobin; the bound oxygen does not contribute directly to
the Po2. However, bound oxygen has an important indirect
17/11/2015 15:32

effect on blood Po2; unloading of oxygen from haemoglo-
bin slows the rate of fall of Po2 as blood passes through the
systemic tissue capillaries. In anaemia, the oxygen store
is reduced, so that although the arterial Po2  is normal,
Po2 falls more rapidly as blood flows through the tissue cap-
illaries; mean capillary, tissue and venous Po2 are reduced.
The polycythaemia that develops in response to chronic
arterial hypoxia (high altitude residence or chronic hypoxic
lung disease) can help tissue oxygen delivery; although the
blood enters the tissue capillaries with a reduced arterial
Po2 the rate of fall of Po2 along the capillary is reduced and
this helps reduce the fall in mean capillary and tissue Po2.
HAEMOGLOBIN
Oxygen combines reversibly with haemoglobin to form
oxyhaemoglobin. The maximum amount of oxygen that can
combine with 1 g of haemoglobin is about 1.34 mL (STPD).
The maximum amount of oxygen that can combine with
haemoglobin per litre of blood is the oxygen capacity; with
a normal haemoglobin concentration of 150  g/L (15  g/dL)
this is about 200 mL/L (1.34 × 150). The oxygen saturation
(SO2) is the percentage of the haemoglobin that is actually
carrying oxygen:
concentration of O2 combined with Hb
SO2 = × 100%
Oxygen capacity of blood
Each haemoglobin molecule consists of four subunits
each containing a polypeptide chain (globin) attached to
100
80
Oxygen saturation of haemoglobin (%)
Oxygen
saturation
60
P50
40
20
0 0
0 20
Oxygen tension (mmHg)
Figure 3.5  Oxygen dissociation curve of blood. Relationship for normal blood (haemoglobin [Hb] concentration
15 g/100 mL) at pH 7.4, Pco2 40 mmHg (5.3 kPa) and 37°C between oxygen tension and oxygen concentration (dashed
curve), and oxygen saturation of haemoglobin (solid curve). The concentrations of physically dissolved and chemically
combined oxygen are shown separately.
K17577_C003.indd 39
Gas diffusion and transport in the blood  39
an oxygen binding haem group containing an iron atom in
the ferrous form (Fe2+). The relationship between SO2  and
Po2 (obtained by equilibrating blood with gas mixtures of
varying Po2 and measuring the oxygen bound) is described
by the oxygen dissociation curve (Figure  3.5). Binding of
one oxygen molecule increases the affinity of the remain-
ing binding sites; the affinity of the last site for the fourth
oxygen molecule is 300 times the affinity for the first oxygen
molecule. This ‘cooperative binding’ helps explain the sig-
moid shape of the oxyhaemoglobin dissociation curve; it is
flat initially, gets steeper in the middle as affinity increases
before flattening to a plateau as the number of free binding
sites declines.
If the haem group iron atom becomes oxidised to the
ferric (Fe3+) form it can no longer bind oxygen; this form
is methaemoglobin and in high concentration it causes
tissue hypoxia, cyanosis and chocolate-brown blood.
Methaemoglobin concentration is normally kept low (<3
per  cent) by intracellular enzymes such as methaemoglo-
bin reductase. Methaemoglobinaemia can occur follow-
ing exposure to chemicals, especially nitrites and nitrates,
and oxidant drugs including some local anaesthetics
and nitroglycerin.
The four polypeptide chains of haemoglobin are similar
but not identical; in normal adult haemoglobin (HbA) there
are two α chains (each with 141  amino acids) and two β
chains (each with 146 amino acids).
The affinity of haemoglobin for oxygen is affected by
Pco2, [H+], temperature and the concentration of 2, 3 di- (or
bi-) phosphoglycerate (2,3  DPG or 2,3  BPG). The affinity
Total oxygen
20
O2 combined
Oxygen concentration [ml/(STPD)/100 ml]
with Hb 16
12
8
4
Physically
dissolved oxygen
40 60 80 100
17/11/2015 15:32
 40  Respiratory physiology
of haemoglobin for oxygen and the position of the oxy-
haemoglobin dissociation curve can be described using
the P50; P50 is the Po2 at which haemoglobin is 50 per cent
saturated. P50  for normal adult haemoglobin, with Pco2  =
40 mmHg, 5.3 kPa, pH = 7.4 and temperature 37°C, is about
26.5 mmHg, 3.5 kPa. A reduced affinity shifts the curve to
the right and increases the P50; an increased affinity shifts
the curve to the left and decreases the P50. Oxygen affinity is
reduced by an increase in Pco2, increased [H+] and increased
temperature, changes that occur in actively metabolizing
tissues aiding oxygen unloading to the tissues. In the lungs,
as these changes reverse, the affinity rises, again enhancing
oxygen uptake in the lungs. These shifts in the dissociation
curve caused by Pco2, [H+] and temperature are known as
the ‘Bohr effect’, after Christian Bohr who first described
the effects of increased CO2.
An increased concentration of the red cell metabolite
2,3 DPG also reduces the affinity of haemoglobin for oxy-
gen. It increases in conditions causing tissue hypoxia such
as severe anaemia and chronic exposure to high altitude. A
rise in 2,3  DPG helps the unloading of oxygen in the tis-
sues but reduces uptake of oxygen in the lungs. Whether a
change in 2,3, DPG is beneficial overall in terms of oxygen
delivery probably depends on the nature of the problem.
When the main problem is release of oxygen in the tis-
sues, as in anaemia, a rightward shift seems to have a net
beneficial effect. Although, the increase in 2,3  DPG that
occurs at high altitude was once assumed to be an adaptive
change, it probably is not; in this situation the problem is
loading oxygen in the lungs, which is not helped by reduced
oxygen affinity. In fact, at very high terrestrial altitude,
marked hyperventilation lowers the Paco2  considerably
(to < 10 mmHg near the summit of Everest) and the result-
ing increased affinity overwhelms the reduction of affinity
caused by the increased 2,3 DPG. The increased affinity at
extreme altitude increases oxygen delivery by improving
oxygen uptake in the lungs.
Other haemoglobin variants differ in the amino acid
sequence of the globin chains and this affects the proper-
ties of the haemoglobin, including the affinity of the hae-
moglobin for oxygen. Fetal haemoglobin has two α and
two γ chains and a high oxygen affinity (P50  ≈ 19  mHg,
2.5  kPa), which aids oxygen loading in the low Po2  envi-
ronment of the placenta. Abnormal haemoglobin vari-
ants can also affect the affinity for oxygen as well as other
properties; in sickle cell anaemia the main problems
caused by the abnormal haemoglobin, HbS (in which the
beta chains have one abnormal amino acid), arise from its
reduced solubility.
The respiratory pigment myoglobin, found in muscle, is
a monomer with a hyperbolic dissociation curve consider-
ably to the left of that for HbA. The P50 of myoglobin is about
2 mmHg compared with 26.5 mmHg for HbA; it is almost
completely saturated when Po2 is only 20 mmHg (2.7 kPa).
Its store of oxygen is only released when tissue Po2 is very low.
Carbon monoxide (CO) can bind to haem groups in place
of oxygen to produce carboxyhaemoglobin. The affinity of
K17577_C003.indd 40
haemoglobin for CO is about 240 times its affinity for oxy-
gen; a low inspired concentration can cause progressive
accumulation of carboxyhaemoglobin. The toxicity of CO
is due to two effects leading to tissue hypoxia: 1. It reduces
the binding sites available for oxygen and 2. It increases the
affinity of the remaining binding sites for oxygen. The oxy-
gen dissociation curve becomes hyperbolic and shifted to
the left (decreased P50). Even if arterial Pao2 is normal, oxy-
gen content is reduced and the remaining oxygen unloads
less easily. The cherry red colour of carboxyhaemoglobin
may give the skin a red colour and cause pulse oximeters to
give falsely high readings.
The oxyhaemoglobin dissociation curve:
values and practical applications
Normal sea level Paco2  is approximately 100  mmHg
(13.3  kPa) and oxygen saturation 97  per cent. The dis-
sociation curve begins to plateau above about 60  mmHg
(8 kPa), where oxygen saturation is more than 90 per cent:
above 200 mmHg (26.6 kPa) saturation is 100 per cent. At
rest, normal mixed venous Po2  is 40  mmHg, 5.3  kPa and
SO2 about 75 per cent; this is at the start of the steep section
of the dissociation curve.
As sea level arterial Po2 can fall by 40 mmHg (5.3 kPa)
to 60  mmHg before SO2  is markedly affected, so mod-
est hypoventilation or ascent to moderate altitude (up to
10 000  feet) has little effect on oxygen delivery to the tis-
sues. In a normal person at sea level, raising arterial Po2 by
hyperventilation or breathing oxygen-enriched air can only
increase content by adding a small amount of dissolved oxy-
gen. Hyperventilation may actually impair cerebral oxygen
delivery because the reduced arterial Pco2 causes cerebral
blood flow to fall.
A person with a normal haemoglobin concentration
but an arterial Po2  of 40  mmHg (5.3  kPa) caused by high
altitude or disease, will have about 75 per cent of the nor-
mal sea-level oxygen content; they may be able to deliver
enough oxygen to their tissues at rest but they are vulner-
able. A small further fall in Pao2  will cause a large fall in
arterial oxygen saturation and content and potentially,
fatal tissue hypoxia. However, when, as here, Pao2  is on
the steep part of the dissociation curve, raising Pao2 a little
(by hyperventilation or breathing oxygen-enriched air) can
cause a significant increase in arterial oxygen saturation
and content.
The oxygen delivery problems of anaemia are not helped
much by breathing oxygen-enriched air. Arterial Po2  is
normal in anaemia (normal alveolar ventilation and nor-
mal respiratory system) so oxygen saturation at sea level
is > 97  per cent; the problem is inadequate oxygen con-
tent because of a decreased concentration of haemoglobin
binding sites.
At sea level, resting mixed venous and tissue capil-
lary Po2 (about 40 mmHg, 5.3 kPa) is normally at the top
of the steep section of the dissociation curve; if metabolic
17/11/2015 15:32

rate increases, a lot more oxygen can be unloaded from the
haemoglobin with a relatively small fall in Po2. The partial
pressure gradient driving diffusion to the tissues is well
maintained as oxygen extraction increases to about three
times its resting value.
Oxygen consumption and delivery
Oxygen consumption is the amount of oxygen delivered to
the tissues (arterial oxygen content, mL/L × cardiac output,
L/min) minus the amount returning from the tissues to the
lungs (mixed venous oxygen content, mL/L × cardiac out-
put, L/min) each minute:
O2 consumption = cardiac × O2 content (arterial -
mL/min output mixed venous
mL/min mL O2/mL blood
This is an example of the Fick principle. With typical
resting values, cardiac output = 5000  mL/min, arterial
O2  content = 0.2  mL/ml (200  mL/L) and mixed venous
O2  content = 0.15  mL/mL (150  mL/L), the oxygen con-
sumption is 250  mL/min (5000  × (0.2  – 0.15). In exercise,
the increased oxygen consumption is made possible by
increasing both cardiac output and the extraction of oxy-
gen in the tissues. Arterial oxygen content is unchanged
in exercise at sea level. Table  2.1  gives cardiorespiratory
values at rest and during heavy exercise in a healthy but
sedentary young man. Both heart rate and stroke volume
increase with the heart rate contributing most to the rise
in cardiac output. From rest to maximum exercise the
cardiac output has increased about 3.4  times and oxygen
extraction about 3.5  times, which together give an oxy-
gen consumption of 3000  mL/min or 12  times the rest-
ing value. Aerobic exercise training increases maximum
oxygen consumption by increasing maximum stroke vol-
ume and cardiac output with little change in maximum
heart rate.
Cyanosis
Tissues containing blood with a high concentration of
deoxygenated haemoglobin have a blue-grey colour known
as cyanosis. Cyanosis occurs when there is at least 50  g/L
of deoxyhaemoglobin in the microcirculation of the tissue.
Peripheral cyanosis occurs in the fingers and toes or other
peripheral location; it is caused by an inadequate blood
flow and oxygen delivery to a region (for example, follow-
ing an arterial embolus) or to all peripheral regions when
cardiac output is low (as in cardiogenic shock). Central
cyanosis is seen in the tongue and buccal mucosa (where
blood flow is rarely severely impaired) and it indicates a
high deoxygenated haemoglobin concentration in the arte-
rial blood; (at least 15–20 g/L to reach the 50 g/L in the tis-
sue microcirculation needed to produce cyanosis). With
a normal haemoglobin concentration of about 150  g/L,
K17577_C003.indd 41
Gas diffusion and transport in the blood  41
SO2  will need to be 85–90  per cent or lower for cyanosis
to be observable. The reduction in SO2 needed to produce
cyanosis is greater in anaemia and less in polycythae-
mia. Cyanosis is never a very sensitive indicator of arte-
rial hypoxia; in severe anaemia death from hypoxia would
occur before cyanosis appeared. Methaemoglobinaemia
and some rare haemoglobinopathies are also causes
of cyanosis.
Causes of tissue hypoxia, inadequate
oxygen utilization and ATP production
Tissue hypoxia can be caused by three main mechanisms:
1. A low arterial Po2 (for example, high altitude, lung dis-
ease) 2. Reduced arterial oxygen content (for example,
anaemia, carbon monoxide poisoning, methaemoglobi-
naemia) and 3. Reduced blood flow (for example, arterial
embolus, cardiovascular shock). Barcroft (1920) originally
used the terms: 1. hypoxic hypoxia 2. anaemic hypoxia
and 3. stagnant hypoxia, for these three mechanisms of tis-
sue hypoxia. However, unqualified, the term ‘hypoxia’ has
come to be used as shorthand for ‘arterial hypoxia’ (low
Pao2); this means the term ‘anaemic hypoxia’ is potentially
confusing as anaemia causes tissue hypoxia but not a low
arterial Po2.
In addition to the above three mechanisms, tissue
hypoxia can be caused by impaired oxygen unloading (car-
bon monoxide poisoning) or impaired diffusion of oxygen
to the cells (oedema). Oxygen extraction and ATP produc-
tion are also impaired if the cells cannot use the oxygen
delivered. This occurs in sepsis and cyanide poisoning and
it is known as ‘histotoxic tissue hypoxia’.
Carbon dioxide carriage in the blood
Carbon dioxide is carried in the blood in physical solu-
tion, as bicarbonate and as carbamino compounds; hae-
moglobin plays an important role in the last two of these.
Carbon dioxide is 20  times more soluble than oxygen.
The concentration of dissolved carbon dioxide in blood
at the normal arterial Pco2  of 40  mmHg (5.3  kPa) is
2.6  mL (STPD)/100  mL. Bicarbonate is formed by the
following reaction:
CO2 + H2O  H2CO3  H+ + HCO3−
The first step happens slowly in plasma but in the red
blood cells the enzyme carbonic anhydrase catalyses the
reaction. Some of the bicarbonate ions formed in the red
cell diffuse into the plasma down the concentration gra-
dient that develops and the hydrogen ions are buffered
by haemoglobin.
Carbon dioxide can also combine with the free amino
groups of proteins to form carbamino compounds.
Quantitatively, the most important protein that forms
carbamino compounds is haemoglobin; it is present in
17/11/2015 15:32
 42  Respiratory physiology

high concentration in the blood and it has a lot of available
amino groups.
− +
HbNH2 + CO2  HbNHCOOH  HbNHCOO + H
When the haemoglobin is in the reduced (deoxygenated)
form, the quantity of carbon dioxide carried at any given
Pco2 is higher than when the haemoglobin is oxygenated;
the dissociation curve, CO2 content versus Pco2 (Figure 3.6),
is shifted up as oxygen saturation goes down. This is known
as the Haldane effect; its aids uptake of CO2 in the tissues
and release in the lungs. There are two mechanisms for
the Haldane effect: reduced haemoglobin is a more effec-
tive buffer, which aids bicarbonate formation, and it forms
carbamino compounds more readily than oxyhaemoglo-
bin. Of the CO2 excreted, about 60 per cent was originally
transported in the form of bicarbonate, about 30 per cent as
carbamino compounds and about 10 per cent as dissolved
carbon dioxide.
The carbon dioxide dissociation curve (Figure 3.6) is much
more linear over the physiologically significant range than
the oxygen dissociation curve (Figure  3.5). At the normal
arterial Pco2 of 40 mmHg (5.3 kPa), CO2 content is about
480  mL/L; mixed venous Pco2  at rest is about 46  mmHg
(6.1  kPa) and CO2  content 520  mL/L. Although the curve
becomes less steep at high Pco2 there is no plateau, as found
on the oxyhaemoglobin dissociation curve. The difference in
content between mixed venous and arterial blood at rest is
similar for carbon dioxide and oxygen (40 mL/L and 50 mL/L
respectively); the slightly lower value for the CO2 content dif-
ference reflects the typical R value of 0.8 (CO2 production
80% of O2 consumption). In contrast, the partial pressure
difference between mixed venous and arterial blood, is very
much less for CO2 (6 mmHg, 0.8 kPa) than for O2 (60 mmHg,
8 kPa), reflecting their different mechanisms of carriage and
different dissociation curves.
Right to left shunts and ventilation
perfusion matching
Although by the end of the pulmonary capillary, blood Po2 is
normally equal to alveolar Po2, arterial Po2 is always lower.
In a healthy young person breathing air at sea level, the dif-
ference between alveolar Po2 (Pao2) and arterial Po2 (Pao2)
is about 3–4 mmHg (0.5 kPa). The main reason for this ‘A–a
Po2 gradient’ is the addition of a small amount of systemic

80

70
Carbon dioxide concentration [mL(STPD)/100mL blood]

0% HbO2
60

Mixed venous
50
Physiological
curve
‘Arterial’

40
70% HbO2

97.5% HbO2

30

20
10 20 30 40 50 60
Carbon dioxide tension (mmHg)

Figure 3.6  Carbon dioxide dissociation curve of whole blood at oxyhaemoglobin (HbO2) saturations of zero (fully
reduced), 70 per cent (mixed venous blood at rest) and 97.5 per cent (arterial blood breathing air at rest). The dashed line
depicts the relationship (the physiological curve) between carbon dioxide tension (Pco2) and carbon dioxide concentration,
which is followed as blood takes up carbon dioxide in the tissues and gives it up in the pulmonary capillaries.

K17577_C003.indd 42 17/11/2015 15:32


venous blood (‘right-sided blood’) to the blood that has
undergone normal gas exchange (‘left-sided blood’). Some
venous blood from the bronchial circulation drains into
the pulmonary veins returning oxygenated blood to the left
heart. In addition, although most of the deoxygenated blood
from the myocardium returns to the right heart by way of
the cardiac veins and coronary sinus, a small amount drains
via small veins (the venae cordis minimae or Thebesian
veins) directly into the left ventricular chamber. These ana-
tomical anomalies produce some ‘right-to-left shunting’ of
blood in normal people amounting to about three per cent
of the cardiac output. In diseases, such as lobar pneumonia
or cyanotic congenital heart disease, the proportion of the
cardiac output failing to undergo gas exchange and there-
fore producing right to left shunting, is much larger and the
A–a Po2 gradient increased.
Another cause of a widened A–a Po2  gradient is venti-
lation–perfusion mismatching. At rest, the total alveolar
ventilation (VA) and the total perfusion (Q, pulmonary
blood flow) are similar, each being about 4–6  L/min in a
healthy adult, so that the usual ratio (VA/Q) of alveolar
ventilation to perfusion for both lungs is close to 1. For
good gas exchange to occur, local ventilation and perfu-
sion need to be reasonably matched in all lung regions.
The more blood that perfuses a region, the greater the
ventilation required in that region to keep local alveo-
lar Po2 high enough to fully saturate the haemoglobin. In
many lung diseases, including COPD and asthma, sig-
nificant mismatching of ventilation and perfusion occurs
and this affects gas exchange. Lung regions with a high
ventilation-perfusion ratio, VA/Q, usually caused by locally
low perfusion, will have a high local alveolar Po2  but this
cannot significantly increase the blood oxygen content.
Qualitatively, such regions behave like dead space. Regions
with a low VA/Q, usually caused by inadequate ventilation,
have a low local alveolar Po2  which may be inadequate to
fully saturate the blood emerging from them with oxy-
gen. Low VA/Q regions behave qualitatively like right-to-
left shunts; these regions are responsible for the arterial
hypoxia and widened A–a Po2  gradient associated with
ventilation-perfusion mismatching. Pure right-to-left
shunts are equivalent to a region with a VA/Q of zero.
Local ventilation and perfusion and VA/Q are variable
even in the normal lungs, partly because of the effect of
gravity on intrapleural and pulmonary vascular pressures.
In the upright posture, the intrapleural pressure is less neg-
ative at the lung base than at the lung apex and so, at the
end of expiration (FRC), alveoli at the lung bases are less
distended; they can expand well during inspiration and
have a higher alveolar ventilation per mL of lung tissue
than at the apex. The higher pulmonary vascular pressures
at the lung base distend the blood vessels there, reducing
local vascular resistance and increasing local blood flow.
Although, both alveolar ventilation and perfusion per mL
of lung tissue are greater at the lung bases than the apices
in the upright posture, the effect of gravity on regional
perfusion is greater than its effect on regional alveolar
K17577_C003.indd 43
Gas diffusion and transport in the blood  43
ventilation, so the VA/Q ratio varies; at the very top of nor-
mal upright lungs the local VA/Q ratio may be 3 and at the
bases 0.6. Although the bases are slightly under-ventilated
relative to their perfusion, the local alveolar Po2 is still high
enough to almost fully saturate the blood flowing in these
regions. The degree of ventilation–perfusion mismatch-
ing caused by gravity in a normal young person has little
effect on gas exchange but mismatching increases with age
and is the main reason for the lower arterial Po2 and larger
A–a Po2 gradient in elderly people.
One mechanism helping to reduce ventilation–perfu-
sion mismatching is hypoxic pulmonary vasoconstriction
(HPV). This helps reduce the blood flow to poorly venti-
lated regions, diverting blood to better-ventilated areas
where Po2 is higher. HPV becomes less useful when hypoxia
is global, as with residence at high altitude or in chronic
hypoxic lung disease; it causes increased pulmonary vascu-
lar resistance and workload for the right heart and some-
times, eventually, right-sided heart failure.
Blood gases in right to left shunts or
ventilation-perfusion mismatching
The primary effect of right-to-left shunting of blood is to
reduce arterial oxygen content and increase arterial car-
bon dioxide content. This will usually be modified rapidly
by a secondary reflex increase in alveolar ventilation in
response to chemoreceptor stimulation. This usually cor-
rects, or more commonly over-corrects, the rise in arterial
Pco2, because the ventilated areas will excrete more CO2.
Increasing alveolar ventilation cannot correct the low arte-
rial oxygen content; no gas reaches the shunted blood and
although the local alveolar Po2  will increase in the venti-
lated regions, oxygen uptake cannot increase much, as the
blood emerging from these regions is already fully  satu-
rated. The final effect of a right to left shunt with a reflex
increase in ventilation is typically a low arterial Po2 with a
normal or low arterial Pco2.
If the reflex increase in ventilation fails to occur, the arte-
rial hypoxia is accompanied by a raised arterial CO2 content
and Paco2 . However, the rise in Paco2 is small because the
CO2 dissociation curve is steep (Figure 3.6); normal resting
mixed venous blood has a Pco2 that is only about 6 mmHg
(0.8 kPa) higher than normal arterial Pco2, despite a content
that is 40 mL/L higher than that in the arterial blood. If a
paralysed patient being ventilated with air at constant min-
ute volume suddenly developed a large right-to-left shunt,
his Pao2  would fall markedly but his Paco2  would rise by
just a few mmHg.
Arterial hypoxia and respiratory failure
Respiratory failure is present when arterial Po2 is less than
60 mmHg (8 kPa) when breathing air at sea level. In type
19/11/2015 06:48
 44  Respiratory physiology
1  respiratory failure, the arterial hypoxia is accompanied
by a normal or low arterial Pco2. In type 2 respiratory fail-
ure (or ‘ventilatory failure’) the arterial hypoxia is accom-
panied by an arterial Pco2 above 50 mmHg (6.7 kPa). This
definition excludes some patients with disabling dyspnoea
at rest (breathlessness) whose ventilatory efforts achieve a
Po2 above 60 mmHg but whose respiratory system is clearly
failing them in any ordinary sense.
Arterial hypoxia (reduced Pao2) results from five
main mechanisms:
1. Low inspired Po2; 2. hypoventilation; 3. dif-
fusion impairment (e.g. pulmonary oedema, lung
fibrosis or exercise at high altitude); 4. pure right to
left shunting; and 5. the right to left shunt effect of
ventilation-perfusion mismatching.
Of these five causes, only hypoventilation inevitably
causes a raised Paco2 . In the other four, Paco2  is often
lowered by a reflex increase in ventilation. In many dis-
eases, more than one of these mechanisms contribute to
the hypoxia. Anaemia lowers oxygen content but arterial
Po2 and saturation are normal.
Adverse effects of high inspired oxygen
concentration
Oxygen-enriched air is often lifesaving, but there are several
potential adverse effects. These include: 1. Oxygen toxicity
related to the production of reactive oxygen species pro-
ducing tracheobronchitis, diffuse alveolar damage, acute
respiratory distress syndrome and, in extreme cases, cen-
tral nervous system (CNS) toxicity. 2. Absorption atelecta-
sis, because unlike the nitrogen it replaces, alveolar oxygen
is rapidly absorbed. It can be a problem during anaesthe-
sia. 3. Increased Paco2 , to potentially dangerous levels, in
patients with chronic type 2  respiratory failure. This may
be due to a fall in alveolar ventilation as the hypoxic drive
to breathing is removed and/or an increase of ventilation–
perfusion mismatching as hypoxic pulmonary vasocon-
striction is reversed. 4. Increased fire hazard, which is an
important consideration when considering home oxygen
therapy in smokers. 5. Retinopathy and blindness associ-
ated with the use of excessively high oxygen concentrations
in premature babies.
The relationship between alveolar Pco2,
alveolar ventilation and CO2 production
Inspired air usually contains no carbon dioxide and so all
the CO2 in the exhaled air comes from the alveolar gas with
none from the dead space. Therefore:
CO2 production = alveolar ventilation × alveolar fractional
concentration of
CO2 (Faco2)
K17577_C003.indd 44
Alveolar Pco2  (Paco2) = PB × Faco2  and arterial
Pco2 remains close to alveolar Pco2 in both health and dis-
ease. This means that:
CO2 production
Paco2 and Paco2 ∝ 
Alveolar ventilation
 Equation 3
Where Paco2 is alveolar Pco2 and Paco2 is arterial Pco2.
Equation 3  predicts the new Paco2  following a change in
alveolar ventilation and/or CO2  production once a new
steady state has been reached (tissue CO2  production =
exhaled CO2  output). This relationship is independent of
environmental pressure; the alveolar ventilation required to
maintain a given alveolar Pco2 is the same at all altitudes. If
Paco2 is to remain constant as CO2 production varies, alve-
olar ventilation must change by proportionally the same
amount. The terms hyperventilation and hypoventilation
are defined in relation to this equation.
Hyperventilation means alveolar ventilation that is high
relative to CO2  production. Hyperventilation gives a low
Paco2 (< 35 mmHg, 4.7 kPa), high arterial pH (respiratory
alkalosis) and a high Pao2; when hyperventilation occurs at
sea level, O2 saturation and content will not change much.
The causes and effects of hyperventilation are discussed in
detail in Chapter 4.
Hypoventilation means an alveolar ventilation that is low
relative to CO2  production. Hypoventilation is caused by
impaired central respiratory drive, respiratory muscle weak-
ness or abnormal respiratory system mechanics. Paco2 will
be high (> 45  mmHg, 6  kPa). The high Paco2  leads to low
arterial pH (respiratory acidosis) and when breathing air,
hypoventilation is inevitably accompanied by a low Pao2 .
Signs and symptoms include headache, flushed skin, extra-
systoles, hand flap, increased blood pressure, confusion
and coma. Chronic hypoventilation may be better tolerated
because adaptive changes, such as polycythaemia and com-
pensatory metabolic alkalosis, have had time to develop.
Oxygen tension gradients (the oxygen
cascade)
The Po2 (oxygen tension) at different points in the oxygen
transport system in an individual breathing dry air at sea
level is shown in Figure 3.7. The step falls in Po2 are caused
by (1) moistening of the inspired air, (2) exchange of O2 and
CO2  across the alveolar–capillary membrane, (3) right to
left shunting of blood and any ventilation–perfusion mis-
matching, (4) oxygen consumption in the tissues, and (5)
diffusion of O2 to the furthest tissues cells. In light exercise
tissue Po2 will be reduced in the exercising muscle but it is
still high enough for aerobic metabolism. In contrast, dur-
ing hyperventilation despite increased alveolar and arte-
rial Po2, the minimum Po2 in the brain is at a critical level
where it is beginning to impair oxidative phosphorylation;
cerebral oxygen delivery has been impaired by cerebral
17/11/2015 15:32
 Control of pulmonary ventilation  45

160 such things as speech, deliberate hyperventilation, and vol-

untary breath-holding. The important peripheral inputs
are from the respiratory chemoreceptors, lung receptors
140
Hyperventilation and arterial baroreceptors.
(PaCO2 = 25 mmHg)

120 Respiratory chemoreceptors

Arterial Pco2, pH and Po2 are the most important respira-
Oxygen tension (mmHg)

100 tory stimuli; they are sensed by the central and peripheral
respiratory chemoreceptors. The central chemoreceptors
are found in several areas of the brain stem but especially
80 just beneath the ventrolateral surface of the medulla. They
Rest
respond to the Pco2 and pH of brain extracellular and cere-
Light brospinal fluid, which reflect the arterial Pco2. They do not
60 exercise
mediate the ventilatory response to acute metabolic acidosis
because the blood–brain barrier prevents easy passage of H+
Hyperventilation from the arterial blood to central chemoreceptors. The cen-
40
(brain)
tral chemoreceptors are not stimulated by hypoxia.
The peripheral arterial chemoreceptors are located in the
20 carotid bodies, which lie in the bifurcations of the common
carotid arteries, and the aortic bodies, which lie around the
aortic arch. These receptors respond to changes in the Po2,
0
Pco2, pH and also potassium concentration of the arterial
blood. The carotid bodies are much more important than
Dry atmosphere

Inspired
(tracheal) gas

Alveolar gas

Arterial blood

Mixed

Minimum
tissue tension
venous blood

the aortic bodies in mediating reflex respiratory responses.

Patients whose carotid bodies have been surgically removed
have no ventilatory response to breathing hypoxic gas mix-
tures. The carotid bodies are responsible for the increased
ventilation that accompanies a metabolic acidosis, such as
Figure 3.7  Oxygen tension gradients from dry atmo- the lactic acidosis of heavy exercise or the ketoacidosis of
sphere to minimum tissue level in an individual breath-
uncontrolled diabetes.
ing air at ground level at rest, during light exercise and
performing hyperventilation.
Responses to carbon dioxide
Increasing arterial Pco2 by adding CO2 to the inspired gas
vasoconstriction caused by the low Pco2. The effects on the results in a rapid and large increase in pulmonary ventila-
oxygen cascade of breathing air with reduced Po2 at altitude tion. The relationship between ventilation and the arterial
are discussed in Chapter 4. Pco2  is linear over a large range; pulmonary ventilation
increasing by about 2–3  L (BTPS)/min for each 1  mmHg
CONTROL OF PULMONARY VENTILATION (0.13  kPa) increase in arterial Pco2  (Figure  3.8a). Above
about 80  mmHg (10.7  kPa) the rate of rise in ventilation
Neural organization decreases and when Paco2  is very high ventilation falls,
reflecting depression of the brain stem respiratory control
The activity of the respiratory muscles is due to the rhyth- areas. When arterial Paco2  is reduced below its normal
mic discharge of neurons located in the medulla and pons. value of 40 mmHg, 5.3 kPa (by prior hyperventilation) the
The primary centre, in the reticular formulation of the resulting ventilation is variable. In anaesthetized patients,
medulla, contains inspiratory and expiratory neurons that the ventilation is that predicted by the line extrapolated
fire rhythmically even when completely deprived of affer- (Figure  3.8a, thick dashed lines) from the response curve
ent impulses. Their activity is modified by inputs from the above 40 mmHg. When Paco2 falls, below where this line
pontine respiratory centres, the reticular activating system crosses the X-axis (Paco2  between 30  and 38  mmHg) the
and a wide variety of peripheral receptors. Other brain subject stops breathing and resumes when Paco2  rises
areas can also activate the respiratory centre; stimulation again above this threshold value. In conscious subjects the
of defence areas of the brain increases ventilation dur- response to low Paco2 is often different, with breathing con-
ing arousal and fear and stimulation of the hypothalamus tinuing at a rate that is not much below the normal resting
mediates increased ventilation during fever. The motor rate (Figure 3.8a, thin dashed line).
neurons to the respiratory muscles can also be controlled The ventilatory response to carbon dioxide is increased
from the cerebral cortex via the pyramidal tracts, enabling by hypoxia (Figure  3.8a, grey line). Hypoxia and

K17577_C003.indd 45 17/11/2015 15:32

 46  Respiratory physiology

hypercapnia show synergism in ventilatory control; the Responses to oxygen

presence of one of them enhances the ventilatory response
to the other.
Normal daytime arterial Paco2  lies between 35  and
45  mmHg (4.7–6.0  kPa) in a healthy young person, with
mean values lower in women than men. In any awake indi-
vidual Paco2 usually varies by less than 4 mmHg (0.5 kPa)
but it rises during sleep.
An acute reduction of arterial Po2 produced by breathing a
hypoxic gas mixture produces little increase in pulmonary
ventilation until Pao2  is below about 50  mmHg, 6.7  kPa
(Figure  3.8b, solid line). Any small increase in ventilation
in response to the hypoxia lowers arterial Pco2 producing
reflex inhibition of ventilation. If Paco2  is maintained at

60

Pa
50 kP

k
.3

5.3
13
Hg

Hg
Ventilation (L/min)

40

m
m
0m

m
40
10

o2 =
=
30
Pa o
2

Pa
20

10 = starting point, breathing CO2-free air

0
30 35 40 45 50 55 60 80 mmHg

(a) 4 5 6 7 8 11 kPa
Alveolar or arterial Pco2

60
Paco2 allowed to fall as
ventilation increases
50 Paco2 fall prevented

Paco2 increased
Ventilation (L/min)

40

30

20

10

0
0 30 60 90 120 mmHg

(b) 0 4 8 12 16 kPa
Arterial Po2

Figure 3.8  (a) The CO2 response curve. In a person with a normal arterial Po2 and pH, raising alveolar Pco2 by breath-
ing CO2 enriched air, produces an increase in ventilation that is large and linear (black line) until Pco2 gets above about
80 mmHg (11 kPa) when the response is reduced (upper dashed line). If the subject is also hypoxic (grey line) the
CO2 response is increased. If Pco2 is lowered below the normal sea level value of 40 mmHg by prior hyperventilation, as
discussed in the text, the ventilation is more variable; the lower dashed lines show the two commonest response patterns.
(b) The ventilatory response to hypoxia. As arterial Po2 falls from its normal sea level value of 100 mmHg, as the subject
breathes a hypoxic gas mixture, ventilation changes little until Po2 falls below about 60 mmHg (8 kPa) after which it rises
more steeply, especially when Po2 falls below about 45 mmHg (6 kPa). The response increases if the fall in Pco2 that occurs
when ventilation increases is prevented by adding some CO2 to the inspired gas (grey line); it increases even more if arte-
rial Pco2 is raised above normal (dashed line).

K17577_C003.indd 46 17/11/2015 15:32


120
100
Pulmonary ventilation [L(BTPS)/min]
80
60
40
20
0 ●●
0 1 2 3
Oxygen uptake [L(STPD)/min]
Figure 3.9  Relationship in steady-state exercise between
pulmonary ventilation and oxygen uptake (metabolic
oxygen consumption). The solid curve depicts the mean
and the shaded area depicts the variation (±2 standard
deviations) of this relationship for a group of 20 young
healthy volunteers.
40 mmHg (5.3 kPa) by adding CO2 to the inspired gas, the
ventilatory response to hypoxia is increased (Figure  3.8b,
grey line). If Paco2 is raised above normal, the ventilatory
response is further increased (Figure 3.8b, grey dashed line).
Increasing arterial Po2 above normal sea level value has lit-
tle effect on pulmonary ventilation.
Exercise
During light and moderate exercise the increase in ven-
tilation is proportional to the increase in oxygen uptake
(Figure  3.9) and carbon dioxide production so that arte-
rial Pco2 and Po2 and also arterial pH are held very close
to their resting values; stimulation of respiratory chemo-
receptors by blood gases cannot explain the large increase
in ventilation in exercise. Many other possible mechanisms
may be involved. Activation of brain areas related to loco-
motion may co-activate the cardio-respiratory control areas
(a mechanism known as central command). Activation of
muscle and joint receptors in the moving limbs or other
stimuli to carotid body chemoreceptors (such as potassium)
may lead to reflex increases in ventilation. In heavy exer-
cise the ventilation rise is out of proportion to the increased
CO2 production and arterial Pco2 falls; the extra stimulus to
breathing responsible for this hyperventilation is the lactic
acidosis that occurs in heavy exercise.
K17577_C003.indd 47
Further reading  47
SUMMARY
●● Delivery of oxygen and other nutrients to the
tissues and removal of metabolites such as
carbon dioxide involves the integrated actions of
the cardiovascular and respiratory systems. In
particular, tissue oxygen delivery is dependent on
arterial oxygen content and tissue blood flow.
●● Aerobic ATP production continues as long as
mitochondrial Po2 is kept above about 2 mmHg.
It falls below this when oxygen delivery is inad-
equate for oxygen consumption, for example
because of inadequate blood supply, inadequate
arterial oxygen content or inadequate unloading
of oxygen in the tissues. This will impair tissue
function and ultimately survival.
Alveolar ventilation is an important determinant
4 5
of alveolar and arterial Po2 and Pco2. Respiratory
muscle activity is controlled by a variety of reflexes
as well as activation of brain regions involved
in exercise, speech and the alerting response.
The most important reflexes are from the brain-
stem central chemoreceptors and the peripheral
arterial chemoreceptors in the carotid body. The
carotid body is the only source of reflex ventila-
tory response to hypoxia and the response is small
until arterial Po2 falls below about 60 mmHg.
●● The work that the respiratory muscles have to do
to overcome the elastic and airway resistance to
breathing is small in health but becomes abnor-
mally high in many common respiratory diseases.
Simple forced expiratory tests can help screen
for respiratory disease and distinguish between
obstructive (high airway resistance) and restric-
tive (high elastic resistance) pulmonary disease.
●● The combination of oxygen with haemoglobin is
dependent on the Po2 of the blood as described by
the sigmoid oxyhaemoglobin dissociation curve
(O2 saturation versus Po2); the curve is steep
below about 60 mmHg and flattens above it. This
relationship is key to understanding the effect on
oxygen delivery of altered arterial Po2 in situa-
tions such as high altitude or respiratory disease.
ACKNOWLEDGEMENT
Revised and updated from the corresponding contribution
to the Fourth Edition written by the late John Ernsting, Jane
Ward and Olga M. Rutherford.
FURTHER READING
Ward JPT, Ward J, Leach RM. The Respiratory System at a
Glance, 4th edn. Oxford: Wiley–Blackwell, 2015.
17/11/2015 15:32
 48  Respiratory physiology
West JB. Respiratory Physiology: The Essentials, 9th edn.
Philadelphia, PA: Lippincott Williams & Wilkins, 2012.
Advanced reading
Astrand PO, Rodahl K, Dahl HA, Stromme SB. Textbook
of Work Physiology, 4th edn. Champaign, IL: Human
Kinetics, 2003.
Cotes JE, Chinn DJ, Miller MR. Lung Function: Physiology,
Measurement and Application in Medicine, 6th edn.
Oxford: Wiley–Blackwell, 2006.
K17577_C003.indd 48
Ernsting J. Respiration and Anoxia. In: Gillies JA (ed). A
Textbook of Aviation Physiology. Oxford: Pergamon
Press, 1965: 214–63.
Shiner RJ, Steier J. Lung Function Tests Made Easy.
Edinburgh: Churchill Livingstone Elsevier, 2012.
West JB, Schoene RB, Luks AM, Milledge JS. High
Altitude Medicine and Physiology, 5th edn. Boca
Raton, FL: CRC Press, 2012.
17/11/2015 15:32

Hypoxia and hyperventilation
Revised by DAVID P. GRADWELL
Introduction 49
Acute hypobaric hypoxia: hypoxia in flight 50
INTRODUCTION
Living organisms obtain energy for their biological pro-
cesses by the oxidation of complex chemical foodstuffs to
simpler compounds, usually with the eventual formation of
carbon dioxide, water and other waste products. Oxygen,
therefore, is essential for the maintenance of continued
aerobic respiration and normal function by living mate-
rial. Normoxia describes the state in which a physiologi-
cally adequate supply of oxygen to the tissues, whether in
quantity or molecular concentration, is available. When the
level of oxygen available is below that requirement, a state
of hypoxia is said to exist. Humans are extremely sensi-
tive and vulnerable to the effects of deprivation of oxygen,
and severe hypoxia nearly always results in a rapid deterio-
ration of most bodily functions; eventually, it will lead to
death. Hypoxaemia is a general term meaning a deficiency
in the oxygenation of the blood, but it is not synonymous
with the term tissue hypoxia, which may arise from one or
more causes.
Four different types of tissue hypoxia are recognized
and may be classified according to the primary mechanism
involved:
●● Hypoxic hypoxia: the result of a reduction in the oxygen
tension in the arterial blood and, hence, in the capillary
blood. The aetiology includes the low oxygen tension
of inspired gas associated with exposure to altitude, i.e.
hypobaric hypoxia. Other causes are hypoventilatory
states, e.g. paralysis of respiratory musculature, depres-
sion of central control of respiration, airway obstruction
K17577_C004.indd 49
4
Hyperventilation 62
Further reading 63
and pulmonary atelectasis (including that due to expo-
sure to high sustained accelerations); impairment of
gas exchange across the alveolar–capillary membrane,
e.g. pulmonary oedema, pulmonary fibrosis; impair-
ment of the circulation with right-to-left shunts, as may
occur with congenital or acquired communications;
and ventilation–perfusion mismatches, e.g. chronic
bronchitis, emphysema.
●● Anaemic hypoxia: the consequence of a reduction in
the oxygen-carrying capacity of the blood. Although
the arterial oxygen tension is normal, the amount
of haemoglobin available to carry oxygen is reduced
and, thus, the ability to deliver oxygen molecules to
the tissues is compromised. The oxygen tension of
the blood falls more rapidly than normal as it flows
through the capillary beds and so, at their venous
ends, is inadequate to maintain the required minimum
level throughout the tissue involved. Causes of anae-
mic hypoxia include reduced erythrocyte count, e.g.
haemorrhage, increased red cell destruction, decreased
red cell production; reduced haemoglobin concentra-
tion, e.g. hypochromic anaemia; synthesis of abnor-
mal haemoglobin, e.g. sickle-cell anaemia; reduced
oxygen-binding capability, e.g. carbon monoxide
inhalation; and chemical alteration of haemoglobin,
e.g. methaemoglobinaemia.
●● Ischaemic (stagnant or circulatory) hypoxia: the conse-
quence of a reduction in blood flow through the tissues.
Gas exchange in the lungs and the oxygen tension and
content of the arterial blood are normal, but oxygen
delivery to the tissues is inadequate. This, therefore, is
49
17/11/2015 15:32
 50  Hypoxia and hyperventilation
an example of tissue hypoxia in the absence of arte-
rial hypoxaemia. There is increased oxygen extraction
and the oxygen tension falls to a low level in the venous
ends of the capillaries. Causes include local arteriolar
constriction, e.g. exposure of digits to cold; obstruction
of arterial supply by disease or trauma; general circula-
tory failure, e.g. cardiac failure, vasovagal syncope; and
the fall in cardiac output and blood pressure associated
with exposure to high sustained accelerations. Oxygen
therapy is of little use in such forms of hypoxia.
●● Histotoxic hypoxia: the result of an interference with
the ability of the tissues to utilize a normal oxygen sup-
ply for oxidative processes. Poisoning by cyanide is an
example. In this case, the action of cytochrome oxidase
of the mitochondria is completely blocked, even in the
presence of adequate molecular oxygen. Certain vita-
min deficiencies, for example, beriberi resulting from
inadequate intake of vitamin B1, will have the effect of
compromising several stages in the utilization of oxygen
by the tissues. Furthermore, oxygen toxicity, a condition
in which an excessive tissue pressure of oxygen occurs
and may arise in association with exposure to high oxy-
gen concentrations under hyperbaric pressures, itself
gives rise to a failure of oxidative metabolism.
This chapter addresses the effects of acute hypoxia
associated with flight. It is beyond the scope of this text to
address the range of effects of more chronic exposure to alti-
tude as occurs in mountaineers and highland populations.
Although the physical changes in environmental pressure
and temperature may have some degree of commonality
in the effect, the differences in the durations of exposure
to reduced ambient pressures are related to the differences
in the physiological and pathological changes observed and
the clinical pictures that may present. Tissue hypoxia is also
associated with clinical conditions such as neoplasia, where
the role of mechanisms related with cellular control at a
genetic level, such as the role of hypoxia inducible factors, is
an area of very active research. However, its significance in
aviation-associated hypoxia is unclear. The immediate chal-
lenges of acute hypoxia at altitude, however, are well known
and described below.
Thus, hypoxic hypoxia is by far the most common form
of oxygen deficiency that occurs in aviation and results from
a reduction in the oxygen tension in inspired gas. However,
other forms of hypoxia can and do occur in aviation, e.g.
anaemic hypoxia produced by carbon monoxide poisoning,
the ischaemic hypoxia produced by exposure to cold and the
circulatory shunting produced by sustained accelerations,
which are described in subsequent chapters. One or more
forms of hypoxia may occur concurrently, on the ground
and in the air. Consideration of an increased hypoxic bur-
den may be required in patients who are already relatively
hypoxic at sea level and then exposed to relatively modest
increases in altitude during flight.
Oxygen therapy is of great value in certain types of
hypoxia but of little or no benefit in others. For example,
K17577_C004.indd 50
increasing the partial pressure of inspired oxygen can cor-
rect the inadequacies of oxygen deficiencies in hypobaric
hypoxia (up to limits addressed in the following chapter)
and in hypoventilatory states. In cases of impaired diffu-
sion, oxygen therapy can increase the molecular oxygen
content of the respired gas and reduce the degree of hypoxia.
However, tissue hypoxia arising from anaemia, haemoglo-
binopathies, circulatory deficiencies (including right-to-left
shunts) and histotoxic factors may be relieved only partially
or even derive no benefit at all from supplemental oxygen.
Thus, in aviation, consideration must be given to the poten-
tial interaction of various forms of hypoxia, and an aware-
ness of the limitations of oxygen therapy is required.
Hyperventilation is a state in which the level of pulmo-
nary ventilation is in excess of that required to remove from
the body an amount of carbon dioxide equal to that pro-
duced by the tissues and hence maintain equilibrium. Such
overbreathing is characterized by a reduction in the alveolar
and arterial tensions of carbon dioxide, a condition termed
hypocapnia. Thus, hyperventilation may be contrasted with
the conditions that arise when an increase in respiration
is proportional to an increase in carbon dioxide produc-
tion during, for example, exercise. Moderate hypocapnia
produces a significant impairment of the ability to per-
form psychomotor tasks, while an acute reduction in arte-
rial carbon dioxide to about 15  mmHg frequently causes
unconsciousness. Hypocapnia is a normal concomitant of
hypoxia and, indeed, the two conditions produce similar
symptoms. However, hyperventilation can, and perhaps
more commonly does, occur in its own right under certain
other conditions of the flight environment, such as expo-
sure to low-frequency vibration, emotional stress and dur-
ing positive-pressure breathing.
The remainder of this chapter is concerned with a more
detailed consideration of the physiological and clinical con-
sequences of hypobaric hypoxia and hyperventilation.
ACUTE HYPOBARIC HYPOXIA: HYPOXIA
IN FLIGHT
Hypobaric hypoxia is generally recognized to be the most
serious single physiological hazard during flight at altitude,
because on ascent as barometric pressure falls, breathing
ambient air will result in a fall of the partial pressure, and
thus the molecular content, of oxygen in the lung. Even the
25 per cent reduction in the partial pressure of oxygen in the
atmosphere associated with ascent to an altitude of 8000 feet
produces a detectable impairment in some aspects of mental
performance, while sudden exposure to 50 000 feet as a con-
sequence of rapid decompression, which reduces the partial
pressure of oxygen within the lungs to ten per cent of its sea-
level value, will cause unconsciousness within 12–15 seconds
and death in four to six minutes. In the past, lack of oxygen
took a regular toll of both lives and aircraft: Many military
air personnel were killed by hypoxia in flight, while the abil-
ity of many more to perform their duties was impaired by the
condition. As a result, most military air personnel receive
17/11/2015 15:32

detailed training on this topic. They also have the opportu-
nity to gain personal experience of hypoxia under controlled
conditions in hypobaric chambers or, in recent years, regu-
lar revision of their personal symptoms through the use of
reduced oxygen breathing gases at normobaric pressures.
The world of civilian flying is not exempt from this hazard,
although the aircrew involved may not necessarily have had
the same degree of personal experience of hypoxia in train-
ing. Tragic incidents have occurred in which the occupants
of civilian aircraft have perished as a result of hypoxia at
high altitudes. In one recent study of fatal general aviation
accidents, in-flight hypoxia was reported to be the cause of
impairment or incapacitation in more than four per cent
of cases. Therefore, notwithstanding that improvements in
the performance and reliability of cabin pressurization and
oxygen-delivery systems have greatly reduced incidents and
accidents due to hypoxia, they do still occur and constant
awareness and vigilance throughout the aviation commu-
nity remains essential.
Aetiology
The principal causes of hypoxia in flight are:
●● Ascent to altitude without supplementary oxygen.
●● Failure of personal breathing equipment to supply oxy-
gen at an adequate concentration and/or pressure.
●● Decompression of the pressure cabin at high altitude.
The relative incidence of the various causes of hypoxia
in flight over a 14-year period in a large military air force
is presented in Table 4.1. Failure of oxygen regulators and
decompression of aircraft cabins together account for more
than half of the total reported incidents in this series. A fur-
ther study conducted in a rather smaller air force revealed
that 63 per cent of cases of hypoxia in flight in its aircraft
Table 4.1  Relative incidence of the causes of 397 cases of
hypoxia in flight in a military air force
Relative
Cause of hypoxia incidence (%)
Failure of oxygen supply:
Line failure 2 bon dioxide tension, FiO2 is the fractional concentration of
Low/depleted 1
Failure of oxygen regulator 25
Regulator off 1
Inadvertent break of connection in 9 alveolar gases. But, as explained in Chapter 3, the tension of
hose between regulator and mask
Hose defect or failure 1 ratio of carbon dioxide production to alveolar ventilation,
Inadequate seal of mask to face 7 and this ratio is independent of environmental pressure.
Malfunction of mask valves 3 Accordingly, therefore, alveolar carbon dioxide tension
Decompression of pressure cabin 32
Toxic fumes giving rise to hypoxia 2 ratio of carbon dioxide production to alveolar ventilation
Other 17
NB: The demand oxygen regulators used in this air force delivered
safety pressure only at altitudes over 28 000 feet.
K17577_C004.indd 51
Acute hypobaric hypoxia: hypoxia in flight  51
arose from a failure of either the mask or the regulator.
Thus, failure of pressurization or oxygen systems remains a
factor in a number of aircraft incidents and losses.
The physiological consequences of hypoxia in flight can
be considered in three main areas: the respiratory and car-
diovascular responses to the insult, the neurological effects
of the insult itself and of the responses to it. The clinical
consequences can be expected to be the result of the combi-
nation of changes in all these areas.
Respiratory responses to acute hypobaric
hypoxia
The time course of the physiological changes produced
by breathing air at altitude is a function of the manner in
which the condition is induced. Thus, the changes usually
are produced relatively slowly by ascent at the common rate
for an aircraft of 2000–3000  feet/min; more abruptly by
the reversion to breathing air after failure of oxygen deliv-
ery equipment; and fastest following rapid decompression.
Although breathing air during a routine steady ascent is
now an uncommon cause of hypoxia in professional air-
crew, it does occur in leisure flying, e.g. in people flying light
aircraft, gliders and balloons and it is convenient to begin
by describing the respiratory changes induced by hypoxia
produced in this manner.
Alveolar gases when breathing air
The fall in partial pressure of oxygen in the inspired gas that
occurs on ascent to altitude causes a progressive reduction in
alveolar oxygen tension. The main determinant of the differ-
ence in oxygen tension between inspired gas and alveolar gas
is the alveolar carbon dioxide tension. That this is so can be
demonstrated by rearranging the alveolar air equation thus:
(1 Fi O2 )
Pi O2 Pa O2 = Pa CO2 Fi O2 +
R
where PiO2 is the inspired (tracheal) oxygen tension, PaO2
is the alveolar oxygen tension, PaCO2 is the alveolar car-
oxygen in the (dry) inspired gas, and R is the respiratory
exchange ratio.
A fall in alveolar carbon dioxide tension will reduce the
difference between the oxygen tensions in the inspired and
carbon dioxide in the alveolar gas is itself determined by the
remains constant on ascent to altitude, provided that the
is unchanged. In practice, however, on acute exposure to
altitude, alveolar carbon dioxide tension remains constant
only between sea level and an altitude of 8000–10 000 feet.
17/11/2015 15:32
 52  Hypoxia and hyperventilation
Above this altitude, arterial oxygen tension falls to a level
that stimulates respiration, and so alveolar carbon dioxide
tension is reduced by virtue of increased alveolar ventila-
tion. Thus, alveolar oxygen tension falls linearly with the
decline in environmental pressure associated with an ascent
from sea level to about 10 000 feet, but above this altitude
the reduction in alveolar oxygen tension is less than would
occur if there was no increase in ventilation and no conse-
quent fall in alveolar carbon dioxide tension. The changes in
alveolar gas tensions associated with ascent to altitude when
breathing air are shown graphically in Figure 4.1.
The increase in pulmonary ventilation produced by expo-
sure to an altitude above 8000–10 000 feet may be regarded
as the resultant of two conflicting factors, i.e. the lowered
arterial oxygen tension stimulates ventilation through its
effect on the chemoreceptors of the carotid and aortic bod-
ies, but the increase in ventilation is itself opposed by the
respiratory depressant effect of the associated reduction in
carbon dioxide tension. The compromise struck between
these two competing influences is essentially that of the
demand for an adequate oxygen supply versus the need to
120
100
Alveolar oxygen tension (mmHg)
80
60
40
B a raised value of R will produce a higher alveolar oxygen ten-
20
0
dioxide tension (mmHg)
40
Alveolar carbon
20
0 dioxide and the value of R, both of which are themselves
0 5000 10000
Altitude (feet)
Figure 4.1  Effect of acute exposure to various alti-
tudes, while breathing air, on the alveolar tensions
of oxygen (curve A) and carbon dioxide (curve C).
The curves describe the mean values for a group of
30 subjects seated at rest. The broken lines indicate
the values of alveolar tensions of oxygen (curve B) and
carbon dioxide (curve D) that would be obtained if the
hypoxia induced by ascent to altitude did not increase
pulmonary ventilation.
K17577_C004.indd 52
maintain a normal acid–base balance. The magnitude of the
increase in ventilation and, hence, the fall in alveolar car-
bon dioxide tension, exhibits considerable individual varia-
tion. During acute exposures of subjects at rest, pulmonary
ventilation at 18 000  feet is, on average, 20–50  per cent
greater than that observed at sea level, while at 22 000 feet it
is 40–60 per cent greater.
The effect of altitude on the ventilatory response to mild
and moderate exercise is a similar but slightly greater pro-
portional increase in pulmonary ventilation, and such an
effect can be demonstrated at altitudes as low as 3000 feet.
The increase in pulmonary ventilation induced by exercise
in moderate hypoxia is, however, such that alveolar carbon
dioxide tension is reduced below that produced by breath-
ing air at rest at the same altitude. There is, therefore, a
corresponding rise in alveolar oxygen tension, perhaps by
3–5 mmHg (0.4 –0.7 kPa).
The increase in pulmonary ventilation and cardiac out-
put stimulated by the hypoxia arising from breathing air at
altitudes of up to about 20 000 feet produces a small, almost
insignificant, increase in the total oxygen consumption of
the tissues and in the carbon dioxide production by them.
The fall in alveolar carbon dioxide tension produced by the
disproportionate rise in pulmonary ventilation, however,
liberates carbon dioxide from the very substantial body
stores of the gas, such that for a while the output of carbon
dioxide in the expired gas actually exceeds its metabolic pro-
duction by the tissues. Thus, the respiratory exchange ratio
(R) is raised at the beginning of an exposure to altitude when
breathing air. It returns slowly to the previous resting value
as the excess carbon dioxide is removed from body stores and
A
a steady state is regained. For example, R is raised to just over
1 on acute exposure to air at 18 000 feet, and its normal rest-
ing value of 0.85 is not regained for 30–40 minutes. Clearly,
sion for a given inspired oxygen tension and alveolar carbon
dioxide tension than would otherwise be the case; therefore,
in the example given, with an alveolar carbon dioxide ten-
sion of 28 mmHg (3.7 kPa), alveolar oxygen tension will fall
D from about 41 mmHg (5.5 kPa) at the beginning of the expo-
sure to about 37 mmHg (4.9 kPa) at the end.
The relationship between the alveolar tensions of oxygen
C and carbon dioxide, therefore, changes progressively
throughout an exposure to a given altitude, since the alveolar
oxygen tension is determined by the level of alveolar carbon
15000 20000 25000 functions of the intensity of the ventilatory response to
hypoxia and of the duration of exposure. The relationship
between alveolar oxygen tensions and increasing altitude,
with a period of 10–20  minutes spent at each, is shown
graphically in Figure  4.1. The same data are presented
numerically in Table 4.2, where the considerable individual
variability is indicated by the values of standard deviations.
In general, the alveolar oxygen tension is reduced in short-
duration exposures to 45  mmHg (6  kPa) at 15 000  feet, to
40 mmHg (5.3 kPa) at 18 000 feet, to 35 mmHg (4.7 kPa) at
21 000 feet and to 30 mmHg (4 kPa) at 25 000 feet.
17/11/2015 15:32
 Acute hypobaric hypoxia: hypoxia in flight  53

Table 4.2  Mean values for alveolar gas tensions in 30 seated resting subjects after acute (10–20 minutes) exposure to
breathing air at altitude

Alveolar tension of oxygen Alveolar tension of carbon

(mmHg) dioxide (mmHg)
Inspired oxygen tension
Altitude (feet) (mmHg) Mean SD Mean SD
0 148 103.0 5.5 39.0 2.5
8000 108 64.0 5.0 38.5 2.6
15 000 80 44.7 5.0 30.5 2.7
18 000 69 39.5 4.2 28.0 2.5
20 000 63 36.5 4.0 26.5 2.5
22 000 57 33.2 3.0 25.0 2.6
25 000* 49 30.0 — 22.0 —
* After 3–5 min exposure.
SD, standard deviation.

ALVEOLAR GASES WHEN BREATHING OXYGEN
When 100  per cent oxygen has been breathed for several
hours, so that virtually all the nitrogen has been washed
out of the body tissues and alveolar gas, the relationship
between the alveolar tensions of oxygen and carbon dioxide
and the environmental pressure simplifies to
Pa O2 = (PB − PH2O ) − Pa CO2
where PaO2 is the alveolar oxygen tension, PB is the envi-
representation of the changes in alveolar gas tensions with
altitude when breathing 100 per cent oxygen and should be
compared with Figure 4.1.
The concept of physiologically equivalent altitudes for a
person breathing air or 100 per cent oxygen is useful in the
120
100
Alveolar oxygen tension (mmHg)

ronmental pressure, PH2O is the water vapour tension at

80
37°C (i.e. 47 mmHg [6.3 kPa]), and PaCO2 is the alveolar car-
bon dioxide tension.
Generally in aviation, however, the time for which 60
100 per cent oxygen is breathed is less than two hours, and
A
the alveolar gas still contains a small amount of nitrogen,
sufficient to exert a tension of 3–5  mmHg (0.4–0.7  kPa). 40
Thus, in practice, the alveolar oxygen tension when breath-
ing 100  per cent oxygen is usually some 3–5  mmHg less B
20
than that predicted by the equation, but provided that the
alveolar carbon dioxide tension remains constant, alveolar
oxygen tension will fall linearly with environmental pres- 0
sure (as it does up to 10 000 feet when breathing air). When
breathing 100  per cent oxygen, however, it is not until an D
dioxide tension (mmHg)

altitude of 33 000–33 700  feet is reached that the alveolar 40

partial pressure of oxygen falls to 103  mmHg (13.7  kPa),
Alveolar carbon

i.e. to the value observed when breathing air at sea level. C

20
When an altitude of about 39 000  feet is reached, breath-
ing 100  per cent oxygen, the alveolar oxygen tension falls
to 60–65 mmHg (8–8.7 kPa), i.e. to a similar value to that 0
reached at 10 000 feet breathing air. Above 39 000 feet, the 30000 34000 38000 42000 45000
further fall in alveolar oxygen tension stimulates respira- Altitude (feet)
tion, even though 100 per cent oxygen is being breathed, just
as it does above 10 000 feet when breathing air. The alveolar Figure 4.2  Effect of acute exposure to altitudes between
30 000 and 45 000 feet while breathing 100 per cent
oxygen tension rises by 1 mmHg for every 1 mmHg reduc-
oxygen on the alveolar tensions of oxygen (curve A) and
tion in alveolar carbon dioxide tension. Thus, for example, carbon dioxide (curve C).The broken lines indicate the
the alveolar carbon dioxide tension at 43 000 feet is about values of alveolar tensions of oxygen (curve B) and carbon
30  mmHg (4  kPa) and the corresponding alveolar oxygen dioxide (curve D) that would have occurred in the absence
tension is 43–45 mmHg (5.7–6 kPa). Figure 4.2 is a graphical of any increase in pulmonary ventilation.

K17577_C004.indd 53 17/11/2015 15:32

 54  Hypoxia and hyperventilation
design of protective equipment. However, although equiva-
lent altitudes may be stated in terms of equality of alveolar
oxygen tension, a strict interpretation of the alveolar equiv-
alence would require steady-state conditions, the determi-
nation of the carbon dioxide tensions in both cases, and
knowledge of the value of the respiratory exchange ratio.
For most practical purposes, therefore, it is more satisfac-
tory to determine equivalence on the basis of equality of
inspired (tracheal) oxygen tension. Figure 4.3 describes the
relationship of equivalent altitudes for both inspired gas and
alveolar gas. As a simple example, the effect of the 5000 feet
increase in altitude from 40 000 to 45 000 feet when breath-
ing 100 per cent oxygen is equivalent to a 9000 feet increase
in altitude from 11 000 to 20 000 feet when breathing air.
Finally, when considering the alveolar gases when breath-
ing oxygen, it is important to consider the situation that can
occur in practice as a result of a change from breathing oxy-
gen to breathing air at altitude, such as may occur as a result
of a regulator failure or disconnection of an oxygen supply
hose. In such circumstances, the composition of the inspired
gas changes from that containing a high concentration of
oxygen to air and the alveolar oxygen tension falls progres-
sively as the concentration of nitrogen in the inspired and
alveolar gases rises to 79–80 per cent. During the early part
of this process, the oxygen tension of the inspired gas is fre-
quently less than that of the blood returning to the alveoli,
30000
25000
Alveolar
equivalence
Altitude breathing air (feet)
20000
Inspired
15000
(tracheal
equivalence)
10000
5000
0 slows to reach a value, in this example, of about 60 mmHg
30000 40000
Altitude breathing oxygen (feet)
Figure 4.3  Equivalent altitudes when breathing air and
when breathing 100 per cent oxygen. The solid curve indi-
cates equivalence based on equal tensions of oxygen in
the inspired (tracheal) gas, i.e. inspired gas saturated with
water vapour at 37°C. The broken curve indicates equiva-
lence based on equal tensions of oxygen in the alveolar
gas during acute exposures of seated resting subjects for
10–15 minutes.
K17577_C004.indd 54
and so oxygen will pass out of the body from the return-
ing mixed venous blood into the alveolar gas and, hence,
into the expirate. The rate at which alveolar oxygen tension
falls in these circumstances is proportional to the alveolar
ventilation, but a new steady state is usually attained in the
resting subject two to three minutes after the reduction in
concentration of oxygen in the inspired gas.
ALVEOLAR GASES DURING RAPID DECOMPRESSION
The use of cabin pressurization systems for aircraft flying
at medium and high altitudes brings with it the possibility
that the aircraft occupants could be exposed to the risks of
rapid decompression should a failure occur in the structural
integrity of the pressure cabin or in the pressurization sys-
tem (see also Chapter 6). The sudden fall in environmen-
tal pressure that accompanies a decompression produces
almost as rapid a fall in the tensions of the constituents of
alveolar gas. Thus, such an emergency can produce a very
profound fall in alveolar oxygen tension, the magnitude of
which will depend on the gas being breathed at the moment
of decompression and the ratio of the environmental pres-
sures at the beginning and end of the event. For example, a
rapid decompression from 8000 to 40 000 feet in 1.6 seconds
while breathing air will cause the alveolar oxygen tension
to fall from 65 mmHg (8.7 kPa) to about 15 mmHg (2 kPa).
Furthermore, since the inspired (tracheal) oxygen tension
at that final altitude is only about 20 mmHg (2.7 kPa), the
alveolar oxygen tension will remain below about 18 mmHg
(2.4 kPa) for as long as air is breathed. Under these condi-
tions, the oxygen tension in the pulmonary capillary blood
is considerably higher than that in the alveolar gas and so,
as described above, oxygen passes into the alveoli from the
mixed venous blood as it flows through the pulmonary cap-
illaries. The change in alveolar tension during rapid decom-
pression is illustrated in Figure 4.4.
Alveolar carbon dioxide tension also falls during such a
rapid decompression, since venting of the expanded alveolar
gases removes carbon dioxide more quickly than it can be
replaced and may reach a value of only 10 mmHg (1.3 kPa).
This then partially recovers to a level of 25–30  mmHg
(3.3–4  kPa) over the ensuing 30  seconds as carbon diox-
ide passes rapidly from pulmonary capillary blood into the
alveolar gas. The inspiration of 100 per cent oxygen during
or a short time after rapid decompression will modify the
changes described by causing an immediate rise in alveolar
oxygen tension (Figure 4.4). The rise is rapid at first but then
50000 (8  kPa) some 30–40  seconds after oxygen breathing com-
mences. Clearly, the higher the final altitude and the longer
the delay in administering 100 per cent oxygen, the greater
will be the degree of hypoxia. The composition of the gas
being breathed immediately before rapid decompression
will also influence the severity of hypoxia suffered: a high
alveolar oxygen tension in the inspired gas before decom-
pression will minimize the fall in tension seen during and
after decompression. Thus, for example, when 100  per
cent oxygen is breathed before, during and after a rapid
17/11/2015 15:32

80
O2 throughout
Alveolar oxygen tension (mmHg)
60
O2 early
40 O2 late
20 Critical line*
0
0 10 20 30 40
Time (s)
Figure 4.4  Mean alveolar oxygen tensions of four subjects
before and after rapid decompression at time 0 from
8 000 feet to 40 000 feet in 1.6 seconds. Each subject was
decompressed on three occasions: once breathing air
before and after the decompression with 100 per cent
oxygen delivered to the facemask eight seconds after
time 0 (O2 late:-------), once breathing air before and after
the decompression with 100 percent oxygen delivered to
the facemask two seconds after time 0 (O2 early:…………),
and once breathing 100 per cent oxygen through-
out (O2 throughout:________). *Note that if the area
described by the alveolar oxygen tension curve below the
critical line exceeds 140 mmHg/s, then consciousness will
almost certainly be lost.
de­compression from 8000  to 40 000  feet, alveolar oxygen
tension does not fall below about 60 mmHg (8 kPa) at any
time (Figure 4.4).
The brief but profound hypoxia associated with rapid
decompression has its most marked effects on the central
nervous system (see below), specifically the psychomotor
performance of the subject. In order to avoid the poten-
tially catastrophic consequences of hypoxia induced by
rapid decompression to a high altitude, alveolar oxygen ten-
sion must not fall below 30 mmHg (4 kPa). Such a fall is an
inevitable consequence of a rapid decompression to a final
altitude greater than 30 000 feet when breathing air, even if
100 per cent oxygen is delivered to the respiratory tract at the
moment decompression occurs. The intensity of the hypoxic
insult will be correspondingly greater with a higher final alti-
tude and if delivery of 100 per cent oxygen is delayed. These
extremely rapid physiological changes have very important
implications for the design of personal oxygen equipment
for use at high altitudes, since they indicate that in order to
avoid severe neurological disturbances after a rapid decom-
pression, an oxygen-enriched breathing gas must be being
breathed before the decompression. Indeed, the concentra-
tions of oxygen required in the breathing gas before a rapid
decompression, in order to maintain an alveolar oxygen ten-
sion above 30 mmHg (4 kPa) immediately after it, and where
the final altitudes are 35 000, 40 000 and 44 000 feet are 30,
40 and 60 per cent, respectively. Even then, in order to pre-
vent significant features of hypoxia developing, 100 per cent
oxygen must be delivered within two seconds of the start of
K17577_C004.indd 55
Acute hypobaric hypoxia: hypoxia in flight  55
rapid decompression and, therefore, functional dead space
in the breathing system must be kept to a minimum to avoid
delay in the delivery of oxygen to the respiratory tract.
ARTERIAL BLOOD GASES
Although the difference between the oxygen tension of the
alveolar gas and that of the blood entering the pulmonary
capillaries (i.e. mixed venous blood) is markedly reduced
on exposure to altitude, the diffusion characteristics of the
alveolar–capillary membrane are such that the tension of
oxygen leaving the pulmonary capillaries still equals that of
50 60 the alveolar gas when the individual is at rest. Thus, even in
moderate hypoxia, the arterial oxygen tension may be only
8  mmHg (1.1 kPa) less than the alveolar oxygen tension,
while the carbon dioxide tension of alveolar gas is virtually
equal to that of arterial blood. Typical values for the arte-
rial blood gases of resting subjects, breathing air at various
altitudes up to 20 000  feet and 100  per cent oxygen up to
45 000 feet, are presented in Table 4.3. It should be noted,
however, that there are large variations in the tensions of
arterial blood gases in acute hypoxia, both with time in the
same individual and between individuals. For example, the
oxygen saturations of the arterial blood in six resting sub-
jects breathing air at 18 000  feet varied from 65  to 78  per
cent. These large variations reflect the sensitivity of alveolar
oxygen tension, and therefore arterial oxygen tension, to the
level of alveolar ventilation.
During exercise, when transit time of red blood cells
through pulmonary capillaries is reduced, there can be
a failure of the oxygen tension in the blood to reach equi-
librium with that of the alveolar gas. The alveolar–arterial
­oxygen tension gradient, therefore, is increased by exer-
cise in moderate hypoxia from its resting value of about
8 mmHg (1.1 kPa) to 16–20 mmHg (2.1–2.7 kPa). In addi-
tion, although exercising while hypoxic does produce a
small increase in alveolar oxygen tension by virtue of the
alveolar hyperventilation, the large rise in the alveolar–
arterial oxygen tension difference results in an overall fall in
arterial oxygen tension and saturation. Thus, the symptoms
and signs of hypoxia will be exacerbated by exercise.
Cardiovascular responses to acute
hypobaric hypoxia
BLOOD FLOW
As described in preceding chapters, the rate of blood flow
through a tissue bed is a cardinal determinant of the tension
at which oxygen is delivered to its cells. The reverse is also
the case, however, and the hypoxia produced by a reduc-
tion in oxygen tension of the inspired gas will induce both
general and regional changes in the circulation. Vasovagal
syncope may, occasionally, also complicate the picture.
GENERAL CARDIOVASCULAR CHANGES
In the resting subject, heart rate increases immediately
when breathing air above 6000–8000  feet. At 15 000  feet,
17/11/2015 15:32
 56  Hypoxia and hyperventilation

Table 4.3  Typical values for arterial blood gases of resting subjects acutely exposed to altitude

Arterial blood gases

Oxygen
concentration (mL
Oxygen tension Carbon dioxide (STPD)/100mL Oxygen saturation
Altitude (feet) ( mmHg) tension ( mmHg) blood) of haemoglobin (%)
Breathing air
0 95 40 20.5 97
8000 56 38 18.8 93
12 000 43 35 16.9 84
15 000 37 30 15.7 78
18 000 32 28 14.5 72
20 000 29 26 13.2 66
Breathing 100% oxygen
33 000 95 40 20.5 97
40 000 45 38 16.9 84
43 000 36 30 15.4 76
STPD, standard temperature and pressure, dry.

the average increase is about 10–15 per cent above the sea-
level value; it rises to a 20–25 per cent increase at 20 000 feet,
and the heart rate is approximately doubled at 25 000 feet.
Since stroke volume remains essentially unchanged as the
heart rate increases, there is a proportional increase in car-
diac output. Both heart rate and cardiac output are also ele-
vated proportionally during exercise at altitude, although
the maximum levels of each (which are the same in moder-
ate hypoxia as when breathing air at sea level) are, however,
attained at a lower degree of work under hypoxic conditions.
At altitude, the maximum oxygen uptake is limited by the
cardiac output and the reduced arterial oxygen saturation
so that, for example, when breathing air at 15 000 feet, max-
imum oxygen uptake during exercise falls to about 70 per
cent of the sea-level value.
Despite the increase in cardiac output, mean arte-
rial blood pressure during moderate hypoxia usually is
unchanged from that of an individual breathing air at sea
level. However, the systolic pressure is usually raised, and
there is an overall reduction in peripheral resistance, with a
resulting increase in the pulse pressure. There is a redistri-
bution of blood flow by local and vasomotor mechanisms.
Although hypoxia causes vasodilation in most vascular
beds, there are some important features of, and differences
in, the responses of certain regional circulations.
REGIONAL CARDIOVASCULAR CHANGES
Acute hypoxia causes immediate increases in blood flow
through the coronary and cerebral circulations, but renal
blood flow is markedly reduced. Blood flow through skel-
etal muscle may increase by 30–100  per cent. Thus, there
is a redistribution of cardiac output, with flow to essential
organs such as the heart and brain increased at the expense
of other less acutely essential organs, such as the viscera,
skin and kidneys.
Flow through the coronary circulation increases in
parallel with the rise in cardiac output, in response to the
metabolic requirements of the myocardium. The increase
in blood flow through the coronary vessels is such that a
subject breathing air at 25 000  feet exhibits no electrocar-
diographic (ECG) evidence of cardiac hypoxia, even up to
the point at which consciousness is lost. Cardiac reserve
is reduced, however, and a profound fall in arterial oxy-
gen tension will cause myocardial depression. In severe
hypoxia, myocardial depression is reflected in the elec-
trocardiograph by a depressed S–T segment and a reduc-
tion in the height of the T wave. Later, disorders of rhythm
and conduction supervene. Occasionally, in such circum-
stances, there is a severe compensatory vasoconstriction of
the coronary vessels that swamps all other reflex responses
and causes cardiac arrest.
The response of the cerebral circulation to hypoxic
hypoxia is also of considerable importance since, as would
be expected, the changes in arterial oxygen and carbon
dioxide tensions associated with that condition have pro-
found regional effects. At arterial oxygen tensions above
45–50  mmHg (5.3–6.7  kPa) cerebral blood flow is deter-
mined exclusively by the arterial carbon dioxide tension
to which it bears a directly linear relationship over the
normal (tolerable) physiological range of 20–50  mmHg
(2.6–6.7 kPa). For example, a reduction in arterial carbon
dioxide tension from the normal 40  mmHg to 20  mmHg
(5.3–2.7 kPa) will halve cerebral blood flow. A fall in arte-
rial oxygen tension below about 45 mmHg (5.3 kPa), how-
ever, will induce hypoxic vasodilation, so that, for example,
an arterial oxygen tension of 35–40  mmHg (4.6–5.3  kPa)
causes a 50–100  per cent increase in blood flow through
the brain. A balance therefore exists between the vaso-
dilating effect of hypoxia on the cerebral vessels and the
vasoconstricting influence of a declining arterial carbon

K17577_C004.indd 56 17/11/2015 15:32


dioxide tension caused by the hypoxic drive to ventila-
tion. Generally, the conflict results in a reduction in cere-
bral blood flow when breathing air at altitudes up to about
15 000  feet, but results in an increase, modified by the
degree of coexisting hypocapnia, above 16 000–18 000 feet.
Hypoxia of a degree sufficient to desaturate the blood by
about 20 per cent causes a rapid, reversible vasoconstriction
in the pulmonary circulation, probably as a consequence of
the direct action of oxygen on chemoreceptor cells in the
walls of the pulmonary blood vessels. The vasoconstriction
of parts of the pulmonary vasculature may be the means by
which local blood flow is matched to local ventilation. On
acute ascent to altitude, the entire pulmonary vascular bed
constricts, however, which, in the presence of a raised car-
diac output, increases pulmonary arterial blood pressure.
This occurs in normal subjects but can also acerbate pre-
existing pulmonary hypertension.
SYNCOPE
Heart rate, arterial blood pressure and cerebral blood
flow are usually maintained at or above their resting val-
ues when unconsciousness occurs as the result of a gross
lowering of alveolar oxygen tension (see below). In about
20  per cent of individuals, however, the immediate cause
of unconsciousness in hypoxia is failure of cerebral blood
flow, subsequent to a precipitate fall in arterial blood pres-
sure associated with a marked bradycardia. The mecha-
nism underlying the fall in arterial blood pressure in this
form of faint is the same as for other types of vasovagal
syncope, i.e. loss of peripheral resistance in the systemic
circulation brought about by profound dilation of arteri-
oles in muscle vascular beds. Syncope is accompanied by
pallor, sweating, nausea and, occasionally, vomiting.
TISSUE OXYGEN TENSION
The minimum acceptable oxygen tension in a tissue
depends critically on the oxygen tension in the blood flow-
ing through its capillaries. The major factor minimizing the
fall of oxygen tension towards the venous ends of capillar-
ies in the presence of hypoxic hypoxia is the relationship,
reflected in the sigmoid shape of the oxygen dissociation
curve, between oxygen tension and the saturation of hae-
moglobin with oxygen. A typical oxygen dissociation curve
is shown in Figure 4.5.
Figure  4.5  shows that when air is breathed at sea level,
producing an arterial oxygen tension of about 95  mmHg
(12.7  kPa), the extraction of 5  mL of oxygen from every
100  mL of blood flowing through the tissues results in a
venous oxygen tension of about 40  mmHg (5.3  kPa), i.e.
a  fall of 55  mmHg (7.3  kPa). The extraction of the same
quantity of oxygen per unit volume of blood when the arte-
rial oxygen tension is reduced to 32  mmHg (4.3  kPa) by
breathing air at 18 000  feet decreases the oxygen tension
of the venous blood to 22  mmHg (2.9  kPa); thus, the fall
in oxygen tension as the blood flows through the tissues is
reduced to only 10 mmHg (1.3 kPa). This most important
protective effect of the manner in which oxygen combines
K17577_C004.indd 57
Acute hypobaric hypoxia: hypoxia in flight  57
24
A1
20
5 ml/100 ml
Oxygen concentration [ml(STPD) /100ml]
16
V1
55 mmHg
A2
5 ml/100 ml
12
8 V2
10 mmHg
4
0
0 20 40 60 80 100
Oxygen tension (mmHg)
Figure 4.5  Oxygen dissociation curve of whole blood (at
a pH of 7.4 and a temperature of 37°C), illustrating the
effect of the sigmoid shape of the relationship on the fall
in oxygen tension of the blood produced by the extrac-
tion of 5 ml of oxygen per 100 mL of blood by the tissues,
as blood flows through them at two different levels of
arterial oxygen tension. At an arterial oxygen tension
of 95 mmHg (point A1), then the extraction of 5 mL of
oxygen per 100 mL of blood reduces the oxygen ten-
sion to 40 mmHg (point V1), i.e. the fall in oxygen tension
from arterial to venous blood is 55 mmHg. In moderate
hypoxia, with an arterial oxygen tension of 32 mmHg
(point A2), then the extraction of the same amount of
oxygen reduces the oxygen tension to 22 mmHg (point
V2), i.e. the fall in oxygen tension from arterial to venous
blood is only 10 mmHg. STPD, standard temperature and
pressure, dry.
with haemoglobin results in a halving of the arteriovenous
oxygen tension difference when the arterial oxygen tension
is reduced from 95  to 65  mmHg (12.7–8.7  kPa), and to a
reduction in that difference to a quarter when the arterial
oxygen tension is 40 mmHg (5.3 kPa). Although the over-
all increase in cardiac output produced by acute hypoxia
reduces still further, the fall in arteriovenous oxygen ten-
sion difference, this effect is of much less importance
than that associated with the oxygen dissociation curve.
For example, the 20  per  cent increase in cardiac output
induced by breathing air at 18 000  feet, where the arterial
oxygen tension is 32 mmHg (4.3 kPa), will raise the oxygen
tension in mixed venous blood from 22 mmHg (2.9 kPa) to
only 24 mmHg (3.2 kPa).
Regional changes in blood flow, and especially the
changes in the cerebral circulation described above, are
also of importance. The marked reduction in cerebral
blood flow, produced by the hypocapnia associated with
the mild hypoxia induced by breathing air at 12 000  feet,
can result in an appreciable further lowering of the jugular
17/11/2015 15:32
 58  Hypoxia and hyperventilation

venous oxygen tension. In the more severe hypoxia asso- 160

ciated with breathing air at 18 000  feet, the increased
arteriovenous oxygen tension difference produced by
hypocapnia is more than offset by the associated increase 140
in alveolar and arterial oxygen tensions produced by
the hyperventilation.
120
The combined effects of acute hypobaric hypoxia and Uniform tissues
the hypocapnia arising from the hypoxic drive to venti- at sea level
lation, induced by a reduction in the oxygen tension of

Oxygen tension (mmHg)

100
inspired gas, are summarized in the gradients of oxygen
tension from the dry atmosphere to the lowest tension in At 18000 feet
the tissues. Figure  4.6  illustrates oxygen tension gradients 80
Cerebral tissue
for a person breathing air at sea level and at 18 000 feet. The (Paco2 = 20 mmHg)
figure shows three oxygen tension gradients at 18 000 feet:
60
the gradient for the body as a whole (assuming that all tis- Uniform
sues are uniform), and two gradients for oxygen transport tissues
to the brain with mild and severe hypocapnia (alveolar car- 40
bon dioxide tensions of 35 and 20 mmHg, (4.7 and 2.7 kPa)
respectively) that would result from different degrees
of increased alveolar ventilation. The curves illustrate 20
Cerebral tissue
the effect of hyperventilation on the fall in oxygen ten- (Paco = 35 mmHg)
sion between inspired and alveolar gases, and the marked 2

reduction in the fall in oxygen tension along the capillar- 0

ies in hypoxia due primarily to the relationship demon-

Dry atmosphere

Inspired
(tracheal) gas

Alveolar gas

Arterial blood

Mixed venous
blood

strated by the shape of the oxygen dissociation curve. The
net effect in this example is that in the face of a reduc-
tion of 79  mmHg (10.5  kPa) in the oxygen tension of the
inspired gas, the oxygen tension of mixed venous blood is
reduced by only 16  mmHg (2.1  kPa) when air is breathed
at 18 000 feet. The estimated minimum oxygen tension, on
the simplifying assumption that the body is a single uni-
form tissue, is reduced only from 20  to 10  mmHg (2.7  to
1.3 kPa). In the absence of hyperventilation at 18 000 feet,
however, the minimum oxygen tension in the brain falls to
almost zero, and some decline in oxidative phosphoryla-
tion would be expected under these conditions.
CYANOSIS
Cyanosis is a sign of clinical hypoxia and manifests itself
as a bluish colouration of the skin, nail beds and mucous
membranes. It is caused by the presence of an increased
concentration of reduced haemoglobin in the capillaries
and venules of the hypoxic tissues and is a reflection of the
profound desaturation of haemoglobin at low tissue oxygen
tensions. Broadly, the degree of colouration in an individual
is proportional to the desaturation of the blood. There must
be at least 5 g of reduced haemoglobin per 100 mL of cap-
illary blood before cyanosis can be detected reliably, and
thus may not be observed with hypoxia in the presence of
significant anaemia. Conversely, an individual with poly-
cythaemia may show signs of cyanosis in normoxia. Thus,
although cyanosis is a useful sign of hypoxia, it must be
treated with caution, and the central cyanosis of hypoxic
hypoxia can be detected reliably only if the oxygen satura-
tion of the arterial blood is less than 75  per cent. Normal
subjects breathing air are noticeably cyanotic at altitudes
above 17 000–19 000 feet.
Minimum
tissue tension
Figure 4.6  Oxygen tension gradients from dry atmo-
sphere to minimum tissue level in an individual breathing
air at sea level and at 18 000 feet (--------), assuming that
body tissues are uniform and that the alveolar carbon
dioxide tension is 40 mmHg at sea level and 30 mmHg at
18 000 feet. The gradients for cerebral tissue in an indi-
vidual breathing air at 18 000 feet with an alveolar carbon
dioxide tension of 20 mmHg (………) and35 mmHg (-------)
are also shown (see text).
Neurological effects of acute hypobaric
hypoxia
IMPAIRMENT OF MENTAL PERFORMANCE
The impairment of psychological performance produced by
lack of oxygen at altitude is of great practical significance
in aviation, although there is great variability within and
between individuals exposed to hypobaric hypoxia. Much
of this variation is the result of differences in the respiratory
response to hypoxia, with consequently very significant
temporal and individual differences in the tensions of oxy-
gen and carbon dioxide in the arterial blood when exposed
to a given level of inspired oxygen tension. The hypocapnia
induced by the low arterial oxygen tension affects mental
performance by reducing still further cerebral tissue oxygen
tension, as a consequence of the cerebral vasoconstriction it
produces, and by increasing the pH of cerebral tissue.

K17577_C004.indd 58 17/11/2015 15:32


PSYCHOMOTOR TASKS
Performance of well-learned and practised tasks generally is
preserved adequately up to an altitude of at least 10 000 feet,
but when alveolar oxygen falls to below 38–40 mmHg (i.e.
above an altitude of 16 000–18 000  feet), simple reaction
time begins to be affected, although even a reduction of the
alveolar oxygen tension to 35  mmHg (4.7  kPa) increases
the simple reaction time by only 50  per cent on average.
Performance at pursuit-meter tasks is unaffected until the
altitude exceeds 12 000–14 000  feet, although the decre-
ment of performance at this type of task does not become
severe until altitudes of 16 000–17 000  feet are exceeded.
More demanding tasks such as a choice-reaction time are
affected, however, by much less severe degrees of hypoxia;
for example, performance at such a test is usually impaired
significantly at 12 000 feet. However, tasks requiring com-
plex eye–hand coordination such as instrument flying
that have been well-learned in a flight simulator before the
exposure usually are unaffected until the alveolar oxygen
tension is reduced below 55 mmHg (7.3 kPa) (i.e. until air
is breathed at altitudes above 10 000  feet). If the alveolar
oxygen tension falls to less than 50  mmHg (6.7  kPa) (i.e.
breathing air at 12 000  feet), then there is an approximate
ten per cent decrement in the ability to maintain a given air
speed, heading or vertical velocity. This decrement rises to
20–30 per cent at alveolar oxygen tensions of 40–45 mmHg
(5.3–6 kPa) (15 000 feet).
Psychomotor performance is compromised further by
the impairment of muscular coordination produced by
moderate and severe hypoxia. Above 15 000 feet, for exam-
ple, a fine tremor of the hand develops, so the ability to
hold a stylus or control lever in a fixed position in space is
progressively impaired. Muscular incoordination becomes
greater with increasing altitude, and the subject’s writing
becomes difficult to read.
COGNITIVE TASKS
Performance of previously learned coding and concep-
tual reasoning tasks is unaffected at altitudes up to about
10 000  feet, i.e. for as long as the alveolar oxygen tension
remains greater than 55 mmHg (7.3 kPa). At alveolar ten-
sions less than this, however, performance declines, initially
slowly but then with increasing rapidity with increasing
altitude. Thus, the time taken to complete a simple cod-
ing task is increased by 10–15  per cent at 15 000  feet and
by 40–50 percent at 18 000 feet. The decline in performance
at conceptual reasoning tasks is even greater, although the
altitude at which impairment of mental ability commences,
and the severity of the decrement, varies with the difficulty
and complexity of the task.
Short-term and long-term memory, as tested by paired-
word association, and immediate and delayed recall of
patterns and positions, are affected significantly when
the alveolar oxygen tension is reduced to about 60 mmHg
(8 kPa) (breathing air at 8000–10 000 feet). Memory scores
may be 25 per cent lower at an altitude of 15 000 feet than
at sea level.
K17577_C004.indd 59
Acute hypobaric hypoxia: hypoxia in flight  59
An individual breathing air at 8000  feet may take sig-
nificantly longer to achieve optimum performance at novel
tasks than is the case at sea level. For example, this degree
of hypoxia has been found to double the reaction times of
initial responses to a complex choice-reaction task as com-
pared with responses at sea level. The intensity of this effect
increases with altitude and complexity of the task – mark-
edly so above 12 000 feet – and, indeed, the threshold for the
detrimental effect of hypoxia on performance remains the
subject of debate. Although it is recognized that there is very
considerable individual variation in the threshold of effect,
a number of studies have concluded that such changes can
be demonstrated at altitudes as low as 5000–6000 feet.
The mechanisms responsible for the cerebral effects of
mild hypoxia are not understood, although it is likely that
retardation of some oxygenation processes within the brain,
leading to disruption of neurotransmitter formation and
decay is involved, rather than a failure of oxidative phos-
phorylation (see Chapter 3). This is because the oxygen ten-
sion of cerebral venous blood falls by only 2–4 mmHg on
ascent from sea level to 8000 feet, and such a slight fall is
unlikely to be responsible for the effects seen.
IMPAIRMENT OF THE SPECIAL SENSES
A subjective darkening of the visual field is a common
symptom of hypoxia, although the individual may become
aware of this only after the normal alveolar oxygen tension
has been restored, when there is a marked apparent increase
in the level of illumination. Even very mild hypoxia, such
as that produced by lowering the alveolar oxygen tension
to 75  mmHg (10  kPa) (i.e. equivalent to breathing air at
5000  feet), can be shown in the laboratory to impair the
light sensitivity of the dark-adapted eye (scotopic or rod
vision). The degree of reduction in light sensitivity of sco-
topic vision becomes significant when the alveolar oxygen
tension falls below about 50 mmHg (6.7 kPa) (i.e. when air
is breathed at altitudes above 12 000  feet). Retinal sensi-
tivity in relatively bright light (photopic or cone vision) is
unaffected by hypoxia until the alveolar oxygen tension is
reduced below 40 mmHg (5.3 kPa). The influence of mild to
moderate hypoxia on vision in the intermediate, mesopic,
range between scotopic and photopic ranges is the subject
of specific, ongoing investigations. Finally, moderate and
severe hypoxia cause restriction of the visual field, with loss
of peripheral vision (‘tunnelling’) and the development of a
central scotoma.
Auditory acuity is also reduced by moderate and severe
hypoxia, but some hearing is usually retained, even after the
other special senses have been lost. The effect of hypoxia on
directional hearing remains under investigation and may
have operational significance in the use of warning tones
with a directional component given to a pilot through
his headset.
LOSS OF CONSCIOUSNESS
Although the arterial oxygen tension in the cerebral tis-
sue is of crucial importance to an individual’s degree of
17/11/2015 15:32
 60  Hypoxia and hyperventilation
consciousness, its effect is subject to considerable modifica-
tion as a result of other influences, such as cerebral blood
flow and the degree of hypocapnia present. It has been found
that a much closer correlation exists between the oxygen
tension of jugular venous blood and the level of conscious-
ness under conditions of hypoxic hypoxia, provided that
vasovagal syncope does not supervene. Consciousness is
lost when the jugular venous oxygen tension (see Figure 4.6)
is reduced to 17–19 mmHg (2.3–2.5 kPa). Therefore, uncon-
sciousness may occur with arterial oxygen tension between
20  and 35  mmHg (2.7–4.7  kPa), depending on the degree
of hypocapnia. Accordingly, although consciousness usu-
ally is lost when the alveolar oxygen tension is reduced to
30 mmHg (4 kPa) or below for a significant period of time,
it is possible to lose consciousness with an alveolar oxygen
tension as high as 40  mmHg (5.3  kPa) if there is marked
hyperventilation, or to retain consciousness, for a time, at
an alveolar oxygen tension as low as 25  mmHg (3.3  kPa)
if there is no hypocapnia. A subject breathing air on acute
exposure to altitude therefore may become unconscious at
an altitude as low as 16 000 feet or may stay conscious for
some minutes as high as 24 000 feet.
EFFECTS DURING RAPID DECOMPRESSION
As described earlier, rapid decompressions to altitudes above
30 000 feet when breathing air are inevitably accompanied
by a fall in alveolar oxygen tension to 30 mmHg (4 kPa) or
lower. Such severe falls will have profound neurological
consequences if they are allowed to persist. Consciousness
will almost certainly be lost if the duration of exposure to
an alveolar oxygen tension of less than 30  mmHg (4  kPa)
on rapid decompression is such that, on plotting the oxygen
tension against time, the area of an alveolar oxygen tension
curve below the 30 mmHg level is greater than 140 mmHg/s
(see Figure 4.4).
Even if air continues to be inspired at the final altitude,
however, there is no decrement in the performance
of a psychomotor task until 12–14  seconds after the
decompression. Thereafter, at a final altitude of 40 000 feet,
for example, the time taken to complete the task increases
to about three times its control value 20 seconds after the
event. Provided that 100 per cent oxygen is inspired within
eight seconds of decompression, performance at the task
returns to its control level about one minute later. There is
no significant decrement in performance if the severity of
the decompression is such that the alveolar oxygen tension
never falls below 30 mmHg and then rises rapidly as oxygen
is supplied.
Thus, to ensure that the skilled performance of military
aircrew is not compromised should a loss of cabin pressur-
ization at high altitude occur, it is essential to maintain, or
rapidly restore, alveolar oxygen tension above 30  mmHg
(4 kPa). This requirement is of obvious significance in the
design of personal breathing equipment for both mili-
tary and civilian aircrew, as will be discussed further in
subsequent chapters.
K17577_C004.indd 60
Clinical features of acute hypobaric hypoxia
The clinical picture of acute hypobaric hypoxia is a combi-
nation of the cardiorespiratory responses and neurological
effects described above; consequently, the symptoms and
signs are extremely variable. The speed and order of appear-
ance of signs, and of the severity of symptoms produced by
a lowering of inspired oxygen tension, depend on the rate
and the degree to which the tension is lowered and on the
duration of exposure to hypoxia. Even when these factors
are kept constant, however, there is considerable variation
between individuals in the effects of hypoxia, although for
the same individual the pattern of effects does tend to follow
the same trend from one occasion to another.
The factors that may influence an individual’s pattern of
symptoms and signs produced by hypoxia and their per-
sonal susceptibility are as follows:
●● Intensity of hypoxia: maximum altitude, rate of ascent
and duration of exposure to altitude.
●● Physical activity: exercise exacerbates the features of
hypoxia.
●● Ambient temperature: a cold environment will reduce
tolerance to hypoxia, in part at least, by increasing
metabolic workload.
●● Intercurrent illness: similarly, the additional metabolic
load imposed by ill health will increase susceptibility
to hypoxia.
●● Use of certain drugs, including alcohol: many phar-
macologically active substances have effects similar to
those of hypoxic hypoxia and so mimic or exacerbate
the condition. Alcohol and preparations containing
antihistamines are particularly likely to cause problems.
CLINICAL PICTURE
Although, in general, the higher the altitude, the more
marked will be the features of hypoxia, rapid rates of ascent
can allow high altitudes to be reached before severe symp-
toms and signs occur. In such circumstances, however,
unconsciousness may supervene before any or many of the
classic features appear. For descriptive purposes, therefore,
it is convenient to consider the influence of slow ascent to
various approximate altitudes on the evolution of the clini-
cal picture of hypoxia.
UP TO 10 000 FEET BREATHING AIR (UP TO ABOUT
39 000 FEET BREATHING OXYGEN)
The resting subject has no symptoms of hypoxia on ascent to
an altitude of 10 000 feet when breathing air, or 39 000 feet
when breathing 100  per cent oxygen, but performance of
novel tasks may be impaired.
FROM 10 000 TO 15 000 FEET BREATHING AIR (FROM
ABOUT 39 000 TO 42 500 FEET BREATHING OXYGEN)
The warm resting subject exhibits no or few signs and
has virtually no symptoms. The ability to perform skilled
17/11/2015 15:32
 Acute hypobaric hypoxia: hypoxia in flight  61

tasks is impaired, however, an effect of which the subject ●● Peripheral vision narrowed.

is frequently unaware. Prolonged exposure to the moderate
hypoxia at about 15 000 feet frequently causes a severe gen-
eralized headache. Physical work capacity is reduced mark-
edly, and exposure to extremes of temperature may induce
symptoms and signs of hypoxia.
●● Psychomotor function:
●● Learning novel tasks impaired.
●● Choice-reaction time impaired.
●● Eye–hand coordination impaired.
●● Cognitive function: memory impaired.

FROM 15 000 TO 20 000 FEET BREATHING AIR (FROM The overt features of acute hypobaric hypoxia may be
ABOUT 42 500 TO 45 000 FEET BREATHING OXYGEN) summarized as follows:
Even in the resting subject, the symptoms and signs of
hypoxia appear on acute exposure to altitudes greater than ●● Personality change.
15 000 feet when breathing air. Higher mental processes and ●● Lack of insight.
neuromuscular control are affected; in particular, there is ●● Loss of judgement.
a loss of critical judgment and willpower. Because of the ●● Loss of self-criticism.
loss of self-criticism, the subject is usually unaware of any ●● Euphoria.
deterioration in performance or, indeed, of the presence of ●● Loss of memory.
hypoxia; it is this that makes the condition such a potentially ●● Mental incoordination.
dangerous hazard in aviation. Thought processes are slowed, ●● Muscular incoordination.
mental calculations become unreliable and psychomotor ●● Sensory loss.
performance is grossly impaired. Marked changes in emo- ●● Cyanosis.
tional state are common. Thus, there may be disinhibition ●● Hyperventilation:
of basic personality traits and emotions, and the individual ●● Dizziness.
may become elated or euphoric or pugnacious and morose. ●● Light-headedness.
Occasionally, the individual may become physically violent. ●● Feelings of unreality.
In parallel with this group of cerebral features, distur- ●● Feelings of apprehension.
bances due to hypocapnia commonly occur and, indeed, ●● Neuromuscular irritability.
may dominate the clinical picture as hyperventilation ●● Paraesthesia of face and extremities.
occurs. Light-headedness, visual disturbances (including ●● Carpopedal spasm.
tunnelling of vision) and paraesthesiae of the extremities ●● Semi-consciousness.
and lips may be followed in severe cases by tetany with car- ●● Unconsciousness.
popedal and facial spasms. Central and peripheral cyanosis ●● Death.
develops and there is decreased muscular coordination with
loss of the sense of touch, so that delicate or fine movements TIME OF USEFUL CONSCIOUSNESS
are impossible. The interval that elapses between a reduction in oxygen ten-
Physical exertion greatly increases the severity and speed sion of the inspired gas and the point at which there is a
of onset of all of these symptoms and signs and may lead specified degree of impairment of performance is termed
to unconsciousness. the ‘time of useful consciousness’ (TUC). The length of this
interval is influenced by many factors, of which the most
ABOVE 20 000 FEET BREATHING AIR (ABOVE ABOUT important is the accepted degree of impairment. In the lab-
45 000 FEET BREATHING OXYGEN) oratory, this may vary from an inability to perform complex
The resting subject exhibits a marked accentuation of the psychomotor tasks to a failure to respond to simple spoken
symptoms and signs described above. Comprehension and commands. In practice, however, the most useful concept is
mental performance decline rapidly, and unconsciousness to regard the TUC as the period during which the affected
supervenes with little or no warning. Myoclonic jerks of individual retains the ability to act appropriately to correct
the upper limbs often precede loss of consciousness, and his or her predicament.
convulsions may occur thereafter. Hypoxic convulsions are Values for the TUC at various altitudes following hypoxia
characterized by intense, maintained muscular contrac- induced by changing the breathing gas from oxygen to air
tions that produce opisthotonos, preceded or followed by are presented in Table 4.4. The large standard deviations at
one or more myoclonic jerks. low altitudes serve to emphasize the considerable individual
The early (covert) cerebral features of hypobaric hypoxia variation in the TUC. The variation is a reflection of the
may be summarized as follows: influence of many factors, including the pulmonary ventila-
tory response to hypoxia and the general physical fitness,
●● Visual function: age, degree of training and previous experiences of hypoxia
●● Light intensity perceived as reduced. of the subject. It should be noted that the TUC at a given
●● Visual acuity diminished in poor illumination. altitude is shorter when hypoxia is induced by rapid decom-
●● Light threshold increased. pression rather than by slow ascent.

K17577_C004.indd 61 17/11/2015 15:32

 62  Hypoxia and hyperventilation
Table 4.4  Times of useful consciousness at various
altitudes of 50 seated young men following a change
from breathing oxygen to breathing air
Time of useful consciousness
(seconds)
Standard
Altitude (feet) Mean deviation
25 000 270 96
26 000 220 87
27 000 201 49
28 000 181 47
30 000 145 45
32 000 106 23
34 000 84 17
36 000 71 16
Consideration of the TUC when breathing 100 per cent
oxygen rather than air is aided by the concept of equiva-
lence of altitude, as described previously. This suggests that
an individual breathing 100 per cent oxygen at 42 000 feet
would be at an alveolar equivalent of breathing air at
16 000  feet; however, at higher altitudes than this tracheal
values tend to overestimate actual alveolar conditions,
with TUCs considerably less than might be predicted from
simple equivalence.
Recovery from hypoxia and the oxygen
paradox
The administration of oxygen to a hypoxic subject usually
results in a rapid and complete recovery, as is also the case
if environmental pressure is increased, so that alveolar oxy-
gen tension is restored towards its normal level. A general-
ized headache is the only symptom that persists, and only
then if the exposure to hypoxia was prolonged.
In some subjects, however, sudden restoration of the alve-
olar oxygen tension to normal may cause a transient (para-
doxical) worsening of the severity of the symptoms and signs
of hypoxia for 15–60 seconds. This oxygen paradox is usually
mild and is manifest only by flushing of the face and hands
and perhaps deterioration in performance of complex tasks
over the immediate period following restoration of the oxy-
gen supply. Occasionally, oxygen administration may pro-
duce a severe paradox, with the appearance of clonic spasms
and even loss of consciousness. The mechanisms responsible
for the phenomenon are undetermined. The paradox usu-
ally occurs in subjects who have become hypocapnic during
hypoxia, and it is also accompanied by a period of arterial
hypotension. It may be that there is a significant reduc-
tion in peripheral resistance on the restoration of a normal
arterial oxygen tension, which induces a generalized fall
in blood pressure. This hypotension, in combination with
persistent and marked hypocapnia, may result in cerebral
hypoperfusion and vasoconstriction that persists for some
time after the restoration of the arterial oxygen tension and
K17577_C004.indd 62
may intensify cerebral hypoxia for a short while. Clearly, it
is important that oxygen continues to be delivered to the
victim of a paradox, despite the apparent worsening of the
condition on initial administration of the gas.
HYPERVENTILATION
Hyperventilation is a condition in which pulmonary venti-
lation is greater than that required to eliminate the carbon
dioxide produced by the tissues. The consequent excessive
removal of carbon dioxide from the alveolar gas, the arterial
blood and the tissues results in a reduction in the tension of
carbon dioxide throughout the pathway.
Furthermore, there is a close relationship between car-
bon dioxide tension and hydrogen ion concentration in the
blood and tissues, since these substances are in equilibrium
according to the equation
CO2 + H 2O  H 2CO3  H+ + HCO3−
A reduction in carbon dioxide tension will drive the
equilibrium towards the left. Consequently, there is a fall in
hydrogen ion concentration, i.e. a rise in pH. Thus, hyper-
ventilation also causes an increase in the pH of blood and
tissues, i.e. respiratory alkalosis.
Aetiology
As described above, hyperventilation is a normal response
to hypoxia and is seen when alveolar oxygen tension is
reduced to below 55–60 mmHg. It may also occur as a result
of voluntary over-breathing, e.g. in preparation for a breath-
hold dive into water.
More commonly, however, the condition is produced by
emotional stress, particularly anxiety, apprehension and
fear. Thus, a significant proportion of student pilots under
instruction exhibit gross hyperventilation in flight. Indeed,
it has been claimed that 20–40 per cent of student aircrew
suffer from hyperventilation at some stage during flying
training. The condition is also seen in experienced aircrew
when, for example, they are exposed to the mental stress of
a sudden in-flight emergency or when they are being trained
to operate a new aircraft type. Aircraft passengers who are
afraid or anxious frequently hyperventilate.
Pain sometimes induces hyperventilation, as do motion
sickness and certain environmental stresses, such as high
ambient temperature and whole-body vibration at 4–8 Hz as,
for example, produced by clear-air turbulence when flying at
low level. Finally, hyperventilation is almost invariable in air-
crew during pressure breathing and, although this tendency
may be reduced by training, it cannot be eliminated entirely.
Physiological features of hyperventilation
The hypocapnia of hyperventilation has no significant effect
on cardiac output or arterial blood pressure, although there
is a redistribution of the former. Thus, hypocapnia induces
17/11/2015 15:32

a marked vasoconstriction of the cerebral arterioles and the
vessels of the skin, while blood flow through skeletal muscle
is increased. Although the intense cerebral vasoconstriction
tends to minimize the change in hydrogen ion concentra-
tion within cerebral tissues, it also markedly reduces the
minimum tissue oxygen tension. Therefore, it is probable
that many of the changes produced by gross hyperventila-
tion, and especially deterioration in performance, appear-
ance of slow-wave activity in the electroencephalogram and
loss of consciousness, are due to a combination of hypoxia
and alkalosis in the cerebral tissues.
Reduction in the arterial carbon dioxide tension to
below 25  mmHg (3.3  kPa) causes a significant decrement
in the performance of psychomotor tasks, such as track-
ing and complex coordination tests. The reaction time at a
two-choice task is increased by about ten per cent by such
a fall and is increased by 15 per cent at an arterial carbon
dioxide tension of 15 mmHg (2 kPa). The ability to perform
complex mental tasks, such as mental arithmetic, is com-
promised by a reduction in carbon dioxide tension to below
25–30  mmHg (3.3–4  kPa). Steadiness of the hands is also
impaired by a reduction in arterial carbon dioxide tension
to 25 mmHg (3.3 kPa). The ability to perform manual tasks
is affected markedly by the muscle spasm that occurs if arte-
rial carbon dioxide tensions fall below 20 mmHg (2.7 kPa).
Reduction of carbon dioxide tension below 10–15  mmHg
(1.3–2  kPa) produces gross clouding of consciousness and
then unconsciousness.
The rise in tissue pH induced by hyperventilation
increases the sensitivity of peripheral nerve fibres and
reduces the threshold for their response to stimuli. The
threshold is lowered by the local fall in hydrogen ion con-
centration and spontaneous activity occurs, giving rise
to sensory disturbances, such as paraesthesiae in the face
and extremities and motor disruption, in the form of reflex
firing of proprioceptive fibres via the spinal cord, causing
muscle spasm (tetany). Different types of nerve fibres are
affected in a consistent sequence: fibres conveying informa-
tion with regard to touch, position, pressure and vibration
are affected first, followed by motor fibres and then cold,
heat and, lastly, pain fibres.
Clinical features of hyperventilation
The earliest symptoms produced by hyperventilation
become manifest when the arterial carbon dioxide tension
has been reduced to 20–25  mmHg (2.7–3.3  kPa). Usually,
there are feelings of light-headedness, dizziness, anxiety
(which, since apprehension itself is a cause of hyperventila-
tion, frequently establishes a vicious circle) and a superficial
tingling (paraesthesiae) in the extremities and around the
lips. The paraesthesiae are followed by muscle spasms, par-
ticularly of the limbs and of the face, when arterial carbon
dioxide tension has fallen below 15–20 mmHg (2–2.7 kPa).
Contraction of muscle groups in the wrist and hand and
the ankle and foot give rise to carpopedal spasm. In this
state, the thumb is flexed acutely across the palm, the hand
K17577_C004.indd 63
Hyperventilation 63
is flexed at the wrist, the metacarpophalangeal joints are
flexed and the interphalangeal joints are extended (the
main d’accoucheur). The ankle is profoundly plantar-flexed.
Spasm of the facial muscles causes stiffening of the face, and
the corners of the mouth are drawn downwards (the risus
sardonicus). In more severe hypocapnia, when arterial car-
bon dioxide tension is less than 15 mmHg (2 kPa), the whole
body becomes stiff as a result of general tonic contractions
of skeletal muscle (tetany).
The increased irritability of nervous tissue in moderate
hypocapnia causes augmentation of tendon reflexes. An
example of this lowered threshold can be demonstrated by
tapping the branches of the facial nerve as they pass forward
over the mandible: such tapping, in the presence of mod-
erate alkalosis, which itself leads to reduction in ionized
calcium, causes twitching of the facial muscles (Chvostek’s
sign). Finally, as described above, moderate and severe
hyperventilation produce a general deterioration in mental
and physical performance, which is followed by impairment
of consciousness and finally unconsciousness.
It is most important to realize that, in the uncommon
event of an individual hyperventilating to the point of
unconsciousness as a result of anxiety, the supervention
of coma will be followed by a gradual recovery as respira-
tion is inhibited and carbon dioxide tensions regain their
normal levels. This is clearly not the case, however, if the
hyperventilation has been induced by hypoxia. It will be
apparent from the previous sections of this chapter that
most of the early symptoms of hypoxia are very similar
to those produced by hypocapnia. Indeed, the light-head-
edness, paraesthesiae and apprehension seen during acute
hypoxia in a subject breathing air at altitudes between
15 000  and about 20 000  feet are due to the related hypo-
capnia. Thus, hypoxia should always be suspected when
symptoms or signs of hypocapnia occur at altitudes above
about 12 000  feet, and the corrective procedures must be
based on the assumption that the condition is caused by
hypoxia until proved otherwise.
SUMMARY
●● When tissues have inadequate oxygen to con-
duct normal metabolism they are described as
hypoxic.
●● Hypobaric hypoxia arises from inadequate
oxygenation as a consequence of the reduced
barometric pressure on ascent to altitude. It is a
form of hypoxic hypoxia. Other forms of hypoxia
are anaemic, ischaemic and histotoxic.
●● Oxygen therapy may alleviate some forms of
hypoxia, but not all.
●● Acute hypobaric hypoxia in flight is caused by:
ascent (above specific altitudes) without supple-
mentary oxygen, failure of an oxygen system or
failure of cabin pressurization.
17/11/2015 15:32
 64  Hypoxia and hyperventilation
●● Responses to acute hypoxia are respiratory, circu-
latory and neurological. The clinical picture can
be a combination of all three.
●● Physiological effects of hypoxia occur with
increasing severity and speed of onset with
increasing altitude, especially following rapid
decompression. There are individual variations
in the physiological manifestations and clinical
presentations.
●● When breathing 100% oxygen at ambient pres-
sures a similar pattern of physiological effects to
hypoxia breathing air is seen when the ascent is
sufficiently high. These are equivalent altitudes
for breathing air and oxygen.
●● The tolerance to an altitude, the time of use-
ful consciousness, is related to the altitude (and
influenced by other factors) but shows physiologi-
cal variability. Recovery from hypoxia may be
associated with paradoxical, temporary aggrava-
tion of symptoms.
●● Hyperventilation arises from excess elimination
of carbon dioxide and has many causes, of which
hypobaric hypoxia is one. Hyperventilation has
its own symptom pattern but these may be dif-
ficult to distinguish from hypoxia and can be
merged with it.
●● Aircrew are advised that if they experience any
symptoms of hypoxia or hyperventilation at
altitudes that could produce hypoxia they are to
assume that is the cause.
FURTHER READING
Brown EB. Physiological effects of hyperventilation.
Physiological Reviews 1953; 33: 445–71.
Cable GG. In-flight hypoxia incidents in military aircraft:
causes and implications for training. Aviation, Space,
and Environmental Medicine 2003; 74: 169–72.
Crow TJ, Kelman GR. Psychological effects of mild
hypoxia. Journal of Physiology 1969; 204: 248.
Denison DM. High Altitudes and Hypoxia. In: Edholm OG,
Weiner JS (eds). Principles and Practice of Human
Physiology. London: Academic Press, 1981: 241–307.
K17577_C004.indd 64
Ernsting J. The effect of brief profound hypoxia upon the
arterial and venous oxygen tensions in man. Journal of
Physiology 1963; 169: 292–311.
Ernsting J. Prevention of hypoxia-acceptable compro-
mises. Aviation, Space, and Environmental Medicine
1978; 49: 495–502.
Ernsting J, Byford GH, Denison DM, Fryer DI. Hypoxia
Induced by Rapid Decompression from 8 000 Feet to
40 000 Feet: The Influence of Rate of Decompression.
Flying Personnel Research Committee Report No.
1324. London: Ministry of Defence, 1973.
Gibson TM. Hyperventilation in aircrew: a review. Aviation,
Space, and Environmental Medicine 1979; 50: 725–33.
Guyton AC, Hall JE. Textbook of Medical Physiology, 10th
edn. Philadelphia: W.B. Saunders, 2000.
Harding RM. The Early Symptoms of Cerebral Hypoxia.
In: Amery WK, Wauquier A (eds). The Prelude to the
Migraine Attack. London: Baillière Tindall, 1986: 54–8.
Harper AM, Jennett S. Cerebral Blood Flow and
Metabolism. Manchester: Manchester University Press,
1990.
Lambertson CJ. Respiration. In: Mountcastle VB (ed.).
Medical Physiology. St Louis: Mosby, 1980: 1677–1946.
Lum LC. Hyperventilation and anxiety state. Journal of the
Royal Society of Medicine 1981; 74: 1–4.
National Transport Safety Board. NTSB Report no. AAB-
00-01. Washington, DC: National Transport Safety
Board, 2000.
Taneja N, Wiegmann DA. An analysis of in-flight impair-
ment and incapacitation in fatal general aviation acci-
dents (1990–1998). Proceedings of the Human Factors
and Ergonomics Society, 2002: 155–9.
Weil JV. Ventilatory Control at High Altitude. In:
Cherniack NS, Widdicombe JG (eds). Handbook of
Physiology, Section 3, Vol. II, Part 2. Bethesda, MD:
American Physiological Society, 1986: 703–27.
West JB. Respiratory Physiology: The Essentials, 9th edn.
Philadelphia: Lippincott Williams and Wilkins, 2011.
West JB, Schoene RB, Luks AM, Milledge JS. High
Altitude Medicine and Physiology, 5th edn. London:
CRC Press, 2013.
Whipp BJ. The Control of Breathing in Man. Manchester:
Manchester University Press, 1987.
17/11/2015 15:32

Prevention of hypoxia
Revised by DAVID P. GRADWELL
Introduction 65
Minimum acceptable concentration of oxygen 66
Maximum acceptable concentration of oxygen 67
Pulmonary ventilation in flight 67
INTRODUCTION
As described in the previous chapter, ascent to altitude can
result in hypoxia and most aircraft are capable of carry-
ing their occupants to an altitude at which this is a poten-
tial hazard. The adverse physiological effects of breathing
ambient air at a sufficiently reduced atmospheric pressure
at altitude to induce hypoxia must be prevented during
flight. For many balloons, light aircraft and gliders, this is
achieved by applying strict limits to the altitudes flown, pro-
tection against a significant degree of hypoxia being pro-
vided by avoiding hazardous altitudes. For the vast majority
of air travellers, however, protection from hypoxia can be
achieved most comfortably by the provision of an artificial
pressure environment, i.e. a pressurized cabin. Then the
occupants are not exposed to the same reduced barometric
pressure as the aircraft’s ambient environment in flight (see
Chapter 6). Inside the aircraft cabin the occupants breathe
air at a sufficiently high pressure to avoid an unacceptable
degree of hypoxia.
The alternative means of preventing hypoxia in flight is
to increase the concentration and hence the partial pressure
of oxygen in the lungs by the use of oxygen equipment. In
modern commercial aircraft, the former method is used,
with the latter available as an emergency system in the
event of failure of the pressure cabin. In military aircraft
however, both methods of preventing hypoxia are generally
employed concurrently. Throughout this chapter, the alti-
tudes and environmental pressures given refer to conditions
surrounding the occupants of an aircraft (cabin altitude and
pressure) rather than the aircraft itself.
K17577_C005.indd 65
5
Respiratory gas flow patterns in flight 68
External resistance to respiratory gas flow 69
Prevention of hypoxia above 40 000 feet 70
Further reading 78
In this chapter consideration will be given to the means
by which airborne oxygen equipment can be used to protect
against hypoxia by maintaining an adequate supply of oxygen
to the tissues of the body despite a reduction in barometric
pressure. The physiological ideal is for the partial pressure of
oxygen in the alveolar gas to remain at the level that occurs
when air is breathed at sea level. At altitudes up to approxi-
mately 33 000 feet, the alveolar oxygen tension may be main-
tained at its ground-level value by increasing progressively
the proportion of oxygen in the inspired gas. Above this alti-
tude however, as ambient pressure continues to diminish, the
alveolar oxygen pressure falls too, even when 100 per cent oxy-
gen is breathed. Although some degree of fall from the physi-
ological ideal can be acceptable to allow 100 per cent oxygen
at ambient pressure to be delivered through a relatively simple
breathing system, the continuing reduction in the alveolar
partial pressure of oxygen on further ascent can be prevented
only by artificially maintaining the total alveolar gas pressure
above ambient. The manoeuvre whereby the pressure in the
lungs is raised above the environmental pressure is termed
positive pressure breathing (PPB). Thus, the serious hypoxia
that would otherwise occur on exposure to altitudes in excess
of 40 000 feet may be prevented by this means.
To be acceptable, oxygen systems must meet the primary
requirement to protect against hypoxia in a manner that mini-
mizes the physiological disturbances of ascent to altitude and
may be required also to fulfil a secondary function, i.e. pro-
tecting the user from the additional adverse effects of inhala-
tion of contaminated air, should it be present in the cockpit. In
this chapter, the fundamental performance of oxygen systems
to meet these demands will be discussed in detail.
65
17/11/2015 15:33
 66  Prevention of hypoxia
MINIMUM ACCEPTABLE
CONCENTRATION OF OXYGEN
To prevent the fall in alveolar oxygen tension that occurs
when air is breathed at reduced barometric pressures, the
proportion of oxygen in the inspired gas must be increased.
The fractional concentration of oxygen required in the
inspired gas to maintain a desired alveolar partial pressure
of oxygen (Pao2) at any particular altitude may be calcu-
lated. Figure  5.1  shows the relationship between altitude
and concentration of oxygen in the inspired gas required to
maintain (i) the normal Pao2 (103 mmHg, 13.7 kPa), (ii) the
Pao2 that exists when breathing air at 5000 feet (75 mmHg,
10 kPa) and (iii) the Pao2 that exists when breathing air at
8000 feet (65 mmHg, 8.7 kPa).
It might seem attractive on grounds of oxygen economy
to choose a Pao2  that is lower than the normal sea-level
value. Thus, at 25 000  feet, the inspired gas must contain
63  per cent oxygen to maintain an alveolar oxygen ten-
sion of 103 mmHg (13.7 kPa) but only 41 per cent oxygen
to provide an alveolar oxygen tension of 60 mmHg (8 kPa).
However, the disadvantages of choosing a relationship
between oxygen concentration and altitude that allows the
alveolar oxygen tension to fall below the ground-level value
are as follows:
●● Even the mild degree of hypoxia associated with a
lowering of the alveolar oxygen tension to 75 mmHg
(10 kPa) may impair the ability to recall recently
learned procedures.
100
80
PAO2 = 103 mmHg
Oxygen concentration (%)
60 PAO2 = 75 mmHg
40
PAO2 = 65 mmHg
20
0 15 000
0 10000 20000 30000 40000
Altitude (feet)
Figure 5.1  Concentrations of oxygen required in dry
inspired gas at various altitudes in order to maintain
alveolar oxygen tensions of 103 mmHg (13.7 kPa) (equiva-
lent to breathing air at ground level), 75 mmHg (10 kPa)
(equivalent to breathing air at 5000 feet) and 65 mmHg
(8.7 kPa) (equivalent to breathing air at 8000 feet).
K17577_C005.indd 66
●● Lowering the alveolar oxygen tension to the order of
60 mmHg (8 kPa) induces a significant performance
impairment, which is accentuated by physical exercise.
●● There is a lower margin of safety in the event of either a
partial or a complete failure of the breathing equipment
to deliver oxygen to the respiratory tract.
Thus, solely on the grounds of preventing hypoxia at
altitudes up to 35 000  feet, the concentration of oxygen
in the inspired gas should not be allowed to fall below
that required to maintain an alveolar oxygen tension of
80 mmHg (10.7 kPa). From a practical point of view, how-
ever, the third consideration in the list above is probably
equally important: when an ill-fitting oxygen mask allows
the oxygen delivered to the user to be diluted by the inward
leakage of air, the consequent risk of hypoxia is dimin-
ished in proportion to the amount by which the concen-
tration of oxygen in the breathing gas supply exceeds that
required to prevent hypoxia. For example, at an altitude
of 25 000 feet, an inward leak equal to half the pulmonary
ventilation would reduce alveolar oxygen tension from
80  mmHg (10.7  kPa) to about 65  mmHg (8  kPa) (equiva-
lent to breathing air at 8000 feet). If the oxygen system was
designed to maintain an alveolar oxygen tension of just
65  mmHg (8.7  kPa), then a similar leakage would reduce
the alveolar oxygen tension to 40 mmHg (5.3 kPa) (equiv-
alent to breathing air at 16 000 feet) – a significant degree
of hypoxia.
Thus, an oxygen system should be designed to deliver
the concentration of oxygen, in relation to altitude, that will
maintain a sea-level alveolar oxygen tension (i.e. 103 mmHg,
13.7 kPa), as indicated by the upper curve of Figure 5.1 and
the minimum oxygen concentration in Table 5.1. As noted
above, this sea-level alveolar oxygen tension can be main-
tained in such a manner only up to an altitude of 33 000 feet.
Above this altitude, with the continuing fall in barometric
pressure, the alveolar oxygen tension falls progressively
even when 100 per cent oxygen is breathed. At 40 000 feet,
Table 5.1  Limits for concentration of oxygen delivered to
the respiratory tract by an aircraft oxygen system
Concentration of oxygen in dry
inspired gas (%)
Cabin altitude
(feet) Minimum Maximum*
0 21 60
5000 25 60
10 000 31 60
38 60
20 000 49 67
25 000 63 80
30 000 81 100
33 000 95 100
35 000 100 100
40 000 100 100
*Typical values allowed by current specifications.
17/11/2015 15:33

breathing 100 per cent oxygen at ambient pressure will pro-
duce an alveolar oxygen tension of only about 54  mmHg
(7.2 kPa) and so, above this altitude, PPB oxygen is required.
In some countries it has been common for pressure breath-
ing to be adopted at altitudes below 40 000  feet to avoid
even that degree of hypoxia, but this policy does have the
inevitable consequence of applying higher breathing pres-
sures when PPB is used and thus greater adverse effects as
described below.
In certain circumstances, such as when aircrew are pres-
sure-breathing or after the loss of cabin pressurization in
a military or passenger aircraft, lower alveolar oxygen ten-
sions are acceptable for short periods. Thus, in the case of
rapid decompression in a military aircraft, alveolar oxygen
tensions of 30 mmHg (4 kPa) may be acceptable, although
not desirable, for a very short time provided that 100  per
cent oxygen is delivered within two seconds of the start
of decompression. Similarly, alveolar oxygen tensions of
75 mmHg (10 kPa) are acceptable in an emergency for the
flight-deck crew and cabin staff of a decompressed commer-
cial aircraft, and tensions of 50 mmHg (6.7 kPa) are gener-
ally acceptable for seated passengers.
MAXIMUM ACCEPTABLE
CONCENTRATION OF OXYGEN
An oxygen system that provides aircrew with 100 per cent
oxygen at all altitudes has the advantage of simplicity, hav-
ing fewer mechanical components and being cheaper to
manufacture than a system that supplies a mixture of air
and oxygen that varies appropriately with altitude. The
objections to breathing 100 per cent oxygen at all altitudes
in flight are as follows:
●● It is uneconomical in terms of the consumption of the
aircraft oxygen supply, since in order to prevent serious
hypoxia, 100 per cent oxygen is required only above a
cabin altitude of 33 000 feet.
●● Breathing 100 per cent oxygen continuously for
long periods (12–16 hours) at cabin altitudes below
18 000 feet may cause substernal discomfort due to the
irritative effect of a high partial pressure of oxygen on
the mucosal lining of the respiratory passages.
●● Breathing 100 per cent oxygen at altitude and during
return to ground level frequently gives rise, some hours
later, to ear discomfort and deafness (delayed otic baro-
trauma). This phenomenon is due to rapid absorption
of oxygen from the middle-ear cavity into the blood;
the intensity of the symptoms is reduced greatly by the
presence of nitrogen in the inspired gas and hence in the
gas in the middle-ear cavity.
●● Respiratory symptoms such as coughing, dyspnoea and
retrosternal discomfort occurring immediately after
flight in a high-performance aircraft are produced by
breathing 100 per cent oxygen before and during expo-
sure to +Gz acceleration. The severity of this syndrome
is increased by the use of anti-G trousers. The nature of
K17577_C005.indd 67
Pulmonary ventilation in flight  67
this condition is discussed in Chapter 7, but it should
be noted that the symptoms of acceleration atelectasis
may be prevented by ensuring that the concentration of
nitrogen in the inspired gas is greater than 40 per cent.
For these reasons, an aircraft oxygen system should
deliver a mixture of oxygen and nitrogen derived either
from mixing the supply gas with air or by controlling the
retention of nitrogen in molecular sieve oxygen concen-
trating systems (see Chapter 6). While the concentration
of oxygen should vary with altitude in such a manner that
the alveolar oxygen tension is maintained at or just greater
than the value obtained when air is breathed at ground level
(103  mmHg, 13.7  kPa), the concentration of nitrogen in
the gas delivered by the system should be as high as per-
mitted by the primary requirement to maintain the ideal
oxygen tension. In practice, the concentration of oxygen
delivered at a given altitude by an aircrew breathing system
varies with the demand and from one regulating device to
another. Thus, it is necessary to allow some deviation from
the ideal oxygen concentration–altitude curve (upper curve
of Figure  5.1). Typical maximum oxygen concentrations
allowed by current specifications for aircrew oxygen breath-
ing equipment are presented in Table 5.1.
At altitudes above 40 000 feet, when 100 per cent oxygen
must be delivered at a pressure greater than ambient, the
absolute pressure that must be contained within the lungs
depends on the degree of hypoxia that is deemed acceptable;
this, in turn, is determined by several factors, which will
be discussed later in this chapter. Generally, however, most
pressure breathing systems maintain an absolute pressure
in the respiratory tract of between 120 and 150 mmHg (16–
20 kPa). The relationship between altitude and the positive
pressure at which oxygen must be delivered to the respira-
tory tract (breathing pressure) to maintain various absolute
pressures within the lungs is shown in Figure 5.4.
PULMONARY VENTILATION IN FLIGHT
Oxygen equipment must be capable of meeting the pulmo-
nary ventilation (respiratory minute volume) requirements
of the user in a variety of situations, both on the ground and
during flight. The pulmonary ventilation is determined by
the metabolic rate and modified by factors such as hypoxia,
excitement and anxiety. Measurements of respiratory min-
ute volume have shown large differences in pulmonary ven-
tilation between individuals under similar flight conditions.
Typical values of respiratory minute volume obtained under
various conditions of flight are shown in Table 5.2. The fig-
ures are based on data derived from many sources and relate
to aircrew who are oxygenated adequately.
Measurements of aircrew respiratory demands have
revealed that the greatest increase from resting minute
volume requirements can occur when a pilot runs to the
aircraft in urgent operations. Thus, when the pilot then
connects the oxygen mask to the aircraft breathing sys-
tems, substantial minute volume demands have to be met.
17/11/2015 15:33
 68  Prevention of hypoxia
Table 5.2  Pulmonary ventilation in various conditions of
flight
Pulmonary ventilation
Condition (L (BTPS)/min)
Seated at rest 10–15
Seated active 15–50
Moving about aircraft 25–50
After running to aircraft Up to 60
The mass flow of gas required from an oxygen regulator to
meet given pulmonary ventilation varies inversely with the
pressure in the respiratory tract. It follows, therefore, that
the sea-level requirement demands most from the delivery
system in terms of mass flow. Aircrew oxygen breathing
equipment should, therefore, be capable of meeting pulmo-
nary ventilations of up to 50  L (atmospheric temperature
and pressure, dry [ATPD])/min at sea level. (It is helpful for
engineering purposes when considering breathing systems
to specify flow requirements under ATPD rather than body
temperature and pressure, saturated with water vapour
[BTPS] conditions, the former being 84–87 per cent of the
latter at normal cabin altitudes in combat aircraft.)
RESPIRATORY GAS FLOW PATTERNS IN
FLIGHT
During the breathing cycle the flow of gas in and out of the
respiratory tract changes very rapidly. Oxygen equipment
must be capable of responding to and meeting these changes
while imposing the minimum of resistance to breathing.
Respiratory gas-flow patterns related to the various con-
ditions that occur in flight can be measured best using a
pneumotachograph. Typical records obtained (pneumo-
tachograms) are shown in Figure 5.2 for:
●● Aircrew seated at rest (curve A).
●● Aircrew performing physical exercise approximating to
the effort of moving about an aircraft (curve B).
●● Aircrew speaking aloud while seated at rest (curve C).
There are, however, very wide individual variations in
the airflow pattern obtained during any particular activity,
and the shape of the pattern depends on the level of physi-
cal activity, the nature of the work undertaken, the degree
of arm movement, posture and the phase of flight, e.g. the
level of +Gz acceleration. In the resting subject (Figure 5.2,
curve A), the flow of air increases rapidly at the beginning
of inspiration, but then the rate of increase of flow falls pro-
gressively until the peak flow of about 25–30 litres (BTPS)/
min is reached. The air velocity falls slowly and then more
rapidly until it reaches zero at the end of inspiration. The
whole inspiratory phase lasts for one to two seconds, and
expiration follows without a pause. This lasts longer than
inspiration and the peak flow achieved is less than that
occurring during inspiration. In a resting, non-speaking
K17577_C005.indd 68
125
100
C Speech
75
B Exercise Inspiration
50
25
Flow [L(BTPS)/min]
A Rest
1 2 3 4
0
25
50
Expiration
75
100
125
Time (s)
Figure 5.2  Typical respiratory flow patterns (pneumo-
tachograms) for aircrew seated at rest (trace A); aircrew
moving about an aircraft (trace B); and aircrew speaking
aloud while seated at rest (trace C). The flow throughout a
single respiratory cycle is shown for each of the three con-
ditions. BTPS, body temperature and pressure, saturated
with water vapour.
subject, the peak inspiratory flow is generally about three
times the respiratory minute volume. During moderate
exercise (Figure  5.2, curve B), the volume of gas in each
phase of the breathing cycle is increased and the duration
of each phase is shortened. The peak inspiratory flow also
increases, but in these conditions this value amounts to
only about 2.6  times the respiratory minute volume. The
duration of the expiratory phase becomes shorter relative
to the duration of inspiration, and at higher work rates it
may be less. During speech at rest (Figure  5.2, curve C),
the volume of gas breathed in each phase is similar to that
during rest without speech, but the duration of inspiration
is very short (0.5–0.6 seconds) and the duration of expira-
tion is lengthened. Speech modulates the flow pattern in
the expiratory phase. In inspirations taken during speech,
the peak flow and the rate of increase and decrease of gas
flow are very high. Thus, speech places one of the most
severe demands on oxygen equipment in terms of the peak
flow delivery and rate of change of flow.
17/11/2015 15:33

Studies of the pressure/flow relationships, and thus the
requirements placed upon a system, have allowed national
and international standards for the performance of breath-
ing systems to be defined. Oxygen equipment, however,
must cater for the wide variety of breathing flow patterns
that may occur in aircrew in flight. In addition, for any given
set of circumstances, there are considerable individual vari-
ations (by as much as 100 per cent between maximum and
minimum peak flow values). The mean values of gas flow, as
typified in Figure 5.2, do not provide an adequate basis for
the design of breathing systems. In practice, it is usual to
specify the curves given by the mean values plus twice the
standard deviation, which will include the gas flow require-
ments of 95 per cent of normal individuals. Graphs of this
type show that oxygen equipment should be designed to
meet inspiratory peak flows of up to 200  L (ATPD)/min,
with a maximum rate of change of 20 L (ATPD)/s/s at these
peak flows.
EXTERNAL RESISTANCE TO RESPIRATORY
GAS FLOW
Most oxygen breathing equipment imposes additional
flow resistance on the respiratory system, over and above
the normal physiological influences. This added breathing
resistance must be kept to a minimum in order to avoid
adverse side effects.
There have been many experimental studies of the
effects of imposed resistance to breathing, but often the
results of these studies are difficult to interpret in terms
of the requirements for oxygen systems, since the effects
vary greatly depending on the type and magnitude of the
resistance used. Furthermore, in most studies, the exter-
nal resistance has been imposed for relatively short periods
(10–30 minutes). However, the general effects of imposing
external resistance to breathing in either or both of the
inspiratory and expiratory phases of respiration are known.
These effects include the following:
Change in respiratory rhythm: moderate resistances
●●
generally cause slowing and deepening of respiration,
while high resistances cause rapid shallow breathing.
Decrease in pulmonary ventilation: for a given resis-
●●
tance, the reduction is greatest when the resistance is
applied both in inspiration and in expiration.
●● Reduction in alveolar ventilation: this causes an
increase in alveolar carbon dioxide tension.
●● Increase in functional residual capacity: this is greatest
when a resistance load is applied in expiration alone.
●● Reduction of maximum ventilatory capacity.
●● Increase in total respiratory work per minute:
this rises in an approximately linear manner with
increasing resistance.
●● Subjective disturbances: these range from conscious
appreciation of a very slight resistance to breathing
to severe resistance to breathing, with sensations of
impending asphyxia.
K17577_C005.indd 69
External resistance to respiratory gas flow  69
The physiological disturbances induced by the addi-
tion of resistance to breathing show great variation of
response between subjects and between the effects on the
same subject on different occasions. Thus, although reduc-
tion in alveolar ventilation and hypercapnia may result
from breathing against high levels of resistance, susceptible
subjects (e.g. aircrew untrained and inexperienced in the
use of oxygen equipment) may hyperventilate and exhibit
symptoms of the consequent hypocapnia. The results of one
investigation into the subjective effects of applied respira-
tory resistance are shown in Figure 5.3. In this study, resis-
tance was applied by means of orifices of different sizes.
After a few minutes, the subject was asked to comment on
the degree of resistance to breathing, with a view to estab-
lishing the value of resistance at which mask pressure fluc-
tuations became perceptible. During quiet breathing (peak
inspiratory flow of about 30 L/min), an inspiratory suction
of 1.6 cm water gauge (160 Pa) was not noticed by the sub-
ject. When inspiratory suction reached 2.8 cm water gauge
(280 Pa), resistance was noticed on all occasions. In many
aircraft oxygen systems, the ability to detect imposition of
breathing resistance has been used to provide warning of
either supply malfunction or inadvertent disconnection of
components of the system. The sensation of resistance to
breathing and the physiological disturbances produced by
breathing from oxygen equipment depend not only on the
total change of pressure in the mask cavity during the respi-
ratory cycle but also on the relationship of these pressure
changes to the pressure of the environment. Thus, the dis-
turbances induced by the imposition of a given resistance to
respiration are less if the mean pressure in the mask is raised
slightly (2–6 cm water gauge, 200–600 Pa) above that of the
environment, compared with when the mean pressure is
equal to or less than the environmental pressure. Thus, in
10
t
en
es
s pr
ay
Peak inspiratory suction (cm H2O)
8 lw
c ea
an
s ist
6 of re me
s
n ti
a tio so me
ns ted
Se c
ete
4 ed
ta nc
sis ce
Re stan
esi
2 of r
on
sati
sen
No
0
0 50 100 150
Peak inspiration flow (L/m)
Figure 5.3  Relationship between peak inspiratory flow
and peak inspiratory suction at the nose and lips, which
give rise to a sensation of resistance to breathing. The
added resistance was in the form of a sharp-edged orifice.
The subject’s comments on the presence or absence of
the sensation of resistance were recorded after exposure
to it for several minutes.
17/11/2015 15:33
 70  Prevention of hypoxia
the presence of safety pressure – a small overpressure in the
mask – not only would any leak be outward (rather than an
inward oxygen-diluting leak) but also any small resistance
to breathing is tolerated more easily.
Although it is possible to determine the magnitude of
resistance that will give rise to the described subjective dis-
turbances and undesirable physiological changes, it is diffi-
cult to define the acceptable limits of resistance. In general,
the aim is to keep the added breathing resistance imposed
by the system to a minimum. In practical terms, the maxi-
mum acceptable limit for the resistance imposed by aircrew
oxygen breathing equipment is that the total changes of
pressure in the mask during the respiratory cycle should not
exceed 5  cm water gauge (500  Pa) during quiet breathing
(peak inspiratory and expiratory flows of 30 L [ATPS]/min)
or 11 cm water gauge (1.1 kPa) during heavy breathing (peak
inspiratory and expiratory flows of 110 L [ATPS]/min). At
the maximal flows defined above, that is inspiratory peak
flows of up to 200 L (ATPS)/min, with a maximum rate of
change of 20  L (ATPS)/s/s, the total change of pressure at
the mouth and nose during the respiratory cycle should not
exceed 30.5 cm water gauge (3 kPa).
Trained aircrew will, under most normal circumstances,
be unaware of any effect of increased resistance to breathing
in a modern oxygen system. If it does become noticeable to
them, it may be an indication of a failure in the breathing
system. However, naïve individuals may find the effects of
increased resistance to breathing at least discomforting and
may suffer adverse symptoms. Thus, emergency oxygen sys-
tems for use by untrained individuals such as commercial
passengers should be both easy to use and impose as little
resistance to breathing as possible.
Added dead space
An oxygen system must either adequately and safely dispose
of the expired carbon dioxide or disperse the entire expi-
rate to ambient. To avoid significant rebreathing, the effec-
tive additional dead space imposed by the use of an oxygen
mask should be no more than about 150 mL. Furthermore,
following a rapid decompression, it can be essential that the
amount of gas trapped in the dead space is small, as any
delay in the inspiration of a breathing gas rich in oxygen
may result in severe hypoxia. Any expanded gas present fol-
lowing a rapid decompression that contains a concentration
of oxygen inappropriate for the new, higher altitude, should
be dispersed as soon as possible and not have to be breathed
by the user. The requirements for a very limited added dead
space are generally achievable in the closely fitting masks
worn by aircrew, linked to an oxygen regulator supplying
breathing gas on demand. Therapeutic oxygen masks and
passenger masks used only during emergencies may utilize
a rebreathing bag to economize on the supply of oxygen, and
the total dead space commonly will then exceed 150  mL.
However, the expirate is easily dispersed, since such masks
do not fit tightly and carbon dioxide and water vapour in
the expirate can be dispersed in ambient air.
K17577_C005.indd 70
PREVENTION OF HYPOXIA ABOVE 40 000
FEET
When breathing 100 per cent oxygen at 40 000 feet, where
the atmospheric pressure (PB) is 141  mmHg (18.8  kPa),
the Pao2  is 54  mmHg (7.2  kPa). A significant degree of
hypoxia will occur if Pao2  falls below 50–54  mmHg. To
prevent hypoxia above 40 000  feet, therefore, an oxygen
system must be capable of delivering breathing gas to the
respiratory tract at pressures greater than that of the ambi-
ent environment (Figure  5.4). For example, at an altitude
of 45 000  feet, where PB is 111  mmHg (14.8  kPa), 100  per
cent oxygen must be delivered at a positive pressure of
30  mmHg (4  kPa) to ensure that Pao2  is elevated to the
equivalent of breathing 100 per cent oxygen at 40 000 feet.
It is important to remember, however, that the associ-
ated elevation of intrapulmonary pressure has significant
adverse physiological consequences. These disturbances
are influenced by the type of breathing system utilized.
Thus, the manner in which the pressure is applied to the
respiratory tract will alter the resulting respiratory and
circulatory changes.
PPB was originally introduced for military flying to
allow short excursions above 40 000 feet to be conducted in
unpressurized aircraft without the pilot suffering an unac-
ceptable degree of hypoxia. With the advent of pressurized
cockpits, this was no longer necessary. However, pressure
breathing has remained in use as an important emergency
provision to enable aircrew to continue to fly their aircraft
in the event of loss of cabin pressure above 40 000  feet.
In more recent years, it has also been adopted as a means
of improving tolerance to high levels of sustained accel-
erations (high Gz). Therefore, an understanding of the
140
120
Breathing pressure (mmHg)
100
Lung pressure
141 mmHg abs
80 130 mmHg abs
120 mmHg abs
60
40
20
0
40000 60000 80000 100000
Altitude (feet)
Figure 5.4  Relationship between pressure at which gas
must be delivered (relative to that of the environment)
and altitude to maintain absolute pressures in the respira-
tory tract of 141, 130 and 120 mmHg.
17/11/2015 15:33

physiological consequences of the use of pressure breathing
remains of great importance. In the following sections, the
physiological consequences of pressure breathing at 1  Gz
for altitude protection (PBA) will be considered under the
following headings: respiratory effects, circulatory effects,
effects on the head and neck and the acceptable degree
of hypoxia. The specific influences of the use of pressure
breathing for Gz protection (PBG) will be considered in
subsequent chapters.
Respiratory effects of pressure breathing
BREATHING EFFORT
Early observations on the respiratory effects of pressure
breathing described the reversal of the normal respiratory
cycle. At breathing pressures in excess of approximately
10  mmHg (1.3  kPa), inspiration becomes a passive pro-
cess, with the lungs being inflated by the inhaled breath-
ing gas without muscular effort. Expiration, however,
becomes an active, tiring process, with an expiratory effort
maintained continuously to support the chest and prevent
overdistension of the lungs. Since elastic recoil plays little
part in exhaling gas during pressure breathing, the work
of breathing thereby is increased still more. Furthermore,
the normal inspiratory and expiratory flow patterns are
markedly affected. Inspiration becomes sharper, with a
more rapid rise to a peak and an abrupt end. Expiration
becomes protracted because of the effort needed to breathe
out against the constant positive pressure.
People experienced in pressure breathing can breathe
for short periods at pressures of up to 50 mmHg (6.7 kPa),
but people unaccustomed to the procedure are unable to
tolerate breathing pressures of more than about 30 mmHg
(4 kPa). Trained individuals can generally tolerate breath-
ing pressure of up to 30 mmHg (4 kPa) for some minutes
but, inevitably, this is associated with hyperventilation
and fatigue. Commonly, breathing pressures greater than
30  mmHg are used only when respiratory support
through the application of counter-pressure is available.
The only exception to this is found when increased Gz
forces provide a degree of counter-pressure, as can occur
during PBG.
DISTENSION OF LUNGS AND CHEST
In a relaxed subject (when the distensibility of the lungs
and thorax is high), the lungs are distended fully by a
breathing pressure of approximately 20  mmHg (2.7  kPa).
The maximum pressure that can be exerted and held in
the lungs by active contraction of expiratory muscles
of the chest and abdominal walls depends on the length
of time for which the pressure is operative. Thus, dur-
ing coughing or sneezing, the intrapulmonary pressure
may reach peak values of 200–300  mmHg (27–40  kPa)
for very brief periods, but these are compressive respira-
tory events associated with muscular activity of the chest
wall and abdomen, which provides support to the lung
tissue. When the pressure is held for about three seconds,
K17577_C005.indd 71
Prevention of hypoxia above 40 000 feet  71
the maximum expiratory pressure that can be produced is
about 120  mmHg (16  kPa). If the lungs are unsupported
by the chest wall, they may rupture when the intrapul-
monary pressure exceeds 40–50  mmHg (5.3–6.7  kPa).
However, when the lungs are supported by the walls of
the thoracic cavity, intrapulmonary pressures of up to
80  mmHg (10.7  kPa) can be tolerated without damage.
Intrapulmonary pressures above 80–100  mmHg (10.7–
13.3 kPa) can cause tearing of the lung parenchyma when
the expiratory muscles are relaxed. Gas can pass from the
damaged tissue into the tissue planes, causing pneumo-
thorax, pneumomediastinum and surgical emphysema,
and into pulmonary blood vessels causing gas embolism.
Radiographic studies of the chest while pressure breath-
ing have shown elevation and expansion of the thoracic
cage and descent of the diaphragm, despite increased mus-
cular tone. Spirometric studies of the lung have revealed
that pressure breathing gives rise to an increase in total
lung capacity and, in particular, an increase in expiratory
reserve volume, with a proportionate reduction in inspi-
ratory reserve volume and an increase in residual volume,
probably principally due to displacement of blood from
the thorax (Figure 5.5). So, although pressure breathing at
30 mmHg (4 kPa) reduces the inspiratory reserve volume by
about 2.5 L, total lung volume is increased by 500 mL.
Inspiratory
7.0
reserve
volume
Tidal
6.0
volume
5.0
Volume [L(BTPS)]
4.0 Expiratory
reserve
volume
3.0
2.0
1.0 Residual
volume
0
10 20 30
Breathing pressure (mmHg)
Figure 5.5  Effect of continuous positive-pressure breath-
ing on total lung capacity and its subdivisions. Total lung
capacity, residual volume and functional residual capac-
ity (residual volume + expiratory reserve volume) all
become greater with an increase in breathing pressure.
The greatest increase occurs, however, in the expiratory
reserve volume, while the inspiratory reserve volume is
markedly reduced.
17/11/2015 15:33
 72  Prevention of hypoxia
INCREASED PULMONARY VENTILATION
Tidal volume commonly is increased in response to pres-
sure breathing, as is respiratory frequency, especially in
people less experienced in the technique. In most subjects,
therefore, there is an increase in the respiratory minute
volume, although there is wide individual variation in this
response. Whereas some individuals double their minute
volume at a breathing pressure of 30 mmHg (4 kPa), others
barely respond. However, on average, pressure breathing at
30 mmHg (4 kPa) increases the respiratory minute volume
by about 50 per cent above the resting value. Although there
is an increase in respiratory work, and hence carbon dioxide
production, the increase in minute volume is proportion-
ally much greater, giving rise therefore to hyperventilation,
even in well-trained subjects. In untrained or inexperienced
individuals, severe hyperventilation may result. Carbon
dioxide tensions in the blood will then fall during pressure
breathing. During pressure breathing at 30 mmHg (4 kPa),
alveolar and arterial carbon dioxide tensions may be of the
order of 25–30 mmHg (3.3–4 kPa).
RAISED INTRAPLEURAL PRESSURE
Intrapleural pressure rises as intrapulmonary pressure rises
during pressure breathing. This increase in intrapleural
pressure therefore is determined by the applied breathing
pressure, although it is modified somewhat by the degree of
lung distension that it induces. If there is no increase in lung
volume, the rise in intrapleural pressure equals the applied
breathing pressure. If lung distension occurs, then the rise
in intrapleural pressure will be less than the applied intra-
pulmonary pressure as a result of the effect of the additional
elastic recoil generated in the lung tissue, which is approxi-
mately 4 mmHg (0.5 kPa) per 1 L of distension. The increase
in intrapleural pressure that occurs during pressure breath-
ing is, however, of considerable importance, since it deter-
mines the degree of pressure applied to the heart and great
vessels inside the chest and thus the additional force that is
applied to the circulation. It is interesting to note that chest
counter-pressure (see below) will act to reduce distension of
the chest wall and maintain the expiratory reserve volume
closer to its normal value. Thus, for a given breathing pres-
sure, the use of chest counter-pressure results in an increase
in the intrapleural pressure relative to that which would be
induced in its absence.
EFFECTS OF RESPIRATORY COUNTER-PRESSURE
The major respiratory disturbances induced by pressure
breathing (i.e. lung distension, hyperventilation) may be
minimized by applying counter-pressure to the surface of
the trunk. Counter-pressure may be applied by a variety of
methods, the most efficient of which is by gas held within a
full-pressure suit, encasing the whole body in an environ-
ment at an elevated pressure, relative to ambient. Another
method, which is almost as efficient, applies counter-pres-
sure to the chest or trunk by means of a gas-filled bladder
that is connected to the breathing line between the source
K17577_C005.indd 72
of breathing pressure and the oronasal mask or helmet. In
this way, when pressure is applied to the breathing tract, an
equal gas pressure is applied in the bladder that covers the
body. This is the basis of the pressure garments described in
more detail later.
Circulatory effects of pressure breathing
The most immediately significant limitation of pressure
breathing as a means of extending duration of exposure
to very high altitude is the profound circulatory distur-
bances induced by the elevation of intrathoracic pressure.
Such disturbances vary with the magnitude of the pressure
applied and the duration. The heart and the intrathoracic
great vessels are exposed to the elevated intrapleural pres-
sure, and it is the rise in this, rather than the intratho-
racic pressure per se, that determines the stress applied to
the circulation. Provided that the intrathoracic veins and
the heart cavities contain blood, then the diastolic pres-
sures within them are raised as a consequence of the rise
in intrapleural pressure. The increase in intrathoracic vas-
cular pressures gives rise to very considerable disturbance
of the circulation.
POOLING OF BLOOD IN THE PERIPHERAL
VASCULAR BEDS
At the start of pressure breathing, the rise in intrapleu-
ral pressure is transmitted directly to the large intratho-
racic veins and the right atrium, with a consequent rise in
central venous pressure. Since the pressure in the extra-
thoracic veins normally is low, the flow of blood from the
periphery of the body into the chest is impeded severely,
and the venous outflow from the limbs ceases com-
pletely. Overall venous return to the heart does not stop
altogether at the beginning of pressure breathing, since
there is a maintained flow of blood from the brain and
the abdominal viscera. The flow of blood from the abdo-
men continues, since the intra-abdominal pressure rises
in parallel with that in the pleural space. Venous return
and thus right atrial filling are aided by the reduction of
intrathoracic pressure below atmospheric pressure that
occurs during inspiration. Since intrathoracic pressure is
above atmospheric throughout the breathing cycle during
pressure breathing, this assistance to venous return and
cardiac filling is impeded. The jugular venous blood flow,
however, is maintained because of the indistensibility of
the intracranial vascular bed.
The veins of the limbs, especially the legs, act as large
capacitance vessels and with continuing arterial outflow
from the heart during pressure breathing the veins distend
with an increasing volume of blood. This increase in volume
is accompanied by an increase in peripheral venous pres-
sure, until once again peripheral venous pressure exceeds
central venous (right atrial) pressure and venous return
from these capacitance vessels recommences (Figure  5.6).
This initial phase of very marked reduction in venous return
to the heart lasts for 10–20 seconds.
17/11/2015 15:33

The circulation through the limbs is maintained during
pressure breathing by displacement of blood from within
the trunk into the limbs. The amount of blood thus dis-
placed is determined by the increase in venous pressure
and the distensibility of the vessels of the limbs. One of
the reflex cardiovascular changes that occur during pres-
sure breathing is active constriction of the peripheral
veins, which tends to reduce the amount of blood dis-
placed from within the trunk. The amount of blood dis-
placed into the limbs of a seated subject at the onset of
pressure breathing at 30  mmHg (4  kPa) is of the order
of 200  mL, and at 80  mmHg (10.7  kPa) it is 400  mL
(Figure 5.7).
REDUCTION OF EFFECTIVE BLOOD VOLUME
The volume of blood that is available for circulatory
adjustment is reduced as a consequence of the reduc-
tion in venous return, with blood pooling outside the
chest. Furthermore, this gives rise to an increase in the
Limb volume (mL/100 mL limb)
B effective blood volume of about 950 mL. It is not surprising,
2
Forearm volume
1 in the systemic circulation, there are also changes in the
0
Peripheral venous
40
30
Pressure (mmHg)
Central venous
20
A
10
0 800
0 10
–10
(s)
Start pressure
breathing
Figure 5.6  Effect of pressure breathing at 40 mmHg with
trunk counter-pressure on peripheral and central venous
pressures and volume of the forearm. The central venous
pressure rises rapidly to a plateau value determined by
the breathing pressure. The rise of the central venous
pressure raises it above the peripheral venous pressure,
and the flow of blood from the limb to the heart ceases.
Since arterial inflow continues, blood accumulates in the
peripheral vascular bed, increasing the volume of the
limb (top trace) and progressively raising the peripheral
venous pressure. When the capacity vessels in the limb
are distended, the peripheral venous pressure once
again exceeds central venous pressure (at point A–B)
so that venous outflow recommences and the volume
of the limb stabilizes at a new, greater value (continued
increase of limb volume is due to accumulation of fluid in
the tissues).
K17577_C005.indd 73
Prevention of hypoxia above 40 000 feet  73
transmural pressure within the capillary vessels of the
limbs relative to the local tissue pressure. That capillary
pressure rises considerably can be demonstrated by the
observation of petechial haemorrhages in unsupported
areas of the skin. The balance that normally exists between
hydrostatic and osmotic forces at the blood–tissue fluid
interface in the capillary bed is disturbed, such that fluid
moves from the intravascular compartment into the tis-
sues at a rate determined by the increase in the capillary
and, hence, venous pressure. Thus, pressure breathing at
30  mmHg (4  kPa) for ten minutes will result in the loss
of about 250 mL of fluid from the circulation, while pres-
sure breathing for five minutes at 100  mmHg (13.3  kPa)
will result in a loss of 500 mL of fluid into the tissues and
concomitant haemoconcentration (Figure 5.7).
The total reduction in effective blood volume over time
that occurs as a result of these two factors (i.e. initial pooling
of blood and decrease in intravascular fluid) during pressure
breathing at 30 mmHg (4 kPa) for ten minutes causes a loss
in the order of 450  mL. Pressure breathing at 100  mmHg
(13.3 kPa) for five minutes results in a net reduction of the
therefore, that some of the physiological responses to pres-
sure breathing, as described below, are similar in nature to
the effects of acute haemorrhage. In addition to the changes
pulmonary circulation. Radiographic examinations of the
1200
Reduction of effective blood volume (mL)
1000
10 min
20
5 min
600
2 min
400
Immediate
200
0
0 20 40 60 80 100
Breathing pressure (mmHg)
Figure 5.7  Representation of the effects of pressure
breathing with counter-pressure to the trunk on reduc-
tion of effective blood volume in seated subjects. The
reduction of blood volume due to displacement into
the peripheral capacity vessels is indicated by the curve
labelled ‘immediate’. The subsequent further reductions
in effective blood volume due to loss of fluid into the tis-
sues are indicated for pressure breathing for two, five and
ten minutes.
17/11/2015 15:33
 74  Prevention of hypoxia
chest during pressure breathing have shown a reduction in
pulmonary vascular markings, due to a reduction in pul-
monary blood volume, with a net shift to the systemic cir-
culation and a reduction in heart size. Overall, the loss of
circulating blood may be minimized by the application of
counter-pressure, particularly over the capacitance vessels
in the limbs, and this principle is used in the design of par-
tial-pressure clothing, as described in Chapter 6.
INCREASE IN HEART RATE
Pressure breathing gives rise to an increase in heart rate
unrelated to any effect of anxiety or anticipation. Broadly,
the increase in heart rate above resting levels has been related
directly to the magnitude of the applied breathing pressure,
although this is mitigated to a significant extent if counter-
pressure is applied to the trunk and limbs. Nonetheless, the
onset of pressure breathing is associated with an immediate
acceleration of the heart, often with a progressive increase
in the rate throughout the period of raised breathing pres-
sure. Hypoxia itself will, of course, cause a rise in heart rate
and in combination with pressure breathing the effects can
be additive. In one study pressure breathing of 30 mmHg at
ground level (with counter-pressure applied over the trunk
and legs) increased heart rate, on average, by 5–10  beats/
min; at 45 000 feet, the same magnitude of pressure breath-
ing, but with a degree of hypoxia, was associated with an
increase in rate of 14–20  beats/min. However, in some
instances, pressure breathing has been associated with heart
rates in excess of 150 beats/min. The mechanism underlying
the rapid change in heart rate may be mediated by receptors
in the atria and great veins detecting a sharp reduction in
venous return and right atrial filling.
REDUCTION IN CARDIAC OUTPUT
The pooling of blood in the periphery leads to a lowering of
the effective pressure in the right atrium and, as described
above, a sustained reduction in venous return. There is,
therefore, a reduction in atrial filling and, consequently, in
stroke volume. Even in the presence of tachycardia, cardiac
output is not maintained at its normal levels. During pres-
sure breathing at 30 mmHg (4 kPa) without trunk counter-
pressure, the cardiac output is reduced by about 30 per cent
compared with the resting value. If, however, trunk counter-
pressure is applied, then the same degree of pressure breath-
ing reduces the cardiac output by only 15–20  per cent. It
could be expected that a greater level of counter-pressure
would mitigate still further the fall in cardiac output during
pressure breathing.
RISE IN ARTERIAL BLOOD PRESSURE
When a high-altitude rapid decompression initiates pres-
sure breathing, the onset is very swift and associated with an
immediate rise in arterial blood pressure. The blood pres-
sure waveform is modified somewhat, however, becoming
sharper in profile as the heart rate increases and the dicrotic
notch tends to become more prominent. The immediate
changes in the arterial pressure wave are similar to those
K17577_C005.indd 74
observed when a subject carries out a Valsalva manoeuvre,
but after the first few seconds the blood pressure will sta-
bilize at an elevated level, although pulse pressure tends to
show an exaggerated variability with respiration.
Blood pressure is raised during pressure breathing, pri-
marily as a result of the transmission of the raised intra-
pleural pressure to the blood within the left ventricle. If
cardiac output and peripheral vascular resistance were
constant and no baroreceptor-mediated response to pres-
sure breathing occurred, the pressure within the left ven-
tricle would be increased by an amount equal to the rise
in pleural pressure. This rise in intraventricular pressure
would be reflected in the systemic arterial blood pressure.
In fact, neither cardiac output nor peripheral resistance
remain unchanged, and the reduction in cardiac output
during pressure breathing will tend to reduce the rise in
arterial blood pressure. This effect is counteracted partially
by active constriction of the peripheral resistance vessels,
the arterioles.
The net rise in arterial blood pressure that occurs in pres-
sure breathing is an expression of the integrated effects of
reflexes, including the compensatory circulatory adjust-
ments that occur in this condition, i.e. the increase in heart
rate and constriction of arterioles and veins. These reflex cir-
culatory adjustments probably result from the stimulation
of volume receptors in the right side of the heart, produced
by the displacement of blood from the central part of the
circulation into the periphery, and baroreceptor influences
which modify further the observed response. An elevation
of arterial blood pressure will be detected in the carotid
baroreceptors as an increase in transmural pressure, unless
an equal counter-pressure is applied to prevent the walls of
these vessels being stretched. This would, therefore, stimu-
late reflexes to lower blood pressure. Conversely, the intra-
thoracic baroreceptors of the aortic arch would be exposed
to the increase in intrapleural pressure and unless the rise
in arterial pressure was equal to that elevated intrapleural
pressure, these baroreceptors would be less distended than
normal and, through a reduction in their tonic discharge,
in effect, signal a fall in blood pressure. It is interesting to
note in this context that when pressure breathing is carried
out wearing an oronasal mask (and, hence, when carotid
baroreceptors are unsupported), the rise in blood pres-
sure associated with a specific breathing pressure has been
observed, at least in some cases, to be less than when a pres-
sure helmet is used, since with the latter, counter-pressure is
applied to the anterior triangle of the neck and thus over the
carotid baroreceptors.
It can be useful to consider the degree to which blood
pressure rises as a result of pressure breathing as a pro-
portion of the applied breathing pressure. Expressed as
a ratio of increased blood pressure (δBP) and breathing
pressure (PPB), if no attenuation of the applied pressure
occurred, then the resulting arterial blood pressure would
be the simple sum of the resting blood pressure and the
increased breathing pressure, giving a ratio of 1. In fact,
during pressure breathing at 30 mmHg (4 kPa), the rise in
17/11/2015 15:33

mean arterial blood pressure is commonly of the order of
15–20  mmHg (2–2.7  kPa), i.e. a δBP/PPB ratio of 0.5–0.7.
The application of counter-pressure to the chest, abdomen,
limbs and the head and neck can influence the blood pres-
sure response to pressure breathing. Essentially, the greater
the degree of counter-pressure, the better the circulatory
support provided. Then, the ratio as described above will
more closely approach 1. The mechanisms involved are
outlined below.
Although the elevation of arterial pressure by PPB may be
seen as a side effect of its use to improve protection against
hypoxia, this response is the basis of the use of this respira-
tory technique as a means of enhancing tolerance of +Gz
acceleration. The physiological mechanisms of this applica-
tion of pressure breathing are discussed in Chapter 7.
PRESSURE BREATHING SYNCOPE
Cardiac output is maintained during the first 10–15 seconds
following the onset of pressure breathing by the venous
return from the abdomen and head, as described above. If,
after that time, the breathing pressure applied to the respi-
ratory tract remains very high (e.g. 80–100 mmHg), and if
no counter-pressure is applied to the trunk, then the reduc-
tion in venous return may be so severe that the arterial
blood pressure falls and consciousness may be lost within
10–15 seconds. Normally, however, the venous return to the
heart is adequate to maintain a reasonable, albeit reduced,
cardiac output. This, together with peripheral vasoconstric-
tion, helps to maintain the elevated arterial blood pressure
already described. Under these circumstances, there is no
impairment of consciousness. If, however, pressure breath-
ing is continued for long enough, circulatory integrity can-
not be maintained and collapse occurs. The length of time
that elapses before syncope occurs during pressure breath-
ing depends primarily on the pressure that is applied to the
respiratory tract and the external support of the circula-
tion by counter-pressure assemblies. Thus, subjects may
be able to breathe at 30  mmHg (4  kPa) for 10  minutes or
more without syncope. In one study, less than ten percent of
subjects became presyncopal after two minutes of pressure
Altitude Systolic BP
200 (000’s ft) (mmHg)
150
100
50
0
–120 –60 0 60
Time (s)
Figure 5.8  A graph of blood pressure and heart rate during a rapid decompression which shows a PPB induced syncope.
Time zero represents the moment of rapid decompression. See also colour plate 5.8.
K17577_C005.indd 75
Prevention of hypoxia above 40 000 feet  75
breathing at 70  mmHg (9.3  kPa) with counter-pressure
applied to the trunk and lower limbs, but collapse occurred
almost invariably after two minutes of breathing at a pres-
sure of 100 mmHg (13.3 kPa) with trunk counter-pressure
alone. Although studies have shown a much greater toler-
ance of pressure breathing in recumbent subjects, as would
be expected, this is of limited value for operational aircrew
following a rapid decompression of the cockpit at very high
altitude. The variability of individual susceptibility may be
related to a number of factors, but the likelihood of syncope
during pressure breathing may be increased by hypoxia,
hypocapnia, anxiety, discomfort, pain, intercurrent infec-
tion and a post-alcohol state. In all cases, however, the
symptoms and signs are very similar, and pressure-breath-
ing collapse has the following features:
●● Nausea and uneasiness.
●● Dimming of vision.
●● Intense facial pallor.
●● Profuse facial and palmar sweating.
●● Loss of consciousness.
●● Loss of postural tone.
●● Jerky movements of limbs (occasionally major epilepti-
form convulsions).
The feeling of nausea and facial pallor persist for some
time after consciousness returns, frequently for several
hours. Pressure-breathing syncope is accompanied by gross
changes in the circulatory system. The onset of collapse is
heralded by a progressive increase in heart rate and a grad-
ual fall in the arterial blood pressure. A sudden profound
bradycardia occurs, arterial blood pressure falls precipi-
tously, and unconsciousness follows within five to ten sec-
onds. When the pressure breathing is stopped, the arterial
blood pressure increases slowly over the next 30–60  sec-
onds. The heart rate also increases, although both heart rate
and arterial blood pressure may remain below resting level
for as long as an hour (Figure 5.8).
Pressure breathing collapses have many of the features
of fainting of other causes, such as haemorrhage and pain.
Diastolic BP Heart rate
(mmHg) (bpm)
120 180
17/11/2015 15:33
 76  Prevention of hypoxia
The prime cause of the sudden profound hypotension that
occurs in fainting is dilation of the arterioles in muscles.
The cardiac output, which usually falls in the period pre-
ceding syncope, does not decrease further when the faint
occurs and, thus, does not contribute to the fall in arte-
rial pressure. The disturbances of cerebral function are
due to the reduction in cerebral blood flow consequent to
the fall in arterial pressure. In pressure breathing syncope,
the extreme peripheral arteriolar vasodilation that occurs
in muscle probably is produced by vasodilator fibres of
the sympathetic outflow. The nausea, abdominal discom-
fort, facial pallor and skin vasoconstriction are probably
humoral in origin (during and following a faint, there is
an increase in the secretion of antidiuretic hormone). The
receptors and afferent pathways in pressure breathing
syncope are, in all probability, the same as those that are
responsible for syncope due to loss of blood (50  per cent
of semi-reclining subjects will faint after about 1100 mL of
blood has been withdrawn by venesection). The stimulus in
this type of syncope may be the reduction in the intratho-
racic blood volume and a sharp fall in the volume of blood
in the right ventricle.
The afferent impulses responsible for initiating the car-
diovascular changes (bradycardia, muscle arteriolar vasodi-
lation, secretion of antidiuretic hormone) almost certainly
arise from receptors in the walls of the right atrium and
ventricle. In trained subjects, the degree by which the effec-
tive blood volume must be reduced to produce pressure-
breathing syncope (about 800 mL) is similar to that which
will cause fainting by venesection.
Effects of pressure breathing on the head
and neck
Although the most significant physiological disturbances
associated with pressure breathing may principally affect
the respiratory and cardiovascular systems, the symptom-
atic consequences of breathing at pressures greater than
ambient may be felt most clearly in the head and neck. The
most common method of delivering breathing gas to the
respiratory tract at pressures above ambient is by means of
an oronasal mask. At high breathing pressures, some of the
drawbacks associated with an oronasal mask may be over-
come by the use of a pressure helmet. These two methods
of delivering oxygen at pressures greater than ambient are
discussed below.
PRESSURE BREATHING WITH AN ORONASAL MASK
Using an oronasal mask, pressure is applied to the mouth and
nose, with physical support given to only a very limited area
of the face. There are certain mechanical limitations to the
pressure that may be delivered in this manner. Most orona-
sal masks in current use have a specially designed reflected
edge seal, which, under increased mask cavity pressures, is
pressed more closely to the face. This type of mask will, when
fitted correctly, hold pressures of up to 100 mmHg (13.3 kPa)
without significant leakage. In order to sustain this mask
K17577_C005.indd 76
cavity pressure, the tension applied to the mask by means
of the harness attaching it to the helmet must be such that it
counterbalances the force tending to lift the mask off the face
when the delivery pressure is raised. A force of almost 60 N is
necessary to seal a pressure of 40 mmHg (5.3 kPa) in the type
of Royal Air Force (RAF) pressure-demand oronasal mask
illustrated in Figure 5.9. Since such a high tension is neither
tolerable nor necessary during routine flight, a manual or
automatic means of increasing the tension, when required,
is incorporated in the suspension harness. In the mask illus-
trated this is achieved manually by rotating a toggle over
the suspension bar in order to increase the tension in the
supporting harness.
In practice, however, well-defined physiological effects
limit the pressure that can be delivered using an oronasal
mask, since no external support is applied to the floor of the
mouth or the neck, eyes or ears. These effects are as follows:
Distension of the upper respiratory passages commences
when the breathing pressure exceeds 10  mmHg (1.3  kPa)
and progresses so that with high breathing pressures, there
is distension of the mouth, the whole of the pharynx and
the cervical portion of the oesophagus. It therefore makes
speech difficult and impedes communication between crew
members and with ground controllers. At pressures greater
than about 70 mmHg (9.3 kPa), this distortion causes severe
discomfort in many people and is the main limitation to the
use of oronasal masks.
Increased intravascular pressure caused by the raised
intrathoracic pressure dilates the conjunctival vessels. At
breathing pressures above 70–80 mmHg (9.3–10.7 kPa), the
conjunctival capillaries may rupture. In contrast, the reti-
nal vessels may constrict as a result of hypocapnia induced
by the PPB. Intraocular pressure increases as breathing
pressure rises. It is possible that this change in intraocular
pressure provides some protection to retinal vessels during
pressure breathing.
Figure 5.9  Typical pressure-demand oronasal mask.
17/11/2015 15:33

If the nasolacrimal ducts are open during pressure
breathing the gas passes directly into the conjunctival
sacs, causing blepharospasm. The severity of the condi-
tion is related to the magnitude of the breathing pressure
and, although it is uncommon below 70  mmHg (9.3kPa),
in a small proportion of people it may interfere seriously
with vision.
In normal circumstances, the Eustachian tubes are
occluded during pressure breathing by compression of the
lower end of the tube at the pharynx. Unless the subject swal-
lows during the exposure, the tympanic membrane remains
in the normal position and auditory acuity is unchanged.
Although it is difficult to swallow during pressure breath-
ing, should it occur, gas will pass up the Eustachian tube
into the middle ear cavity. The ensuing rise in middle-ear
pressure causes the tympanic membrane to bulge out into
the external auditory canal, resulting in discomfort and
reduced auditory acuity.
As pressure breathing is used as an emergency tech-
nique to provide short-duration protection against
hypoxia at high altitudes, its onset coincides with rapid
decompression and, hence, expansion of gas in the gas-
trointestinal tract. The high pressure in the orophar-
ynx during PPB prevents the release of trapped gas
from the gastric air and thus has the potential to cause
upper-abdominal discomfort.
In summary, a suitable oronasal mask may be used to
deliver pressures of up to 70–75 mmHg (9.3–10 kPa) to the
respiratory tract, provided that the length of time for which
the pressure is applied is short (i.e. about one to two min-
utes). Breathing for longer periods or higher pressures fre-
quently gives rise to severe discomfort. On the other hand,
a pressure of 30 mmHg (4 kPa) may be breathed for longer
without undue disturbance or discomfort, although even
then pressure breathing is fatiguing.
PRESSURE BREATHING WITH A PRESSURE HELMET
A pressure helmet may be used as an alternative to the oro-
nasal mask for delivering oxygen to the respiratory tract
at pressures greater than that of the environment. Partial
pressure helmets give support to the cheeks, the floor of the
mouth and the eyes, and most of the head and the upper
part of the neck are also pressurized. Thus, the pressure dif-
ferentials that develop between the air passages and the skin
of the head and neck when an oronasal mask is employed
are eliminated and pressure breathing is symptomatically
easier. In addition, no abnormal pressure differentials are
applied to the vessels of the eyes. Some pressure helmets,
however, do not increase the pressure in the external audi-
tory meatus. Failure to provide counter-pressure to the
outer aspect of the tympanic membrane in the presence of
breathing pressures of 110–140  mmHg can be associated
with rupture of the vessels in the outer layers of the mem-
brane, giving rise to haemorrhagic bullae on its surface if
a patent Eustachian tube allows the middle-ear cavity to
become pressurized.
K17577_C005.indd 77
Prevention of hypoxia above 40 000 feet  77
Acceptable degree of hypoxia
The pressure that must be delivered to the respiratory
tract at a given altitude above 40 000 feet is determined by
the degree of hypoxia that is acceptable. This is because
two factors interact: from the point of view of prevent-
ing hypoxia, it is desirable to have a high breathing pres-
sure, but from the point of view of the cardiovascular
and respiratory stress imposed by pressure breathing,
it is desirable to keep the breathing pressure low. Two
aspects of the influence of hypoxia are of interest in the
present context. The first relates to the general mental
and physical performance of the individual and the sec-
ond to the modifications of the cardiovascular and respi-
ratory responses to pressure breathing that are induced
by hypoxia.
A complicating feature is the fact that pressure breath-
ing causes a certain degree of hyperventilation, even
in trained subjects, and if the alveolar oxygen tension is
less than 60  mmHg (8  kPa), then there is an additional
stimulus to increase ventilation. The arterial carbon diox-
ide tension therefore is usually reduced markedly dur-
ing pressure breathing at altitude. When 100  per cent
oxygen is breathed, a fall in alveolar carbon dioxide ten-
sion (caused by hyperventilation) gives rise to an equal
increase in alveolar oxygen tension. Initially, it may seem,
therefore, to increase the oxygen tension in the arte-
rial blood; however, the lowered arterial carbon dioxide
tension causes cerebral vasoconstriction and reduction
of blood flow through the brain. These changes, there-
fore, have a negligible net effect on the oxygen tension
in cerebral tissue. Furthermore, as discussed previously,
hypocapnia has undesirable effects on the circulation as
a whole and renders the subject more liable to pressure
breathing syncope.
The general mental and physical performance of groups
of subjects has been determined while pressure breathing
for two to four minutes with different intrapulmonary pres-
sure at various altitudes. The results of these studies are
summarized in Table  5.3. As will be seen, when intrapul-
monary pressure is maintained at 141 mmHg (18.8kPa) no
significant impairment was reported. If, however intrapul-
monary pressure falls below this value, increasing degrees
of impairment were observed.
When significant hypoxia is present (alveolar oxygen
tension < 60  mmHg, 8  kPa), the cardiovascular responses
to pressure breathing are modified in that the tachycardia
and increase in arterial blood pressure are greater. The most
striking effect of hypoxia during pressure breathing is, how-
ever, the increased incidence of syncope. Thus, hypoxia dur-
ing pressure breathing results in impaired performance and
an increased risk of syncope. The effects of varying degrees
of hypoxia when different degrees of body counter-pressure
are applied have been investigated thoroughly. The results
of these investigations have led to the development of vari-
ous partial pressure systems, which are discussed in the
following chapter.
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 78  Prevention of hypoxia

Table 5.3  Relationship between absolute intrapulmonary pressure and overall performance during pressure breathing

Intrapulmonary Breathing
pressure (mmHg Equivalent pressure
absolute) altitude (feet) (mmHg) Applied counter-pressure Performance
141 40 000 0–141 Trunk and lower limbs No significant impairment
130 41 600 0–70 Trunk and lower limbs Mild impairment
120 43 300 0–60 Trunk only Mild to moderate impairment
115 44 300 0–30 None Moderate to severe impairment

Ernsting J. Some Effects of Raised Intrapulmonary

SUMMARY
●● Flight is associated with the risk of hypoxia
unless appropriate equipment is provided to
achieve adequate protection.
●● A minimum acceptable concentration of oxygen is
required. To prevent a fall in alveolar oxygen ten-
sion on ascent at reduced barometric pressures, the
proportion of oxygen in the inspired gas must be
raised. The fractional concentration of oxygen in the
inspired gas should maintain, as far as possible, at
least the alveolar oxygen equivalent of breathing air
at sea-level.
●● Consider the maximum acceptable concentration
of oxygen. Using 100 per cent oxygen at all alti-
tudes is wasteful and potentially irritating. It also
increases the risk of acceleration atelectasis.
●● Oxygen equipment should allow the user to meet
all ventilatory demands that may be encountered
even with high respiratory gas flow patterns in
flight. Systems should not impose significant
external resistance to respiratory gas flow.
●● At altitudes above 40 000 feet, breathing 100 per
cent oxygen under added pressure (positive pres-
sure breathing) is required to avoid an unaccept-
able degree of hypoxia. Pressure breathing has
adverse physiological effects in the cardiovascular
and respiratory systems.
FURTHER READING
Air & Space Interoperability Council. Minimum
Physiological Requirements for Aircrew Demand
Breathing Systems. ASM4039 2010.
Ernsting J. The ideal relationship between inspired
oxygen concentration and cabin altitude. Aerospace
Medicine 1963; 34: 991–97.
Pressure. AGARDograph 106. Maidenhead, UK:
Technivision, 1966.
Ernsting J. Prevention of hypoxia-acceptable compro-
mises. Aviation, Space, and Environmental Medicine
1978; 49: 495–502.
Ernsting J. Operational and Physiological Requirements
for Aircraft Oxygen Systems. In: AGARD Seventh
Advanced Operational Aviation Medicine Course.
AGARD report No. 697. Neuilly-sur-Seine, France:
AGARD/NATO, 1983.
Ernsting J, Millar RL. Advanced Oxygen Systems for
Aircraft. AGARDograph 286. Neuilly-sur-Seine, France:
AGARD/NATO, 1996.
Gradwell DP. The Experimental Assessment of New Partial
Pressure Assemblies. AGARD-CP-516. Neuilly-sur-
Seine, France: AGARD/NATO, 1991.
Gradwell DP. Human Physiological Responses to Positive
Pressure Breathing for High Altitude Protection. PhD
thesis, University of London, 1993.
Gradwell DP. Pressure Breathing Inflation Schedules/
Ratios. Presented at Raising the Operational Ceiling
AL/CF-SR-1995-0021. Armstrong Laboratory, Brooks
Air Force Base, Texas, 13–15 June 1995.
Harding RM. Human Respiratory Responses during High
Performance Flight. AGARDograph 312. Neuilly-sur-
Seine, France: AGARD/NATO, 1987.
Lindelis AE, Fraser WD, Fowler B. Performance during
positive pressure breathing after rapid decompres-
sion. Human Factors 1997; 39: 102–10.
Morgan TR, Reid DH, Baumgardner FW. Pulmonary
ventilation requirements evident in the operation
of representative high performance aircraft. In:
Proceedings of 47th Annual Scientific Meeting of the
Aerospace Medical Association, 1970: 158.
Ryles MT, Perez–Becerra JL. The effect of positive pres-
sure breathing for altitude protection on intraocular
pressure. Aviation, Space, and Environmental Medicine
1996; 67: 1179–84.

K17577_C005.indd 78 17/11/2015 15:33


Oxygen systems, pressure cabin and clothing
DAVID P. GRADWELL AND ALISTAIR J.F. MACMILLAN
Introduction 79
Oxygen systems 79
General classes of oxygen systems 80
Oxygen system requirements 81
Oxygen equipment 82
On-board oxygen production 85
Continuous flow delivery systems 88
Demand-flow delivery systems 90
Typical oxygen systems 100
INTRODUCTION
The physiological disturbances induced by exposure to the
low environmental pressures encountered during flight
at high altitude must be reduced to a minimum. Previous
chapters have described the nature of hypobaric hypoxia
and physiological considerations associated with its preven-
tion. This chapter is concerned with the way in which those
physiological factors can be met in practice; by the use of
oxygen systems to maintain an adequate alveolar partial
pressure of oxygen despite the fall in barometric pressure
and by artificially raising the pressure environment in the
crew and passenger compartments above that of the imme-
diate environment of the aircraft. This can be provided in an
aircraft by some form of cabin pressurization. Thus, the crew
and passenger compartments of virtually all modern high-
performance combat and transport aircraft are pressurized
to some degree with air. At first sight there would appear to
be great advantages in maintaining the absolute pressure in
the cabin at one atmosphere (760 mmHg) throughout flight.
Such a requirement would, however, impose considerable
penalties with regard to the weight of the pressure cabin and
the pressurization equipment, the power required to pres-
surize the air and, hence, the performance of the aircraft.
Furthermore, the larger the pressure differential across the
wall of a cabin, the greater the risk of damage to the aircraft
and its occupants in the event of a failure of the structure.
K17577_C006.indd 79
6
Pressure clothing 106
Pressure cabins 112
Physiological requirements of pressure cabins 112
Pressurization schedules 116
Principles of cabin pressurization systems 118
Causes of failure of cabin pressurization 120
Physics of rapid decompression 121
Effects on cabin occupants 123
References and further reading 129
Therefore, it is very unusual for an aircraft to operate when
pressurized to the equivalent of sea level. Most commercial
aircraft have a maximum cabin altitude of 8000 feet and in
combat aircraft the cockpit, although pressurized, may have
an equivalent pressure to an intermediate altitude that could
induce a potentially significant degree of hypoxia. Thus, in
almost all aircraft capable of ascent to an altitude at which
hypoxia would ensue, were the occupants to be exposed to
the ambient atmosphere, provision for personal protection
against hypoxia by use of some form of oxygen system is
required. It may be worn throughout flight or it may only
be used in the event of cabin pressurization failure, such as
the emergency oxygen systems fitted to commercial aircraft.
Additionally, there are aircraft that have no cabin pressur-
ization system and their occupants use an oxygen system
whenever operating at an altitude at which hypoxia is a haz-
ard. In all cases, oxygen systems should provide hypoxia pro-
tection without unacceptable physiological consequences. It
is, therefore, appropriate to consider oxygen systems and
then examine the consequences of artificially altering the
environmental pressure to which users are exposed.
OXYGEN SYSTEMS
The development of airborne oxygen systems in fixed-
wing aircraft dates from the First World War and, over
the following decades, systems have evolved from crude
79
17/11/2015 15:37
 80  Oxygen systems, pressure cabin and clothing
and unreliable devices to sophisticated items of advanced
technology. The differing needs of military combat and
commercial passenger aircraft, and the influence of differ-
ent degrees of cabin pressurization, have implications for
the design of appropriate oxygen systems. Major develop-
ments have commonly been driven by the requirement to
enhance the facilities and protection offered to the crew
of military combat aircraft and such improvements have
thereafter been adapted for use in civil aircraft. In all cases,
the primary purpose is to ensure that the user is protected
adequately from hypoxia.
National military and civil aviation authorities usually
set out under various regulations the minimum acceptable
provision of oxygen to be carried on board aircraft regis-
tered in that state or country. In aircraft with low-differen-
tial pressure cabins (i.e. with a cabin altitude greater than
8000  feet in normal flight, such as small military combat
aircraft), personal oxygen equipment is worn routinely
and used by the aircrew throughout flight. The defini-
tion and performance of such systems in military aircraft
are addressed in relevant military documentation, e.g.
Defence Standards and Military Specifications. For com-
mercial aircraft registered in the USA, the Federal Aviation
Administration (FAA) sets out the requirement for oxygen
in various classes of aircraft under FAA Regulations (FARs
parts 25, 121 and 135). In the UK, Schedule 4 of the CAP
393  Air Navigation Order (2014) requires that equipment
that will deliver oxygen-enriched air or 100  per cent oxy-
gen to the crew be installed in all commercial (i.e. public
transport) aircraft that fly above an altitude of 10 000 feet.
Furthermore, if the aircraft is capable of maintaining its
cabin altitude below 10 000 feet, then oxygen must be avail-
able in sufficient quantity to supply all crew members and
passengers in the event of a failure of pressurization above
15 000  feet for a specified interval, and to supply all crew
members and ten per cent of the passengers if pressuriza-
tion fails below 13 000 feet. In all other aircraft, i.e. in those
that fly unpressurized, sufficient oxygen must be carried
for continuous use by all occupants whenever the aircraft is
flying above 12 000 feet and for continuous use by the crew
and ten per cent of the passengers for any period in excess
of 30  minutes during which the aircraft flies between
10 000  and 12 000  feet. In aircraft with high-differential
pressure cabins, i.e. with a cabin altitude below about
8000 feet at all times during routine flight, such as passen-
ger aircraft and large military transport or bomber aircraft,
such equipment is used only if the cabin altitude exceeds
safe limits, although emergency therapeutic oxygen may be
required by ill passengers at normal cabin altitudes.
GENERAL CLASSES OF OXYGEN SYSTEMS
Oxygen delivery systems may be classified into two major
groups: those in which the expired gas is rebreathed
(closed-circuit systems) and those in which the expired
gas is dispersed to the environment (open-circuit systems).
K17577_C006.indd 80
Conventional aircraft, both military and civil, employ the
latter almost exclusively.
Closed-circuit oxygen systems
Oxygen is extracted from inspired gas to meet the metabolic
needs of tissue oxygenation, but this demand can be met at
sea level by a relatively small proportion of inspired minute
ventilation. It is for this reason that the 16 per cent oxygen
in expired gas (cf. 21  per cent in inspired air) is adequate
to support life at sea level, as demonstrated by its use in
mouth-to-mouth resuscitation techniques. Thus, consider-
able savings in the rate of consumption of an oxygen supply
can be achieved if expired air is rebreathed from a closed
circuit after removal of carbon dioxide.
This benefit, however, decreases with altitude, and there
are at least four other potentially serious disadvantages of
such a system. The first is the need to control the flow of
oxygen into the circuit. Automation of this is difficult and
complicated. The second problem is freezing: the expired
and, frequently, the inspired, gases in a closed circuit are
saturated with water vapour. Therefore, ice may form and
occlude hoses and valves if the cabin temperature falls
below 0°C. The third problem is accumulation of nitro-
gen: an inboard leakage of air as a result of, for example,
an ill-fitting mask will lead to a progressive increase in the
concentration of nitrogen in the circuit and eventually to
hypoxia. The risk of freezing may be overcome by electrical
heating of critical components, and a slight overpressure in
the system (safety pressure) may be imposed to ensure that
any leakages are outboard; however, all of this adds to the
complexity of the system. The fourth major disadvantage
is the need to remove carbon dioxide. Chemical absorb-
ers, such as barium and lithium hydroxide, can be used,
but these are heavy and have to be renewed frequently.
Carbon-dioxide-permeable membranes have been devel-
oped, and these could reduce considerably the bulk and
inconvenience of the purification hardware, but they have
not yet been used in airborne oxygen systems although
they have a use in spacecraft.
These problems, therefore, have resulted in closed-cir-
cuit systems being used very infrequently in conventional
aviation. One exception is in some forms of smoke hood
for use in the event of aircraft fires. A number of systems
are available that incorporate a gas cylinder contain-
ing either air or oxygen and some form of carbon diox-
ide absorber. Such devices are relatively simple to operate
but may become hot, may be cumbersome to use and may
affect vision and hearing adversely. For these reasons,
they have been reserved for use by trained crew rather
than passengers.
Closed-circuit oxygen systems are employed widely
in anaesthetic, fire-fighting and underwater breathing
equipment. They are mandatory in manned spaceflight
programmes during extra-vehicular activity in which the
astronauts have to carry all their consumables.
17/11/2015 15:37

Open-circuit oxygen systems
Open-circuit oxygen systems are those in which most or
all of the expired gas exhausts to the environment. These
types are encountered commonly in aviation, and the
remainder of this description is devoted to them and the
associated equipment.
Although relatively wasteful of breathing gas, an open-
circuit system has the considerable merit, especially in
military aviation, of simplicity. There are two main types
of such systems: those in which oxygen flows from the sup-
ply source throughout the respiratory cycle (continuous
flow systems) and those in which oxygen flows only during
inspiration (demand flow systems). In both types, flow to
the user from the source passes through a crucial compo-
nent, the regulator, which essentially governs the delivery
behaviour of the entire system. The major disadvantage of
continuous-flow systems is that the flow of gas from the reg-
ulator has to be pre-set and, thus, cannot vary in response
to the respiratory demand of the user. This disadvantage is
overcome in demand systems, where the flow of gas from
the regulator varies directly with inspiratory demand.
Although a demand regulator is inherently more complex
than a regulator providing a continuous flow, it can provide
the additional automatic facilities required of oxygen equip-
ment fitted to aircraft operating at high altitudes. Therefore,
high-performance combat aircraft are generally equipped
with open-circuit demand oxygen systems, as are the flight
decks of commercial and military transport aircraft.
OXYGEN SYSTEM REQUIREMENTS
The requirements of an adequate oxygen system can be con-
sidered under two principal interrelated categories: physi-
ological and general.
Physiological requirements
The physiological requirements of oxygen systems were
described in the previous chapter. They are:
●● Adequate concentration of oxygen.
●● Adequate concentration of nitrogen.
●● Adequate flow capacity with minimal (added external)
resistance.
●● Disposal of expirate.
General requirements
SAFETY PRESSURE
The system should maintain the desired alveolar oxygen
tension even in the presence of potential inboard leakage,
such as may result from an inadequate seal between the
edge of the mask and the skin of the face. This requirement
may be met by providing a slight but continuous overpres-
sure in the mask (safety pressure), at least at altitudes above
K17577_C006.indd 81
Oxygen system requirements  81
12 000–15 000 feet, or by further oxygen enrichment of the
gas delivered to the mask, or both.
PROTECTION AGAINST TOXIC FUMES AND
DECOMPRESSION SICKNESS
The user must be able to select 100 per cent oxygen manu-
ally at any cabin altitude in the event that toxic fumes or
smoke contaminate the cockpit. This is especially the case
when ambient cockpit air is used as the diluent of 100 per
cent oxygen from the aircraft oxygen store. When decom-
pression sickness is liable to develop or symptoms have
occurred, the individual should breathe 100 per cent oxygen
and, therefore, it is necessary to prevent mixing of oxygen
with air. The method of delivery must be such as to mini-
mize any inboard leakage of cabin air because of an ill-fit-
ting mask, and it is clear that the requirement for protection
against toxic fumes and decompression sickness is interde-
pendent on the provision of safety pressure.
APPROPRIATE TEMPERATURE
The inspired gas should be neither too warm nor too cold
for comfort, and its temperature should therefore be within
5°C of cockpit environmental temperature. In practice, no
active method is used to achieve this requirement; reli-
ance is placed on equilibration of temperature during pas-
sage of the breathing gas through delivery pipework within
the cockpit.
CONVENIENCE
The operation of the system should, as far as possible, be
automatic. Ideally, the user should be required only to don
a mask (or pressure helmet) and connect it to the remainder
of the system. Similarly, facilities such as safety pressure and
pressure breathing should be provided automatically. The
drills to cope with failures of the system should be simple
to perform.
EVALUATION OF INTEGRITY
The equipment should be designed so that it is immediately
apparent to the user that there has been either a failure of
the system or appropriate drills have not been carried out
correctly. For example, ideally, it should not be possible for
the pilot of a combat aircraft to breathe through the mask
until it has been connected correctly to the rest of the sys-
tem or for the pilot to take off without having turned on
the oxygen supply. One satisfactory means of achieving
such a requirement is to ensure that inspiratory resistance
through the mask is high until it is connected to the system
and the oxygen supply is turned on. However, such devices
tend to impose an inspiratory resistance in normal opera-
tion and are less commonly seen in modern systems than
earlier ones.
The user must also be able to confirm the adequacy of
the seal of the mask both before and during flight. This
requirement is usually met by providing a manual means of
selecting some degree of positive-pressure breathing at any
altitude (termed the ‘press-to-test’ facility).
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 82  Oxygen systems, pressure cabin and clothing
INDICATION OF SUPPLY AND FLOW
The user must have a positive indication of oxygen flow
and, where appropriate, a display of the quantity of stored
oxygen so that they can monitor the correct function of the
oxygen system.
INDICATION OF FAILURE
In aircraft where the personal oxygen system provides
the primary protection against hypoxia, any failure of the
equipment that might lead to that condition must be indi-
cated immediately and clearly to the user. Such warnings
may be objective, as, for example, in the illumination of a
low-pressure warning light, or subjective, as in an increase
in inspiratory resistance on inadvertent disconnection of a
supply hose.
DUPLICATION
In aircraft with low-differential pressure cabins, in which
the personal oxygen system provides the primary protec-
tion against hypoxia, a degree of redundancy in the delivery
system is essential. Thus, many modern oxygen regulators
have a secondary regulator or a standby operating mode that
can be selected if the primary regulator fails. In addition,
an alternative oxygen supply should be provided in case the
main supply system fails or the store becomes depleted. Such
an alternative usually takes the form of a small independent
source of oxygen (emergency oxygen (EO), or backup oxy-
gen system, BOS) together with an independent delivery
regulator. The volume of oxygen contained in such an emer-
gency supply is generally based on the assumption that fail-
ure of the main supply will be followed by selection of EO
and an immediate descent to below 10 000 feet. However, in
systems incorporating a molecular sieve oxygen concentra-
tor (MSOC; see below), a larger backup or auxiliary oxygen
store may be appropriate to allow for temporary cessation
of the main supply resulting, for example, from jet engine
flameout. In modern MSOC based systems the auxiliary
oxygen bottle (AOB) or BOS may be initiated automatically
in the event of failure of the main system.
There is no requirement for such a secondary oxygen
supply in aircraft with high-differential pressure cabins,
where the cabin itself provides the primary protection
against hypoxia, and oxygen equipment is used only if cabin
pressurization fails or if toxic fumes contaminate the cabin.
PROTECTION DURING HIGH-ALTITUDE ESCAPE
In military aircraft from which abandonment at high alti-
tude is a possibility, a separate oxygen supply is needed to
protect the escapee. Clearly, the equipment must be stowed
on the individual, in the parachute pack or on the seat itself
in the case of assisted escape systems, in which the crew
member does not separate from the ejection seat until a low
altitude is reached (10 000–15 000 feet). The quantity of oxy-
gen contained in this supply must be sufficient to prevent
significant hypoxia during freefall descent or until man
– seat separation. In most military aircraft, the bail-out
K17577_C006.indd 82
oxygen supply mounted on the ejection seat also serves as
the secondary oxygen supply (EO or BOS) described above.
INDEPENDENCE FROM THE ENVIRONMENT
Oxygen equipment must perform satisfactorily under all
the environmental extremes that may be met in flight.
These inevitably include pressure changes and extremes of
temperature, especially cold. With regard to the latter, the
equipment must function normally after prolonged expo-
sure to temperatures as low as −26°C in an aircraft on the
ground and to the even lower temperatures likely after a
serious failure of cabin pressurization at high altitude (down
to −56°C). In combat aircraft, the mask or pressure helmet
must not be displaced from the face or head by exposure to
the maximum sustained accelerations (G forces) produced
by the aircraft in normal flight or by exposure to the accel-
erations and windblast (Q forces) associated with an escape
while flying at high speed. Furthermore, the mask valves
must continue to function normally under such conditions.
UNDERWATER BREATHING
Aircraft that ditch in water usually sink rapidly. Therefore,
oxygen equipment frequently is designed to provide
breathing gas down to a certain depth (generally 30  m),
and some air forces also require the bail-out oxygen sup-
ply to protect an individual who has entered water after a
parachute descent.
ECONOMY OF WEIGHT, BULK AND COST
The weight, bulk and cost of military aircraft installations
are critical logistic design features and so must be mini-
mized within the constraints of safety. This is particularly
so with regard to conventional oxygen storage systems.
Clearly, therefore, physiological requirements should not
be met at the expense of wastefully high flows of oxygen
and for equally sound ground-logistic reasons, too frequent
replenishment of on-board systems should not be necessary.
OXYGEN EQUIPMENT
Figure 6.1 lists the various general components of a typical
oxygen system. This section describes each of these in turn.
Oxygen sources
Airborne oxygen may be obtained from a store that is
replenished while the aircraft is on the ground or it may
be produced as required in flight by some physicochemical
means. In storage, it may exist as a gas under high pressure,
as a liquid at low temperature under moderate pressure, or
as a solid in inert chemical combination. Both gaseous and
liquid oxygen stores are in common use in military aviation,
while gaseous oxygen is commonly the preferred medium
for the emergency store on board commercial aircraft. Solid
oxygen stores are also used in commercial aircraft, particu-
larly as the emergency supply for passenger use in the event
of loss of cabin pressurization. Finally, several methods
17/11/2015 15:37

Oxygen source Charge point
Contents/pressure gauge
Filters
Pressure reducing valves
Personal equipment connector
(if appropriate)
Figure 6.1  Generic components of typical oxygen systems.
of concentrating oxygen on board an aircraft, from an air
source, have been actively investigated; one of these meth-
ods, MSOCs outlined above, is now installed in many mod-
ern combat aircraft. Portable oxygen concentrators are also
being used to provide therapeutic oxygen for sick passen-
gers in commercial flights, especially when the requirement
is known and the system ordered in advance of the flight
(see below).
For rechargeable systems, whatever the source of breath-
ing oxygen, the quality of the gas to be supplied must be of a
high standard. It must contain at least 99.5 per cent oxygen
and be odourless and virtually free of any toxic substances,
e.g. the carbon monoxide concentration must be less than
0.002  per cent. The maximum allowable levels for various
hydrocarbons are specified in relation to the type of stor-
age used, since this will influence the potential contamina-
tion hazard. In order to avoid the risk of ice formation at
low temperatures, the stored oxygen must also be very dry:
the water content must not exceed 0.005 mg/L at 00C and
760 mmHg (101.3 kPa) (that is, under STP conditions).
GASEOUS OXYGEN STORAGE
Gaseous oxygen usually is carried in steel cylinders at a
pressure of 1800  lb/in2  (12 411  kPa), although other pres-
sures and storage materials have been used, especially
higher pressures in some combat aircraft, in an attempt
to overcome some of the disadvantages of liquid oxygen
(LOX). The capacities of cylinders commonly used in air-
craft vary between 400 and 2250 L (normal temperature and
pressure, NTP) of oxygen when charged fully to 1800  lb/
in2 (12 411 kPa).
The aircraft oxygen cylinders are charged from large trol-
ley-mounted cylinders, filled with oxygen at a maximum
pressure of 3600 lb/in2 (24 822 kPa), through a connection,
fitted with a sealing cap and an on/off valve, mounted at or
just beneath the outer skin of the aircraft. The pressure and
flow of gas into the aircraft system are controlled by a regu-
lating device on the charging trolley, while the quantity of
K17577_C006.indd 83
Oxygen equipment  83
On-board store/source
Pipework
(high/medium pressure)
Demand regulator
Pipework (low pressure)
Emergency oxygen supply
Oronasal mask
oxygen on board is indicated by a cockpit pressure gauge
connected to the main high-pressure supply pipework. A
duplicate pressure gauge is often fitted at the charging point,
and both gauges usually are graduated in fractions of ‘Full’,
mounted at or just beneath the outer skin of the aircraft.
The pressure in a gaseous oxygen storage system should not
normally be allowed to fall to ambient, to prevent moisture
entering the system. The risk of water collecting in storage
cylinders is also reduced by regular purging of the entire
system, including pipework, with dry gas.
The size and number of cylinders installed, usually out-
side the pressure cabin, clearly will depend on the type of
aircraft and its flight endurance. In military aircraft, the
cylinders frequently are wire-wound to minimize shatter-
ing if hit by a projectile. The pipework connecting the cylin-
ders to the delivery system is usually duplicated and, where
two or more cylinders are installed, contains non-return
valves arranged in such a way that a leak from one cylinder
or junction will lead to only a partial loss of oxygen. The
pressure of the oxygen is decreased by the use of reducing
valves from the storage pressure to that required at the inlet
to the demand valve, commonly between 70  and 200  lb/
in2 (483–1380 kPa).
Gaseous oxygen storage systems have several important
advantages over other forms. They are relatively simple in
construction and, therefore, inherently more reliable, gas-
eous oxygen is readily available worldwide, the on-board
supply is available for use immediately after charging, and
no gas is lost when the system is not in use. Even the gaug-
ing of the contents of a gaseous store is simpler than a liq-
uid store. The major disadvantage, however, is that they are
heavy and bulky. Table 6.1 illustrates this by comparing typ-
ical weights and overall volumes of different types of oxygen
storage system.
Despite these logistic penalties, gaseous oxygen storage is
the system of choice when weight and bulk are not at a great
premium or when the supply is intended only for use in
an emergency (and consequently is relatively small). Thus,
17/11/2015 15:37
 84  Oxygen systems, pressure cabin and clothing
Table 6.1  Comparison of typical weights and overall
volumes of oxygen storage/supply systems of various
types. The figures for gaseous, liquid and solid chemical
sources are for systems each yielding 3000 L (NTP) of
oxygen; yield figures for molecular sieve systems are not
applicable.
Weight of Space
charged occupied by
Storage system system (kg) system (L)
High-pressure cylinders 19 52
containing gas at 1800
lb/in2
Liquid oxygen converter 8 25
containing 3.5 L of
liquid
Solid chemical generator 12 10
containing sodium
chlorate
Molecular sieve oxygen 19 20
concentrator
gaseous oxygen storage is commonly used in the emer-
gency supply to the crew and passengers on large trans-
port aircraft and as the emergency and bail-out supplies in
combat aircraft. In addition, portable and therapeutic sys-
tems generally are supplied from a small gaseous oxygen
storage cylinder.
LIQUID OXYGEN STORAGE
For many years, LOX storage was the mainstay of military
combat aircraft oxygen systems. This arose from its ability
to yield 840 L (NTP) of gaseous oxygen for each 1 L of liquid
oxygen, an expansion ratio almost seven times greater than
that for gaseous oxygen stored at 1800 lb/in2 (12 411 kPa). In
addition, the low pressure at which LOX can be held in its
insulated container (typically at 70–115 lb/in2, 483–793 kPa)
markedly reduces the overall weight of liquid oxygen stor-
age devices when compared with gaseous oxygen cylinders
(see Table 6.1). However, to achieve the liquid state, oxygen
must be cooled to a temperature below −183°C at normal
atmospheric pressure, i.e. its vaporization point. Much of
the LOX is wasted before use; furthermore, it is a difficult
and potentially hazardous material to handle. LOX produc-
tion plants have been subject to a number of serious fires,
both on land and on aircraft carriers at sea. Therefore,
although it remains in use, most of the latest generation of
combat aircraft do not have LOX systems but use molecular
sieve oxygen concentrator systems (MSOCs). Nonetheless,
the basic principles of LOX systems and their components
are outlined below.
An aircraft LOX converter consists of an insulated con-
tainer, control valves and connecting pipes (Figure  6.2).
The converter may be installed permanently in the aircraft,
or it may be removable so that there is a choice of either
replacement or recharging in situ. The LOX is contained
in a double-walled stainless steel vessel with connections
K17577_C006.indd 84
through its walls at top and bottom. The capacity of the ves-
sel varies according to the total amount of gaseous oxygen
required during flight, but typically it will be 3.5, 5, 10 or
25 litres. The space between the vessel walls is evacuated to
minimize convective and conductive heat transfer to the
LOX. Operation of a LOX converter takes place in three
distinct phases:
1. Filling phase: when the charging hose from the ground
LOX dispenser is first connected to the vessel, LOX
passes into the container and evaporates. This evapora-
tion cools the internal walls of the system, eventually
to –183°C. Evaporation then ceases and the container
rapidly fills with liquid oxygen.
2. Build-up phase: after disconnection of the charging
hose, the top and bottom of the vessel are connected by
an uninsulated pipe. LOX is now able to flow from the
bottom of the container into a pressure build-up coil,
where it evaporates, and, thence, into the top of the
vessel as a gas. The heat carried in by the gas warms the
surface layer of the liquid so that its vapour pressure
rises. This process continues until the pressure within
the container reaches the operating pressure of the
converter, i.e. 70–115 1b/in2 (483–793 kPa). The pressure
closing valve then shuts, and the flow of LOX into the
pressure build-up coil ceases.
3. Delivery: when a demand is made upon the system, gas
is drawn from the top of the container, via a pressure-
opening valve, to the delivery supply line and so to the
user. Should the demand be so great as to cause the pres-
sure within the container to fall below its normal level,
LOX again passes into the pressure build-up coil, where
it evaporates and carries gas and heat back to the top of
the vessel, thus restoring the normal operating pressure.
The insulation of a LOX converter is never absolute, so
that its temperature and, hence, the pressure of its contents
rise slowly. A relief valve is fitted to limit this pressure rise,
Figure 6.2  Typical liquid oxygen converter of
10 L capacity.
17/11/2015 15:37

and this opens at 20–30 lb/in2 (138–207 kPa) above nor-
mal operating pressure. Such a pressure is usually attained
10–12 hours after filling, and thereafter up to 10 per cent of
the liquid is lost in a 24-hour period.
The amount of LOX in the vessel is monitored con-
tinuously by means of a probe immersed in the liquid and
gaseous oxygen mixture, which measures the electrical
capacitance between the two containing shells. The output
of this capacitance probe is displayed in the cockpit and at
the charging point for use during in situ refilling. The pres-
sure at which gaseous oxygen is delivered to the main supply
line is usually also displayed to the crew, or there may be a
low-pressure warning device.
One major disadvantage of the simple converter described
above is that any agitation of the vessel within six to eight
hours of filling will produce a gross fall in delivery pressure
as a result of a phenomenon termed temperature stratifica-
tion. The agitation, which may be caused by the vibration
of aerobatic manoeuvres or even while taxiing, disturbs the
warm layer of liquid at the liquid–gas interface, so bringing
colder layers of liquid into contact with the gas, which then
condenses. Pressure consequently falls in the gaseous phase.
This drawback may be overcome by adding sufficient heat
to the contents of the container immediately after filling to
raise the temperature of the liquid to that at which its vapour
pressure equals its normal operating pressure; for liquid
oxygen with a vapour pressure of 85  lb/in2  abs (586  kPa),
for example, the appropriate temperature would be −160°C.
The contents of the container are then said to be stabilized.
The heat required for this stabilization is derived from the
evaporation of LOX delivered to a separate, uninsulated
container during the charging process. As soon as filling is
complete, this liquid boils and the gas bubbles up through
the liquid in the main container, condenses in so doing and
heats all the liquid in the vessel to the required temperature,
thus eliminating the temperature stratification. Stabilized
LOX converters are installed mainly in combat aircraft.
The gaseous oxygen is warmed as it flows through the
delivery pipework from the LOX converter into the pressure
cabin and to the crew. This dictates that there must be either
a minimum length of pipework to ensure that this warming
can occur or a heat exchanger has to be incorporated in the
system within the warm pressure cabin to ensure that the
temperature of the gas delivered to the pilot meets the gen-
eral requirement described above.
The transfer of liquid oxygen from the production plant
to the aircraft is wasteful, complex and expensive. It is esti-
mated that only 10 to 15 per cent of the liquid oxygen pro-
duced in a LOX reaches a converter in an aircraft.
A serious potential hazard of LOX is contamination by
toxic materials, including the oxides of nitrogen and car-
bon, hydrogen sulphide and hydrocarbons. Such contami-
nation is derived from the atmospheric air from which
the LOX is produced, from plant compression and refrig-
eration equipment, and from storage, transport and other
handling equipment. These contaminants do not evaporate
at the same time as LOX and they can accumulate in the
K17577_C006.indd 85
On-board oxygen production  85
container. Eventually, particles or ‘slugs’ of contaminant
may pass from the vessel into the warming coils, where they
evaporate and may then be breathed by the user in relatively
high concentrations. Great care must be taken, therefore,
to eliminate the entry of contaminants during the manu-
facture and transfer of LOX; once in an aircraft converter,
control must be exercised to ensure that the concentration
of any contaminant remains very low. Routine infrared
spectroscopy during ground replenishment is the preferred
method used to monitor contamination.
The complexity of LOX systems results in a relatively
high rate of failure of components. This and the other sig-
nificant disadvantages noted above made LOX the storage
method of choice only when the weight and bulk of the oxy-
gen container must be as small as possible, and when oxy-
gen is used routinely throughout flight, as in combat fighter
aircraft. One further benefit of LOX converters in this role is
that the container, essentially a vacuum flask, is unlikely to
explode if punctured by enemy action. However, although
LOX systems still exist in some in-service combat aircraft,
they are now becoming less common as a result of the adop-
tion of on-board generation, commonly through the use of
molecular sieve technology.
ON-BOARD OXYGEN PRODUCTION
The need to replenish the oxygen store of an aircraft imposes
considerable operational and logistic penalties on both mil-
itary and civil aviation. There are also significant fire haz-
ards associated with the production and replenishment of
oxygen, especially during military operations. Because of
these disadvantages, the on-board production of oxygen
is desirable, and several methods of so doing have been
explored, with varying degrees of success. Developments
in on-board generation started in the manned space pro-
gramme of the 1960s. A number of different technologies
have been pursued, but they may be divided conveniently
into those that are dependent on a supply of compressed air
and those that are not.
Air-independent systems
SOLID CHEMICAL OXYGEN GENERATION
When a mixture of sodium (or potassium) chlorate and
finely divided iron is ignited, a proportion of the oxygen
contained in the sodium chlorate molecule is released
as gaseous oxygen, the reaction proceeding according to
the equation
NaClO3 + Fe = FeO + NaCl + O2
The reaction is exothermic, so once the temperature of
the reactants has been raised above 250–600°C, it is self-
generating. The proportion of iron in the mixture controls
the temperature, speed of reaction and oxygen yield.
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 86  Oxygen systems, pressure cabin and clothing
The reaction proceeds at a temperature of 250–600°C
over the cross-sectional area of the candle, and oxygen is
produced at a rate that is influenced both by the size of this
area and by the degree of insulation of the device.
This chemical property has been used as the basis of
devices which when initiated will produce oxygen rapidly.
The sodium chlorate and iron powder are usually cast or
pressed together with an inorganic binder, such as fibre-
glass, into a cylindrical mass termed a candle. The heat
required to initiate the reaction is provided by a small iron-
enriched zone at one end of the candle which is activated
by a percussion cap, an electric squib, a friction lighter or
an electrically heated wire. The reaction proceeds at a tem-
perature of 250–600°C over the cross-sectional area of the
candle, and oxygen is produced at a rate that is influenced
both by the size of this area and by the degree of insulation
of the device. Thus the desired oxygen flow-time relation-
ship can be obtained by shaping the candle. Free chlorine,
carbon monoxide and carbon dioxide may all contaminate
oxygen produced in this manner, but the inclusion of a
small percentage of barium peroxide neutralizes these sub-
stances so that the purity of oxygen produced by a candle
made of a sodium chlorate/iron/barium peroxide mixture
approaches 99.9 per cent with no significant concentration
of toxic contaminants.
Once ignited, a sodium chlorate candle provides a con-
tinuous flow of pure oxygen and is not extinguished easily.
This form of oxygen storage, therefore, is most appropri-
ate for use in situations where a constant flow of oxygen is
required for a specified period as, for example, in emergency
oxygen supplies for aircraft passengers. In such cases, the
cylindrical candle, with a suitable igniting mechanism fit-
ted to one end, is enclosed in a gas-tight container within
a thermally insulated shroud. A unit designed to provide
oxygen for ten passengers for 30 minutes, i.e. a total oxygen
supply of 1300 L (NTP), would be 22 cm in length and 15 cm
in diameter and weigh about 6 kg (see also Table 6.1).
The advantages of this form of oxygen storage include its
simplicity (since oxygen can be delivered without the need
for reducing valves or regulators), its almost unlimited shelf-
life, its relatively small bulk and the absence of a need for
routine servicing. The sodium chlorate candle is also inert
at temperatures below 250°C, even under severe impact
loads. Once initiated, oxygen delivery continues unabated.
Although it is possible to devise a means whereby a solid sys-
tem can be used to supply oxygen on demand (by the use of
multiple candles and a reservoir), the complexity, weight and
bulk of such an arrangement make it unsuitable for use as the
primary supply in combat aircraft. Furthermore, although
in general when handled correctly each candle is associated
with a relatively low fire risk, there have been reports impli-
cating oxygen candles in on-board fires in aircraft.
ALKALI METAL SUPEROXIDES
When treated with water, potassium superoxide liberates
oxygen to form potassium hydroxide. This chemical reac-
tion forms the basis of the use of this system in self-contained
K17577_C006.indd 86
breathing escape devices. The moisture of the breath reacts
with the superoxide to generate oxygen, and in a convenient
co-reaction the potassium hydroxide formed reacts with
expired carbon dioxide to give potassium carbonate.
REVERSED FUEL CELL AND OTHER SYSTEMS
The normal processes whereby electricity is generated as
the energy released when hydrogen and oxygen combine
may be reversed by supplying electrical power to a fuel cell.
In this so-called reversed fuel cell, oxygen is produced at
the anode and hydrogen at the cathode. Hydrogen is then
oxidized to water by combination with oxygen in the air
flowing over the cathode. A reversed fuel cell capable of pro-
viding 26 L (NTP)/min of oxygen at 300by electri2  (2068–
2758 kPa) would require a supply of clean moist air at 25 lb/
in2 (172 kPa), would consume about 7 kW of electrical power,
and would weigh about 30 kg. A power requirement of this
magnitude makes such a system operationally impractical
in the aviation environment.
Air-dependent systems
A number of air-dependent oxygen-generating techniques
including: electrochemical oxygen concentration, praseo-
dymium-cerium oxide systems and barium oxide (Brin
process), have been investigated but not developed beyond
laboratory studies. A fluomine (a chelate of cobalt) system
was developed in the 1970s for airborne use and flight-
tested. Such a system could generate oxygen in dual cyclic
heat-exchange beds. While one bed was absorbing oxygen,
the other was desorbing it; in one development of this prin-
ciple, a unit capable of delivering 26 L (NTP)/min oxygen
of 98.5 per cent purity was tested successfully in flight. The
disadvantage of the system is its high cost, its relatively
short lifecycle (300 operating hours) and a tendency to pro-
duce small quantities of noxious chemicals. This system,
therefore, has been surpassed by pressure-swing adsorption
systems, as described below.
PRESSURE-SWING ADSORPTION (MOLECULAR
SIEVE OXYGEN CONCENTRATION SYSTEMS)
Molecular sieves are alkali-metal aluminosilicates of the
crystalline zeolite family. They consist essentially of very
regular tetrahedral structures of SiO4  and AlO4  linked
by cations of sodium or calcium to form cages or cavities,
which are normally filled by water molecules. These crys-
tals can be produced synthetically and can be tailor-made
in terms of the size of the cage entrances and cavities, which
vary according to the precise chemical structure of the zeo-
lite. When the sieve material is heated, the water molecules
are driven off to leave an open structure with the affinity
to adsorb polar molecules. The adsorption of a substance
depends not only upon its degree of polarity but also upon
its molecular size; clearly, then, if the molecule is too large to
enter the cage, it cannot be adsorbed. The two most common
types of sieve material that currently are in use are the so-
called 5A and 13X. The former has some of its sodium atoms
17/11/2015 15:37
 On-board oxygen production  87

Reducing
valve Non-return valve
Rotary
valve
1
Molecular sieve Plenum
Air
2 Bed 2
supply
Purge
orifice
Product
3 Molecular sieve
Filter
4 Bed 1 Filter

Non-return valve
Exhaust to
ambient

Figure 6.3  Mode of operation of a simple two-bed molecular sieve oxygen concentrator (MSOC). In this schematic
molecular sieve, bed 1 is being pressurized via line 3 and delivering oxygen-rich product gas to the plenum before passing
to the user. A large bleed flow of product gas is diverted to purge nitrogen from molecular sieve bed 2, via orifice * and
line 1, in readiness for that bed’s pressurization via line 2 when the control valve rotates. Line 4 then becomes the purge
route from bed 1 via orifice *.

replaced by calcium, which results in a smaller cage entrance The first operational two-bed MSOC used in the UK,
(4.9×10−4 µm) than that of the 13X material (1×10−3 µm). capable of supplying the varying breathing requirements
The adsorption process is an exothermic reaction and is of a single pilot, weighed less than 19 kg, consumed about
dependent upon both pressure and temperature. An increase 50 W of 28 V DC electrical power, and occupied a volume
in pressure generally enhances adsorption, while an increase of about 20  L which is less than that of a 3.5  L LOX con-
in temperature causes a decrease. In MSOC devices, the verter. Such a device, therefore, represented an extremely
oxygen and nitrogen are separated by virtue of the fact that attractive alternative to the LOX storage devices previ-
nitrogen, despite its slightly larger molecular size, is held ously in common use. MSOC technologies are now the
more strongly within the sieve cage than oxygen. The cage standard form of oxygen system installed in modern com-
structure, especially when pressurized, induces a quadru- bat aircraft, including the latest generation of agile fighter
pole moment in the nitrogen molecule, thus enhancing its aircraft. Units, such as that illustrated in Figure  6.4, have
adsorption energy and producing an oxygen-rich and argon- achieved further savings in the weight, volume and energy
rich gas phase around the sieve. Since argon also passes requirements of the MSOC by arranging the sieve beds
through the sieve, the product gas in such a system contains a in very close proximity to one another or even, as in the
maximum of about 94 per cent oxygen, the remainder being example shown, by arranging them concentrically.
argon. By using a pressure-swing technique, whereby the The principal disadvantage of this form of oxygen pro-
molecular sieve bed is alternately pressurized and depressur- duction is that a failure of engine bleed air supply, as, for
ized, complete separation can be achieved. Furthermore, the example, during an engine flameout in a single engine
adsorption of nitrogen is reversible and without a chemical
bond being formed between nitrogen and the bed material.
Thus, the bed can be purged of the gas during the depres-
surized phase. The adsorption of more polar molecules such
as water (when in contact with the sieve material for some
time) is irreversible, however, and so water contamination
will deactivate a molecular sieve.
An oxygen concentrator of this type usually consists
of two or more beds of molecular sieve material, through
each of which, in turn, conditioned compressed air from
an engine bleed source is passed. Thus, in the two-bed sys-
tem illustrated in Figure 6.3, one bed is depressurized and
purged of its nitrogen (by means of a bleed flow of prod-
uct gas from the pressurized bed) in readiness for oxygen
concentration during its next pressurized phase, while the
other bed is producing oxygen-enriched breathing gas. The Figure 6.4  Advanced molecular sieve oxygen concentra-
supply of product gas, therefore, is continuous, and any tor, in which three beds are arranged concentrically to
reduce volume.
small fluctuations in delivery pressure may be minimized
by the presence of a plenum chamber. Photograph courtesy of Honeywell International Inc.

K17577_C006.indd 87 17/11/2015 15:37

 88  Oxygen systems, pressure cabin and clothing
aircraft, clearly will result in a failure of the molecular
sieve to produce oxygen. This drawback can be overcome
by the provision of a gaseous backup oxygen store that can
be selected automatically if air supply to the concentrator
is lost. Such a backup supply is also required to provide an
immediate source of 100 per cent oxygen to prevent hypoxia
following decompression of the cabin to an altitude above
25 000–30 000  feet as the speed of response of the sieve is
inadequate in these circumstances. The same gaseous auxil-
iary bottle or backup store (AOB or BOS), if mounted on the
ejection seat, can be used to supply the crew with oxygen if it
becomes necessary to eject from the aircraft at high altitude.
In contrast to the potential lack of an adequate oxy-
gen concentration, an MSOC product gas concentration
of 94 per cent is too rich for routine flight at normal cabin
altitudes. It is, thus, necessary to provide a means of reduc-
ing the concentration of oxygen in the gas delivered to the
pilot. Several generic techniques are available for the con-
trol of oxygen concentration in the product gas. The vari-
ous methods used vary according to the precise design of
the sieve system employed, but the techniques used have
common principles and are based on the factors that may
influence product gas composition. One method that was
used successfully in the first generation of MSOC combat
aircraft exploits the characteristic of molecular sieve behav-
iour, whereby the concentration of oxygen in the product
gas is reduced if the flow demanded through the system is
increased. Artificially increasing the flow through the sieve,
therefore, has the effect of reducing the oxygen concentra-
tion in the MSOC product gas. This technique is, however,
wasteful. Currently, the more preferred method is to vary
the bed charge and purge cycle times, either by continu-
ous variation of cycle times or by appropriate selection of
fixed fast and slow cycles. Further alternatives are to alter
the purge flow, varying the control of inlet or exhaust flow
and pressure control, or even to mix product gas with air as
in a conventional air-mix breathing regulator. In all but the
last case, the concentration of oxygen in the product gas is
monitored and used in the control of operation of the sieve.
Considerable effort has been expended in the development
of suitable oxygen sensors for airborne use in the control of
MSOC systems. These closed-loop controls have employed
a number of different sensors based on a range of physical
principles, including gas-fluidic properties, polarity and
paramagnetism, to measure the product oxygen concen-
tration. Sophisticated zirconia solid-state monitors using
variations in the oxygen molecular occupancy of mem-
brane vacancies have been introduced into service in some
MSOC control systems. In each case, the control method
and operation of the sieve unit must be robust and reliable
under the wide range of environmental challenges associ-
ated with in-flight conditions.
The use of MSOC systems as the source of breathing
gas for the crew of a military aircraft has implications for
the mode of operation of the individual pressure-demand
breathing regulator and for the selection of safety pressure
(see below). Where the oxygen concentration required to
K17577_C006.indd 88
meet the physiological demands of the aircrew is controlled
within the MSOC system itself, it is clearly inappropriate
for further dilution of the oxygen concentration to occur
within the regulator. In addition, given the inexhaustible
supply of breathing gas available from an MSOC, it is highly
advantageous to have safety pressure applied from ground
level. Both of these features allow very considerable simpli-
fication of the demand regulator used to control the flow of
breathing gas to the pilot.
The logistic advantages of an MSOC generally outweigh
its disadvantages and can be summarized thus:
●● Reduction of equipment and staffing costs by elimi-
nating ground manufacture, transport and storage
of oxygen.
●● Further reduction of staffing costs and speedier, safer
turnaround of aircraft by eliminating the need for
ground replenishment of the oxygen store.
●● Reduction in frequency of routine maintenance
of the oxygen system, as a result of an increase in
overall reliability.
●● Simplification of breathing gas demand regulator and
hence reduced unit cost but increased reliability.
MSOC systems have become the system of choice for
single- and multi-crew military combat aircraft. However,
there has been criticism of the oxygen systems of some of
the most modern combat aircraft in which a number of
hypoxia-like episodes have been reported. (West 2013).
Investigations into the possible interaction between on-
board aircraft computer control systems and the operation
of the oxygen system are being conducted. Furthermore,
some of the logistic advantage of MSOC systems is lost if
there is frequent reversion to a backup oxygen storage in
routine operations as this cylinder will need to be refilled if
its contents fall below a specific minimum.
In much simpler forms MSOCs are also used as a source
of therapeutic oxygen on some commercial aircraft. In the
latter case, a portable unit incorporates its own compressor
powered from the cabin electrical systems or batteries and
uses cabin air as its gas source. Some airlines allow their use
by passengers who have such a device or provide them on
request. The use of self-contained MSOC units for provision
of therapeutic oxygen removes the logistic problems associ-
ated with the provision of cylinders of oxygen for a hypoxic
passenger on a long flight.
CONTINUOUS FLOW DELIVERY SYSTEMS
From whatever source the breathing gas is derived, the sim-
plest way that it can be delivered to the user is by a con-
tinuous-flow system, whether by direct flow or via some
form of rebreathing or non-breathing reservoir. Although
continuous-flow systems have advantages in that the accu-
rate prediction of oxygen consumption is possible and the
resistance imposed to breathing is relatively low, direct-flow
systems are extremely wasteful of breathing gas. They are
17/11/2015 15:37

also, by their nature, inflexible because to meet the possible
range of ventilatory demands that may be made requires a
gas flow of such a volume as to potentially be distracting
and inevitably this is wasteful of a limited store. Failure to
meet ventilatory demands, however, would induce respira-
tory discomfort, as described in previous chapters. Adding a
reservoir between the flow regulator and the mask decreases
the rate of consumption of the aircraft oxygen store by 50–70
per cent. It is very difficult, however, to provide a continu-
ous flow delivery system incorporating the automatic provi-
sion of pressure-breathing at very high altitudes.
Direct-flow systems
The most elementary form of continuous flow oxygen sys-
tem consists of an oxygen store, a regulating device which
delivers a continuous flow of oxygen, a flexible delivery hose
and a nasal or oronasal mask or nasal cannulae. Nasal can-
nulae have been in use in clinical settings for some con-
siderable time but are now used under certain conditions
for the delivery of therapeutic oxygen to commercial air-
line passengers. Nasal cannulae systems have a number of
advantages over mask systems, including being less con-
spicuous in their use. With a continuous oxygen flow of
2–4 L/min many clinically compromised passengers may be
protected from hypoxia at normal cabin altitudes. A refine-
ment of this system, termed pulse dose delivery (Figure 6.5)
releases a bolus of oxygen when a pressure fall induced by
an inspiratory effort is detected through the cannulae at the
regulating device incorporated into the system. The bal-
ance of the ventilatory demand is met through inhalation of
cabin air as is described in more detail below. There may be
a requirement to confirm that the patient can generate suf-
ficient inspiratory effort, and its associated pressure drop, to
initiate the delivery from a pulse dose system. Some form of
Figure 6.5  An example of a pulse dose oxygen system that
releases a bolus of oxygen when a pressure fall induced by
an inspiratory effort is detected through the cannulae at
the regulating device incorporated into the system.
Photograph courtesy of Aeromedic Innovations Ltd.
K17577_C006.indd 89
Continuous flow delivery systems  89
suitable alarm should alert the user or a companion if the
expected delivery is not taking place.
When a mask system is used for therapeutic or other
purposes the mask has apertures, which may be controlled
by valves, through which air can be drawn into the lungs
when the demanded inspiratory flow exceeds the flow of
oxygen from the system. The same apertures allow expired
gas to be expelled to the environment.
This form of oxygen system is very inefficient, since oxy-
gen flowing into the mask during expiration, which occu-
pies 50–60 per cent of the total respiratory cycle time, does
not enter the respiratory tract at all. Even during inspira-
tion, oxygen flowing into the mask will enter the lungs only
when the instantaneous inspiratory flow equals or exceeds
the oxygen flow. To ensure that no air is inspired, therefore,
the oxygen flow must exceed the maximum inspiratory
flow, which is usually about two to three times the respi-
ratory minute volume and increases to about ten times
during speech.
Despite their inefficiency, direct-flow systems are very
simple and have been used widely to provide bail-out and
EO in combat aircraft. A typical oxygen system of this type
consists of a small cylinder containing about 55 L (NTP) of
gaseous oxygen stored at 1800 lb/in2 (12 411 kPa), a contents
gauge, an on/off valve, a metering orifice, and a delivery
pipe to the inlet hose of the mask. Flow from such an EO
cylinder is then triggered on ejection. More commonly, in
modern ejection-seat EO systems the oxygen is delivered
through a demand regulator (see below), and the pilot con-
tinues to breathe through this until pilot–seat separation
occurs, at an altitude at which supplemental oxygen is no
longer required.
Rebreathing reservoir systems
The efficiency of a continuous-flow oxygen system is
enhanced greatly by incorporating a reservoir between the
regulating device and the inlet port of the mask. In rebreath-
ing reservoir systems, a flexible reservoir is placed in direct
communication with the cavity of the mask, as shown in
Figure 6.6. The addition of a reservoir ensures that all the
oxygen flowing from the regulating device enters the respi-
ratory tract during inspiration, provided that, as with direct
continuous-flow systems, pulmonary ventilation equals or
exceeds the flow of oxygen.
In this type of system, oxygen is delivered continuously
from the regulating device into the reservoir bag. The mask
usually has a single aperture, which may not be controlled by
a valve and through which air may be drawn into the mask
if inspiratory demand exceeds the volume of gas in the res-
ervoir. Excess oxygen and expired gas are expelled from the
mask through the same aperture, which has a resistance to
flow deliberately greater than that acting against flow from
the reservoir. Thus, the contents of the latter enter the respi-
ratory tract at the beginning of each inspiration before any
air is drawn in. Similarly, during expiration, the first part
of the expirate passes into the reservoir, and only when this
17/11/2015 15:37
 90  Oxygen systems, pressure cabin and clothing
Oronasal mask
Air top-up and
expiratory port
Rebreathing
bag
Continuous flow
of oxygen
Figure 6.6  Simple rebreathing reservoir oxygen mask.
Oxygen passes at a constant flow into the distal end of
the rebreathing bag. The first portion of the expirate fills
the bag, while the remainder flows out through the expi-
ratory port. The contents of the bag pass into the respira-
tory tract at the beginning of inspiration to be followed
by the continuous flow of oxygen supplemented with air
drawn in through the air inlet (top-up) port.
is full is expired gas expelled to the environment. In addi-
tion, oxygen flow into the reservoir bag is directed to that
part that is furthest from the mask cavity, so that oxygen
entering the reservoir during expiration displaces any pre-
viously expired gas. At the levels of oxygen flow employed,
the volume of oxygen that enters the reservoir during expi-
ration is less than the volume of the reservoir, so that a part
of the previously expired gas is re-inspired. The gas that is
rebreathed clearly includes that which was held in the respi-
ratory dead space during the previous inspiration, and so
it has a higher oxygen tension and a lower carbon dioxide
tension than the alveolar gas. Rebreathing using this type of
system increases oxygen economy, but at the expense of an
increase in the effective respiratory dead space.
Rebreathing reservoir continuous-flow oxygen equip-
ment was used extensively in US combat aircraft during the
early 1940s, but its use had several serious disadvantages,
including freezing, an inability to respond appropriately to
changes in pulmonary ventilation, a lack of indication of
gas flow into the mask, an inability to incorporate pressure
breathing and difficulties associated with mask leaks, which
negated the value of the reservoir at all. Because of these
drawbacks, rebreathing reservoir oxygen equipment is now
used mainly for the administration of therapeutic oxygen to
patients in flight and to prevent hypoxia in passengers fol-
lowing loss of cabin pressurization in transport aircraft. The
K17577_C006.indd 90
oxygen flow supplied to this type of equipment is increased
from about 2 L (NTP)/min at a cabin altitude of 20 000 feet
to about 4.5  L (NTP)/min at 40 000  feet, a volume that is
adequate to prevent serious hypoxia developing in a seated
passenger. Finally, it is assumed that a decompression is very
unlikely to be so severe that the cabin temperature cannot
be maintained above 0°C, and the impaired performance of
the system below −5°C therefore is of no consequence.
Non-rebreathing reservoir systems
In non-rebreathing reservoir systems, a non-return valve is
placed between the reservoir and the cavity of the mask so
that expired gas cannot enter the reservoir. As in rebreath-
ing systems, the mask has apertures, which may or may not
be controlled by valves, through which air can be drawn
into the respiratory tract to augment the oxygen supply and
expired gas is expelled to the environment. To ensure that
air is not drawn into the lungs until the oxygen reservoir has
been emptied, the reduction in mask pressure required to
draw air through the air-inlet aperture must again be greater
than that required to empty the reservoir. The correct phas-
ing of oxygen and air delivery during inspiration usually
is accomplished by a combination of a very low-resistance
non-return valve placed between the reservoir and the mask
and a spring-loaded higher-resistance air-inlet valve placed
in the mask itself.
Although used widely during the 1940s, non-rebreathing
continuous-flow systems are now rare. The most success-
ful non-rebreathing reservoir system employed in military
aviation was the RAF economizer system, which was in use
for almost 40  years and only disappeared from service in
the 1980s.
DEMAND-FLOW DELIVERY SYSTEMS
All of the disadvantages of continuous-flow delivery systems
are overcome by systems in which the flow of gas from the
regulator varies directly with the inspiratory demand of the
user. In such systems, it is also possible to provide many of
the additional automatic and manual facilities listed earlier,
including air dilution, safety pressure, pressure breathing
and an indication of flow. The key component in demand
oxygen systems is the regulator, although its integration
with the downstream delivery pipework and the oronasal
mask is crucial. A regulator that is capable of delivering
gas at increased pressure, i.e. of delivering safety pressure
and pressure breathing, is termed a pressure-demand oxy-
gen regulator (see ASIC air standard).
Demand regulators
The principles underlying the design and function of
demand regulators are essentially the same regardless of
whether the device is panel-mounted, seat-mounted or
man-mounted: all are designed to fulfil a number of auto-
matic and manual functions, including the following:
17/11/2015 15:37
 Demand-flow delivery systems  91

BREATHING GAS ON DEMAND
In a demand system, the flow of gas from the high-pressure
source is controlled by the fluctuations in mask cavity pres-
sure induced by respiration. To achieve this, in the simplest
form of such regulators, it is divided into two chambers by a
flexible control diaphragm, as shown in Figure 6.7. On one
side of the diaphragm, the (demand) chamber receives the
high-pressure supply from the aircraft oxygen source and
also communicates with the user via a delivery hose and
the mask, while the (reference) chamber on the other side
of the diaphragm is open to the environmental pressure of
the cockpit.
The pressure changes of respiration are transmitted to
the demand chamber, where they displace the flexible dia-
phragm. By means of a connecting lever and pivot, the posi-
tion of the diaphragm controls the degree of opening of the
(demand) valve through which gas from the oxygen source
flows into the demand chamber and then to the user. Thus,
the reduction of pressure in the mask cavity and the demand
chamber produced by the initiation of inspiration displaces
the diaphragm into the chamber and opens  the demand
valve. The greater the inspiratory demand, the greater
will be the reduction in mask cavity pressure transmitted
to the demand chamber and the further will the demand
valve open, so increasing the flow of gas to the mask. When
inspiration ceases, mask cavity pressure increases and so,
too, does pressure in the demand chamber. The diaphragm
is restored to its resting position, the demand valve closes
and flow of gas to the mask stops. The flow of gas through
the demand valve, thus, is equal to the instantaneous
inspiratory flow.
The forces needed to open the demand valve are such
that a regulator that employs a mechanical link between the
control diaphragm and the valve requires the diaphragm to
be relatively large if the resistance to inspiration is to be kept
High-pressure
oxygen
Demand
chamber
Demand
valve
Spring
within acceptable limits. This type of regulator, therefore,
has to be large enough to accommodate a diaphragm that
typically is 8–10  cm in diameter. Alternatively, and espe-
cially in modern regulators, the link between the demand
valve and the control diaphragm is pneumatic. In this case,
the opening of a flexible demand valve is controlled by gas
pressure applied to the side of the valve opposite to that
exposed to the high-pressure supply line (Figure 6.8).
The controlling pressure is itself determined by a second
pilot valve, the opening of which is governed by a mechani-
cal link to the control diaphragm. As before, movement of
the control diaphragm is influenced by the pressure trans-
mitted from the mask cavity to the demand chamber of
the regulator. The great advantage of such servo-controlled
demand regulators is the magnification of the control signal
made possible by the pneumatic link. Hence, the size of the
control diaphragm can be markedly reduced, and the diam-
eter of the control diaphragm in a typical servo-controlled
regulator is only 2–3 cm. Furthermore, safety pressure and
pressure breathing facilities can be provided by gas-loading
the control diaphragm, and all of these pneumatic control
systems enable the size of the regulator to be reduced sig-
nificantly. Electronic systems have developed the operating
arrangements still further but for aeromedical purposes the
principles still apply.
AIR DILUTION
The physiological requirements of an oxygen system call for
the dilution of oxygen in order to avoid the consequences
(and waste) of breathing 100 per cent oxygen continuously
and sufficient nitrogen to prevent acceleration atelectasis.
Such dilution is usually achieved in conventional systems
(i.e. those based on gaseous or liquid oxygen storage) by
mixing cabin air with oxygen in the demand regulator. The
degree of air dilution (air-mix) decreases automatically and
Mask
Inlet port

Expiratory valve

Spring
Diaphragm Safety pressure
spring

Figure 6.7  Mode of operation of a simple demand oxygen regulator and oronasal mask system. The flow of oxygen to
the mask from the high-pressure supply is controlled by the demand valve, which is held in the closed position by the
demand valve spring. The reduction in pressure (produced by inspiration) within the mask, the mask hose and the regu-
lator demand chamber displaces the control diaphragm and opens the demand valve. The rise in mask pressure when
inspiration ceases allows the control diaphragm to return to its resting position and the demand valve to close. Biasing
the control diaphragm by means of a safety pressure spring raises the mask pressure above that of the environment. The
expiratory valve must also be biased (e.g. by spring-loading) in order to hold safety pressure in the mask.

K17577_C006.indd 91 17/11/2015 15:37

 92  Oxygen systems, pressure cabin and clothing

To mask

Demand valve

Sensing port
Orifice
High-pressure
oxygen
Pilot valve Demand chamber
Orifice

External cavity
(reference chamber)
Bleed to
ambient

Pressure breathing Control

aneroid diaphragm

Figure 6.8  Mode of operation of a typical servo-controlled miniature pressure-demand regulator. The flexible demand
valve is held closed by the inlet pressure applied to its rear surface. The suction created by inspiration reduces the pres-
sure within the demand chamber and opens the pilot valve. This allows the reduction in pressure to be transmitted to the
back of the demand valve which, therefore, opens and allows oxygen to flow through it to the mask. Pressure breathing
is produced by increasing the pressure within the reference chamber, so that the control diaphragm is loaded. This is
achieved by an aneroid capsule, which progressively increases the resistance to flow to the environment of a small bleed
into the chamber (which itself is controlled by an orifice).

progressively with ascent to altitude in order to maintain
adequate oxygenation at all times. Two principal mecha-
nisms are employed to draw cabin air into the regulator:
suction dilution and injector dilution.
In regulators employing suction dilution, air is drawn
into the demand chamber through a spring-loaded air-inlet
valve (Figure  6.9a), while an aneroid capsule controls the
relative resistances to flow through both this valve and the
demand valve. Thus, as altitude increases and the aneroid
expands, flow through the former falls and flow through the
latter rises.
Suction dilution cannot provide air-mix in the presence
of safety pressure. Therefore, in systems in which that facil-
ity is provided, the suction required to induce or entrain
a flow of cabin air into the demand chamber is created by
passing oxygen through an injector (Venturi) as it flows
from the demand valve: injector dilution. As with the suc-
tion dilution technique, the flow of cabin air is governed by
another valve, the opening of which is again controlled by
an aneroid capsule (Figure 6.9b). The injector dilution tech-
nique has been employed widely, but it does tend to deliver
a relatively high (but acceptable) concentration of oxygen
during quiet breathing and at low altitudes. For example, a
typical injector dilution regulator will deliver 40–50 percent
oxygen even at sea level.
In both forms of air dilution, the air-inlet port can be
closed by manual operation of a shutter on the regulator,
thus providing 100  per cent oxygen at any altitude in the
event of toxic fumes within the cabin or if decompression
sickness is suspected or likely to develop. This manual
override facility is not required in regulators used in MSOC
systems, where no dilution with cabin air takes place.
A potential hazard of air dilution is that the user can
continue to breathe air through the air-inlet port following
a failure of the oxygen supply to the regulator. The devel-
opment of hypoxia is then a distinct possibility, since the
increase in resistance to inspiration associated with such a
failure may well go undetected, even at cabin altitudes of
15 000–18 000 feet. In many modern regulators, the risk of
an undetected failure is eliminated by the incorporation
of an additional valve in the air-inlet mechanism, which is
operated by oxygen pressure. This valve remains shut unless
there is adequate oxygen pressure at the inlet to the regula-
tor, and a failure of the oxygen supply pressure, therefore,
results in the immediate occlusion of the air-inlet port,
with consequent gross impedance to inspiration alerting
the user.
In the most modern systems, in which gas composition
is controlled via the operation of the MSOC supplying the
breathing gas, some of the altitude sensing may be provided
within other aircraft systems and linked to the life support
functions. However, as mentioned above, there have been
concerns that errors in this process could be associated with
hypoxic-like episodes in flight.
SAFETY PRESSURE
Since the operation of the regulator demand valve depends
on the transmission of pressure fluctuations produced in
the mask cavity by respiration, the mask must seal well
against the face and be fitted with an effective non-return

K17577_C006.indd 92 17/11/2015 15:37

 Demand-flow delivery systems  93

High-
pressure
oxygen
Oxygen control
valve Air inlet valve
Pivot Spring Air inlet

Non-return
valve
Air dilution aneroid
To mask
Demand valve

Diaphragm

High-pressure
oxygen Air shut-off valve
Air inlet
Air dilution aneroid

Non-return
valve

Demand valve To mask

Diaphragm Air/oxygen
Oxygen injector
mixing tube

Safety pressure
spring

Figure 6.9  Two techniques for diluting oxygen with cabin air, employed in demand regulator systems. (a) Mode of opera-
tion for air dilution in a suction demand regulator: suction dilution. Air is drawn into the regulator by the inspiratory effort,
and the relative flows of oxygen and air are controlled by an aneroid capsule, which varies the resistances to flow through
the oxygen- and air-inlet ports to the regulator outlet. (b) Mode of operation for air dilution in a pressure-demand regula-
tor: injector dilution. In this case, air is drawn into the regulator by the suction induced by oxygen flow, from the demand
valve, through an injector. The proportion of air to oxygen mixing is controlled by an aneroid capsule, which operates a
throttle plate in the air-inlet port of the regulator.

expiratory valve (see ‘Oxygen masks for aircrew’, p. 95). An
ill-fitting mask will induce an inboard leak of air during
inspiration and, thus, will dilute the oxygen contained in
the gas delivered by the regulator; this is a serious poten-
tial disadvantage of suction dilution demand regulators.
In injector dilution demand regulators, however, this
disadvantage may be prevented by creating a slight over-
pressure, termed safety pressure, in the mask cavity. The
pressure in the mask then remains greater than that of the
environment throughout inspiration, thus ensuring that
any leak of gas as a result of an ill-fitting mask is outboard
and not inboard.
Safety pressure can be delivered by the demand regulator
through applying an appropriate force to the control dia-
phragm via a spring, which displaces the diaphragm and so
opens the demand valve (Figure 6.7). As soon as the pres-
sure in the mask reaches the required level, the rise in pres-
sure within the demand chamber overcomes the force of the
spring and the diaphragm returns to its resting position and
shuts the demand valve. Clearly, the mask expiratory valve
must be modified so that it does not open until mask cavity
pressure exceeds the nominal safety pressure. To do this,
the expiratory valve may be either spring-loaded so that its
opening pressure is raised at all times or compensated to the
delivery pressure of the regulator, so that the raised open-
ing pressure is present only when safety pressure is being
provided. The magnitude of the safety pressure required to
prevent inboard leakage around an ill-fitting mask depends
on the delivery pressure-flow characteristics of the regula-
tor and on the resistance to flow from the regulator to the

K17577_C006.indd 93 17/11/2015 15:37

 94  Oxygen systems, pressure cabin and clothing
mask cavity. The level of safety pressure, however, gener-
ally lies between 2  and 3  mmHg 15–25  mm Water gauge
(0.15–0.25 kPa).
The disadvantage of spring-loading the control dia-
phragm to provide safety pressure is that gas will flow from
the regulator outlet or the mask whenever they are open to
the environment. Furthermore, consumption of the oxygen
supply is increased at all altitudes when safety pressure is
being delivered, although hypoxia arising as a consequence
of an inboard mask leak is a significant risk only at altitudes
above about 15 000 feet. In many (non MSOC) demand sys-
tems, therefore, safety pressure is invoked only when it is
required and is provided automatically by the expansion
of a pressure-sensitive aneroid capsule, within the refer-
ence chamber, on ascent to cabin altitudes above 10 000–
15 000 feet. A manual switch is also incorporated in some
systems so that safety pressure can be selected at a lower
cabin altitude if toxic contamination of the cockpit occurs.
PRESSURE BREATHING
The increase in regulator delivery pressure required to pro-
vide pressure breathing and the inflation and operation of
pressure garments at cabin altitudes above 40 000  feet is
achieved by progressively loading the control diaphragm
with a suitable spring force, as shown in Figure 6.10 (see also
Figure 6.8).
The spring force opens the demand valve and gas flows to
the mask until the pressure in the mask and in the demand
chamber has built up to the required level. The diaphragm
then returns to its resting position and the demand valve
shuts. The load is applied to the diaphragm either by a spring,
High-pressure
oxygen
Demand
valve
Diaphragm
Pressure
breathing
spring
Figure 6.10  Mode of operation for provision of pressure breathing by a demand regulator. The pressure-breathing aner-
oid capsule starts to expand at the altitude from which pressure breathing is to commence. This expansion allows the
pressure-breathing spring to load the control diaphragm and so increase the delivery pressure from the regulator to the
mask. The progressive expansion of the aneroid capsule with altitude produces concomitant increases in loading of the
control diaphragm and delivery pressure from the regulator.
K17577_C006.indd 94
which is allowed to expand progressively under the control
of an aneroid capsule within the reference chamber of the
regulator, or by gas, the pressure of which is also raised by
the expansion of an aneroid capsule. The required relation-
ship between regulator delivery pressure and cabin altitude
is obtained by appropriate design of the springs and control-
ling aneroids. As in the case of safety pressure, the pressure
breathing mask must be fitted with a compensated expiratory
valve. For test purposes on the ground, a means of obtain-
ing increased breathing pressure by manual selection is also
provided: the test pressures are usually about 20  mmHg
(2.7  kPa) for use with a mask alone and 40–60  mmHg
(5.3–8 kPa) for use with partial pressure garments.
INDICATION OF FLOW
An indication of the passage of oxygen through the demand
regulator serves as a means of confirming that oxygen
flows with each inspiration and as a means of detecting
outboard leakage in the presence of safety pressure or pres-
sure breathing. Commonly, the changes in pressure imme-
diately downstream of the demand valve induced by flow
through it have been used to operate a visual indicator via
some form of pressure switch. Thus, for example, pressure
variations, as a consequence of flow, may deflect a small
diaphragm that completes an electromagnetic circuit and
operates the indicator. In the case of panel-mounted regula-
tors, the magnetic indicator is an integral part of the device;
in the case of seat- or man-mounted regulators, the indica-
tor is located elsewhere on the instrument panel. In some
systems, the flow sensor may take the form of a spring-
loaded slug within the lumen of the oxygen supply line to
To mask
Movement
on expansion
of aneroid
Pressure breathing
aneroid
17/11/2015 15:37

the regulator. In this case, movements of the slug produced
by oxygen flow are transduced electromagnetically or by a
light beam, and the indicator is again mounted in a promi-
nent place on the instrument panel. Wherever the indicator
is mounted, its regular operation is confirmed throughout
flight by the user. The indicator usually displays a white bar
in the presence of flow and goes black when there is no flow.
The absence of oxygen flow will therefore be readily appar-
ent, as will a continuous flow caused by an outboard leak.
INDICATION OF CONTENTS/PRESSURE
In systems supplied by gaseous or liquid oxygen, a continu-
ous indication of the quantity of gas available is given to the
user by means of gauges that display contents in fractions of
full or the system operating pressure. In many aircraft, both
displays are provided.
Oxygen hoses and personal equipment
connectors
The final routing taken by oxygen delivery pipework to the
user will depend on the location within the cockpit of the
demand regulator and on the presence or otherwise of an
ejection seat. Furthermore, in many aircraft in which ejec-
tion seats are installed, the usual way in which the user is
connected to their personal services is by means of an addi-
tional item of equipment: the personal equipment connec-
tor (PEC) or a unit providing similar functions. The various
potential routings by which oxygen is delivered to the user
from the source are shown diagrammatically in Figure 6.11.
In most modern UK combat aircraft, the PEC is joined
to a double (duplex) seat-mounted pressure demand breath-
ing regulator. In such cases, gas flows via the PEC to the
regulator and back through the PEC to the user’s oxygen
hose. As well as the main oxygen supply, the PEC provides
the conduits by which the EO supply, the G-trousers’ supply
and the electrical connections for communication can be
delivered easily to the user. In some variants, an additional
gas passage may be incorporated with an air supply for ther-
mal or nuclear, biological and chemical warfare ventilation
purposes. A PEC consists of three interlocking parts – the
aircraft portion, the seat portion and the man portion –
which enable coupling and uncoupling of services, during
Non-ejection Reg
Source
seat P–M
Reg
Source
P–M
Ejection
Source
seats
Source
Figure 6.11  Schematic showing the various routes by which an oxygen supply is delivered to the user in demand regulator
systems. The routes depend on the location of the regulator within the cockpit and on the presence or otherwise of an
ejection seat. PEC, personal equipment connector; Reg M-M, man-mounted regulator; Reg P-M, panel-mounted regula-
tor; Reg S-M, seat-mounted regulator.
K17577_C006.indd 95
Demand-flow delivery systems  95
routine entry and exit and during the ejection sequence, to
be accomplished in a single simple action. Figure 6.12 shows
a typical PEC assembly.
Wide-bore oxygen hoses are used only after the delivery
pressure has been reduced by the regulator. Such hoses usu-
ally are made of vulcanized rubber, reinforced by spirally
wound galvanized steel wire and covered with rubberized
gauze or stockinet. They have anti-kink properties and
incorporate appropriate end connectors to accommodate
the fittings for different aircraft systems. The medium-
pressure (70 lb/in2, 483 kPa) hoses used in conjunction with
servo-operated man-mounted pressure-demand regulators
are made of narrow-bore anti-kink reinforced rubber.
Oxygen masks for aircrew
GENERAL REQUIREMENTS
A mask for aircrew use must satisfy several interrelated
requirements: it must be stable and comfortable to wear for
long periods, be small, fit a variety of facial sizes and shapes
and seal against the skin of the face effectively. A typical
oronasal oxygen mask, such as is used by British military
pilots, is illustrated in the previous chapter (see Figure 5.9).
Comfort demands that the facepiece of the mask should
be made of a flexible material that retains that property over
the whole range of temperatures in which it may be worn.
Silicone rubber is commonly used for this purpose, but
it is important that the sensitizing properties of any rub-
ber mixture used should be as low as possible in order to
reduce the potential for skin irritation and inflammation.
It is also clearly desirable that body secretions should not
affect the rubber adversely. The flexible facepiece generally
is supported by a rigid or semi-rigid exoskeleton, which
also provides the mounting for the means by which the
mask is suspended from a headset or protective helmet.
The mask should be as small as possible in order to reduce
any restriction of the visual fields and to keep limitations
on head movement to a minimum. The internal volume or
dead space of the mask must be low (typically 120–150 mL)
in order to avoid significant rebreathing. Sizing is much
simplified if the lower edge of the mask sits in the sulcus
beneath the lower lip rather than beneath the chin itself. In
the UK, the mask line of skin contact profile has been over
Mask
PEC Mask
Reg
PEC PEC Mask
S–M
Reg
PEC Mask
M–M
17/11/2015 15:37
 96  Oxygen systems, pressure cabin and clothing

Locking
bayonet
Communications
connector
socket
Oxygen Communications
supply hose connector
G
Trousers
AVS connector bush
connector
bush
Anti-kink
oxygen hose Man
portion

Locating pin

Seat portion Dust cover

Aircraft
portion
Communications
Main AVS G
oxygen supply trousers
(a) Man portion (complete) (b) supply supply

Figure 6.12  Typical (low-pressure) personal equipment connector (PEC). AVS, air-ventilated suit.

the bridge of the nose, descending just lateral to the mouth
and then passing along the sulcus below the lower lip. For
many years only two sizes of mask were required to fit the
male only pilot group. As women generally have smaller
faces there is now a need for a slightly greater size range, but
it remains the case that if the chin is enclosed more sizes of
mask are required.
The most effective and commonly used method of obtain-
ing a seal between the mask and the face is to reflect the edge
of the rubber facepiece, so that a thin flap of rubber lies on
the surface of the skin within the mask cavity (Figure 6.13).
A slight tension in the reflected edge causes it to lie snugly
against the skin, and any increase in mask pressure, such as
safety pressure or pressure breathing, will tend to improve
the seal even further. The flexibility of the mask material
and of the seal must be sufficient for comfort and yet rigid
enough to prevent deformation caused by accelerative forces,
which tend to displace the mask. The security of the mask
on the face depends primarily, however, on the suspension
harness by which it is attached to the headgear and on the
security of the latter on the head. A relatively rigid suspen-
sion system is required if the user is exposed to high levels
of acceleration and vibration in flight, and to high levels of
acceleration and windblast during an ejection sequence. The
suspension system must also incorporate a means of normal
adjustment of fit to the headgear and of rapid tightening for
pressure breathing. One method of achieving the former is
simply to place the mask comfortably on the face and lock
bayonet-type connectors on the mask into one of a series
of ratchet notches on the helmet. Pushing the mask further
on to the face in order to engage the bayonets on a deeper
notch provides the means to enhance the seal for pressure
breathing. Another, more effective, method of attaching the
mask to the helmet involves engaging chains or wire cables
mounted on the mask exoskeleton over adjustable hooks
mounted on the helmet or headset. Tension in this case can
be augmented for pressure breathing by drawing the chains
or cables over a suspension/tensioning bar on the front of
the mask. With the advent of routine pressure breathing for
enhancement of tolerance of +Gz accelerations, however, it
is very advantageous to have some form of automatic ten-
sioning in the system, to balance the increased mask cav-
ity pressure and avoid the mask lifting off the face. Some
such systems already are in routine use by several air forces,
although achieving adequate mask sealing at all breathing
pressures is difficult.
Although the valves fitted to oxygen masks vary with the
type of system in which the mask is to be used (see below),

K17577_C006.indd 96 17/11/2015 15:37


Reflected
edge seal
Microphone
Expiratory
valve
Figure 6.13  Oronasal mask with a reflected edge seal.
When gas at a raised pressure is delivered to the mask,
the reflected edge of the seal is driven firmly against the
skin of the face by the pressure, so preventing leakage.
a number of general features are common to all masks. The
delivery hose to the mask usually has an internal bore of
15–20  mm and has a flexible but non-crushable wall. The
lower end of the hose carries a connector by which it is
attached (preferably by a locking mechanism) to the supply
hose from the regulator. The weight of the hose assembly is
often transmitted to the personal clothing by a mounting
attached to the mask–hose connector, in order to eliminate
the downward pull by the hose on the mask. The upper end
of the mask hose is attached to the inspiratory port, within
which the inspiratory (inlet) valve is located. The inspira-
tory valve is usually placed high up in the mask to mini-
mize the possibility of its obstruction by particles of debris
and to limit contact with moist expired air. An ice-guard
is fitted to its internal surface to provide further protection
against debris and moisture. The expiratory (outlet) valve
usually is fitted in the most dependent part of the mask to
allow sweat and saliva to drain effectively. Furthermore, the
external surface of the expiratory valve is protected against
the effects of low environmental temperatures by an exten-
sion of the rubber facepiece, which traps 10–15 mL of rela-
tively warm expired air just beyond the valve. The walls of
this extension (or snout) are flexible so that the wearer can
break up and remove any ice that has accumulated within it.
The oxygen mask is also used as the carrier for the
microphone component of the aircraft communication sys-
tem. The presence of a mask greatly modifies the qualities
of speech, and sound-pressure levels within the mask cav-
ity during speech may be relatively high, typically 120 dB.
Furthermore, speech may be masked by noise generated
during the flow of breathing gas through the regulator (par-
ticularly when man-mounted), by the flow of gas through
delivery hoses and mask valves, and by the direct trans-
mission of cabin noise through the walls of the mask or an
open expiratory valve. Finally, the mask forms part of the
K17577_C006.indd 97
Demand-flow delivery systems  97
personal protection of the head, and its stability, therefore, is
especially vital in the event of the cockpit being breached by,
for example, a bird strike or should the need arise to escape
from the aircraft at high speed, with consequent exposure to
high windblast (Q) forces.
PARTICULAR REQUIREMENTS OF DEMAND MASK
VALVES
In simple demand oxygen systems, in which the regulator
delivers gas only when suction is created at its outlet, the
associated mask requires just a single non-return valve in
the outlet (expiratory) port. This valve prevents cabin air
from being drawn into the lungs and also allows the creation
of the suction required to open the demand valve during
inspiration. As no gas can be discharged to the environment
from the demand chamber of the regulator, expired gas can-
not flow back to that chamber and so no valve is required in
the inlet (inspiratory) port.
When the delivery pressure of the regulator is capable
of being raised above that of the environment (i.e. when
safety pressure or pressure breathing is being delivered), the
non-return expiratory valve must be loaded so that it does
not open under the influence of the increased mask cavity
pressure. If unacceptable resistance to expiration is to be
avoided, however, the setting of the expiratory valve must
be such as to allow gas to be expelled from the lungs with
only a small additional rise in mask cavity pressure. In those
pressure demand systems in which the regulator is capable
of delivering safety pressure but not pressure breathing (i.e.
systems used only at cabin altitudes of less than 40 000 feet),
a simple spring-loaded non-return expiratory valve may be
fitted to the mask; the pressure required to open this valve is
set at a slightly higher level than that of the safety pressure
delivered by the regulator. When safety pressure is pres-
ent, breathing when using this system is very comfortable;
when safety pressure is absent, however, the spring-loading
of the valve is noticeable as an increased resistance to expi-
ration. Occasionally, therefore, the expiratory valve of the
mask is fitted with a control that allows the user to raise the
spring-loading manually. Such a variable resistance expira-
tory valve may be used to hold not only safety pressure in
the mask but also low levels, e.g. 10–15 mmHg (1.3–2 kPa),
of pressure breathing. This technique is rarely used because
it requires manual operation and, during pressure breath-
ing, results in excessive resistance to expiration and/or loss
of oxygen.
The most satisfactory and extensively employed method
of automatically varying the pressure at which the expira-
tory valve opens is to compensate the device (Figure 6.14).
A compensated expiratory valve has a gas-loading facil-
ity, whereby the pressure in the inlet port of the mask
is also transmitted, by a flexible diaphragm, piston and
spring, to the valve plate on the downstream side of the
expiratory valve.
The area of the flexible diaphragm/piston is equal to that
of the expiratory valve port, so that any increase in the pres-
sure at which gas is delivered to the mask is also transmitted
17/11/2015 15:37
 98  Oxygen systems, pressure cabin and clothing
Iceguard
Non-return
inspiratory
valve
Compensation
tube
Inlet port Diaphragm
Figure 6.14  Valve system of a pressure demand oronasal mask. The inspiratory valve is a simple non-return device, with a
mesh cover that acts as an ice-guard. The expiratory valve is compensated, the pressure of gas in the inlet port also being
applied along the compensation tube and through a diaphragm and piston to the external surface of the expiratory valve
plate. In the resting condition, the expiratory valve is held closed by a spring in the compensation chamber. The valve
plate above is separated from the diaphragm and piston below by a second spring, which ensures that any reduction in
pressure within the inlet port will not open the expiratory valve.
through the compensation chamber to the underside of the
valve. The expiratory valve, therefore, remains shut despite
the increase in mask cavity pressure. The additional increase
in mask cavity pressure required to open the expiratory
valve is unchanged, however, so that the small increase in
mask pressure induced by expiration opens the expiratory
valve and allows expired gas to flow out. An additional and
essential requirement of a mask fitted with a compensated
expiratory valve is the need for a non-return inspiratory
valve. If such a valve was not fitted in the inlet port, or if
even a small leak was present around a fitted valve, then
the increase in mask cavity pressure caused by expiration
would be free to pass back into the mask hose and then to
the compensation chamber of the expiratory valve. The
expiratory valve would then be held firmly shut by the expi-
ratory effort, and the user would be unable to breathe out.
In addition, since the inspiratory valve is prone to freezing
as a result of expirate flowing over its cold surface, a deflec-
tor plate or ice-guard must be fitted to the valve to protect it
against this hazard. Finally, under certain conditions, such
as during excessive head movements, the mask hose may
‘pump’, i.e. cause an increase in pressure in the mask tube,
and hence the rise in mask cavity. This rise acts to hold the
expiratory valve closed, so markedly increasing the added
external resistance to expiration.
Pumping can also cause the pressure in the inlet port
to become less than that of the environment, although this
should initiate a flow of gas from the demand breathing reg-
ulator. However, if this reduction in pressure is transmitted
K17577_C006.indd 98
Facepiece
of mask
Valve seat
Valve plate
Springs
Compensation
chamber
Piston Outlet snout
along the compensation tube to the expiratory valve, then
this could open and allow the unacceptable possibility of
inspiring air from the cabin. Equally, a failure of gas supply
through the breathing regulator would have the same effect.
This sucking open of the expiratory valve may be prevented
by a further refinement of the compensated expiratory valve:
an additional spring interposed between the valve plate and
the flexible diaphragm/piston of the compensation cham-
ber. If pressure within the latter falls, and the diaphragm/
piston moves downwards, then the expiratory valve remains
sealed as a result of the valve plate being held against the
valve seat by the additional spring (see Figure 6.14). A unit
that incorporates such a refinement is termed a split-com-
pensated expiratory valve. The combination of a non-return
inspiratory valve and a split-compensated expiratory valve
ensures that the mask cavity pressure is controlled automat-
ically to the datum pressure being delivered by the demand
regulator, while the increase required in mask cavity pres-
sure to open the expiratory valve during expiration remains
constant at 1–2 mmHg (0.13–0.25 kPa).
In those masks used routinely throughout flight by mili-
tary aircrew, and in association with a personal equipment
connector, a third valve is fitted frequently to provide an
anti-suffocation facility. The reason for this is that the user’s
portion of the personal equipment connector contains an
anti-drowning, self-sealing ‘prop’ valve that closes the oxy-
gen port of the connector whenever it is detached from the
seat portion (see Figure  6.12). Thus, should water entry
occur after an ejection escape, or should the connector
17/11/2015 15:37

release inadvertently during flight, the user is able to con-
tinue breathing through the anti-suffocation valve. In the
case of water entry, the prop valve prevents the inhalation
of water through the personal equipment connector. The
anti-suffocation valve itself is an inward relief valve that
opens when the pressure within the mask cavity falls to
9–13 mmHg (1.2–1.7 kPa) below ambient pressure, a suction
sufficiently high to warn the user that the valve is operative.
Masks for passengers
Although the degree of comfort and standard of seal
required of oxygen delivery masks for emergency use by
passengers is considerably less than that necessary for air-
crew, such masks do have some important design con-
straints. Thus, one size of mask must fit all shapes and sizes
of face, and the mask must be easy to don and secure in
place by completely untrained passengers. To this end, the
mask should be circular in shape to avoid the need to orient
the device on the face, and the harness is usually a simple
elastic loop. Passenger masks are not usually designed for
use at environmental temperatures below −5 to −100°C.
One very common type of passenger emergency oxygen
mask receives a continuous flow of oxygen and incorpo-
rates a small reservoir bag in either the rebreathing or non-
rebreathing configuration (see above). Passengers should be
briefed to be aware that in use the reservoir may not fill with
gas but can still be operable. At least one form of passenger
mask has a simple demand valve used in conjunction with
a metered oxygen flow. In this case, the intervening hose
between the metering orifice and the mask acts as a reser-
voir for oxygen during expiration.
The masks are usually stowed in overhead compart-
ments or in the backrests of the seats. The doors of the
stowage compartment are opened and the masks pre-
sented to the passengers automatically if the cabin
altitude exceeds a pre-determined level, commonly 13 000–
15 000 feet. Flow of oxygen to the mask is not normally ini-
tiated, however, until the mask is actively pulled towards
the face. A simple bobbin flow-meter inserted in the sup-
ply hose to the mask indicates that flow is occurring. The
automatic presentation of the masks, and the magnitude
of the subsequent continuous flow of oxygen, generally is
controlled from the flight deck by varying the pressure in
the ring main that supplies oxygen to all outlets (see also
Figure 6.27; p. 106). The pressure in the ring main is itself
controlled either automatically or manually by a member
of the flight-deck crew.
Simple continuous-flow systems, usually of the
rebreathing reservoir type, are also used to adminis-
ter therapeutic oxygen to passengers in clinical need, e.g.
passengers who become ill during flight and passengers
for whom flight was predicted to embarrass their cardio-
respiratory status. The oxygen supply is then obtained
either from a direct connection to the aircraft’s main oxy-
gen store or from a portable gaseous oxygen source. An
­example of a simple therapeutic oxygen set is shown in
K17577_C006.indd 99
Demand-flow delivery systems  99
Figure 6.15. National and international regulations deter-
mine the number of such therapeutic/emergency oxy-
gen sets that are to be carried. National and international
regulations determine the number of such therapeutic/
emergency oxygen sets that are to be carried. Pre-arranged
oxygen usage by passengers with a medical condition
likely to be adversely affected by exposure to the mod-
est altitude of an aircraft cabin appears to be increasing.
A variety of systems are in use, each with their specific
advantages and disadvantages.
Smoke-hoods
Fire and toxic fumes on board an aircraft have obvious
and often tragic consequences. Even if the aircraft is on the
ground or manages a successful emergency landing when
a fire occurs, the occupants may succumb to smoke and
fumes before escape is possible. There is, therefore, a need
to provide some form of respiratory protection for crew-
members and passengers so threatened.
Following several such disasters in civil aircraft dur-
ing the 1980s, the appropriate regulating authorities have
actively pursued the possibility of providing smoke-hoods
for use by passengers and crew of stricken aircraft. While
the small numbers required for crew protection suggest
that quite sophisticated devices could be (and, by some
airlines, are) provided, the large numbers of passengers
carried places severe constraints, in terms of weight, bulk
and cost, on the design of suitable hoods for passenger use.
Furthermore, problems of size, the ease of use by untrained
subjects, compromised visibility and communication must
all be addressed, as must be the all-important ability of
the device to protect the user for the duration of the emer-
gency. Many smoke-hoods, all of which envelop the head
Figure 6.15  Typical portable oxygen set for therapeutic
use by passengers or walk-around use by cabin staff.
Oxygen is supplied from a 120 L (NTP) capacity cylin-
der, at one of two pre-set flows, to a simple rebreathing
reservoir facemask.
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 100  Oxygen systems, pressure cabin and clothing
entirely, have been developed de novo or adapted from
breathing devices used for other purposes. The sophisti-
cation of such equipment varies from simple hoods made
of transparent plastic and equipped with a charcoal filter
through which to breathe, to hoods providing an integral
breathing gas supply. The source of supply may be from a
chemical candle or from a gaseous oxygen cylinder com-
bined with active or passive carbon dioxide absorption.
Currently, only crew usage forms of smoke-hoods with an
integrated gas supply are widely available.
In military transport aircraft, where relatively few
people are involved, equipment to allow a crew mem-
ber to breathe in irrespirable atmospheres, e.g. when fire-
fighting, can be provided with less constraint in terms of
weight or bulk. A typical smoke set for such a purpose is
shown in Figure  6.16. In the system illustrated, breathing
gas is supplied as oxygen from two 200  L (NTP) capacity
cylinders contained in a unit carried on the chest. Oxygen
is supplied on demand via a regulator assembly mounted
on the side of a combined mask and visor facepiece, and
expiration is through a non-return valve combined with
a speech-transmitter unit. The system can provide pro-
tection in hostile environments and up to an altitude of
30 000 feet.
Figure 6.16  Typical military portable oxygen set for use
in irrespirable atmospheres. The weight and bulk of such
equipment makes it unsuitable for use as a smoke-hood
for passengers.
K17577_C006.indd 100
TYPICAL OXYGEN SYSTEMS
Examples of the various components described above are
integrated to provide a complete oxygen system. The choice
of components and their layout clearly will depend on the
type and role of the aircraft in which the system is to be
installed. This section summarizes the general features
of some typical oxygen systems, both in military and in
civil aircraft.
Aircraft with low-differential pressure
cabins: combat aircraft
Combat aircraft have low-differential pressure cabins (see
later in this chapter for an account of such systems), and so
the oxygen system provides an essential element of the pro-
tection against hypoxia on ascent to cabin altitudes above
5000  feet. Consequently, those components of the oxygen
system that may fail in flight should, as far as practicable, be
duplicated. Such an installation, therefore, consists of a pri-
mary or main oxygen system and a secondary or emergency
oxygen system. When the aircraft is fitted with ejection
seats, as is essentially always the case in modern combat air-
craft, the emergency oxygen system also serves to prevent
the development of serious hypoxia following escape from
the aircraft at high altitude.
The main oxygen system comprises a store of oxygen or a
means of production, such as an MSOC, a pressure demand
oxygen regulator at each crew position, and a pressure
demand oxygen mask. The emergency system comprises a
small store of oxygen stowed somewhere in or on the escape
equipment, so that it can also provide the bail-out supply;
there can be either a separate emergency oxygen regula-
tor or the supply of emergency oxygen should be delivered
through a duplicated demand regulator.
The main supply in some in-service combat aircraft is
from liquid oxygen in converters located outside the pressure
cabin and that can be replaced rapidly when partially used.
Single-seat aircraft are typically equipped with a 5  L con-
verter, while two-seat and long-range aircraft usually have
10 L converters. Gaseous oxygen, at an appropriate operat-
ing pressure, is led from the converter by a main supply pipe
through the wall of the pressure cabin to the inlet of the regu-
lator. Increasingly, in fast jet aircraft such LOX systems have
been replaced with MSOC systems, the appropriately sized
sieve (depending on the number of crew that it must support)
is located outside the pressure cabin and supplied with com-
pressed air drawn from the aircraft’s engines. The EO supply
is carried as compressed gas in relatively small cylinders with
capacities varying up to 300  L (NTP). The contents of the
emergency supply are indicated on a pressure gauge, which
is checked before every flight, and the cylinder is equipped
with a charging point, which allows replenishment in situ.
Emergency oxygen can be selected manually in flight or auto-
matically during a failure of the MSOC system or on ejection.
The main pressure demand oxygen regulator for each
crew-member may be mounted in a variety of positions, and
17/11/2015 15:37

it is convenient to classify the sites used into three groups:
the airframe (panel-mounted), the man (man-mounted)
and the ejection seat (seat-mounted).
PANEL-MOUNTED REGULATOR SYSTEMS
When the regulator is mounted on the airframe, it is usu-
ally sited on a front or side console (panel) in such a position
that its controls can be reached in flight. Wide-bore, low-
pressure hose from the outlet of the regulator passes, via
either single inline connectors (Figure  6.17) or a personal
equipment connector (Figure 6.18), to end in a second con-
nector in the region of the user’s chest. The inlet hose of the
oxygen mask then plugs directly into this connector.
In older aircraft, the associated emergency oxygen sys-
tem generally was connected to the main system either
at, or immediately upstream of, the mask–hose coupling
Gaseous oxygen
(1800 lb/in2)
Pressure
reducer Mask
Pressure Quick disconnect
demand and EO relief store
regulator Emergency oxygen
(EO) store
Continuous flow
regulator
Figure 6.17  Typical pressure demand oxygen system
comprising a gaseous oxygen source, a panel-mounted
demand regulator, and an oxygen mask. Breathing gas
is delivered to the user via a wide-bore, low-pressure
hose connected directly to the mask hose by means
of a quick disconnect. The continuous flow emergency
oxygen supply enters the system at the quick disconnect
which, therefore, also incorporates an excess-pressure
relief valve.
Pressure
demand
regulator
R/T lead
Figure 6.18  Typical pressure demand oxygen system comprising either a gaseous or a liquid oxygen source, a panel-
mounted demand regulator, and an oxygen mask. Breathing gas is delivered to the user via a wide-bore, low-pressure
hose, passing via the personal equipment connector to a locking coupling at the mask hose. The emergency oxygen sup-
ply, via its own demand regulator, enters the system through the seat portion of the personal equipment connector and
thence passes to the user.
K17577_C006.indd 101
Typical oxygen systems  101
(see  Figure  6.17) and delivery from the emergency supply
was regulated by a simple orifice that provides a continuous
flow. In more modern systems, however, a small pressure-
demand emergency regulator may be fitted that provides
100 per cent oxygen with safety pressure from sea level, and
automatic pressure breathing if necessary, delivery being
via the personal equipment connector (Figure 6.18).
Panel-mounted regulators usually have large control dia-
phragms linked mechanically to the demand valve and are
able to provide all the desirable automatic facilities described
above. Figure 6.19 illustrates a modern panel-mounted oxy-
gen regulator. The major disadvantages of panel-mounted
oxygen regulator systems are that the regulator occupies
valuable panel space, there is often a long unwieldy length of
hose between the regulator and the mask and the main oxy-
gen supply cannot be routed through the emergency regula-
tor if the main regulator fails to pass gas. They are therefore
now less frequently used and the development of pneumatic
servo-controlled regulators has allowed miniaturization.
The consequent reduction in weight and bulk has enabled
other mounting sites to be utilized.
BODY-MOUNTED REGULATOR SYSTEMS
A miniaturized servo-controlled pressure demand regu-
lator can be mounted either on the chest or on the head.
The length of delivery hose from the regulator to the mask,
therefore, is short and there is little resistance to inspira-
tion in such systems. Oxygen at medium pressure (70  lb/
in2, 483  kPa) is carried directly to the inlet of the regula-
tor through narrow-bore (8 mm outside diameter) flexible
hose. Routine connection/disconnection between the air-
craft supply, the ejection seat and the regulator mounted
on the user is accomplished via a (narrow-bore) personal
equipment connector. The same device allows automatic
separation of supplies during the ejection sequence. Since
the main regulator travels out of the aircraft with the seat
Mask
Locking mask–
hose connector
Emergency oxygen
store
Inward and pressure
relief valve unit
Personal equipment
connector
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 102  Oxygen systems, pressure cabin and clothing

SEAT-MOUNTED REGULATOR SYSTEMS

Seat-mounted regulators may be located either on the seat
structure itself or in the personal survival pack. The latter is
the site of choice in which to carry the emergency/bail-out
supply for the occupants of non-ejection seat aircraft, but
the size and weight of emergency regulators to be carried in
personal survival packs clearly must be kept as low as pos-
sible. No such constraints apply to ejection-seat-mounted
regulators. When used in combination with gaseous or LOX
systems they can provide air dilution with automatic safety
pressure from about 15 000  feet and pressure breathing at
high altitudes. As with the other systems described, oxygen

Mask
Miniature pressure-
demand regulator
(main/secondary) Emergency
Figure 6.19  A panel-mounted pressure-demand oxygen R/T lead oxygen store
regulator as installed in F-22 aircraft. Reducing
Personal equipment valve
Photo courtesy of Honeywell International Inc.
connector

during such an event, it can be utilized by the emergency

supply as well as by the main system. Consequently, the
From liquid
emergency oxygen supply, after passing through a reducing oxygen converter
valve, which is usually mounted on the emergency cylinder
itself, is delivered into the main supply system upstream of Figure 6.20  Typical pressure-demand oxygen system
the main regulator (Figure 6.20). comprising a liquid oxygen in source, a chest-mounted
A mask-mounted or helmet-mounted regulator can be demand regulator and an oxygen mask. Gaseous oxygen
used in association with an emergency oxygen supply car- is delivered to the user via a narrow-bore, medium-pres-
ried in the personal survival pack (see below) to provide sure hose, passing via the personal equipment connector
breathing gas during and immediately after a parachute to a locked connection at the regulator. The wide-bore
mask hose couples directly to the regulator. The emer-
descent into water and so reduce the risk of drowning.
gency oxygen supply enters the system through the seat
Considerations of size and weight, however, dictate that a portion of the personal equipment connector and then
pressure-demand regulator mounted in these sites can- passes to the regulator which, therefore, is able to pro-
not provide air dilution. The additional space on the chest vide emergency oxygen on demand.
allows a miniaturized air-dilution device to be carried.
Indeed, some chest-mounted regulators not only provide
air dilution, safety pressure and pressure breathing but also Breathing gas outlet
incorporate a second or standby regulator that can be used Anti-G garment supply port
in the event of failure of the main regulator.
Body-mounted regulators (Figure 6. 21) are very liable to
damage by handling and are required in greater numbers
than panel-mounted or seat-mounted devices, since each
crew-member must be issued with a regulator. Furthermore,
emergency drills are relatively complicated, because separa-
tion of the regulator from direct contact with the aircraft
or seat services complicates the system, increases the like-
lihood of problems, and lengthens the drills necessary to
correct such problems. A final disadvantage is that minia-
Breathing gas inlet
turization to a marked degree precludes the opportunity to
incorporate additional safety features and increase system G-valve reference pressure inlet
redundancy (and hence operational effectiveness). These
disadvantages can be overcome, at the same time as retain- Figure 6.21  A chest-mounted pressure-demand oxygen
ing the benefits of pneumatic engineering, by mounting the regulator. This regulator is a Breathing Regulator Anti-G
regulator package on the ejection seat so body-mounted unit as installed in F-18 aircraft.
regulators are now quite rare in service.
Photo courtesy of Honeywell International Inc.

K17577_C006.indd 102 17/11/2015 15:37


usually is delivered to the regulator via the aircraft and
seat portions of a personal equipment connector. The out-
let of the regulator is connected through the user portion
of the personal equipment connector to a wide-bore hose
that passes to the coupling by which attachment is made to
the inlet hose of the oxygen mask (Figure 6.22). The emer-
gency oxygen supply usually is controlled by a second seat-
mounted (standby) pressure demand regulator that supplies
100  per cent oxygen, safety pressure from sea level, and
automatic pressure breathing when required. The standby
regulator can be positioned immediately adjacent to the
main regulator and, indeed, may be in the same unit (such
an arrangement is termed a duplex regulator); it is then pos-
sible to arrange for the main oxygen supply to be routed
through either the main or the emergency regulator, thus
duplicating the regulator in the main system and improving
operational effectiveness. The close association of the main
and standby regulators also leads to relative simple emer-
gency drills in the event of failure of the primary regula-
tor. Figure 6.23 shows an example of a typical seat-mounted
pressure-demand oxygen regulator.
With the increasing introduction into service of MSOC
fast jet aircraft, their oxygen systems are also somewhat
different. The Eurofighter Typhoon employs an MSOC sys-
tem with a duplex seat-mounted regulator (Figure  6.24).
Mask
R/T lead
Emergency
oxygen
store
Reducing
valve
Oxygen
regulator Personal
package equipment
connector
From oxygen
source
Services
unit
Figure 6.22  Typical pressure demand oxygen system
comprising either a gaseous oxygen or a liquid oxygen
source, a seat-mounted duplex demand regulator and an
oxygen mask. Gaseous oxygen is delivered to the regula-
tor via a narrow-bore, medium-pressure hose to the seat
portion of the personal equipment connector (to which
the regulator package is connected directly) and breath-
ing gas from the regulator by way of the wide-bore, low
pressure hose of the user portion of the personal equip-
ment connector to a locking coupling with the mask hose.
The emergency oxygen supply enters the system through
the seat portion of the personal equipment connector and
passes directly to the duplex regulator, both elements of
which, therefore, are able to provide emergency oxygen
on demand.
K17577_C006.indd 103
Typical oxygen systems  103
The technical details of such systems differ markedly from
all previous oxygen systems in several fundamental areas.
Since the output pressure from a molecular sieve is usu-
ally only about 15–30  lb/in2  (207  kPa), the regulator must
be engineered to function normally (i.e. to provide breath-
ing gas on demand, safety pressure and pressure breathing
for G protection (see below)) at this relatively low pressure.
However, the regulator is not required to provide air dilu-
tion, since that facility is achieved by manipulation of flow
through the molecular sieve (see ‘Oxygen sources’, above).
In the system illustrated, control of oxygen concentration
in the product gas is maintained by continuous monitor-
ing of the partial pressure of oxygen (at the existing cabin
altitude) being delivered to a new component of the sys-
tem: the mixture controller. This device incorporates
a sensor which, if the product gas is too rich in oxygen,
acts to reduce the concentration by altering, in the case of
Eurofighter Typhoon, sieve bed cycling, as described above.
If the sensor detects that the oxygen content is too low the
bed cycling is increased to raise the oxygen concentration.
This controlling sensor thus maintains the partial pressure
of oxygen in the gas being delivered to the user at an ade-
quate level at all altitudes. A second partial pressure sensor,
set at about 160 mmHg (21.3 kPa), acts as a warning device
should output from the molecular sieve fail altogether (e.g.
following an engine flameout) or suddenly fall below that
required for adequate oxygenation at high altitude (e.g.
following a rapid decompression), or if there is a failure
within the concentrator itself. Activation of the warning
sensor automatically selects the delivery of 100  per cent
oxygen from a seat-mounted backup store of 200 L (NTP)
gaseous oxygen. The same store acts as the emergency oxy-
gen supply in the event of ejection. As pressure breathing
for altitude protection requires 100  per cent oxygen to be
delivered at pressures above ambient, the source of this
gas will be the backup store. However, since some in-flight
emergencies (flameout, rapid decompression) are poten-
tially recoverable, a unique feature of the backup system
Figure 6.23  Typical seat-mounted pressure-demand
oxygen regulator.
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 104  Oxygen systems, pressure cabin and clothing

design in MSOC equipped aircraft is that it can be turned

off. This is in contrast to the initiation of conventional
emergency oxygen systems in combat aircraft, which com-
mit the pilot to an immediate descent to below 10 000 feet,
with obvious operational implications. Thus, if the pilot
achieves an engine relight after a flameout, the molecular
sieve will once again concentrate oxygen and the flight can
proceed normally. Similarly, once the molecular sieve and
mixture controller have responded to the fall in cabin pres-
sure after rapid decompression, gaseous backup oxygen is
no longer required, so the store can be conserved.
In the most advanced oxygen systems, such as those
installed in the Eurofighter Typhoon and the US/UK
F-35 Joint Strike Fighter, an MSOC provides the breathing
gas, which is monitored by a solid-state oxygen sensor that Figure 6.25  Aircrew services package as installed
controls the bed cycle time, as described above. As these air- in Eurofighter Typhoon contains a duplex breathing
craft are equipped with pressure breathing for G-protection regulator, the anti-G valve and the Personal Equipment
(see Chapter 7), a close functional link is essential between Connector in a single, seat-mounted unit.
the breathing regulator and the anti-G valve. To address
Photo courtesy of Honeywell International Inc.
this requirement, the two units and the PEC are combined
in a single package, mounted on the side of the ejection seat.
A Typhoon Aircrew Services Package (ASP) is shown in
Figure 6.25. design and construction are complex but the principles of
their operation to meet aeromedical requirements remains
ELECTRONIC REGULATORS the same as previous generations of equipment. Duplication
Electronic breathing regulators are now entering service in of critical life support capability remains a design objective.
such aircraft as the F-35 and may prove to be even more reli- An example of a modern electronic breathing regulator and
able than pneumatically controlled units. The details of their combined anti-G unit is shown in Figure 6.26.

Conditioned
EO contents engine bleed air
EO refill

Mask Emergency Oxygen

oxygen concentrator

Main/standby
regulators

Flow Selector Oxygen mixture Plenum

transmitters valve controller and
PO2 sensors

Figure 6.24  Advanced oxygen system employing a molecular sieve oxygen concentrator and a seat-mounted duplex pres-
sure demand regulator. Product gas is delivered from the molecular sieve to the user via the seat portion of a personal
equipment connector, to which the regulator is connected directly, and then via the wide-bore, low-pressure hose of the
user portion of the personal equipment connector to the locking coupling with the mask hose. In this system, the concen-
tration of oxygen within the product gas is controlled by a sensing device, which increases flow through the concentra-
tor if oxygen concentration is too high and decreases flow through the concentrator if oxygen concentration is too low.
The emergency oxygen (EO) supply enters the system through the seat portion of the personal equipment connector
and passes to the duplex regulator and then to the user in the conventional manner. The emergency system also acts to
provide a backup supply of oxygen during temporary reductions in, or failures of, adequate sieve output. Since these situ-
ations may be resolved, the emergency backup supply may be turned off.

K17577_C006.indd 104 17/11/2015 15:37


Press-to-test
Backup/Emergency Oxygen
System (BEOS) selector
“green apple”
Battery pack
Remote PIC release
mechanism
Seat Interface Connector (SIC)
with integral gas supply ports
Figure 6.26  An example of a combined electronic breathing regulator and anti-G valve as used in F-35 Joint Strike Fighter.
Photo courtesy of Air Liquide Advanced Technologies and Honeywell International Inc.
Aircraft with high-differential-pressure
cabins: passenger aircraft
In aircraft with high-differential-pressure cabins, as noted
below, the oxygen system provides the second line of defence
against hypoxia and is consequently used only if there is a
failure of cabin pressurization or if toxic fumes contaminate
the cabin atmosphere.
Because of its advantages, and especially its worldwide
availability, oxygen is often carried in passenger aircraft
in gaseous form at high pressure (1800 lb/in2, 12 411 kPa),
although LOX is used in some aircraft and sodium chlorate
candles in others, at least in part provision of emergency
supplies. The oxygen system for the flight-deck crew is usu-
ally separate from that for the cabin staff and passengers,
although in some types they share a common oxygen store.
The main on/off valve, the contents gauge and all the system
controls are situated on the flight-deck. In gaseous systems
the high-pressure supply is reduced to the working pressures
of the flight-deck oxygen regulators (typically 200–400 lb/
in2, 1379–2758 kPa) and of the ring main for the passenger
circuit (typically 70–100 lb/in2, 483–690 kPa).
The flight-deck system must ensure that the crew con-
trolling the aircraft and its subsystems are fully oxygenated
at all times, since the well-being of the other occupants
depends primarily on their ability to initiate and control a
rapid descent to a low and safe altitude. Therefore, the sys-
tem clearly must provide oxygen for the flight-deck crew for
as long as the cabin altitude exceeds 8000–10 000 feet, and
so demand oxygen equipment is fitted to these crew stations.
If the maximum cabin altitude on rapid decompression
K17577_C006.indd 105
Typical oxygen systems  105
Breathing gas supply to pilot
Pilot Interface Connector (PIC)
manual release
Anti-G garment supply
to pilot
Pilot communications
connector
Main electrical
connector
cannot exceed 30 000–35 000 feet, simple suction demand
regulators may be fitted, but the regulators are most com-
monly of the pressure demand type; these are always fitted
when the cabin altitude can exceed 40 000 feet following a
decompression. A regulator is mounted at each crew position
or may be mask-mounted. The mask is commonly placed
in a purpose-designed stowage unit from which it can be
extracted rapidly when required. The oxygen mask is fitted
with a harness system by which it can be attached to a com-
munications headset; a test of the adequacy of this attach-
ment may form part of the pre-flight checks. In the event of a
rapid decompression, the crew are required to don their oxy-
gen masks, usually within three to five seconds, and to con-
tinue to use the equipment for as long as the cabin altitude
remains above 8 000–10 000 feet. In certain circumstances,
flying regulations require the watch-keeping members of the
flight-deck crew to be wearing oxygen masks whenever the
aircraft is above a specified altitude, e.g. 43 000 feet. The oxy-
gen equipment is also used to protect the respiratory tract if
toxic fumes are detected within the cabin.
The performance required of an oxygen system for pas-
senger use is less demanding, although, as discussed ear-
lier, oxygen must be available for all passengers when the
cabin altitude exceeds 15 000  feet and for a proportion of
the passengers (ten per cent) whenever the cabin altitude
is between 10 000  and 15 000  feet. In practice, this means
that all passenger aircraft that operate at altitudes above
25 000–35 000  feet are equipped with a passenger oxygen
system. The maximum altitude at which aircraft that are not
fitted with an oxygen system for passengers are allowed to
operate depends on the rate of descent that can be achieved
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 106  Oxygen systems, pressure cabin and clothing
following a decompression and may vary according to
national regulations; in the UK, this maximum altitude is
25 000 feet, provided that the aircraft can descend to below
12 000 feet within five minutes of loss of cabin pressure and
of continuing at or below that height to its destination or an
alternative safe landing.
The oxygen supply for passengers can be carried around
the cabin by means of a ring main (Figure  6.27), which
feeds the individual mask presentation units. Pressure
in the ring main is controlled automatically, so that if the
cabin altitude exceeds a predetermined level of between
10 000  and 14 000  feet, the pressure is increased to about
80  lb/in2  (552  kPa). This rise in pressure sounds an alarm
on the flight-deck, opens the doors of the mask presenta-
tion units so that the masks drop in front of the passengers
and provides a high flow of oxygen when a passenger pulls
the mask to his face. The flow of oxygen after the aircraft
has descended to low altitude can be reduced or turned off
by the flight crew, who can also control the pressure in the
ring main manually. Portable (walk-around) oxygen sets or
additional outlets from the ring main are provided in pas-
senger aircraft for therapeutic purposes, and the cabin staff
can use walk-around sets to provide assistance to passengers
when the cabin altitude exceeds 10 000 feet (see Figure 6.15).
Such walk-around therapeutic oxygen sets often provide
two levels of oxygen flow: a 2 L (NTP)/min level for use at
altitudes below 18 000  feet and a 4  L (NTP)/min level for
use at altitudes above 18 000 feet. Masks for the cabin crew
are, like passenger masks, usually of the continuous flow
reservoir type.
PRESSURE CLOTHING
Aircrew operating modern combat aircraft are normally
protected against the hazards of high altitude by a combina-
tion of cabin pressurization and a personal oxygen system.
When operating at extreme altitudes, however, additional
personal protection is provided by means of pressure cloth-
ing. Such garments are normally worn uninflated and are
pressurized only if the cabin altitude exceeds a certain
level or if it is necessary to abandon the aircraft at high
Supply pressure Presentation
gauge control
Quick-don Demand
crew masks regulators
Figure 6.27  Typical arrangement of an oxygen ring main system on board a large passenger aircraft.
K17577_C006.indd 106
altitude (above 40 000 feet). The extent of this form of emer-
gency equipment ranges from full-pressure suits, which
apply pressure to the whole person, to partial pressure
garments, which pressurize the respiratory tract together
with a greater or lesser part of the external surface of the
body. Pressure breathing equipment that pressurizes only
the respiratory tract, via an oronasal mask, may be consid-
ered as the simplest form of partial pressure protection. Full
pressure suits are also used in space flight to provide pro-
tection against exposure to the vacuum of space either as
a result of a failure of the sealed cabin of the spacecraft or
during extra-vehicular activity.
In most circumstances, the crew of an aircraft flying at
high altitude will initiate an immediate emergency descent
in the event of a failure of cabin pressurization. Operational
considerations may, however, dictate that a military aircraft
must remain at high altitude until the mission is completed.
Thus, pressure clothing may be used either to provide the
wearer with the short-term protection needed to enable a
descent to be made to an altitude where such protection is
no longer required, or to provide longer term protection
so that the aircraft and its crew can remain safely at high
altitude. Such potential requirements may influence the
choice of a full or partial pressure system as will the final
altitude to which occupants could be exposed in the event
of a decompression.
The major physiological effects of exposure to high alti-
tude are hypoxia, decompression sickness and hypother-
mia, which are described in detail in Chapters 4, 34 and 12,
respectively. It will be recalled that severe and unacceptable
hypoxia occurs within a few seconds of exposure to altitudes
above 40 000–43 000 feet, even when 100 per cent oxygen is
breathed. Consequently, protection against hypoxia must be
provided irrespective of whether the duration of exposure
to such altitudes is short or long. The relative importance
of the other effects, however, depends on the duration of
exposure. Thus, a short exposure to high altitude is very
unlikely to give rise to serious decompression sickness, and
quite limited duration exposure to low environmental tem-
peratures will not cause serious impairment of performance
or serious damage to subjects wearing normal aircrew
Ring main Therapeutic supply Presentation
pressure gauge control valve stowages
Gaseous oxygen
installation
17/11/2015 15:37

clothing. However, if exposure to altitudes above 25 000 feet
lasts for more than about five to ten minutes, then the risk
of developing decompression sickness increases markedly.
Similarly, if exposure to temperatures below approximately
−34°C lasts for more than a few minutes, uncovered skin
will suffer cold thermal injury and general hypothermia
may develop. Therefore, protection against hypoxia, decom-
pression sickness and cold is essential if exposure to alti-
tudes above about 25 000 feet is to be sustained for more
than a very few minutes. Only if, by virtue of a rapid descent
or an ejection, exposure will be limited to a period of less
than two to five minutes can additional protection against
decompression sickness and cold be omitted. These consid-
erations lead to the following conclusions:
●● Prolonged physiological protection against the effects of
exposure to very high altitudes can be attained only by
means of a garment that maintains a pressure equal to
or greater than 282 mmHg (37.6 kPa) absolute around
the body (to prevent hypoxia and decompression sick-
ness) and to which heat can be supplied (to maintain
a satisfactory thermal environment). The only form
of garment that can fulfil these requirements is a full
pressure suit.
●● If the aircraft is able to descend rapidly, however, pro-
tection is needed only against hypoxia. In this situation,
a full pressure suit once again is the ideal solution, since
it applies the required pressure evenly to the respira-
tory tract and to the whole of the external surface of the
body. Pressure differences between different parts of the
body do not occur, therefore, and thus no serious physi-
ological disturbances arise in either the cardiovascular
or the respiratory system. However, a full pressure suit
is bulky and all-enveloping; it impairs routine flying
even when uninflated, applies a considerable heat load
to the wearer and is expensive to purchase and service.
For these reasons, partial pressure garments provide
a useful and attractive alternative for short-duration
emergency protection against hypoxia.
Full-pressure suits
PHYSIOLOGICAL AND GENERAL REQUIREMENTS
The distinguishing feature of a full-pressure suit is that it
applies pressure evenly to the entire body surface. The mag-
nitude of the applied pressure is determined by the need to
protect against both hypoxia and decompression sickness.
Severe hypoxia can be prevented by delivering 100  per
cent oxygen to the respiratory tract and maintaining an
absolute pressure within the suit of at least 141  mmHg
(18.8 kPa), equivalent to an altitude of 40 000 feet. However,
since the suit is also worn in conditions where it is neces-
sary to prevent decompression sickness, the absolute pres-
sure within the garment ideally should not be less than
282  mmHg (37.6  kPa), i.e. equivalent to an altitude of
25 000 feet or below. However, experience has shown that an
K17577_C006.indd 107
Pressure clothing  107
absolute pressure within the suit equivalent to an altitude
of 30 000 feet (226 mmHg, 30.1 kPa) is sufficient to prevent
serious decompression sickness in seated aircrew, provided
that the duration of exposure is no longer than four to five
hours. If the pressure within the suit is less than 226 mmHg
(30.1 kPa), then serious decompression sickness may occur,
the severity of which is related directly to the altitude and
duration of exposure. In practice, therefore, the absolute
pressure in a full pressure suit may range from as low as
141  mmHg (18.8  kPa) for short-duration protection to as
high as 282 mmHg (37.6 kPa) when protection is required
for several hours.
Some full pressure suits are inflated with air, oxygen
being delivered to the respiratory tract via an oronasal mask
mounted within the helmet (see below). Consequently, if the
suit operating pressure is at the lower end of the range (i.e.
141  mmHg, 18.8  kPa), any inward leakage of air due to a
poorly fitting mask will cause severe hypoxia, a risk that is
clearly reduced if the pressure in the suit is higher.
Although, if necessary, heat can be delivered to a full
pressure suit by various means (including ventilation with
hot air, electric heating and circulation of heated liquid), its
pressure-containing layer is impermeable, and the garment,
therefore, imposes a considerable heat load. Consequently,
a means of removing metabolic heat and perspiration may
be required. It is necessary to take special precautions to
avoid freezing of valves by the passage through them of
moist gas and to prevent misting of the inner surface of the
helmet visor.
When unpressurized, a full pressure suit should not
place restrictions on posture or functional movements, and
it must provide an efficient oxygen and intercommunica-
tion system. It must be compatible with the aircraft escape
system, and it should afford protection against any hostile
ground environment that is likely to be encountered after
leaving the aircraft. Finally, the pressure helmet should also
provide some protection against noise and glare.
TECHNICAL CONSIDERATIONS
Full pressure suits usually consist of an impermeable inner
layer of pressure-containing material with an outer retain-
ing layer that prevents overexpansion on pressurization.
It is very difficult to match the characteristics of a flexible
inflated system to the shape of the human body and to match
the mechanical design of the suit to the natural movement
of human joints. Movement is resisted both by friction
and by the force required to expel gas from the appropri-
ate part of the suit, and delicate manipulative movements
of the fingers may have to be combined with large forces
at the shoulder, elbow and wrist. Consequently, there are
many problems associated with the design and construction
of full pressure suits, particularly the tendency of the suit
to become rigid when it is inflated, with subsequent reduc-
tion in mobility, especially at the neck, shoulder and wrist
and the marked tendency of the headpiece to rise from the
trunk of the wearer. Although the movement of joints may
be improved by the use of lightweight metal and gas-tight
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 108  Oxygen systems, pressure cabin and clothing

rotating bearings, the bulk, weight and additional restric-
tions that these impose limit the value of the full pressure
suit as a flying garment in conventional aviation, even when
modern fabric manufacturing techniques have been used to
reduce the problems of general rigidity.
To maintain the thermal balance of a crew-member
wearing a full pressure suit, a large ventilating flow of gas
is required beneath the impermeable layer, even when the
suit is not inflated. Air can be taken from the engines to
provide gas for ventilation and pressurization, while an oxy-
gen-rich supply for breathing is delivered through an orona-
sal mask or a helmet. Such suits, therefore, effectively have
two separate gas compartments: one for conditioning and
pressurization, and one for the breathing supply. The pres-
sure differential between these compartments must be kept
very small to avoid positive or negative pressure breathing.
Furthermore, in order to prevent air being drawn into an
ill-fitting mask from the remainder of the suit, the pressure
within the former must not fall below that of the air inflat-
ing the latter. Expired gas from the respiratory tract may be
passed either into the air compartment of the suit or directly
to the exterior. There are two common methods of pressure
control in full pressure suits, as illustrated in Figure 6.28.
In the first method, termed an oxygen pressure-control
system (Figure 6.28a), a pressure-demand regulator is used
to produce the desired absolute pressure in the oxygen com-
partment of the suit. This oxygen pressure is itself then used
to control the air outlet valves, so that the desired pressure
differential is maintained between the two compartments of
the air suit. In the second method, termed an air-control sys-
tem (Figure 6.28b), the pressure of the air in the suit is con-
trolled by a barometrically operated outlet valve. A relatively
simple demand valve can then be used to deliver oxygen to
the breathing compartment, since the absolute pressure
delivered by the oxygen regulator is determined solely by
the air pressure in the suit. For pressure suits used in space,
where no engine air source is available and where the astro-
naut or cosmonaut may leave the spacecraft, a closed-circuit
system is required. Breathing gas is circulated around the
body, and a backpack unit is employed to remove carbon
dioxide, water vapour, heat and odour and to add the neces-
sary amounts of oxygen to the system. Thermal balance is
maintained by a liquid-conditioning garment worn next to
the skin and beneath the pressure garment.
In addition to the technical difficulties outlined above, it
would be even more problematic to combine adequate pro-
tection against altitude exposure with protection against
sustained acceleration, high Gz. This is achieved more easily
by the combination of anti-G garments with high-altitude
partial pressure assemblies (see also Chapter 7).
Partial pressure garments and assemblies
The benefits of using counter-pressure applied to regions
of the body to mitigate against the adverse physiological
effects of pressure breathing were described previously.
Counter-pressure of this type is achieved by the use of par-
tial pressure assemblies (in contrast to full-pressure suits, as

Pressure High-
Pressure demand Automatically
demand pressure Visor
regulator, monitored closing visor
regulator oxygen (closes automatically)
by air pressure in
Oronasal mask
Oronasal mask headpiece Air monitor discharging
discharging expirate line expirate into
into suit through suit through
compensated compensated
Demand valve
expiratory valve expiratory valve

Demand
High- valve
Aneroid pressure
pressure oxygen
control Control of air Control of air
temperature temperature
and flow and flow Discharge
valve and
aneroid
control of
Discharge valve absolute
loaded by oxygen pressure
delivery pressure Air for suit Air for suit
in suit, with
pressurization pressurization
manual
and ventilation and ventilation
(a) (b) adjustment

Figure 6.28  Methods of pressure control of breathing oxygen and ventilating air in full pressure suits. (a) Oxygen pressure
control system. The oxygen regulator delivers gas to the oxygen compartment of the suit (oronasal mask) at the required
absolute pressure. The pressure of air in the air compartment of the suit (head, trunk and limbs) is controlled by the oxy-
gen pressure fed to the air discharge valve. (b) Air control system. An aneroid-operated discharge valve controls the pres-
sure of air in the air compartment which, in turn, controls the pressure at which gas is delivered by the oxygen regulator to
the oxygen compartment of the suit.

K17577_C006.indd 108 17/11/2015 15:37


described above). Partial pressure garments are less restric-
tive than full pressure suits and so offer considerable advan-
tages where short-term protection against the effects of
hypoxia is all that is required. From the physiological stand-
point, the ideal solution is to apply counter-pressure to as
much of the body as possible. The advantages of the ‘partial’
principle, however – i.e. low thermal load, less restriction
when unpressurized, and greater mobility when pressurized
– make it desirable that counter-pressure should be applied
to the minimum area of the body. Thus, the proportion of
the body covered by partial pressure garments represents a
compromise between physiological ideal and operational
expediency. Furthermore, since partial pressure assemblies
for high altitude protection are used for only very short
exposures, certain compromises with regard to the presence
of a moderate degree of hypoxia are also acceptable. Some
practical pressure breathing systems incorporating partial
pressure assemblies of increasing complexity and effective-
ness are described below.
MASK ALONE
The maximum breathing pressure for altitude protec-
tion that can be tolerated using a mask alone (i.e. without
counter-pressure to the body) is about 30  mmHg (4  kPa).
If an alveolar oxygen tension of 60 mmHg (8 kPa), i.e. an
absolute lung pressure (breathing pressure + environmen-
tal pressure) of 141 mmHg (18.8 kPa), is to be maintained,
then this system will provide respiratory protection to an
altitude of 45 000  feet. It is practical, however, to accept a
greater degree of hypoxia than that associated with an
alveolar oxygen tension of 60  mmHg (8  kPa). A breath-
ing pressure of 30  mmHg (4  kPa) at 50 000  feet provides
an absolute lung pressure of 117  mmHg (15.6  kPa) and
an alveolar oxygen tension of 45–50  mmHg (6–6.7  kPa).
Although this degree of hypoxia gives rise to very marked
impairment of performance if it is experienced for any
length of time, it is acceptable if a rapid descent is initi-
ated immediately. Typically, the oxygen regulator used in
this type of system delivers pressure breathing at altitudes
above 40 000  feet, with the breathing pressure increasing
from 0.75–7.5  mmHg (0.1–1  kPa) at 40 000  feet to about
30–34.5 mmHg (4–4.6 kPa) at 50 000 feet. Between the alti-
tudes of 40 000 and 50 000 feet breathing pressure increases
linearly with the decrease in environmental pressure. The
absolute pressure in the respiratory tract therefore falls
progressively above 40 000  feet and produces a gradual
increase in the intensity of the hypoxia. Above 50 000 feet,
the hypoxia is very severe and unconsciousness supervenes
rapidly. This, therefore, limits mask-only pressure breath-
ing to altitudes not exceeding 50 000  feet but this type of
pressure-breathing system is used widely throughout
the world. In summary, the combination of a pressure-
breathing mask and a suitable oxygen regulator (capable
of delivering a pressure of 30–34.5  mmHg (4–4.6  kPa) at
50 000 feet) will provide protection for one minute against
the effects of loss of cabin pressurization up to cabin alti-
tudes of 50 000  feet, provided that immediate descent at
K17577_C006.indd 109
Pressure clothing  109
a minimum rate of 10 000  feet/min is then undertaken to
below 40 000 feet. The degree of protection afforded by this
system is shown diagrammatically in Figure 6.29.
CHEST AND TRUNK COUNTER-PRESSURE
Considerable physiological advantage can be gained by the
application of counter-pressure to the chest or, better, the
whole trunk. Furthermore, this has the added benefit of
reducing the fatigue associated with pressure breathing by
providing mechanical assistance to the expiratory muscles
of the chest wall. An inelastic counter-pressure garment cov-
ering the chest only, commonly termed a pressure waistcoat
incorporates a pneumatic bladder in communication with
the mask hose. As mask hose pressure rises, so, too, does
the pressure in the waistcoat. There is significant benefit to
using a garment with a bladder that provides full circum-
ferential protection of the chest. This serves to reduce dis-
tension of the chest and consequently reduces the changes
in lung volumes during pressure breathing described above.
Since distension of the chest is reduced, so, too, is the dif-
ference between the applied breathing pressure and the
intrapleural pressure, i.e. there is a smaller loss of intrapul-
monary pressure as a result of chest distension and the pres-
sure breathing therefore is likely to be more effective.
However, although chest counter-pressure is helpful in
providing some support to muscles of the thoracic cage, it
alone confers little or no benefit with respect to circulatory
disturbances. Application of counter-pressure to the whole
of the trunk, however, does contribute to circulatory sup-
port by applying compression to the abdomen. Therefore, a
70
a  Mask alone
b  Mask, pressure jerkin
b  and G trousers
c c  Pressure helmet,
b  pressure jerkin and
Altitude (thousands of feet)
b  G trousers
60
b
50
a
40
0 1 2 3 4
Limiting Time (min)
Figure 6.29  Limits of protection against hypoxia provided
by pressure breathing systems. (a) Pressure breathing
mask alone (maximum breathing pressure 30–34.5 mmHg,
4–4.6 kPa). (b) Pressure breathing mask with counter-pres-
sure to the trunk and lower limbs (maximum breathing
pressure 68–72 mmHg, 9.1–9.6 kPa). (c) Partial pressure
helmet with counter-pressure to the trunk and lower
limbs (maximum breathing pressure 107–110 mmHg,
14.3–14.7 kPa).
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 110  Oxygen systems, pressure cabin and clothing
garment covering the whole of the trunk, known as a jerkin,
can make higher breathing pressures tolerable and extend
the allowable duration of pressure breathing. Such counter-
pressure jerkins were in use for many years in a number of
countries, especially the UK. They were even more effective
in preventing over distension of the chest, as they offered
mechanical support to the diaphragm as well as the chest
wall. The abdominal element of the garment helps to prevent
visceral pooling of blood and aids venous return through
the inferior vena cava.
Counter-pressure to the trunk alone, however, may
induce syncope as a consequence of the large displace-
ment of blood to all four limbs. Therefore, to provide more
effective circulatory support, limb counter pressure is also
required and so mask-and-jerkin-only counter-pressure
assemblies are now rarely, if ever, used.
MASK WITH TRUNK AND LOWER LIMB
COUNTER-PRESSURE
A long-established partial pressure assembly used in the
RAF up until 2006, and copied elsewhere, incorporated
both trunk and lower limb counter-pressure and made full
use of the pressure-sealing properties of current orona-
sal masks to a maximum breathing pressure of 70 mmHg
(9.3 kPa). Trunk counter-pressure was applied by a partial
pressure jerkin (Figure  6.30), which comprised a rubber
bladder restrained by an outer inextensible cover. The blad-
der extended over the whole of the trunk and also over the
upper parts of the thighs. Lower limb counter-pressure is
provided by incorporation of anti-G trousers to the assem-
bly and breathing gas supplies were delivered to the mask,
Figure 6.30  The Royal Air Force partial pressure jerkin.
K17577_C006.indd 110
jerkin and anti-G trousers. Since all are supplied from the
same source the pressure in each is equal.
If the absolute pressure within the lungs is maintained
at 141  mmHg (18.8  kPa), then the mask/partial pressure
jerkin/anti-G trousers combination will provide ideal pro-
tection to a maximum altitude of 54 000  feet. In practice,
however, a certain degree of hypoxia is acceptable, and a
breathing pressure of 68–72  mmHg (9.1–9.6  kPa) can be
employed at 60 000  feet, where it will provide an absolute
pressure in the lungs of 122–126 mmHg (16.3–16.8 kPa) and
an alveolar oxygen tension of 55–60 mmHg (7.3–8 kPa). The
combination of the discomfort of a high breathing pres-
sure in the mask and a certain degree of hypoxia limits the
duration of protection afforded by this ensemble. The limit,
shown diagrammatically in Figure  6.29b, is an interval of
60 seconds at 60 000 feet followed immediately by descent at
a rate of at least 10 000 feet/min to 40 000 feet.
In this form of partial pressure assembly, both the jer-
kin and the anti-G trousers were inflated to the same pres-
sure, but there are advantages to inflating the latter to a
greater pressure than that being delivered to the jerkin and
mask. Work carried out in a number of centres has dem-
onstrated that if lower-body counter-pressure is provided
by the inflation of anti-G trousers to a pressure consider-
ably higher than the breathing pressure, then this serves to
improve support to the diaphragm, increase venous return,
improve cardiac filling and, hence, result in better main-
tenance of an appropriate blood pressure, and reduce the
degree of tachycardia associated with pressure breathing.
The degree to which the anti-G trousers should be inflated
has been the topic of considerable research and is influenced
by the differing degree of body coverage offered by conven-
tional five bladder anti-G trousers or those with extended
or full coverage. Overall, inflation of anti-G trousers to
two or three times the breathing pressure appears valuable
but inflation to too high a pressure such as would occur
if the anti-G trousers are inflated to four times breathing
pressure (at 1  Gz) may have adverse consequences, possi-
bly related to partial occlusion of arterial flow, and is very
uncomfortable when breathing pressure is high. With such
assemblies, the extent of counter-pressure bladder coverage
of the upper garment can be reduced drastically (and with
it the bulk and weight of the garment) with few additional
cardio respiratory penalties. The abdominal portion of the
anti-G trousers provides counter-pressure to the lower half
of the trunk, in lieu of the abdominal portion of the jerkin,
as described previously. This, then, has considerable advan-
tages for use in the latest generation of agile combat aircraft
capable of high accelerative performance at high. The anti-
G garments therefore can be integrated into an ensemble
that supports pressure breathing for both high altitude and
high G (Figure 6.31).
PARTIAL PRESSURE HELMET WITH TRUNK AND
LOWER LIMB COUNTER-PRESSURE
For completeness, although not currently in service, it is
appropriate to consider the role of partial pressure helmets
17/11/2015 15:37

Figure 6.31  A modern RAF counter-pressure assembly
comprising a chest counter-pressure waistcoat integrated
within the flight jacket and worn in combination with
full coverage anti-G trousers which are inflated, dur-
ing pressure breathing, to a pressure higher than the
breathing pressure.
within a partial pressure assembly. In this system, a par-
tial pressure helmet was the means by which pressure was
delivered to the respiratory tract, a jerkin provided trunk
counter-pressure and the anti-G trousers provided lower
limb counter-pressure to reduce the circulatory disturbance
induced by high breathing pressures. The disadvantages of
a pressure helmet are its weight and bulk, which has made it
less acceptable for use in aircraft with high agility as well as
a high altitude capability.
As described therefore, a partial pressure helmet is
an alternative device for applying positive pressure to the
respiratory tract and to give support to the cheeks, the eyes
and the floor of the mouth, so eliminating the uncomfort-
able pressure differentials that develop between the air pas-
sages and the skin of the head and neck when an oronasal
mask is employed. In most partial pressure helmets, coun-
ter-pressure is also applied by oxygen bladders to a limited
area of the upper neck, but although the extent of this cover-
age ensures reasonable head mobility during routine flying,
K17577_C006.indd 111
Pressure clothing  111
severe neck discomfort may occur during pressure breath-
ing at levels greater than 110 mmHg (14.7 kPa).
Physiologically, the pressure demand oxygen regulator
used with this assembly need only provide an absolute pres-
sure of 141 mmHg (18.8 kPa) at altitudes above 40 000 feet.
In practice, however, the regulator formerly used by the
RAF in this role delivered a maximum breathing pressure
of 107–110 mmHg (14.3–14.7 kPa) at 66 000 feet, so provid-
ing an absolute pressure in the lungs at that altitude of 148–
151  mmHg (19.6–20.1  kPa). The partial pressure helmet/
partial pressure jerkin/G-trousers ensemble therefore could
be used up to a maximum altitude of 66 000 feet, where it
would provide protection for up to one minute, provided
that descent to 40 000  feet follows within a further three
minutes (see Figure 6.29c).
PRESSURE HELMET WITH TRUNK AND UPPER AND
LOWER LIMB COUNTER-PRESSURE
It is clearly physiologically advantageous to include the
upper limbs in the areas to which counter-pressure is
applied, and a wide variety of garments have been employed
to provide this extensive coverage in combination with a
pressure helmet. Many garments, such as sleeved jerkins
formerly in RAF systems, made use of oxygen-filled blad-
ders that covered much of the body surface. Others, such
as the United States Air Force (USAF) ‘capstan’ partial
pressure garment, utilize a mixture of fabric tensioning
by means of capstans and gas-filled bladders (see below).
In these systems, an inflatable torso garment is supplied
with breathing gas at elevated pressure, but a separate sup-
ply inflates relatively narrow tubes that run the length of
the limbs to a pressure considerably greater than breathing
pressure. On inflation, the capstans, which are attached to
inelastic material by figure-of-eight bands around the limb,
act as pneumatic levers to hold the garment encasing the
limb under tension and thereby apply counter-pressure.
Although this is a relatively efficient method of applying
limb counter-pressure, it is restrictive, especially when
operative, since the capstans are inflated to high pressures.
Such systems were in common use in the USAF in the past
and remained in use in a number of former Warsaw Pact
air forces for much longer.
The pressure helmets employed in combination with
such extensive partial pressure assemblies vary from the
RAF partial pressure helmet described above (in which
pressure is applied only to the face, part of the head and the
upper neck) to the USAF version (in which gas is applied to
the whole of the head and neck). A range of combinations
have been used in the past to provide limited duration pro-
tection at very high altitudes. Most do not apply counter-
pressure to the lower neck, the axillae or the hands and feet.
Virtually all of these systems employ oxygen regulators that
maintain an absolute pressure in the respiratory tract, and
over the pressurized areas of the body, of 145–150 mmHg
(19.3–20  kPa). Such combinations will provide prolonged
protection against the effects of hypoxia on exposure to
altitudes well above 40 000 feet; for example, protection is
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 112  Oxygen systems, pressure cabin and clothing
possible for some minutes at 65 000–70 000 feet and even up
to 100 000 feet. However, protection against decompression
sickness, ebullism and the effects of low temperature is not
provided and their relative advantage compared with a full
pressure suit diminished.
Thus, although they do not provide the same degree
of physiological protection as full pressure suits, opera-
tional considerations make partial pressure assemblies an
attractive alternative for short-duration protection against
hypoxia at high altitude. In combination with enhanced
anti-G systems, such assemblies are in relatively common
use in the latest generation of fast jet combat aircraft.
PRESSURE CABINS
As noted above, pressurizing an aircraft cockpit or cabin
can provide good protection against the adverse effects
of ascent to altitude. In practice, compromises are made
between the physiological ideal of a cabin pressure of one
atmosphere absolute, the weight and performance penalties
of a high cabin pressure differential, and the probability of
explosive failure of the cabin. The compromises that have
been adopted in the design of pressure cabins can be clas-
sified into two groups. If comfort is of prime concern and
the probability of structural damage to the aircraft is very
remote, then the pressure in the cabin is maintained at a
level at which the occupants can breathe air from within
that cabin throughout flight. In combat aircraft, where
weight is at a premium and there is a risk of failure of the
integrity of the cabin due to enemy action, a much lower
level of pressurization of the cabin is adopted, and the occu-
pants breathe oxygen or an oxygen/air mixture.
There are two methods of maintaining the pressure
in the cabin of aircraft above that of the immediate envi-
ronment. The conventional method, used in virtually all
current aircraft, is to draw air from outside the aircraft,
compress it and deliver it into the cabin. The desired pres-
sure is maintained within the cabin by controlling the flow
of compressed air out of the cabin to the atmosphere. The
continuous flow of air ventilates the compartment; in most
aircraft, this flow of air also controls the thermal envi-
ronment within the cabin, so that the control of pressure
and temperature are closely related. As modern turbofan
engines were developed, the amount of fuel required to
provide thrust decreased, but fuel consumption relative
to extracting bleed air for control of the cabin environ-
ment increased considerably. Thus, efficient recirculation
systems were developed, incorporating high-efficiency
particulate air (HEPA) filters, which provided fuel savings
without compromising cabin air quality. Consequently,
since the mid-1980s, most passenger-carrying aircraft have
been fitted with environmental control systems that recir-
culate 50 per cent of the air in the cabin.
At very high altitudes, the energy required to compress
the low-density air to the pressure required in the cabin and
the heat generated in the process of compression become
excessive. It is impracticable to pressurize the cabin with
K17577_C006.indd 112
external air during sustained flights at altitudes above about
80 000 feet. In these circumstances, and in the vacuum of
space, the pressurizing gases must be carried within the
vehicle. It then becomes uneconomical to condition the
cabin with a through-flow of gas that escapes to the envi-
ronment. Used gases are recycled and loss of gas is reduced
to a minimum. Such systems will not be discussed further
in this chapter.
The difference between the absolute pressure within and
that of the atmosphere immediately outside an aircraft is
termed the cabin differential pressure. The differential pres-
sure is frequently controlled, so it varies with aircraft alti-
tude. Although the pressure in the cabin generally is greater
than that of the atmosphere at the aircraft altitude (i.e. a pos-
itive differential), in some circumstances, e.g. during a rapid
dive, it can be less (i.e. a negative differential). The absolute
pressure in an aircraft cabin is almost always stated in terms
of pressure altitude (feet above mean sea level) in accordance
with the International Civil Aviation Organization (ICAO)
standard scale. The absolute pressure in the cabin equals the
sum of the atmospheric pressure and the cabin differential
pressure. Thus, the cabin pressure of an aircraft flying at an
altitude of 25 000 feet (atmospheric pressure 38 kPa, 5.5 lb/
in2) and with a cabin differential pressure of 31 kPa (4.5 lb/
in2) gauge is 69 kPa (10 lb/in2) absolute, which is equivalent
to an altitude of 10 200 feet.
PHYSIOLOGICAL REQUIREMENTS OF
PRESSURE CABINS
Four main groups of physiological factors must be consid-
ered when defining the requirements for a pressure cabin.
The first group consists of the factors that determine the
maximum acceptable cabin altitude: hypoxia, decompres-
sion sickness and expansion of gastrointestinal gas. The
second group determines the maximum acceptable rate of
change of cabin altitude during ascent and descent of the
aircraft: the ventilation of body cavities containing gas, e.g.
the middle-ear cavities and the paranasal sinuses. The third
group of factors relate to the magnitude of the effects of a
sudden cabin failure. The final group of factors concerns the
quality of the cabin air and the effect this has on comfort
and well-being.
Hypoxia
The acceptable cabin altitude in an aircraft in which the
occupants breathe air is set by considerations of the effects
of mild hypoxia on the performance of the aircrew and
on the well-being of the passengers. As noted in previous
chapters, at altitudes greater than 10 000–12 000 feet, there
is a potential for significant impairment of ability to per-
form flight tasks. Indeed, individuals have been reported
to be detectably slower to react to a novel situation when
they are breathing air at an altitude of 8000 feet, although
at 5000  feet, there is very little detectable impairment of
this type of performance. Thus, although the maximum
17/11/2015 15:37

permissible cabin altitude in routine flight in commer-
cial aircraft flying at high altitude is 8000  feet, there is a
view that an environmental pressure equivalent to 5000–
7000 feet would have physiological advantages and at least
one modern commercial aircraft has been introduced
into service with its maximum cabin altitude limited to
6000 feet.
Certain people, particularly those suffering from cardio-
respiratory disease, may be unable to maintain full oxygen-
ation of tissues at normal cruising cabin altitudes, a matter
of considerable importance in civil transport aircraft, where
passengers may not report any known inadequacy of their
respiratory or cardiovascular systems. Exposure of the
standard passenger population to cabin altitudes of the
order of 8000 feet for several hours may result in noticeable
fatigue and potentially more significant medical problems,
which are probably induced by the combination of mild
hypoxia, expansion of abdominal gas, lack of movement
and seated posture. Limitation of the cabin altitude to a
maximum of 6000 feet has been reported to eliminate some
of these incidents.
If the inspired air is progressively enriched with oxygen,
then the alveolar oxygen tension (Pao2) may be maintained
at the value associated with normal air breathing at sea level
up to 33 000 feet. The hypoxia induced in a person breath-
ing 100 per cent oxygen at 40 000 feet is equivalent to that
produced when he or she breathes air at 8000 feet. Since the
latter was generally recognized as the maximum degree of
hypoxia acceptable, it could be argued that, given 100 per
cent oxygen is breathed, the cabin altitude could be allowed
to rise to 40 000  feet. However, this argument ignores the
effects of possible malfunction or failure of the oxygen-
delivery system and the consequent rapidly increased rate at
which impairment of judgement and performance develop
in an individual who has to revert to breathing air above
20 000 feet. Thus, the time available to an individual to rec-
ognize that the oxygen supply has ceased and to carry out
the appropriate corrective action falls from 10–12 minutes
at 20 000 feet, to three to five minutes at 25 000 feet, and to
1–1.5 minutes at 33 000 feet.
Furthermore, the reduction of inspired Po2  produced
by a given fractional inboard leak of air due to an ill-fitting
breathing mask increases with rise of altitude. In practice,
the incidence and severity of hypoxia become significant
at a cabin altitude of about 22 000  feet and rise markedly
above that, so that 20 000–22 000 feet is now regarded as
the standard limit for regular operations by crews breath-
ing supplemental oxygen. However, some aircraft with a
25 000-feet maximum cabin altitude remain in service in
air forces all over the world.
Decompression sickness
Although decompression sickness can occur when indi-
viduals are exposed to an altitude of 18 000 feet, it is very
rare below 22 000  feet. A small but significant number of
cases have occurred during exposure to altitudes between
K17577_C006.indd 113
Physiological requirements of pressure cabins  113
22 000 and 25 000 feet. Since decompression sickness dur-
ing routine flights is unacceptable, the maximum cabin alti-
tude to which aircrew may be exposed should not exceed
22 000 feet. In some circumstances, it may be necessary for
aircrew to operate at cabin altitudes as high as 25 000 feet.
However, unless susceptible individuals are protected by
pre-oxygenation, occasional cases of decompression sick-
ness will occur.
Expansion of gastrointestinal gas
In normal healthy individuals, the stomach and intes-
tines contain a quantity of gas, the volume of which varies
between 0 and 400 mL, with an average value of 100 mL.
This gas is derived from swallowed air, from the action of
bacteria within the gut, and from exchange with the gases
in the tissues and blood.
During ascent, the gas contained within the stomach
expands and usually escapes up the oesophagus and out
through the mouth. Gas bubbles within the large bowel
coalesce to form large bubbles, which are vented through
the anus. Some people, usually inexperienced aircrew
members, have difficulty in venting gas from the mouth
and anus, even with low rates of ascent. At very high rates
of ascent and during rapid decompression, this difficulty
increases, and even experienced aircrew members have
some difficulty in expelling gas from the alimentary tract
as quickly as it expands. The individual may thus develop
symptoms, which vary from mild upper or lower abdomi-
nal discomfort to, in exceptional cases, very severe pain. In
some sensitive individuals, the abdominal pain caused by
the expanding gas may cause vasovagal syncope. Expansion
of the gas in the gastrointestinal tract is not known to pro-
duce visceral damage.
The problem of gas expansion in the alimentary tract
may be aggravated if the individual is suffering from mild
intestinal infection or has eaten a large quantity of food-
stuffs known to be gas-forming (e.g. peas, beans, cauli-
flower, cabbage, high-roughage foods, carbonated drinks).
With experience, aircrew members learn which foodstuffs
cause excessive gas formation and adjust their diet accord-
ingly. The incidence of abdominal discomfort or pain in
healthy aircrew who are frequently exposed to high altitude
is negligible when the maximum altitude does not exceed
25 000 feet. Even when such individuals are decompressed
to altitudes above 40 000  feet, the incidence of abdominal
pain on short-duration exposures is only two to three per
cent. However, although infrequent, symptoms arising from
gas expansion in the alimentary tract are one of the com-
mon causes of early termination of training decompressions
to high altitude.
Passengers suffering from gastro-intestinal disorders
may be distressed even by a relatively small increase in the
volume of gas in the abdomen produced by ascent from
ground level to 8000  feet. The maximum cabin altitude
of passenger and aeromedical evacuation aircraft should,
therefore, be kept as low as possible.
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 114  Oxygen systems, pressure cabin and clothing
The teeth
Expansion of gas in the teeth during ascent to altitude may
cause severe toothache, known as aerodontalgia. The source
of gas in the teeth may be air trapped between the tooth
substance and a deep cavity filling, particularly in unlined
cavities. Modern dental filling materials have reduced the
incidence of trapped gas in dental fillings and aerodontalgia
from this source is now rare. Aerodontalgia may, however,
be experienced by aircrew with unhealthy teeth, where,
for example, gas of putrefaction gathers in a small bubble
at the apex of a tooth in the condition of chronic or acute
apical abscess.
Rates of change of cabin altitude
High rates of ascent to altitude, e.g. 5000–20 000 feet/min,
are usually tolerated very well, but descent is another matter.
The difficulty of equilibration to ambient of the pressures
in the gas-filled cavities of the body limits the maximum
acceptable rate of increase of cabin pressure during descent.
The body contains a number of gas-filled cavities that com-
municate with varying degrees of ease with the external
environment. During ascent or descent in an aircraft or on
sudden loss of cabin pressurization, the pressure of the gas
within these cavities must attain equilibrium with that of
the surrounding environment; otherwise the individual
will suffer adverse effects.
When there is unrestricted communication between
a gas-filled cavity and the outside atmosphere, gas expan-
sion occurs with little difficulty and no discomfort. If,
however, the pressure of the gas in the cavity fails to equili-
brate with the outside environmental pressure, then there
may be considerable discomfort, frank pain or damage to
tissues or organs of the body, which may well incapacitate
the individual. The critical sites where gases can be trapped
and pressures fail to equalize comprise the middle ears and
paranasal sinuses.
The middle ear
The cavity of the middle ear is separated from the outer ear
by the tympanic membrane (Figure 6.32). It communicates
with the nasopharynx and, hence, the atmosphere by way
of the eustachian tube, the proximal two-thirds of which
has soft walls that are normally collapsed. During ascent
to altitude, the gas in the middle-ear cavity expands and
escapes along the eustachian tube into the nasopharynx, so
that pressure remains equal on both sides of the tympanic
membrane. Since the anatomical structure of the pharyn-
geal (or fibrous) portion of the eustachian tube is such that
it acts as a one-way valve, expanding air can escape easily to
the atmosphere, and it is very unusual for passive venting
of the middle ear to present difficulties during decompres-
sion. This intermittent passive ventilation of the middle ear
during ascent may be appreciated as a ‘popping’ sensation
as air escapes from the pharyngeal orifice of the eustachian
K17577_C006.indd 114
A
Middle-ear
Tympanic
cavity
membrane
Atmospheric
External ear
pressure
Eustachian
tube patent
B
Tympanic
membrane Middle-ear
displaced cavity
inwards
Below
External ear atmospheric
pressure
Eustachian
Atmospheric
tube blocked
pressure
Figure 6.32  Diagram of external and middle ear (a) at a
constant altitude with a patent eustachian tube and (b)
during descent with an occluded eustachian tube. While
the eustachian tube is patent, the pressure in the middle-
ear cavity equals that in the nasopharynx, which in turn is
equal to that of the atmosphere. If, however, the eusta-
chian tube is occluded during descent (b), the pressure in
the middle-ear cavity is less than that in the nasopharynx
and the atmospheric pressure, and the pressure differ-
ence across the tympanic membrane displaces it into the
middle-ear cavity.
tube. On ascent, the eustachian tube opens and gas escapes
from the middle ear into the nasopharynx approximately
once every 500–1000 feet.
During descent, gas from the nasopharynx must enter
the middle ear in order to maintain equilibrium between
the atmospheric pressure outside and the gas pressure in the
middle ear. In most individuals, the one-way valve mech-
anism of the eustachian tube prevents the passive flow of
gas back into the middle-ear cavity. The resultant relative
increase of pressure on the outside of the tympanic mem-
brane pushes the membrane into the middle-ear cavity. As
descent continues, the membrane is pushed further into the
middle-ear cavity unless gas enters through the eustachian
tube. This distortion leads to a sensation of fullness in the
ear and a decrease in hearing acuity. If descent continues
further without equalization of pressure between the atmo-
sphere and the middle ear, then the differential pressure
across the ear drum causes pain. In certain susceptible indi-
viduals, a rapid change of pressure in the middle-ear cavity
17/11/2015 15:37

may also affect the organs of balance in the inner ear and
cause vertigo (pressure vertigo).
In order to equalize the pressure across the tympanic
membrane during descent and, thus, prevent the develop-
ment of otitic barotrauma, it is usually necessary to per-
form some active manoeuvre to open the eustachian tubes.
Although several simple manoeuvres, such as swallowing,
yawning and jaw movements, may open the tube, these are
not effective in about half the aircrew population. These
individuals have to raise the pressure in the nasopharynx
in order to force gas into the middle ear cavities. This rise in
pressure is usually achieved by performing either a Valsalva
or Frenzel manoeuvre. The Valsalva manoeuvre is carried
out by attempting a forced expiration with the lips closed and
the nostrils occluded by compressing the nose. This manoeu-
vre is used commonly in flight, but the raised intrathoracic
pressure generated during the procedure may, under certain
circumstances, impair cardiovascular function. The Frenzel
manoeuvre raises the pressure locally in the nasopharynx. It
is performed by closing the glottis and the lips while occlud-
ing the nostrils and simultaneously contracting the muscles
of the floor of the mouth and pharynx. These coordinated
actions are similar to those employed when blowing one’s
nose or stifling a sneeze and have to be learned. The Frenzel
manoeuvre has the advantages of opening the eustachian
tube at lower nasopharyngeal pressures and being capable
of performance during any phase of respiration.
Mention must also be made of the Toynbee manoeuvre,
which consists of swallowing while the nostrils are pinched.
This action also opens the eustachian tubes at ground level
but does so by generation of a reduced pressure in the naso-
pharynx. It is useful, therefore, for checking the patency of
the tubes, but it is not recommended as a procedure for use
during descent.
The frequency with which trained aircrew perform one
or other of these ear-clearing manoeuvres varies consider-
ably, from once every 1000 feet to once every 4000 feet or
more. There is, however, a limit to the pressure rise that
can be created within the nasopharynx, and the eustachian
tube may become locked closed when the differential pres-
sure between the middle ear and the environment exceeds
12–16 kPa (90–120 mmHg).
Upper respiratory tract infection causes congestion and
oedema of the mucosal lining of the eustachian tube, par-
ticularly where it opens into the nasopharynx. This con-
gestion may restrict the passage of gas into the middle-ear
cavity during descent. The tympanic membrane will then
be driven into the middle ear, causing deafness and pain. If
descent is continued, the grossly distorted membrane may
rupture, with immediate relief of the pain. The changes in
the tympanic membrane and middle ear produced by fail-
ure of adequate ventilation of the latter during descent are
termed otitic barotrauma. This condition commonly arises
in association with upper respiratory tract infections, but
it may also be caused by too rapid descent or inadequate
knowledge of the correct procedures for ventilating the
middle ear.
K17577_C006.indd 115
Physiological requirements of pressure cabins  115
The paranasal sinuses
The paranasal sinuses are cavities located in the bones of
the face and skull. The frontal sinuses communicate with
the nose by relatively long ducts. Each of the other sinuses
is connected to the nose by a hole in its wall. During ascent
and descent, the expanding and contracting gas contained
within a sinus is free to communicate with the gas in the
nose, and a pressure difference does not develop between
the gas in the sinus and the external atmosphere. If, how-
ever, the mucous membrane lining the passage connecting a
paranasal sinus to the nose becomes inflamed and oedema-
tous, then the normal passive ventilation of the sinus cavity
may be obstructed, particularly during descent. Such a fail-
ure causes severe pain in the cheeks or forehead or deep in
the head, often accompanied by watering of the eyes. Auto-
inflation of the sinus cavity is not achieved easily when this
condition exists, even by manoeuvres in which the pressure
in the mouth and nose is raised above that of the environ-
ment. Nasal decongestants may help to re-establish auto-
ventilation of the sinus cavity, but it may be necessary to
limit the rate of descent. Damage to the mucosal lining may
occur with subsequent haemorrhage into the sinus cavity.
This condition of acute sinus barotrauma frequently recurs
and eventually may require surgical treatment.
Maximum acceptable rates of change of
cabin altitude
A pressure change of 14 kPa (2 lb/in2)/min is the maximum
that should be permitted for military aircraft if otitic or
sinus barotrauma is to be avoided. Sudden alterations of
descent rates are also undesirable. Inexperienced passen-
gers who are not trained in the techniques of inflation of
the middle ears during descent will complain of ear dis-
comfort if the rate of increase of cabin pressure from the
6000–8000-feet maximum altitude to ground level exceeds
about 1.7 kPa (0.25 lb/in2)/min, i.e. about 500 feet/min. The
maximum rate of increase of cabin pressure adopted for
most civil passenger aircraft is 1 kPa (0.15 lb/in2)/min, i.e.
about 300 feet/min.
Decompression of the pressure cabin
The risk of damage to the occupants of a pressure cabin
in the event of a sudden failure of its integrity increases in
proportion to the ratio of the area of the defect in the wall
to the volume of the cabin and to the ratio of cabin pres-
sures before and immediately after the decompression. A
more detailed account of these relationships is given later
in this chapter. The cabins of transport aircraft are designed
so that the ratio of the area of the maximum size of defect
that could occur in the wall from the loss of a window to
the volume of the cabin is as small as possible and larger
access areas such as doors and hatches are designed to open
inwards. The maximum probable defect will not, therefore,
produce a dangerous rate of decompression, even when the
17/11/2015 15:37
 116  Oxygen systems, pressure cabin and clothing
cabin pressure differential is as high as 69–83 kPa (10–12 lb/
in2) unless there is an additional major structural failure,
which would possibly destroy the aircraft. In military air-
craft, however, battle damage or jettison of a canopy from a
small-volume cabin could lead to very rapid decompression.
To limit the effects of this, the cabin differential pressure
normally does not exceed 28–35 kPa (4–5 lb/in2). However,
in some combat aircraft, a dual differential pressure facility
was adopted in the past. Thus, in cruise or patrol conditions,
a high differential pressure of 55–62 kPa (8–9 lb/in2) could
be selected, thereby permitting aircrew to dispense with
the wearing of oxygen equipment. Reduction of the differ-
ential pressure to 28–35  kPa (4–5  lb/in2) in danger zones
minimized the effects of sudden loss of cabin pressure but
enforced the use of oxygen in combat. Most aircraft with
this dual pressurization capability are, however, no longer
in service.
Cabin air quality
Following the introduction of recirculating environmental
control systems in passenger aircraft, cabin air quality has
been a subject of major interest, stimulating several stud-
ies and reviews. The elements of cabin air quality that con-
tribute to passenger perception of comfort and well-being
are ventilation, removal of contaminants, temperature,
humidity and concerns regarding the spread of infections.
Aircraft recirculation systems exchange the air some five to
ten times more frequently than in buildings and, thus, pre-
cise control of the distribution to seating zones is necessary
to avoid draughts. HEPA filters ensure that contaminants
such as smoke particles and microorganisms are removed.
The former capability is becoming increasingly redundant,
as smoking is banned by most airlines. Studies by Rydock
(2004) indicate that infectious diseases are likely to be
transmitted only between people sitting in close proximity
to each other, and recirculation of ventilation air has a neg-
ligible effect on occupants’ risk of exposure. Temperature is
relatively easy to control, and flight-deck and cabin atten-
dants should cooperate to maximize the comfort level in the
cabin. However, perception of ‘comfort’ may vary between
cabin crew and passengers, and it is not easy to provide ther-
mal comfort for all passengers. Some areas of the aircraft are
regarded by the crew as less favourable than others, e.g. the
galley. Finally, without a humidifying system, low humidity
is inevitable in aircraft operating at moderate and high alti-
tudes. Typically, relative humidity levels of 12–21 per cent
exist; although these low levels may cause mild symptoms
of nasal dryness, no other effects are apparent. These mild
effects probably can be alleviated by increased fluid intake
during air travel. Published data indicate that modern air-
craft maintain a very high quality of ventilating air; in a
study conducted for the European Commission, none of
the values of the contaminants monitored were at levels of
concern for the health of passengers or crew. Nevertheless,
measured temperatures, relative humidities and CO2  lev-
els in the cabin on some flights were outside the range
K17577_C006.indd 116
associated with acceptable indoor air quality and thermal
comfort. Furthermore, air pollutant levels in the cabin gen-
erally were higher on the ground than at cruise altitude.
An additional in-depth review of cabin air quality by the
US National Research Council of the National Academy of
Sciences could not identify a link between the cabin envi-
ronment and reported illness (Rayman 2002). Despite the
reassuring results of the studies monitoring cabin air and
the literature reviews, there remains a general perception of
reduction in well-being associated with air travel and fur-
ther work was advocated by Rayman in 2002. Future design
and technology developments should address improve-
ments to air quality and comfort on the ground, perhaps by
further improvements to filtration and better facilities for
the control of ventilation and thermal comfort by both pas-
sengers and crew in the air.
PRESSURIZATION SCHEDULES
The relationship between cabin altitude and aircraft altitude
is termed the cabin pressurization schedule. By convention,
this is displayed graphically, with the aircraft and cabin
altitudes plotted on linear pressure scales (Figure  6.33). A
straight line through the origin with a slope of one represents
the relationship between cabin and aircraft altitudes when
there is no pressurization. A set of straight lines parallel to
the zero pressurization curve, depicts various constant cabin
differential pressures. It is convenient to recognize three
types of relationship between cabin and aircraft altitudes.
The cabin altitude may be controlled at a constant value over
a range of aircraft altitudes – termed isobaric control. The
cabin differential pressure may be controlled to a constant
value as the aircraft altitude varies – termed differential con-
trol. There is also a form of control intermediate between
isobaric and differential control, in which the differential
pressure, although changing with aircraft altitude, does
not do so to such an extent that the cabin altitude remains
constant. In practice, these three types of control are often
employed over consecutive ranges of altitudes in the same
aircraft. The extent to which the pressurization schedule can
be varied in flight by the crew also varies. In high-altitude
combat aircraft, the cabin pressurization schedule is usu-
ally entirely under automatic control, and the pilot can only
switch on or off the pre-set schedule. In passenger transport
aircraft, the flight-deck crew can, within certain limits, vary
the pressurization schedule during flight.
High-differential passenger cabins
The cabins of passenger-carrying aircraft operating at alti-
tudes above 5000–8000  feet are pressurized so that the
occupants can breathe air throughout flight and move freely
around the cabin, and discomfort and fatigue are mini-
mized. The structure of such aircraft is so robust and the
reliability of the cabin pressurization systems so high that
the risk of a serious decompression of the cabin is no greater
than the risk of other forms of major structural failure. The
17/11/2015 15:37
 Pressurization schedules  117

physiological considerations suggest that the cabin alti- Cabin differential

tude ideally does not exceed 6000  feet, and certainly not pressure (lb/in2)
0 2 4
8000 feet, and that the rate of change of cabin pressure with 30

Cabin altitude (thousands of feet)

change of altitude of the aircraft is as small as possible: the
rate of increase of pressure on descent should not exceed
1 kPa (0.15 lb/in2)/min (approximately 300 feet/min).
The maximum cabin differential pressure used during
normal operation of passenger aircraft is determined by the
physiological requirement and the operational ceiling of the
aircraft. When the aircraft is cruising at an altitude below its
operational ceiling, the flight-deck crew decides whether to
select the maximum cabin differential pressure, thus main-
taining a very low cabin altitude and increasing comfort,
or to allow the cabin altitude to rise to the 6000–8000-feet
band, thus minimizing the differential pressure and pro-
longing the fatigue life of the cabin structure (Table  6.2).
The rate of change of cabin pressure is kept low and within
the maximum for comfort of 11.7  kPa (0.15–0.25  lb/in2)
(300–500 feet)/min by pressurizing the cabin from ground
level and prolonging the change of cabin altitude for as long
as is practicable, taking account of the rate of change of
altitude of the aircraft, the pressure altitude at the airports
of departure and arrival, and the cruising altitude for the
flight. A typical cabin pressurization profile for the flight
of subsonic jet-engined passenger aircraft is depicted by
curve (a) of Figure 6.33, while the behaviour of aircraft and
cabin altitudes throughout a typical flight to an aircraft alti-
tude of 40 000 feet is shown in Figure 6.34. In such aircraft,
the flight-deck crew is able to select the desired aircraft
altitude at which pressurization of the cabin commences
or ceases, the desired rate of change of cabin altitude and
25 6
20
8
15
10 (b) 10
5 (a)
0
0 5 10 15 20 25 30 35 40 50 70
Aircraft altitude (thousands of feet)
Figure 6.33  Typical pressurization schedules of the
high-differential cabins of (a) a passenger aircraft and
(b) a combat aircraft. The cabin and aircraft altitudes are
plotted on linear pressure scales. The zero pressurization
curve (marked 0 lb/in2) passes through the origin and has
a slope of 1.0. Constant differential pressures of 14, 28,
55 and 70 kPa (2, 4, 6, 8 and 10 lb/in2) are indicated by
dashed lines. The cabin pressurization of the passenger
aircraft (a) commences at ground level, and the maximum
differential pressure (60 kPa, 8.8 lb/in2, in this example)
is reached at 36 000 feet. Contrastingly, in the combat
aircraft (b), pressurization does not commence until an
aircraft altitude of 8000 feet is reached, and the cabin
altitude is held at this value until the maximum differential
pressure (63 kPa, 9.2 lb/in2, in this example) is reached at
50 000 feet.
Altitude (thousands of feet)

the desired maximum cabin altitude. With these variables 40

Aircraft
selected, the pressurization system automatically controls 30 altitude
the cabin differential pressure to give the required profile
of cabin altitude. 20

10 Cabin altitude
High-differential combat cabins
0
0 5 10 15 0 5 10 15 20 25 30
As in commercial aircraft, in large military aircraft it is Time (min)
advantageous to be able to breathe air and so move freely
within the aircraft, unencumbered by oxygen equipment. Figure 6.34  Time course of the cabin altitude (lower
As noted previously, in the past, some bomber aircraft were curve) of a high-differential passenger aircraft during a
provided with such a cabin pressurization schedule; how- flight (aircraft altitude, upper curve) up to 40 000 feet and
ever, to minimize the dangers of rapid decompression when back to ground level.

Table 6.2  Typical cabin pressure differentials of passenger aircraft.

Maximum operating cabin Maximum aircraft altitude (feet) at which

differential pressure cabin altitude (feet) is:
Type of aircraft kPa lb/in2 gauge 6000 8000
Turbo-propeller engine 38–52 5.5–7.5 22 000 25 000
30 500 35 000
Subsonic jet engine 59.5–62 8.6–9 37 000 44 500
39 500 47 000
Supersonic jet engine 72.5–77 10.5–11.2 56 000 78 000
71 000 —

K17577_C006.indd 117 17/11/2015 15:37

 118  Oxygen systems, pressure cabin and clothing
the aircraft is liable to damage due to enemy action, a sec-
ond cabin pressurization schedule similar to that for low-
differential combat cabins usually was available.
Since trained combat aircrew can tolerate relatively high
rates of change of cabin pressure (up to 14 kPa (2 lb/in2)/min)
without discomfort, the control of the cabin pressurization
system can be simplified in high-differential combat aircraft
by the use of an isobaric control (curve (b) of Figure 6.33).
Below a predetermined aircraft altitude, e.g. 8000 feet, the
cabin is unpressurized. Above the aircraft altitude at which
cabin pressurization commences, the cabin altitude is held
constant until the aircraft altitude at which the maximum
operating differential pressure required is reached. Above
this altitude, the constant maximum differential pressure is
maintained, so that the cabin altitude rises.
Low-differential combat cabins
In high-performance combat aircraft, where weight and
performance are primary considerations and there is often
a threat to the integrity of the cabin, the crew members use
oxygen equipment throughout flight and the cabin differen-
tial pressure is relatively low. The physiological requirements
are that the cabin altitude should not exceed 22 000 feet, in
order to minimize the effects of hypoxia due to malfunction
or misuse of oxygen equipment and to reduce the incidence
of decompression sickness. The maximum cabin differential
pressure should not exceed 34.5  kPa gauge (5.0  lb/in2), in
order to reduce the hazard of injury on rapid decompres-
sion of the cabin. The maximum cabin differential pressures
employed in practice vary between 24 and 36.2 kPa (3.5 and
5.25  lb/in2). These differential pressures prevent the cabin
altitude exceeding 22 000 feet at aircraft altitudes of up to
40 000 feet and 57 000 feet, respectively. The cabin altitude
will not exceed 25 000  feet with differential pressures of
24 and 34.5 kPa (3.5 and 5 lb/in2) below aircraft altitudes of
46 500 feet and 75 000 feet, respectively.
The operation of cabin pressurization control systems
fitted to low-differential-cabin combat aircraft is almost
always automatic. Thus, cabin pressurization commences at
a fixed altitude, the value of which is kept as low as possible
in order to minimize rates of change of cabin pressure with
ascent and descent of the aircraft but high enough to ensure
that the cabin will not be pressurized if the aircraft lands
at an airfield with a high elevation. Cabin pressurization
generally starts at an aircraft altitude of 5000–8000  feet.
An isobaric control schedule may be used until the maxi-
mum cabin differential pressure has been achieved. At
higher aircraft altitudes, this maximum differential is
maintained (curve (a) of Figure 6.35). An alternative pres-
surization schedule (employed in some older UK military
aircraft) allowed the cabin differential pressure to increase
linearly with reduction of the absolute pressure of the air-
craft environment, to the maximum differential pressure at
about 40 000 feet. Above this height, the constant maximum
cabin differential pressure was maintained (curve (b) of
Figure 6.35). Although the use of isobaric control eliminates
K17577_C006.indd 118
Cabin differential
pressure (lb/in2)
0 2 4
30
Cabin altitude (thousands of feet)
25 6
20
(b) 8
15 10
10 (a)
5
0
0 5 10 15 20 25 30 35 40 50 70
Aircraft altitude (thousands of feet)
Figure 6.35  Typical pressurization schedules for low-
differential-pressure cabins of combat aircraft. The
cabin is unpressurized at very low aircraft altitudes.
(a) Schedule in which the differential pressure increases
so that the cabin altitude remains constant with further
ascent to altitude up to the maximum differential pressure
(34.5 kPa, 5 lb/in2, in this example). (b) Schedule in which
the differential pressure is increased more gradually with
ascent to altitude, so that the maximum is operative only
at aircraft altitudes above 40 000 feet.
changes of cabin altitude over a restricted range of aircraft
altitude, the former UK schedule results in a significantly
lower rate of increase of cabin pressure on descent from
high altitude, a distinct advantage when rapid changes of
aircraft altitude occur.
As long as the oxygen equipment is capable of delivering
100 per cent oxygen at and above 33 000 feet and pressure
breathing above 40 000  feet, serious hypoxia is unlikely if
cabin pressure is suddenly lost. The design of the oxygen
equipment must be such, however, that the concentration
of oxygen in the mask cavity rises rapidly to the required
level as soon as decompression occurs (see Chapter 5 and
above). Thus, the volume of the gas held within breath-
ing system between the air inlet of the regulating device
or the backup oxygen system changeover valve in MSOC
systems and the mask cavity should be kept to a minimum
(less than 600  mL). The required level of pressure breath-
ing must be fully operative within three seconds of the
time that the pressure in the respiratory tract falls below
141 mmHg (18.8 kPa) absolute.
PRINCIPLES OF CABIN PRESSURIZATION
SYSTEMS
Source of air
In piston-engined aircraft and some jet-engined aircraft
(particularly multi-engined jet aircraft), air for pressur-
izing and conditioning the cabin is drawn from outside
the aircraft and compressed by engine-driven auxiliary
compressors. In most jet-engined aircraft, the air for pres-
surizing and conditioning the cabin is tapped off the
17/11/2015 15:37

compressor stages of the main engines, upstream of the
combustion chambers. In multi-engined aircraft, gener-
ally there is one auxiliary compressor per main engine; if
directly tapped air is used, it is drawn from each engine.
A non-return valve in the duct from each compressed-air
source prevents backflow in the event of a failure of that
particular compressor. The flow of air from the engine or
compressor is controlled automatically in order to give the
required mass flow of air through the cabin. The total flow
of air required is determined primarily by the volume of
conditioned air necessary to maintain the desired thermal
conditions in the cabin (for the crew, passengers and elec-
tronic equipment) and to ventilate the crew and passenger
compartments (to remove carbon dioxide and odours and
to replace oxygen). The inflow of air required to maintain
the desired differential pressure in the cabin is gener-
ally much less than that necessary to condition the cabin.
The mass flow of air into the cabin of a two-seat combat
aircraft is about 14–18  kg/min (30–40  lb/min) (approxi-
mately 11 000–15 000 litres [normal temperature and pres-
sure, NTP]/min). In large passenger aircraft, a mass flow
of 0.55  kg/passenger/min (1.2  lb/passenger/min; 440  L
[NTP]/passenger/min) was once commonly employed. This
mass flow has now been approximately halved in modern
turbofan aircraft that utilize recirculating systems with
HEPA filters.
The air passes from the flow controller to the condition-
ing equipment (heat exchangers and refrigeration system)
and through a combined stop valve and non-return valve
into the air distribution pipework within the cabin. The
non-return valve prevents air escaping from the cabin and
passing back through the air supply system in the event of a
failure of the source, e.g. flameout of the engine of a single-
engined aircraft or rupture of the pipework or conditioning
equipment. This valve ensures that the air in the cabin is
held there if a complete failure of the supply occurs, thus
preventing catastrophic loss of cabin pressure and so mini-
mizing the increase of cabin altitude in this type of emer-
gency. The stop valve in the cabin air inlet can be operated
from the cockpit to cut off the inflow of air if it is contami-
nated with smoke or oil. In many aircraft, when the airflow
from the engines or compressor is shut off, a ram air inlet
to the cabin opens automatically so that the cabin is ven-
tilated with uncontaminated external air. In some aircraft,
this flow of air into the cabin may be greatly increased in an
emergency. This facility, which limits the rise of cabin alti-
tude when there is a large leak, is termed ‘flood flow’.
In aircraft with recirculation systems, the incoming
fresh air (after conditioning) enters a mixing chamber
(mix manifold), where it is combined with an equal flow of
recirculated air. From the mix manifold, the air is ducted
to each seating zone via an overhead ventilation distribu-
tion system. These distribution outlets run the length of the
cabin; the air so distributed mixes with cabin air, which is
then exhausted through metal grilles located near the cabin
floor. In most aircraft, the exhaust air from the aft section of
the cabin is extracted by the pressure control outflow valve
K17577_C006.indd 119
Principles of cabin pressurization systems  119
and discharged overboard. The air in the forward section
is continuously extracted from below the floor by recir-
culation fans for processing through the HEPA filters and
returned to the mixing manifold.
Discharge valve and pressure controller
The air flows out of the cabin through one or more dis-
charge valves, which impose a restriction in order to cre-
ate the desired cabin differential pressure. The degree of
opening of the discharge valve is controlled by either pneu-
matic or electric signals from the pressure controller. The
pressure of the aircraft environment and the pressure of
the cabin are fed to the controller, which produces an out-
put signal to the discharge valve(s) in accordance with the
pressurization schedule for the cabin. In passenger-carry-
ing aircraft, it is possible to set the desired maximum cabin
altitude and rate of change of cabin altitude on the pres-
sure controller. If a discharge valve sticks open, the cabin
loses its pressure, so in transport aircraft discharge valves
and the pressure controller are duplicated. An independent
method of closing a discharge valve that has failed in the
open position is also desirable. The discharge valve and
pressure controller are not normally duplicated in high-
performance combat aircraft, where all the cabin occu-
pants have oxygen equipment.
Safety and inward vent valves
The basic cabin pressure control system includes two fur-
ther valves: safety and inward relief valves. The cabin safety
valve prevents the cabin differential pressure rising above
a pre-set maximum if the discharge valve(s) should fail
to open. The setting of the safety valve is usually slightly
greater (1.4–3.5  kPa gauge, 0.2–0.5  lb/in2) than the maxi-
mum operating differential pressure. The inward relief valve
is fitted to allow atmospheric air to enter the cabin if the
pressure in the cabin falls below that of the atmosphere.
This condition may arise during a rapid descent if the flow
of air into the cabin is reduced or absent. The inward relief
valve usually is set to open at a negative differential pressure
of 1.4–2.0 kPa (0.2–0.3 lb/in2).
In certain circumstances, there may be a need to decom-
press the cabin of an aircraft rapidly. If the cabin is filled
with smoke or noxious fumes, then it may be necessary
to decompress and to purge the cabin with external air
through the ram air inlet. Although so drastic an action is
obviously not desirable in a passenger aircraft flying at high
altitude, it can be vital in aircraft carrying passengers at low
altitude and in combat aircraft at any altitude. Another situ-
ation in which rapid decompression of the cabin is required
is if the crew members intend to abandon the aircraft. In
low-differential-pressure cabins, it is acceptable to decom-
press the cabin by jettisoning the cockpit canopy or door;
except in dire emergencies, however, a high-differential-
pressure cabin is decompressed by first fully opening all the
discharge valves.
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 120  Oxygen systems, pressure cabin and clothing
Indicators and warning systems
The performance of the cabin pressurization system is
indicated to the crew of an aircraft by means of a cabin
altimeter. In passenger aircraft, the rate of change of cabin
altitude and the differential pressure between the cabin and
the atmosphere are also displayed on the flight deck instru-
ment panel. Failure of the pressurization control system to
maintain the correct cabin altitude is normally indicated
to the crew by a warning system. The warning, which may
be audible or visual, or both, may be triggered by the cabin
altitude rising above a pre-set value, e.g. 10 000 feet in a high
differential pressure passenger aircraft, or the cabin differ-
ential pressure falling below that which should exist at the
prevailing aircraft altitude.
CAUSES OF FAILURE OF CABIN
PRESSURIZATION
Although pressurization has overcome most of the physi-
ological disturbances induced by exposure to low envi-
ronmental pressure, decompression of the cabin at high
altitude is associated with hazards of its own. Failure of the
pressurization of aircraft cabins can be classified by cause,
according to whether the fall of the cabin differential pres-
sure is due to a reduction of the inflow of air, an excessive
discharge, (which may include failure of the system to be
initiated on take-off) or failure of the cabin structure.
Reduced cabin air inflow
Marked reduction of the air supply from the engine or com-
pressor is much more probable in single-engined aircraft
than in multi-engined aircraft since, in the latter, air for
pressurization of the cabin commonly is tapped from all the
engines or supplied by two or more engine-driven compres-
sors. Loss of the supply of air to the cabin due to flameout
of the engine of a single-engined aircraft normally results in
rapid aircraft descent; if the engine fails during the climbing
phase of a high-altitude ballistic manoeuvre, however, the
cabin differential pressure may fall to a negligible value before
the aircraft starts to descend. Other causes of inflow failure
include unserviceable components in the air-conditioning
system, e.g. the cabin inlet valve may stick closed. The flow
of air into the cabin may be turned off by the crew because
toxic material or smoke is being carried into the cabin, or as
part of the escape drill. However, as long as the outflow of air
through the discharge valves is prevented, failure of inflow
does not cause a rapid fall of the cabin differential pressure.
Pressure cabins are designed to have minimal leakage and
serviceability checks are made regularly to ensure that the
leak rate remains below a specified maximum.
Failure of the pressure control system
If the pressure controller malfunctions or the cabin discharge
valves stick open, then the cabin differential pressure falls. If
K17577_C006.indd 120
all the discharge valves suddenly go to the fully open posi-
tion, then the differential pressure will fall very rapidly to
zero. Such decompressions occur more frequently in single-
seated or two-seated aircraft because there is no duplication
of the pressure control system. In a passenger aircraft, dupli-
cation of the components and provision of an independent
facility for closing the discharge valves ensure that the cabin
differential pressure does not fall significantly in the event
of a failure of a discharge valve. There have been rare but
widely publicized failures of cabin pressurization in passen-
ger aircraft, both commercial and business jets, which may
have been caused by a failure to appropriately select cabin
pressurization prior to take off. In these circumstances, the
crew needed to take appropriate action before the effects of
hypoxia overwhelmed and all on board were killed.
Structural failure
Failure of the structure can range from impaired sealing of
a door, canopy or escape hatch, which may produce a small
leak, to disintegration of a transparency, loss of a complete
door or cockpit canopy, or even gross structural failure of the
wall of the cabin. Failure of a seal or loss of a hatch, door or
canopy may be caused by mechanical failure of a component
such as an inflatable seal, which may not have been identified
because of inadequate or faulty servicing or inadequate pre-
flight/takeoff checks. Structural failure of a transparency or
part of the wall of a cabin may be the result of mechanical
fatigue, excessive stress, sabotage or enemy action. UK and
US government regulations require that the effects of punc-
ture of the cabin wall or a window by a bullet from a personal
weapon be taken into account in the design. Gross structural
failure of the wall of a cabin in the absence of enemy action
or sabotage is extremely unlikely now that the significance
of metal fatigue is generally appreciated. The walls may, how-
ever, be weakened by corrosion, and frequent inspections are
necessary to check that the strength has not deteriorated. In
military aircraft, hatches, doors and cockpit canopies may
be designed to be jettisoned in flight before escape and such
mechanisms may, of course, also be activated inadvertently.
Incidence
The incidence of accidental decompressions of pressure cab-
ins is relatively low, and the incidence in commercial air-
craft throughout the world is of the order of 30–40 per year.
Many of these decompressions are performed voluntarily in
order to cut off the flow of smoke or other toxic material
into the cabin, as a precaution following cracking of a trans-
parency, or as a planned drill following receipt of a bomb
threat. Most accidental decompressions are due to failure of
the compressor system, failure of the pressure control sys-
tem, or opening of a hatch or door. The number of decom-
pressions occurring in military flying even in peacetime is
considerably higher than that in commercial operations.
An incidence of about two to three unplanned decompres-
sions per 100 000 flying hours has been recorded for many
17/11/2015 15:37

years. The major causes of inadvertent decompressions of
military aircraft are flameout in those with single engines,
malfunctions of the pressure control system, failures of
transparencies and loss of canopies. In combat, there is a
rise in the incidence of decompression due to enemy guns
or missiles. With a few exceptions, crew and passengers
survive cabin pressure failure both in commercial and in
military operations. Many deaths attributed to decompres-
sion have occurred when there was massive disruption of
the cabin structure due to metal fatigue or on-board explo-
sions. From time to time, individuals have been sucked out
of a lost hatch, window or door.
PHYSICS OF RAPID DECOMPRESSION
When air can escape from a cabin, the pressure falls rap-
idly at first and then more slowly as the pressures inside and
out approach each other and equalize (Figure 6.36). The rate
at which air flows through a hole cannot exceed the local
speed of sound, regardless of the size of the defect or the
difference between the pressure in the cabin and that of the
atmosphere. The major factors that determine the rate and
time of decompression of a pressure cabin are:
●● The volume of the cabin.
●● The size of the opening in the cabin.
●● The absolute pressure in the cabin at the beginning of
the decompression.
●● The absolute pressure outside the cabin.
The larger the volume of the cabin, the slower the decom-
pression; the larger the defect in the wall, the faster the
decompression. The ratio of the volume of the cabin to the
cross-sectional area of the opening or orifice is one of the
main factors controlling the rate and time of decompression.
12
10
Cabin pressure (lb/in2)
8 cent of the geometric area. The speed of sound is related to
6
4 end of the decompression. The relationship between these
2 decompression is given by the product
0 2 4 6
Time (s)
Figure 6.36  Time course of absolute pressure of air in
cabin of an aircraft during a decompression from 83 kPa
(12 lb/in2, 5500 feet) to 21 kPa (3 lb/in2, 38 000 feet). The
rate of fall of pressure, which is high at the beginning of
the decompression, falls progressively as air escapes from
the cabin.
K17577_C006.indd 121
Physics of rapid decompression  121
Other factors being constant, the time of decompression
is proportional to the ratio of cabin volume to area of the
defect in the structure. The pressure ratio (cabin/ambient) is
the other factor that determines the time of decompression:
the larger the ratio, the longer the time of decompression.
On the other hand, the actual differential pressure does not
directly influence the time but does determine the severity
of a decompression: the larger the pressure difference, the
more severe the decompression. The absolute value of the
atmospheric pressure is, of course, the primary factor that
determines the physiological consequences after a rapid
decompression. These often are of far greater significance
than the effect of the fall of pressure itself. For any given
cabin pressure differential, the higher the aircraft altitude
at the instant of decompression, the greater is the ratio of
cabin pressure to atmospheric pressure; and the higher the
aircraft altitude, the longer the decompression time (for a
constant ratio of cabin volume to area of defect).
Time of decompression
Several equations have been developed to estimate the
time of decompression of a pressure cabin of given volume
according to the area of the defect and the cabin and atmo-
spheric pressures. One of the most useful and accurate is
that developed by Haber and Clamann, which states that
the time of decompression of a cabin is determined by the
product of two factors: (i) the time constant of the cabin
(tc) and (ii) a pressure-dependent factor (P1). tc is calculated
as follows:
V
tc =
(A × c)
where V is the volume of cabin, A is the effective area of
the orifice and c is the local speed of sound.
The values inserted into the equation are expressed in
consistent units. The effective area of an orifice may be less
than its geometric area, in that it may not behave as a sharp-
edged orifice. Thus, the effective area of a defect created by
sudden loss of a complete window or hatch is about 90 per
the temperature of the air flowing through the orifice – in
practice, a value of 1100 feet/s (335 m/s) is used.
P1 is a complex function of the ratio of the cabin pressure
before the decompression to the pressure in the cabin at the
two variables is depicted in Figure  6.37. The total time of
8 10 12
tt= tc× 1
where tt is the total time of decompression.
Examples of calculated times of decompression for the
sudden disintegration of the canopy of a single-seated
fighter aircraft and the loss of a window or door of a pas-
senger aircraft are given in Table 6.3.
17/11/2015 15:37
 122  Oxygen systems, pressure cabin and clothing
6 further the rate of fall of cabin pressure and the final alti-
5
Pressure-dependent factor (P1)
4
3 craft is flying. The movement of the aircraft through the air
2
1 canopy of combat aircraft and at the windows and doors
0 sure altitude of the aircraft. Consequently, the fall of cabin
1 5 10 15
Initial pressure/final pressure
Figure 6.37  Calculation of time of decompression of
pressure cabin at a constant aircraft altitude. The curve
shows the relationship between the pressure-dependent
factor of the Habers–Clamann formula and the ratio of the
absolute pressure in the cabin before (initial pressure) and
after (final pressure) decompression.
Effect of inflow of air
If the decompression of a cabin is due to excessive opening
of discharge valves or a defect in the wall of the cabin, then
the flow of air from the engine compressors into the cabin
continues. The modifying effect that this inflow will have
on the fall of cabin pressure is determined by the relation-
ship between the flow and the size of the orifice in the cabin
wall. If the ratio of flow to the area of the orifice is high, then
this additional flow will create a significant pressure drop
across the orifice, thus reducing the rate of fall of cabin pres-
sure and raising the value to which the absolute pressure in
the cabin falls at the end of the decompression. In practice,
maintained inflow of air from the engine compressors is of
significance only when a relatively small defect, e.g. loss of a
window, occurs in a large aircraft where the inflow is high; it
can maintain the cabin altitude 5000–10 000 feet lower than
aircraft altitude, in spite of loss of a window at an aircraft
altitude of, say, 35 000 feet. In some aircraft, the airflow into
the cabin may be increased in an emergency, so limiting still
Table 6.3  Calculated decompression times
Cabin volume (feet3)
Nature and area of orifice (feet2)
Time constant of cabin (s)
Time of decompression (s)
From 16 000 to 40 000 feet
From 3000 to 25 000 feet
From 5000 to 40 000 feet
K17577_C006.indd 122
tude reached in the cabin.
Aerodynamic suction
The pressure immediately outside a defect is seldom the
static pressure exerted by the atmosphere at which the air-
creates a fall of pressure over much of the external surface
of the aircraft. The magnitude of this effect varies with the
shape of the aircraft, the position of the defect, its speed
and the altitude. The pressure at the external surface of the
of transport aircraft is almost always less than the pres-
20 25 30
pressure is accelerated and the final value of cabin pressure
reduced below that of the atmosphere by this Venturi effect
of aerodynamic suction. The aerodynamic suction at the
windows of transport aircraft cruising at altitude is usually
about 1.4–4  kPa gauge (0.2–0.6  lb/in2), although this may
be considerably greater at windows close to the wing roots.
The aerodynamic suction over the canopy of some high-
performance combat aircraft flying at speed at altitudes
between 35 000 and 45 000 feet amounts to between 7 and
14 kPa gauge (1–2 lb/in2). If the major part or the whole of
the canopy of such an aircraft flying at 40 000  feet is lost,
then the pressure altitude in the cabin may exceed the pres-
sure altitude of the aircraft by 8000–10 000 feet.
Cabin altitude profiles
The time course of the changes of cabin altitude following a
failure of pressurization is complicated by alterations of the
flight path of the aircraft during and following the incident.
Usually, the pilot initiates a rapid descent and so reduces the
rate of fall of cabin pressure and raises the minimum abso-
lute pressure reached in the cabin. Thus, the cabin altitude
first increases and then decreases as the aircraft descends.
If the rate of decompression is very rapid, the cabin alti-
tude rises to equal (or, if aerodynamic suction is present,
to exceed) the aircraft altitude (Figure  6.38a). The cabin
altitude will then fall as the aircraft descends. In large pas-
senger aircraft, however, the decompression of the cabin is
often relatively slow due its large internal volume relative
Combat aircraft Passenger aircraft
50 10 000
Disintegration of canopy Loss of window Loss of door
9 0.5 12
0.005 18.2 0.76
0.007 — —
1.3 30.9 1.3
— 50.0 2.1
17/11/2015 15:37
 Effects on cabin occupants  123

to the size of the defect, and descent is started well before Expansion of gas in body cavities
the decompression is complete. The maximum cabin alti-
tude attained may be very considerably less than the initial Decompression of a pressure cabin is most unlikely to give
altitude of the aircraft (Figure 6.38b). rise to symptoms in the middle ears and paranasal sinuses.
However, passengers will almost certainly develop pain in
Air blast the middle ear during the subsequent emergency descent,
when they are exposed to a large and relatively rapid
The sudden flow of air created in a pressure cabin when a increase of cabin pressure.
decompression occurs, raises dust and debris which may Abdominal disturbances are unlikely if the maximum
markedly reduce visibility. The mist formed by the conden- cabin altitude does not exceed 25 000  feet. As the cabin
sation of water vapour in the expanding air adds to the prob- altitude rises above 25 000  feet, an increasing proportion
lems of the crew. The velocity of the flow of air through the of individuals develop abdominal discomfort and pain
cabin towards a defect in its wall increases rapidly as the air due to expansion of gas in the stomach and intestines. The
approaches the hole. The air blast can blow loose articles, incidence of disturbances is far higher among passengers
furnishings and even people out through the defect. Since than aircrew.
the force of the blast is very high only close to the hole, the
people at risk are those in the immediate vicinity; if there The lungs
is a major structural failure, however, then many or most
occupants may be severely or fatally injured by the associated The large volume of gas in the alveoli, the relatively narrow
air blast. The point is usually academic, since such structural passages that connect the alveoli to the external environ-
failure usually leads to disintegration of the aircraft in flight. ment, and the susceptibility of lung tissue to damage when
it is overstretched combine to make the lungs a vulnerable
EFFECTS ON CABIN OCCUPANTS part of the body during the very rapid reduction of environ-
mental pressure that occurs on sudden loss of cabin pres-
Provided the aircraft remains intact, the effect of failure of sure. Although few serious injuries have been reported so
pressurization of a cabin on the occupants depends on three far in human decompression with open airways, studies on
major factors: the rate of the decompression, the pressure experimental animals have shown that fast decompressions
change during the decompression, and the pressure in the over large pressure ranges can cause structural damage to
cabin after the decompression. The rate and pressure range pulmonary tissue, with haemorrhagic, emphysematous
of the decompression determine the magnitude of the effects and atelectatic changes in the lung. Rare anecdotal clinical
arising from the expansion of the gas within the various gas- accounts of injuries suffered during rapid hypobaric cham-
containing cavities of the body. The intensity of the other ber decompressions, possibly with the individual’s glot-
major effects of decompression – hypoxia and decompres- tis not open, have been reported but in-flight events are
sion sickness – is determined primarily by the consequent extremely rare. The ability of the human lung to withstand
cabin altitude, particularly the maximum cabin altitude and and adapt to sudden changes in pressure is, however, the
the subsequent pattern of change. A major deficiency in the limiting factor in the rate or range of decompression that
wall of a cabin also results in a marked fall in cabin tempera- can be tolerated, and strict attention is paid to this factor in
ture, so that the occupants may suffer from cold. the design of pressurized cabins.

50 50
Altitude (thousands of feet)

Altitude (thousands of feet)

40 40
Cabin Aircraft
30 30
Aircraft Cabin
20 20

10 10

0 0
0 0.5 1.0 1.5 2.0 0 2 4 6 8 10
Time (min) Time (min)
(a) (b)

Figure 6.38  Effects of rapid descent of aircraft and pressure of aerodynamic suction on cabin altitude after failure of cabin
pressurization. (a) Behaviour of cabin altitude when the decompression is due to a large defect that allows equilibrium of
pressure before descent of the aircraft has started. Aerodynamic suction at the site of the defect causes cabin altitude to
exceed aircraft altitude. (b) Time course of cabin altitude when decompression occurs through a relatively small defect
and descent of the aircraft is started 30 seconds after the beginning of the decompression.

K17577_C006.indd 123 17/11/2015 15:37

 124  Oxygen systems, pressure cabin and clothing
The decompression rate of the lungs is limited by the flow
resistance offered by the pulmonary and upper airways.
Thus, any environmental decompression that is faster than
the maximum decompression rate of the lungs will result
in a transient positive differential pressure between the gas
within the lungs and the surrounding cabin environment.
The faster the decompression rate of the cabin, the greater
will be the transient pressure difference. The magnitude and
duration of the difference between the pressure of the gas in
the lungs and that of the cabin environment during a rapid
decompression depend on the following factors:
●● Rate of decompression of the cabin in relation to the
simultaneous rate of decompression of the lungs.
●● Total change of cabin pressure during decompression.
●● Volume of gas in the lungs at the beginning of
the decompression.
●● Ability of the lungs and thorax to expand within nor-
mal limits during decompression.
The normal expansion of the lungs and chest wall, and
the flow of gas from the lungs through the airways to the
environment, will reduce considerably the pressure within
the lungs during a rapid decompression.
A simple model that illustrates the dynamic relation-
ships between the pressure in the lungs and that in the cabin
during a rapid decompression is depicted in Figure 6.39. The
model represents the situation in which the lungs and chest
wall behave as a rigid container. The ratio of the volume of
the lungs to the area of the opening from the lungs to the
cabin environment (the area of an orifice equivalent to the
airways) is greater in this model than the ratio of the vol-
ume of the cabin to the area of the defect in the cabin wall.
Curve (a) shows the behaviour of the pressure in the cabin
as it decompresses through the defect. Curve (b) depicts the
time course of the pressure changes in the lungs. Curve (c) is
the difference between curves (a) and (b) and represents the
pressure difference between the gas in the lungs and that in
the cabin – the transthoracic pressure. This pressure differ-
ence builds up rapidly to a peak and then declines gradually
as the lungs progressively decompress.
Lung damage in rapid decompression is caused by
stretching of the lung tissue beyond its elastic limit. As the
gas within the lungs expands, the chest wall and diaphragm
are displaced outwards. If the expansion of the gas within
the lungs can be taken up without the final lung volume
exceeding the normal total lung volume, then no damage
will occur. If, however, the lung expansion induced exceeds
the normal total lung volume, then the lung tissue will be
overstretched. Eventually, the lung tissue will tear and blood
vessels will be severed. The transthoracic pressure difference
required to tear the lungs when the chest and abdominal
muscles are relaxed is of the order of 80–100 mmHg. When
lung tissue tears, air passes along tissue planes into the
mediastinum and even up into the neck, producing surgical
emphysema. Gas entering torn blood vessels passes into the
systemic circulation (generalized gas embolism).
K17577_C006.indd 124
600 Gas escaping through Aircraft cabin
ruptured cabin wall
Rigid container representing
500 the lung
Pressure (mmHg)
400
300
200 (b) ‘Lung’ pressure
(a) Cabin
pressure
100
200
(c) Pressure differential
‘transthoracic pressure’
100
0
0 0.2 0.4 0.6 0.8 1.0 1.2
Time (s)
Figure 6.39  Simple model demonstrating effects of
rapid decompression of cabin of an aircraft flying at high
altitude (approximately 47 000 feet) on the pressure
difference between the gas within the lung and the gas
surrounding the body (transthoracic pressure differential).
The lung is represented by a rigid container with a rela-
tively narrow opening into the cabin. On rupture of the
cabin wall, the pressure in the cabin (a) falls to that of the
environment in about 0.2 seconds. The rate at which gas
escapes from the ‘lung’ and, hence, the rate at which lung
pressure (b) falls, is much slower than the rate of decom-
pression of the cabin, so there is a transient but large
pressure difference between the lung and cabin gas (c).
The worst-case scenario is if the gas within the lung
cannot escape during the fall of environmental pressure.
The free flow of expanding gas to the atmosphere may be
prevented by closure of the glottis, such as occurs during
breath-holding, swallowing and straining, or by the char-
acteristics of any breathing equipment being used at the
time. Thus, the compensated outlet valve fitted in a typi-
cal pressure-demand oronasal mask (see above) may well be
held shut throughout and immediately after a rapid decom-
pression. The range of decompression that is safe (i.e. the
transthoracic pressure after the decompression does not
exceed 50mmHg when no gas can escape from the lungs)
can be calculated if the initial volume of gas in the lungs
is known. Typical limiting conditions are presented in
Table 6.4. When the gas within the lungs is free to escape,
it is difficult to predict whether the individual circum-
stances – initial and final altitudes, ratio of the volume of
the cabin to the effective area of the orifice through which
it is being decompressed – will produce a trans-thoracic
pressure difference of the order of 80  mmHg and, hence,
cause lung damage. Most of the information available has
17/11/2015 15:37
 Effects on cabin occupants  125

been obtained by animal experimentation, although there Hypoxia

is some information with regard to ‘safe’ decompression
for humans. The limiting conditions of the initial-to-final Hypoxia is by far the most dangerous disturbance produced
pressure ratio and the cabin volume-to-orifice area ratio by failure of the pressurization of the cabin of an aircraft
beyond which lung damage is likely to occur in humans are flying at high altitude. As discussed in previous chapters,
presented in Figure 6.40. Although it is reasonably certain a rapid fall of the pressure of the immediate environment
that conditions of decompression that lie to the left of the produces simultaneous decreases of the oxygen tensions of
curve are ‘safe’ provided that the glottis is open and there the inspired and alveolar air in accordance with Dalton’s law
is no external obstruction to the flow of gas from the lungs, of partial pressures. There is also a concomitant decrease of
decompression under conditions that lie to the right of the the alveolar tension of carbon dioxide. The value to which
curve may or may not cause lung damage. In practice, lung the alveolar oxygen tension is reduced is determined by
damage due to decompression either in an aircraft or in a the composition of the gas breathed before and during the
decompression chamber is a very rare event. decompression, by the initial and final cabin altitudes, and
by the speed of the decompression. The lower the concen-
Table 6.4  Safe limits to rapid decompression without tration of oxygen in the inspired gas, the greater the range
venting of the lungs of decompression, the lower the final cabin pressure and
Initial Initial lung volume Maximum ‘safe’
the faster the speed of the decompression, the lower is the
altitude (fraction of total final altitude
oxygen tension in the alveolar gas at the end of the decom-
(feet) lung capacity) (feet)
pression. Thus, a rapid decompression from 8000  feet to
40 000 feet when an individual is breathing air reduces the
8000 0.25a 44 000 alveolar oxygen tension to 15–18 mmHg (2–2.4 kPa). If the
0.50b 29 700 final cabin altitude exceeds 30 000 feet, the alveolar oxygen
0.75 20 000 tension is reduced to below the tension of oxygen in the
1c 13 000 venous blood flowing into the lungs. In these circumstances,
25 000 0.25a 61 000 oxygen passes out of the blood as it flows through the pul-
0.50b 46 500 monary capillaries; consequently, the blood loses oxygen to
0.75 37 500 the atmosphere. The tension and concentration of oxygen in
1c 31 500 the blood leaving the lungs fall as abruptly as the alveolar
a Minimum lung volume (residual volume). oxygen tension, so that within 5–6 seconds of the start of
b Resting end-expiratory lung volume (functional residual capacity). the rapid decompression, the blood entering the capillaries
c Maximum lung volume (total lung capacity).

11
0.5 s 0.25 s 0.10 s

9
0.05 s
Initial pressure/final pressure

7 Zone of
probable
danger

3
Safe zone

1
100 70 50 30 20 15 10 7 5 4
Cabin volume (m3)/area of orifice (m2)

Figure 6.40  Relationship between speed and range of a decompression and the risk of damage to the lungs as a result
of the decompression. The interrupted lines depict the relationships between the ratio of the cabin volume to the area
of the defect through which the decompression occurs (the ratio as expressed has the dimension of metres), the ratio of
the absolute pressure in the cabin before (initial) and after (final) the decompression, and the total time of decompres-
sion, according to the Haber–Clamann equation. The solid curve separates decompressions that will not cause lung
damage (provided that there is no obstruction to the flow of gas from the lungs) from those that probably will cause
pulmonary damage.

K17577_C006.indd 125 17/11/2015 15:37

 126  Oxygen systems, pressure cabin and clothing
of the brain and other tissues has a very low oxygen ten-
sion. Since the amount of oxygen stored in many tissues,
especially the brain, is very small, the tension of oxygen in
the tissues also falls rapidly. Thus, rapid decompression (one
to two seconds) to a final altitude of 40 000 feet produces an
impairment of performance in 12–15 seconds and leads to
unconsciousness in 20 seconds.
If the aircrew members are breathing pure oxygen, then
the oxygen tension of the alveolar gas is not reduced to
below that of the mixed venous blood until the final alti-
tude exceeds 48 000 feet. Rapid decompression to altitudes
above 52 000  feet, results in loss of useful consciousness
in 10–15  seconds regardless of whether air or oxygen is
breathed. The times to impairment or loss of consciousness
do not change significantly with final altitudes greater than
52 000  feet because the speed of development of cerebral
hypoxia is determined primarily by the lung-to-brain cir-
culation time and the store of oxygen in the cerebral tis-
sue, both of which are relatively constant. When the final
altitude is less than 52 000 feet, the times to impairment of
performance and loss of useful consciousness depend on
the composition of the breathing mixture and the final alti-
tude, as shown in Figure 6.41. Although there is always an
interval of at least 12–15 seconds between the beginning of
a rapid decompression to high altitude and the first impair-
ment of performance, impairment does nevertheless occur,
even if the duration of the exposure to low pressure is as
short as six seconds. Thus, measures to restore the alveolar
oxygen to a near-normal value must be well on the way to
completion in less than 5–6 seconds of the beginning of a
rapid, severe decompression if an adequate level of perfor-
mance is to be maintained.
70
60
Altitude (thousands of feet)
50 Breathing 100% O2
40
Breathing air
30
20
0 20 40 60 80 100
Time of useful consciousness (s)
Figure 6.41  Loss of consciousness induced by rapid
decompression in 2–3 seconds to high altitude. The
curves indicate the effect of the final altitude to which
the decompression occurred on the time elapsing from
the beginning of the decompression to the loss of useful
consciousness. The solid curve shows the relationship
for decompressions from 8000 feet while breathing
air. The interrupted curve shows the relationship for
decompression from 25 000 feet while breathing 100 per
cent oxygen.
K17577_C006.indd 126
The interval between the beginning of a rapid decompres-
sion and loss of useful consciousness when air is breathed
increases markedly as the final altitude of the decompres-
sion is reduced below 30 000  feet. Thus, useful conscious-
ness is maintained for about 60 seconds after a rapid (three
seconds) decompression to 30 000 feet and for 120–140 sec-
onds after decompression to 25 000  feet (Figure  6.41).
Impairment of performance occurs much earlier than loss
of useful consciousness. Thus, performance at psychomotor
tasks is affected very significantly 45 seconds after a rapid
(3 seconds) decompression to 25 000 feet.
The emergency action by the pilot of a passenger air-
craft when a decompression occurs at high altitude is to
initiate a rapid descent. Consequently, a plot of the cabin
altitude against time assumes a triangular profile (see
Figure 6.38b). The hypoxia induced by exposure to such a
triangular profile with a peak altitude of 25 000 feet is very
unlikely to cause seated passengers breathing air to lose
consciousness, provided that the time at the peak altitude
does not exceed one minute and that the total duration of
the exposure to altitudes greater than 8000  feet does not
exceed six minutes. Experiments on monkeys suggest that
although humans are likely to lose consciousness when
the peak altitude exceeds 25 000 feet, exposure to triangu-
lar profiles with peak altitudes of up to 40 000 feet should
not be fatal or cause permanent brain damage, provided
that the total time above 8000  feet does not exceed eight
minutes. Exposure to higher peak altitudes (with approxi-
mately the same total time above 8000  feet) probably will
be either immediately fatal or produce severe permanent
brain damage.
Decompressions occurring in transport aircraft operat-
ing at very high altitudes (above 50 000 feet) would expose
the occupants to profound hypoxia. The loss of pressur-
ization due to a small structural failure, such as loss of a
window, would also expose the passengers to a decompres-
sion of triangular profile (Figure 6.42). The effects of such
decompressions have been studied in primates (Brierly &
Nicholson). As noted above, the effects of such triangular
decompression profiles depend on the peak altitude and
duration of the profile and may prove fatal or lead to per-
manent brain damage. The sequelae of various decompres-
sions of triangular profile are illustrated in Figure  6.42,
together with that of a balloonist who descended with-
out oxygen and suffered permanent brain damage. These
120 studies suggest that certain decompressions of triangu-
lar profile may result in hypoxia of sufficient severity and
duration to produce brain damage, but not so severe as
to disrupt cardiac and respiratory function irreversibly.
In animals that are impaired by decompressions of trian-
gular profile, the brain damage is either predominantly
cortical, centred on the boundary zones between the cere-
bral arteries and spreading from the occipital lobe across
the parietal, temporal and frontal cortex, or predomi-
nantly subcortical (i.e. in the basal ganglia), with damage
restricted to the neocortex. In both patterns, ischaemic
necrosis is found in the hippocampus and cerebellum.
17/11/2015 15:37

0 remains at high altitude after the decompression, so that
150
Ambient pressure (mmHg)
Balloonist
300
Fatal
450 Permanent
brain
damage
600 No
damage
750
0 2 4 6 8 10 12 14 16 18 20
Time from decompression (min)
Figure 6.42  Three triangular decompression profiles that
were investigated using primates and confirmed that per-
manent brain damage can occur. The ‘no damage’ profile
may be expected in the event of a small decompression in
supersonic transport aircraft. Also included is the pres-
sure–time profile of a balloonist who descended without
oxygen and suffered permanent brain damage.
The studies carried out with decompressions of triangu-
lar profile, which essentially simulated the loss of cabin pres-
surization that could be expected in a supersonic transport
aircraft operating around 55 000 feet and involving loss of a
window together with engine failure, were of considerable
practical importance during the development of supersonic
transport aircraft and remain so as consideration is given to
the development of the next generation of very-high-flying
passenger aircraft. The studies were able to define the maxi-
mum area of the windows that would be compatible with
survival without brain damage in the event of a decompres-
sion. The actual profile that could be experienced depends
not only on the area of the window that may be lost but also
on the altitude of the aircraft at the time of decompression
and the maximum rate of descent that would be possible.
Essentially, the rate of descent of a supersonic transport
aircraft is limited, and the cruise altitude is determined by
operational factors and, thus, in this context, the remaining
variable that could avoid permanent brain damage, even in
passengers who did not breathe oxygen during the descent,
is that of the window area.
Decompression sickness
The incidence of decompression sickness becomes signifi-
cant only when the cabin altitude rises above 25 000  feet
and the altitude remains above this value for longer than
five to ten minutes (see Chapter 34). In practice, there-
fore, decompression sickness will occur only if the aircraft
K17577_C006.indd 127
Effects on cabin occupants  127
the cabin altitude exceeds 22 000–25 000 feet for some time.
Prolonged exposure to altitudes above 22 000 feet will give
rise to incidents of decompression sickness unless the crew
has breathed 100 per cent oxygen for some time before the
decompression.
Cold
The temperature in the cabin following a failure of pres-
surization is determined by the outside temperature, the
Very high
nature of the cause of the decompression, and the flight
aircraft path and speed of the aircraft. A large defect in the wall of
transport the cabin of an aircraft at high altitude causes a very large
fall of cabin temperature and a high flow of very cold air
around the occupants. Such exposure rapidly results in cold
injury of exposed skin and to a less rapid fall of body tem-
perature (see Chapters 11 and 12). Vision may be impaired
by the flow of cold air into the eyes. Outlet valves and ports
of breathing equipment may be obstructed by the forma-
tion of ice. Unless the occupants are wearing special pro-
tective clothing, such as full pressure suits, it is necessary
to descend quickly to increase the temperature of the air
entering the cabin through the defect and, thus, reduce the
severity of the cold.
Low-differential cabins
As long as the equipment is capable of delivering 100  per
cent oxygen at and above 33 000 feet and pressure breathing
above 40 000 feet, serious hypoxia is unlikely if cabin pres-
sure is suddenly lost. The design of the oxygen equipment
must be such, however, that the concentration of oxygen in
the mask cavity rises rapidly to the required level as soon
as decompression occurs (see above). Thus, the volume of
the breathing system between the air inlet of the regulat-
ing device or the backup oxygen system changeover valve
in MSOC systems and the mask cavity should be kept to a
minimum (less than 600 mL). The required level of pressure
breathing must be fully operative within three seconds of
the time that the pressure in the respiratory tract falls below
141 mmHg (18.8 kPa) absolute.
High-differential cabins: passengers
Minimizing the effects of hypoxia is best achieved by lim-
iting the magnitude and duration of the exposure to low
pressure. If decompression can result in a cabin altitude
exceeding 25 000  feet, or the duration of the exposure to
altitudes above 13 000 feet may be longer than 4–6 minutes,
then it is current practice to fit an emergency oxygen system
to supply all the passengers. Sufficient oxygen is carried to
maintain the alveolar oxygen tension of all passengers above
50 mmHg (6.7 kPa) for as long as the cabin altitude exceeds
13 000 feet. UK and US government regulations also require
that enough oxygen should be carried for use by a small
fraction (10–15 per cent) of the passengers when the cabin
17/11/2015 15:37
 128  Oxygen systems, pressure cabin and clothing
altitude is between 10 000 and 15 000 feet. Although many
emergency oxygen systems for passengers present oxygen
masks automatically, the proportion of passengers who can
be expected to use the equipment correctly is probably less
than 50 per cent.
High-differential cabin: crew
The flight-deck crew of aircraft with high differential-pres-
sure cabins do not need to use oxygen equipment as long as
the pressure cabin is intact. A rapid decompression (decom-
pression time less than 20 seconds) to a cabin altitude above
30 000 feet will produce a significant impairment of perfor-
mance in people breathing air, even if 100 per cent oxygen
is delivered to the respiratory tract as soon as the decom-
pression commences. This transient hypoxia can be avoided
only by breathing 30–40  per cent oxygen (depending on
the initial and final cabin altitudes) for some time before
the decompression and 100 per cent oxygen as soon as the
cabin pressure begins to fall. Thus, if there is a significant
chance that cabin pressurization may fail, then the watch-
keeping pilot should have the mask secured on his or her
face and be breathing 30–40 per cent oxygen whenever the
aircraft altitude exceeds 30 000 feet. If the probability of a
fast decompression is very remote, as is the case in virtu-
ally all licensed passenger-carrying aircraft, then it is gener-
ally accepted that the pilot can breathe air throughout the
flight, provided that they can don a mask and be breathing
100 per cent oxygen within three to five seconds of the cabin
altitude exceeding 10 000 feet. In certain circumstances, e.g.
when there is only one pilot at the controls of a passenger
aircraft, UK and US government regulations require that he
or she breathes an oxygen/air mixture whenever the aircraft
altitude exceeds 41 000 feet. The design of the oxygen equip-
ment for the flight-deck crew of high-differential-pressure
cabin commercial aircraft must be such that 100  per cent
oxygen is delivered to the mask as soon as it is donned.
Exposure to altitudes above 63 000 feet
If decompression results in exposure to an absolute pres-
sure less than the vapour pressure of water at body tem-
perature, i.e. 47  mmHg (6.3  kPa) (a pressure altitude of
63 000 feet), then the nature of the consequent disturbances
differs from that which occurs at lower altitudes. Tissue
water vaporizes as the local pressure falls below 47 mmHg
(or a lower pressure, if the local temperature is below 37°C).
Thus, at altitudes between 65 000 and 70 000 feet, vaporiza-
tion begins in the lungs and in the low-pressure regions
of the circulation, such as the large intrathoracic veins.
At higher altitudes, water vapour and other gases, such as
oxygen and carbon dioxide, escape from the body fluids, a
phenomenon termed ebullism. In experiments, dogs and
monkeys decompressed to near-vacuum conditions (pres-
sure 1–2 mmHg, 0.13–0.26 kPa) developed gross swelling of
the soft tissues within five seconds, became unconscious in
about 12 seconds, and progressed quickly to general muscle
K17577_C006.indd 128
spasticity, gasping, transitory convulsions and apnoea. The
products of ebullism in the veins and atria of the heart rap-
idly blocked the circulation. Although the electrical activ-
ity of the heart continued, the circulation ceased about ten
seconds after the beginning of the exposure. As soon as the
pressure increased in descent, the gases were reabsorbed
into the body fluids very rapidly. Provided the duration of
the exposure to near-vacuum conditions was less than two
minutes, circulation and respiration in these animals recov-
ered spontaneously. Studies on monkeys and chimpanzees
suggested that exposure to a virtual vacuum for less than
1.5–2 minutes is very unlikely to be fatal or to give rise to
any neurological damage.
SUMMARY
●● The primary means of delivering protection
against hypoxia in flight are by the pressurization
of the aircraft cabin, the breathing of supplemen-
tal oxygen through an oxygen system or both.
●● Pressurization creates a cabin altitude lower than
the height at which the aircraft is flying and thereby
reduces the physiological challenge of hypoxia.
●● Pressurization systems are generally in one of two
classes, high or low differential, which reflects the
pressure difference across the hull of the aircraft.
●● High differential systems, common in commer-
cial transport aircraft, maintain the cabin altitude
at no more than 8000 feet in normal flight and
for most occupants this provides a physiologically
acceptable environment without the need to use
an oxygen system, except in an emergency result-
ing in the loss of the cabin pressurization.
●● Low differential cabin pressurization is common
in high performance military combat aircraft. In
these aircraft, an oxygen system is used through-
out flight as although the pressurization reduces
the hypoxic challenge and provides some protec-
tion against decompression sickness, an exposure
to a significant cabin altitude remains.
●● Oxygen systems can provide protection against
hypoxia by providing a breathing gas containing
supplemental oxygen (up to 100 per cent).
●● Oxygen systems may be classified as open or closed
circuit, the former being much more common in
aviation than the latter. They must meet physiologi-
cal requirements with respect to content of oxygen
and nitrogen, flow capacity and disposal of expirate
gases, including carbon dioxide and water vapour.
Breathing gas may be delivered under added pres-
sure. Safety pressure reduces the risk of inhaling gas
with too low an oxygen content and positive pres-
sure breathing on 100 per cent oxygen can provide
short term protection against severe hypoxia at
altitudes above 40 000 feet.
17/11/2015 15:37

●● Oxygen may be stored as compressed gas or as
liquid oxygen or generated by chemical reac-
tion. It may also be produced by pressure swing
adsorption in a molecular sieve oxygen concen-
trator from compressed ambient air.
●● Oxygen delivery may be via a continuous flow
system, often through a metering orifice, with
or without a reservoir. Alternatively, it may be
provided on inhalation by some form of demand
regulator. Delivery systems should be appropriate
to their use in routine or emergencies and to the
role of the user: aircrew or passengers.
●● Principles of duplication, wherever possible,
reduce the risk of system failure and modes of
operation should be matched to the capability of
the aircraft in which they are used.
●● The use of positive pressure breathing will require
a tight-fitting mask and may be further enhanced
by the use of partial pressure clothing as an alter-
native to a full pressure suit, when the altitude or
duration of use makes such provision possible.
REFERENCES AND FURTHER READING
Air Standard 4039 (formerly 61/101/6A). Minimum
Physiological Requirements for Aircrew Demand
Breathing Systems. Washington, DC: Air & Space
Interoperability Council, 2010.
Brierley JB, Nicholson AN. Neurological study of simu-
lated decompressions in supersonic transport aircraft.
Aerospace Medicine 1969; 40: 830–33.
Civil Aviation Authority. CAP 393 Air Navigation: The
Order and Regulations. London: Civil Aviation
Authority, 2014.
Denison DM, Ledwith F, Poulton EC. Complex reaction
time at simulated altitudes of 5000 feet and 8000 feet.
Aerospace Medicine 1966; 37: 1010–13.
Ernsting J. Prevention of hypoxia acceptable compro-
mises. Aviation, Space, and Environmental Medicine
1978; 49: 495–502.
Ernsting J. Operational and Physiological Requirements
for Aircraft Oxygen Systems. In: Seventh Advanced
Operational Aviation Medicine Course. Report no.
697. Neuilly-sur-Seine, France: AGARD/NATO, 1984a:
1–1–11.
Ernsting J. Molecular Sieve On Board Oxygen Generating
Systems for High Performance Aircraft. In: Seventh
K17577_C006.indd 129
References and further reading  129
Advanced Operational Aviation Medicine Course.
Report no. 697. Neuilly-sur-Seine, France: AGARD/
NATO, 1984b: 3–1–14.
Ernsting J, Byford GH, Denison DM, Fryer DI. Hypoxia
Induced by Rapid Decompression from 8000 Feet to
40 000 Feet: The Influence of Rate of Decompression.
Flying Personnel Research Committee Report No.
1324. London: Ministry of Defence (Air), 1973.
Ernsting J, Miller RL. Advanced Oxygen Systems for
Aircraft. AGARDograph 286. Neuilly-sur-Seine, France:
AGARD/NATO, 1996.
Federal Aviation Administration. FAR Code of US Federal
Regulations. Parts 25, 121 and 125. Washington, DC:
US Department of Transportation, 2014.
Gradwell DP. Pressure Breathing Inflation Schedules/
Ratios. Raising the Operational Ceiling AL/CF-SR-1995-
0021. Armstrong Laboratory, Brooks Air Force Base,
Texas, June 1995.
Haber E, Clamann HG. A General Theory of Rapid
Decompression. Randolph Air Force Base School of
Aviation Medicine, USAF Project no. 2112010008,
Report no. 3, 1953.
Macmillan AJF. The Performance and Deficiencies of
Oxygen Systems Fitted to Current NATO Interceptor
Aircraft. In: Seventh Advanced Operational Aviation
Medicine Course. Report no. 697. Neuilly-sur-Seine,
France: AGARD/NATO, 1984: 2–1–7.
Macmillan AJF. Comfort in Aircraft Cabins’ Air Quality and
Ventilation. Royal Aeronautical Society Proceedings of
Conference on Resting, Testing, Air Quality and Noise,
2.12.10, 1995.
McFarland RA. Human factors in relation to the develop-
ment of pressurised cabins. Aerospace Medicine 1971;
42: 1303–18.
Rayman RB. National Academy of Science report on
cabin air quality. Aviation, Space, and Environmental
Medicine 2002; 73: 319.
Rayman RB. Cabin air quality: an overview. Aviation,
Space, and Environmental Medicine 2002; 73: 211.
Rydock JP. Tracer study of proximity and recirculation
effects on exposure risk in an airliner cabin. Aviation,
Space, and Environmental Medicine 2004; 75: 168.
Thibeault C. Cabin air quality. Aviation, Space, and
Environmental Medicine 1997; 68: 8082.
West JB. A Strategy for in-flight measurements of
physiology of pilots of high performance fighter
aircraft. Journal of Applied Physiology 2013; 115(1):
145–149.
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K17577_C006.indd 130 17/11/2015 15:37

Long duration acceleration
NICHOLAS D.C. GREEN
Introduction 131
What is G? 131
Exposure to +GZ acceleration 134
Exposure to –Gz acceleration 146
Exposure to Gx acceleration 147
Exposure to Gy acceleration 149
Protection against long duration acceleration 149
G-protective systems 150
INTRODUCTION
The human body is acted on continuously by the force of the
Earth’s gravity and is well adapted to an existence in this
environment. However, aircraft and spacecraft are capable
of generating sustained acceleration resulting in much
larger forces, often up to nine or more times those due to
gravity (+9  Gz). This chapter is concerned with the physi-
ological changes that are induced in humans by sustained
acceleration, and the methods used to provide protection
against those changes.
Acceleration can be classified according to duration in
the following manner:
●● Long duration: Long duration acceleration acts for
periods of more than one to two seconds. Forces of this
type are typically encountered during military and
civilian aerobatic aircraft manoeuvring, but may also
occur during launch and re-entry of space vehicles. The
physiological effects of long duration acceleration are
produced by alteration in the flow and distribution of
blood, and by the distortion of tissues and organs of the
body. Tolerance depends primarily on the magnitude of
the plateau acceleration imposed.
●● Short duration: Short-duration acceleration acts on the
body for periods of less than one to two seconds. These
forces are usually encountered during impact, and are
sometimes referred to as impact accelerations or impact
K17577_C007.indd 131
7
High G training 153
Musculo–skeletal injury 153
Physical conditioning 154
Other methods to improve G tolerance 154
Future G protection 154
References 155
Further reading 156
forces. They may also be experienced during assisted
escape from aircraft. Their effects depend principally
on the structural strength of the part of the body on
which they act and are related to the overall velocity
change induced.
The effects of short-duration and oscillating (vibra-
tion) accelerations are discussed in Chapters 8 and 13, 
respectively.
WHAT IS G?
Knowledge of the force environment in flight is essential
to understand the physiological changes associated with
G exposure. The terms ‘G’ and ‘sustained acceleration’
are often used to mean the same thing, and the principles
underlying these concepts are explained below.
●● Speed.
Speed describes the rate of movement of a body,
without specifying the direction of travel. Speed
is defined as the rate of change of distance and is a
scalar quantity.
●● Velocity.
Velocity describes the rate and direction of travel of an
object and is a vector quantity, having both magnitude
and direction. The velocity of a body changes if there is
a change in speed or in direction of travel.
131
17/11/2015 15:38
 132  Long duration acceleration
●● Acceleration.
Acceleration describes a change of velocity of an object.
It is defined as the rate of change of velocity and, like
velocity, is a vector quantity having magnitude and
direction. Hence, acceleration can result from a change
in speed along a straight line (linear acceleration) or
from a change in the direction of travel (radial accelera-
tion). It is usually expressed in units of m/s2.
In order to describe acceleration in terms that are easier
to understand, applied acceleration is often called G (note
use of upper case) in aerospace medicine and is expressed as
a multiple of the acceleration due to gravity. Standard grav-
ity, or acceleration due to gravity at the Earth’s surface, is
defined as 9.81 m/s2 and is indicated by the symbol g (lower
case). Note that neither g nor G are SI units, and lower case
g is sometimes used in place of G by engineers and by air-
crew. The G value of an applied acceleration (a) on a pilot in
a manoeuvre is given by:
a the path it follows, and is given by the equation:
G=
g
For example, if a pilot was accelerated at 58.9 m/s2, they
would be exposed to 6  G, which is six times the accelera-
tion due to gravity (9.81 m/s2). The term G is often used to
represent force, and its magnitude does determine the force
produced. However, as we will see below (see ‘Weight’ sec-
tion), the force that an individual pilot experiences under G
depends on his or her mass, and so it is simpler and more
consistent to talk about the applied acceleration (G) rather
than the resultant force.
Linear acceleration
A linear acceleration is an acceleration produced by a
change of speed without a change in direction. In aviation,
prolonged linear accelerations (such as takeoff and land-
ing) seldom reach a magnitude that will produce significant
changes in human performance, as most aircraft do not
exert sufficient thrust to produce extended changes in lin-
ear velocity. Linear accelerations of around 3 G to 4 G may,
however, be produced during catapult-assisted takeoff and
arrested landings. Prolonged linear accelerations also occur
during the launch of spacecraft and when they are slowed
upon re-entering the Earth’s atmosphere. The magnitude of
acceleration varies with the type of craft and flight profile:
the Russian spacecraft Soyuz may achieve 8 G on re-entry
under some conditions, and some commercial space tour-
ism flights may reach around 6 G.
Radial acceleration
A radial acceleration is an acceleration produced by a
change of direction of motion without a change of speed.
The inherent design of an aircraft is such that, in order for
it to fly, lift must be developed from the wings to counteract
K17577_C007.indd 132
the force of gravity. Fast jet aircraft can produce far more
lift than is required to counter gravity, and this can be used
to change the direction of travel of the aircraft very rap-
idly. Considerable acceleration can be experienced in this
way during banked turns and loop manoeuvres, when large
radial acceleration forces are developed: accelerations of
9 G or more can be maintained for many seconds by some
military aircraft. Centrifuges, such as those used to train
aircrew, also produce radial acceleration.
Newton’s First Law of Motion states that a body will
remain in a state of rest or in uniform motion in a straight
line unless a force acts upon it. An object that is made to move
along a circular path, like an aircraft in a turn, will have the
tendency to continue on a straight line. However, the object
is prevented from doing so by a force that pulls it away from
the straight line towards the centre of the circle. In the case
of an aircraft, this force is the lift produced by the wings. The
magnitude of the radial acceleration of the object towards
the centre of its circular path depends on the circumferential
velocity of the object along its circular path and the radius of
v2
a=
r
where a is the radial acceleration, v is the circumferential
velocity and r is the radius of the circular path.
Using this equation, the radial acceleration of an aircraft
travelling at 500  knots (258  m/s) around a circular path
with a diameter of 1 km can be calculated as 66.3 m/s2 or
6.8  G. Small changes in the speed of the object will have
a proportionally greater effect on the radial acceleration
than small changes in radius, due to the velocity term being
squared in the equation above. In this setting, the accelera-
tion towards the centre of the circle is sometimes termed
centripetal acceleration.
Acceleration onset rate
The rate of change of acceleration is termed the acceleration
onset rate or G onset rate. G onset rate is very important
when considering physiological responses to forces gener-
ated in flight and typically is expressed in units of G/s. Rate
of change of acceleration is also important when consider-
ing human response to impact, but here the term ‘jolt’ is
used more commonly.
Centrifugal force
In the study of aerospace physiology, it is important to
consider forces from the perspective of the human subject
exposed to them. If the brakes are applied to a fast-mov-
ing motor car, then the occupants feel that they are being
thrown forwards, although the applied force is directed
backwards. The passenger’s sensation is of a force in the
direction opposite to that actually applied, and their body
is accelerated (relative to the car) in this opposite direction.
17/11/2015 15:39

The passenger is experiencing inertia, which is considered
in Newton’s Third Law. This law states that every action
has an equal and opposite reaction, and results in human
perception of an applied acceleration being a sensation of
increased weight in the opposite direction. An aircraft in a
level turn is being accelerated radially towards the centre of
the circular path. Newton’s Third Law states that the force
producing the acceleration towards the centre of the turn
must be balanced by an equal force acting in the opposite
direction which, since it acts outwards away from the centre
of the curved path, is termed centrifugal force. The physi-
ological effects of the radial accelerations produced by cir-
cular flight are due to centrifugal forces.
The magnitude of the centrifugal force generated by
flight in a circular path is given by the equation:
mv 2
F=
r the centrifugal and gravitational forces changes continu-
where F is the centrifugal force, m is the mass of the
body, v is the circumferential velocity and r is the radius of
the curved path.
Weight
Newton’s Second Law helps us understand the relation-
ship between force and acceleration. The acceleration of an
object is dependent on its mass and the magnitude of the
force acting on it.
F = ma
where F is force, m is mass and a is acceleration.
Newton’s Second Law enables the concept of weight to
be described. Weight is a force, exerted by the mass of an
accelerating body and is measured in Newtons (N). The
force most commonly experienced by humans is weight
resulting from the acceleration caused by the attraction of
the Earth. This force is constant because acceleration due
to gravity, g, is constant (although there is some planetary
regional variation). When considering weight, the weight
(W) exerted by a mass (m) when accelerated at a value of a is
given by the relationship:
W = ma
For example, if a mass of 1 kg was in an aircraft being
acted upon by a force that produces an acceleration of 3 G
(29.4  m/s2), it would weigh 29.4  N. Confusion sometimes
arises because the term ‘weight’ is used in common lan-
guage as a substitute for the term mass (weight is correctly
measured in N).
There is a difference between the sensation of force
(weight) produced by gravity and that induced by other accel-
erations. Other forms of acceleration produce a sensation of
force acting in a direction opposite to the change in velocity.
In the case of gravity, however, both the acceleration and
K17577_C007.indd 133
What is G?  133
the sensation of weight are in the same direction, towards
the centre of the Earth (this can be seen in Figure  7.1).
Furthermore, it is only when the acceleration due to gravity
is resisted fully by direct or indirect contact with the ground
that normal weight is experienced, and a body has no weight
if it is allowed to fall freely with an acceleration of 9.81 m/
s2. Thus, gravity is unique in that it can be responsible for
acceleration or weight, but not for both at the same time.
Influence of gravity
Gravity must also be considered when thinking about the
forces to which aircrew are exposed in flight. If an aircraft
is carrying out a loop manoeuvre, the occupants will be
exposed not only to the centrifugal forces induced by the
radial acceleration but also to the force generated by the
linear acceleration due to gravity. The relationship between
ously during the manoeuvre, so that the magnitude and
direction of the resultant force vary along the flight path. To
understand the basic principle, consider the resultant iner-
tial acceleration on a pilot flying a perfectly circular verti-
cal loop, in which the aircraft’s airspeed does not change
(Figure  7.1). The lift from the aircraft’s wings produces a
constant radial acceleration of 3 G resulting in a centrifugal
inertial force on the pilot (Fc). When the aircraft is at the
bottom of the loop, the centrifugal (Fc) and gravitational
(Fc) forces are acting in the same direction along the verti-
cal axis of the aircraft. At this point, the resultant inertial
acceleration will be 4 G and the weight of the pilot (Fr) will
be four times its resting value. At the top of the loop, when
the aircraft is inverted, the centrifugal and gravitational
forces are acting along the same line but in opposite direc-
tions, so that the apparent weight will be twice its resting
value, and the resultant inertial acceleration will be 2 G. At
all other points in the loop, the inertial acceleration felt by
the pilot lies somewhere between 4 G and 2 G, in the direc-
tion of the resultant vector sum of Fc and Fg.
The loop depicted in Figure 7.1 is unrepresentative of real
flight, as for most aircraft the effect of gravity is to reduce
airspeed on ascent and increase it on descent. This change
of speed when flying vertically up or down means the force
of gravity is not felt by the pilot (similar to freefall) so the
resultant vector is from Fc alone and tends to remain in line
with the aircraft’s vertical axis throughout; furthermore,
loops usually take the shape of two joined ellipses (termed
clothoid) rather than a perfect circle. The aircraft track is
often made up of only part of a curved path or several differ-
ent curved paths, in which the magnitude of the accelerative
forces acting on the aircraft and its crew can be determined
by treating the complex flight path as a series of sections,
each with its own radius of curvature.
Acceleration terminology
In aerospace medicine, where the main interest is the
effect of acceleration on humans, the direction in which an
17/11/2015 15:39
 134  Long duration acceleration
Resultant acceleration = 2G
Fr = Fc – Fg = 1373N
Inertial acceleration (lift) = 3G
Fc = mv2/r = 2060N
Inertial acceleration (gravity) = 1G
Fg = mg = 687N
r
Inertial acceleration (gravity) = 1G
Fg = mg = 687N
Inertial acceleration (lift) = 3G
Fc = mv2/r = 2060N
Resultant acceleration = 4G
Fr = Fc + Fg = 2747N
Figure 7.1  The inertial acceleration due to lift and due
to gravity for a pilot flying a vertical loop. Centrifugal
inertial force (Fc), gravitational force (Fg) and resultant
force (Fr) are also shown, for a pilot mass (m) 70 kg flying
a loop radius (r) 1000 m at constant velocity (v) of 171 m/s
(330 Kt). The resultant acceleration varies from 4 G at
the bottom of the loop to 2 G at the top. The force on
the pilot (equivalent to weight) varies from 2747 N at the
bottom of the loop to 2060 N at the top; the pilot weighs
687 N under Earth’s gravity alone.
acceleration or inertial force acts is described by the use of
a three-axis coordinate system (x, y, z), in which the verti-
cal (z) axis is parallel to the long spinal axis of the body.
The direction of force applied to an individual is most
commonly referred to in terms of inertial reaction, rather
than the applied accelerative force, as this more readily fits
the human perception of the environment. Table  7.1  and
Figure  7.2  show the internationally agreed standard aero-
medical terminology for indicating the direction of accel-
eration and inertial forces acting on humans, based on
terminology proposed by Gell (1961). As this terminology
relates to the person and their orientation, rather than the
forces acting on the aircraft, cockpit geometry (e.g. seat
angle) is an important consideration when aircraft perfor-
mance data are applied to aircrew.
EXPOSURE TO +GZ ACCELERATION
The number of aviators around the world who are exposed
regularly to high sustained +Gz acceleration is relatively
small, being restricted almost entirely to a few hundred or
K17577_C007.indd 134
– Gz footwards
– Gy
left lateral
+ Gx
forwards
– Gx
backwards
+ Gy
right lateral
+ Gz headwards
Figure 7.2  Standard aerospace medical terminology
for describing the direction of acceleration and inertial
forces. The vector arrows indicate the direction of the
resultant inertial forces.
more military personnel in any one country. Although civil-
ian aerobatic flyers also experience high levels of +Gz accel-
eration (sometimes in excess of +9 to –9 Gz), their aircraft
generally are incapable of sustaining acceleration for very
long due to limitations of thrust and, consequently, their G
exposure tends to be brief, limiting the physiological effects.
In a military setting, exposure to acceleration is dependent
on the aircraft type operated; however, most aircrew will
be exposed to at least +6 Gz during their basic flying train-
ing. Exposure to +6 Gz acceleration can be experienced in
maximum possible rate turns, but also during air combat
manoeuvring (ACM), and ground attack flights, where dive
recovery and missile avoidance may require abrupt changes
in direction.
Usually, military aircraft such as the F-15, F-16  and
F-18 might sustain +7 to +9 Gz for up to five to ten seconds
during ACM, and may remain above +5 Gz for over a minute
in a combat engagement. Aircrew may be expected to gain
between 500  and 5000  hours experience flying these air-
craft types, but only one to five per cent of this time might
be under sustained high +Gz conditions. The net result is a
whole career G dose measured in hours for these aircrew.
High performance aircraft such as F-22, Rafale,
Eurofighter Typhoon, Gripen and to a certain extent F-35
potentially increase aircrew acceleration exposure. These
aircraft are capable of sustaining acceleration for prolonged
periods of time, with an acceleration onset rate in excess of
10 G/s. The increased risk associated with this acceleration
exposure has promoted improvements in acceleration pro-
tection provided to aircrew in these platforms.
Musculoskeletal effects of +Gz acceleration
The most readily apparent effects of exposure to increased
+Gz acceleration are brought about by the increased weight
17/11/2015 15:39

Table 7.1  Three-axis coordinate system for describing direction of acceleration and inertial forces acting on a human.
Direction of resultant
Direction of acceleration inertial force
Headwards Head to foot
Footwards Foot to head
Forwards Chest to back
Backwards Back to chest
To the right Right to left side
To the left Left to right side
of the soft tissues, head, limbs and trunk. Upward move-
ment of the arms becomes very difficult above +7  Gz,
although fine movement, such as that in the fingers, tends to
be preserved due to their relatively low mass. Above +3 Gz,
it is impossible for most people to stand up from the seated
position, making unassisted escape (e.g. from a damaged
aircraft) impossible. For this reason, among many others,
assisted-escape systems such as ejection seats are employed
in high-performance aircraft.
The soft tissues of the face are affected by acceleration
exposure, with a drooping or sagging appearance even
at +2  Gz, which can, at higher acceleration levels, lead to
involuntary closure of the eyes in inexperienced individu-
als. Even without the added weight of a helmet, an indi-
vidual cannot raise their head once the neck has been
allowed to flex above about +8 Gz. When a typical protec-
tive helmet (weighing perhaps 2  kg) is worn, this limita-
tion occurs at +4  to +6  Gz. Of particular relevance is the
position of the centre of mass of the head/helmet combina-
tion, relative to the atlanto-occipital joint and cervical ver-
tebrae. Head-mounted equipment such as helmets, sights,
displays and night-vision goggles may bring the centre of
gravity forward and upward, and may encourage forward
flexion of the head under +Gz acceleration, or head ‘snap’
backwards during neck extension. For all these reasons,
repeated exposures to long-duration +Gz acceleration lead
to fatigue and, in particular, neck pain and associated
soft-tissue injury.
Cardiovascular effects of +Gz acceleration
Exposure to increased +Gz acceleration has a profound
effect on the cardiovascular system, first indicated by
visual symptoms and then, at sufficiently high levels of
acceleration, by loss of consciousness. These effects are
not limited to the latest aircraft types and were observed
at least as early as 1918  (Head 1920). The circulatory dis-
turbance is a result of simple Newtonian physics applied to
the fluid compartments within the body. Exposure to +Gz
acceleration produces immediate changes in the distribu-
tion of pressure in the arterial and venous systems, which,
in turn, induce shifts of blood towards the more dependent
parts. These initial disturbances evoke reflex compensa-
tory changes, which tend to reduce the magnitude of the
initial effects.
K17577_C007.indd 135
Exposure to +GZ acceleration  135
Description Standard terminology
Positive G +Gz
Negative G –Gz
Transverse G, supine G +Gx
Transverse G, prone G –Gx
Left lateral G +Gy
Right lateral G –Gy
HYDROSTATIC PRESSURE
The cardiovascular changes caused by +Gz acceleration
result from an increased hydrostatic gradient in the arterial
and venous systems. The hydrostatic pressure in a column
of fluid exposed to acceleration is given by:
p = hρg
where p is the pressure exerted by a column of fluid, h
is the height of that column, ρ is the density of fluid and g
is the acceleration to which it is exposed. As g is increased,
so the pressure exerted by the column of fluid is increased,
provided the other factors remain constant. In an upright
individual, the immediate effect of +Gz acceleration is
therefore to accentuate the pressure gradients that nor-
mally exist due to the +1 Gz provided by gravity. However,
the vascular pressure in the right and left sides of the heart
remains essentially unchanged at the beginning of +Gz
exposure, as this pressure is created with reference to the
pressure in the pleural space (approximately atmospheric
pressure).
Acceleration increases the weight of the column of
blood above and below the heart. In a person with an
intact circulation, the vascular pressure above the level of
the heart is decreased and the pressure below the heart
is increased. Consider the column of blood in the arte-
rial system between the heart and the head of a seated
individual. In most adults, this is about 30  cm in height.
If the density of blood is assumed to be 1.06  g/mL and
g is assumed to be 9.81  m/s2, then the pressure drop at
head level caused by exposure to +1  Gz may be calculated
using the formula above to be approximately 22  mmHg.
This simple model assumes the vasculature to consist
of inelastic tubes. Thus, the hydrostatic pressure gradi-
ent between heart and head when seated at rest under
Earth’s gravity will result in a head-level blood pressure
that is approximately 22  mmHg lower than that at heart
level. Similarly, exposure to five times the Earth’s grav-
ity (+5  Gz) will result in a hydrostatic pressure drop of
5  × 22  = 110  mmHg. If heart-level systolic blood pressure
is assumed to be 110  mmHg, and in the absence of any
cardiovascular reflexes, it can be seen that most individu-
als will have little or no head-level blood pressure at this
acceleration level. This principle is illustrated diagram-
matically in Figure  7.3. This simple model assumes that
17/11/2015 15:39
 136  Long duration acceleration

Vertical height (m)

0.50

0.25

0.00 Hydrostatic
indifference

–0.25

–0.50
+5 Gz
–0.75
+1 Gz

–1.00
–100 0 100 200 300 400 500
Arterial pressure (mmHg)

Figure 7.3  Variation in arterial pressure in a seated individual at +1 Gz and +5 Gz at different vertical separations from the
point of arterial hydrostatic indifference at heart level. The dotted line corresponds to head-level arterial pressure at +5 Gz.

no vertical movement of the heart occurs within the tho- 300

rax under +Gz acceleration; in reality, individuals exposed
to +Gz acceleration without an anti-G suit experience

Fem
descent of the heart and diaphragm. At +5  Gz, without

ora
an anti-G suit, it has been estimated that head-to-heart

l
distance may increase by 5 cm, which may cause an addi- 200
tional reduction in head-level blood pressure of around
20 mmHg.
Mean pressure (mmHg)

Figure  7.4  shows the pressures in the arterial tree of

an individual seated upright at +1 Gz and +4.5 Gz. In this
example, the mean arterial pressure at heart level both at +4.5 Gz

Fe
100
+1 Gz and at +4.5 Gz is 100 mmHg. The mean pressure in

mo
ral
the cerebral arteries at eye level, which is 30 cm vertically
above the heart, is 22 mmHg less than heart level pressure
Ce
reb

at +1 Gz and 99 mmHg less at +4.5 Gz. Thus, the mean cere-

ral

bral arterial pressure falls from 78 mm Hg at +1 Gz to only +4.5 Gz +1 Gz

1  mmHg at +4.5  Gz. The pressure in the femoral artery,
which is approximately 60 cm below the heart, is 100 + 44 =
144 mmHg at +1 Gz. The pressure exerted by the 60 cm col-
umn of blood is increased to 198 mmHg at +4.5 Gz, so that
the femoral artery pressure at this level of acceleration is
approximately 300 mmHg.
The corresponding pressures in the venous part of the
systemic circulation are also shown in Figure 7.4. The pres-
sure in the right atrium of the heart is virtually atmospheric
both at +1 Gz and at +4.5 Gz. At +1 Gz, the pressure in the
cerebral veins at eye level is of the order of –20  mmHg.
On exposure to +4.5  Gz, the increase in the weight of the
column of blood between the cerebral veins and the heart
would be expected to reduce the pressure in the cerebral
veins to about –100 mmHg. The high negative transmural
pressure across the walls of the jugular veins in the neck
reduces the lumen of the veins greatly, increasing the resis-
tance to flow through them, so that, in practice, the pres-
sure in the jugular bulb falls to only about –50 mmHg on
exposure to +4.5 Gz.
0 Ce
reb
ral
–100
Central Artery Vein Right
aorta atrium
Figure 7.4  Immediate effect of exposure to +1 and
+4.5 Gz on the mean pressures at the following points
in the circulation of a seated individual: (a) immediately
downstream of the aortic valve; (b) in the cerebral arter-
ies and veins at the horizontal level of the eye; (c) in
the femoral artery and vein; and (d) in the right atrium.
Secondary changes in the circulation that occur over the
first 30–60 seconds of the exposure to +Gz modify the
magnitude of these pressures. The pressure in the femoral
vein rises progressively during the first 30–60 seconds of
the exposure to +Gz acceleration as blood accumulates in
the capacity vessels of the lower limbs.

K17577_C007.indd 136 17/11/2015 15:39


BLOOD VOLUME DISTRIBUTION
The changes in intravascular pressure described above have
an effect on the size of the blood vessels, as this is determined
by the vascular transmural pressure (the difference between
intravascular and extravascular pressure), the distensibility
of the vessel and the amount of blood available to fill it. In
turn, changes in the size of the vessels have major effects
on the regional blood flow and blood content. An increase
in the transmural pressure of small arteries and arterioles
below the level of the heart can reduce the peripheral resis-
tance and increase local blood flow, while a decrease in the
transmural pressure of veins above the level of the heart can
produce complete collapse of the vessels and cessation of
blood flow through them.
Although at the onset of exposure to +Gz acceleration, the
arterial pressure at the level of the heart is unchanged, this
pressure falls progressively over the first 6–12 seconds. This
fall of mean arterial pressure is due to a fall in the peripheral
resistance and a reduction in the output of the left side of the
heart. The fall of peripheral resistance is caused by the large
increase in the transmural pressure of the arterioles in the
dependent parts of the arterial tree (causing vasodilation or
preventing vasoconstriction), while the increase in venous
pressure in the regions below the heart causes dilation of
the capacity vessels. The rate of distension of these vessels
depends on their visco-elastic properties and the magnitude
of the pressure change. During the period when distension
is occurring, there is a regional redistribution of blood vol-
ume in the venous compartment. If it is assumed that the
venous valves are competent at preventing backfilling into
the dependent veins (which may not be true at high pres-
sure), then filling occurs via the arterial supply. During the
filling phase, inflow to the venous compartment continues,
but outflow and, hence, venous return back to the right side
of the heart, is greatly reduced or absent.
The net result of these changes is that if acceleration
is maintained, then a progressive fall of pressure occurs
throughout the arterial tree for 6–12 seconds after the onset
of the acceleration. At a particular transmural pressure,
determined largely by the tone of the vessel wall, no fur-
ther increase in venous vessel diameter occurs, peripheral
venous pressure overcomes central pressure and flow is
re-established, such that venous return is restored towards
the initial state, tending to limit further reduction in
arterial pressure.
The redistribution of blood volume produced by +Gz
acceleration occurs mainly towards the lower limbs. Little
volume increase can occur in the capacity vessels within
the abdomen, since intra-abdominal pressure rises in par-
allel with the venous pressure. It has been found that some
60–100 mL of blood is pooled in the lower limbs of a seated
subject exposed to +5 Gz for 15 seconds, although the cir-
culation is already compromised by gravity, as some 300–
800 mL of blood is pooled in the lower limbs upon adoption
of the upright posture. The relatively small blood volume
shift seen during increased +Gz acceleration has led some
K17577_C007.indd 137
Exposure to +GZ acceleration  137
to suggest that, overall, the head–heart hydrostatic gradient
has far greater influence on human acceleration tolerance
than blood volume redistribution.
The rise of pressure within the capillaries in the lower
limbs also causes transudation of fluid from the blood to the
tissues, so that there is a progressive loss of fluid from the
circulation. The rate of fluid loss into the tissues of the lower
limbs during a sustained exposure to +5 Gz is about 270 mL/
min (Howard 1965). In practical terms, aircrew exposure to
acceleration during flight is typically sustained for periods
of 15 seconds or less, and so the effects of transudation are
less apparent. Repeated short exposures during a flight do,
however, sometimes lead to some noticeable swelling in
dependent limbs, particularly where no counter-pressure
has been applied.
High vascular transmural pressure may also be seen
in the forearms if these are positioned significantly below
the level of the heart, a posture usually demanded by low
placement of an aircraft’s control column and throttle. The
pressure rise may be high enough to cause high G arm pain
(see below).
BARORECEPTOR REFLEX
The blood pressure changes and blood volume redistribu-
tion provoked by exposure to increased Gz acceleration pro-
duce reflex responses involving the arterial baroreceptors
and possibly also the low-pressure cardiopulmonary recep-
tors and arterial chemoreceptors. Additionally, exposure to
acceleration may modify activity in skeletal muscle mecha-
noreceptors and metaboreceptors, lung-stretch receptors
and vestibular receptors (Cheung and Bateman 2001), lead-
ing to modulation of cardiovascular function. Reflexes at
the local level are also likely to influence the blood pressure
response to acceleration exposure.
Arterial baroreceptors are located in the adventitial
layer of the carotid sinus and aortic arch. These mechano-
receptors respond to stretch, and the arterial transmural
pressure governs the deformation and hence afferent out-
put rate. They exhibit both static and dynamic properties:
a fall in carotid artery pressure due to acceleration expo-
sure may produce a cessation of output as blood pressure
drops, followed by re-initiation of activity at a lower rate
than the pre-acceleration baseline. Reduced activity is con-
veyed via the IX and X cranial nerves to the nucleus trac-
tus solitarius in the medulla. The output of the nucleus
tractus solitarius is relayed to the nucleus ambiguus, con-
taining vagal cardiac motor neurons and to the caudal ven-
trolateral medulla, which influences sympathetic output
(the hypothalamus also modulates these areas). Heart rate
is increased by reduced vagal inhibition and vasoconstric-
tion occurs (predominantly in muscle and the splanchnic
region), leading to increased peripheral resistance. Cardiac
contractility is increased, both directly and by release
of adrenaline (epinephrine) from the adrenal medulla.
Increase in renal sympathetic nerve activity stimulates
renin secretion, activating the renin–angiotensin system
17/11/2015 15:39
 138  Long duration acceleration
to produce angiotensin II (resulting in generalized vaso-
constriction) and aldosterone (resulting in salt and water
retention), although these are of very limited significance
in acute acceleration exposure.
The baroreceptor reflex provides a compensatory
mechanism to preserve head-level blood pressure under
increased acceleration, and measurement of blood pres-
sure under acceleration demonstrates this as a character-
istic recovery 6–12  seconds after the onset of acceleration
exposure (Figure  7.5). Exposure to +4  Gz typically pro-
duces a maximum heart rate of around 120–140 beats/min.
The venous return to the right side of the heart starts
to increase by 10–15  seconds after the onset of accelera-
tion exposure, and the output of the left side of the heart
increases within a few beats. The venous return and the
cardiac output continue to rise over the next 20–40  sec-
onds: cardiac output after 30–60  seconds exposure to
+4  Gz is reduced by about 20  per cent below the rest-
ing value. Overall, the compensatory changes tend to
restore the heart level arterial blood pressure, so that after
40–60 seconds of exposure to moderate levels of accelera-
tion (+3 to +5 Gz), the mean arterial blood pressure at heart
level is similar to the pre-exposure level.
Baroreceptor sensitivity (‘gain’) is modified by vari-
ous factors, including age and arterial wall distensibil-
ity. Additionally, the ‘set point’ to which blood pressure is
regulated can be modified by central and peripheral fac-
tors. It is possible that exposure to acceleration and the
muscular exertion of anti-G straining may invoke central
(upward) resetting of the baroreceptors. Peripheral reset-
ting of the baroreceptors, whereby the set point is modified
by baroreceptor exposure to a new pressure for 15 minutes
or more, has not been thought to occur in the context of
fast jet aviation. This is because exposure to acceleration
in fast jet aircraft usually is brief, in the order of 5–20 sec-
onds. In practical terms, it has long been assumed that no
physiological adaptation to acceleration exposure occurs.
However, this does not explain the phenomenon of ‘layoff’,
in which aircrew who have not flown at high G for a period
of a week or more notice a reduction in their G tolerance
on return to flying. Even a reduction in routine flying
hours may have some effect (Scott et  al. 2013). Some car-
diovascular adaptation to orthostatic stress has been dem-
onstrated experimentally (Convertino 1998; Newman et al.
2000; Schlegel et al. 2003; Evans et al. 2004), although the
mechanism of this adaptation is unclear. One mechanism
might involve central baroreceptor resetting. However, this
is complicated further by the relationship between carotid
and aortic baroreceptor stimulation under acceleration.
Like upright tilt, the hydrostatic gradient results in more
profound changes in the output of carotid baroreceptors
than of those at the aortic arch, near to the heart. This is
dissimilar to the situation of volume depletion (e.g. by
haemorrhage) where both sets of receptors are generally
exposed to a similar pressure change. The central integra-
tion of baroreceptor responses in the two scenarios is likely
to differ.
K17577_C007.indd 138
Visual effects of +Gz acceleration
To an aviator, visual symptoms are the first obvious symp-
tom of the cardiovascular effects of acceleration exposure.
The earliest record of visual changes associated with +Gz
exposure appears to be that by Henry Head (1920). Head
reported that a test pilot flying a Sopwith triplane in a
+4.5 Gz banked turn experienced ‘characteristic darkening
of the sky which was preliminary to fainting’. Changes in
visual function have since become recognized by aircrew
as an important precursor to impending G-induced loss of
consciousness (G-LOC), and familiarity with visual symp-
toms is an important part of high G training for aircrew.
However, visual symptoms do not always occur before
G-LOC, as we shall see later, and it can be dangerous for
aircrew to rely on visual changes alone.
Classically, the pattern of visual loss associated with +Gz
exposure is described in terms of ‘grey-out’ and ‘blackout’.
Grey-out is usually a cone-shaped loss of vision, which starts
at the periphery with relative sparing of central vision, then
affecting central vision at higher levels of acceleration. The
vision in the periphery is described as grey or black, and in
practical terms individuals are unable to respond to a light
stimulus presented in the affected part of the visual field.
However, not everyone reports identical visual symptoms,
and there appears to be a subgroup of people who have a
widespread dimming of both central and peripheral vision
simultaneously, with apparent reduction in contrast sensi-
tivity. Some also report seeing lines and shapes of various
colours under these conditions.
A more definite visual symptom is that of ‘blackout’. In
aerospace medicine, ‘blackout’ refers to complete loss of
vision with preserved consciousness, in distinction to its
colloquial use to describe loss of consciousness or faint.
Usually, it is the end result of the classical grey-out pattern
described above, in which vision becomes an ever-narrow-
ing tunnel, until finally central vision is lost while hearing
and mental processes are maintained. Blackout occurs at
acceleration levels higher than those that cause grey-out,
and only a little further increase in +Gz acceleration (usu-
ally around 0.5 G) is required to cause loss of consciousness.
Under certain circumstances, aircrew can use the warning
symptoms of grey-out and blackout to avoid G-LOC by tak-
ing corrective action. However, at high acceleration onset
levels, these symptoms may not be present. The largest study
to investigate the acceleration levels associated with visual
symptoms was conducted using 1000 aircrew (Cochran et al.
1954). This revealed that blackout occurred at +4.8 Gz (stan-
dard deviation 0.8 G), and loss of consciousness followed at
+5.4 Gz (standard deviation 0.9 G). However, there is a large
variation in the level of acceleration at which loss of periph-
eral vision occurs, due to factors such as body stature, physi-
cal condition, level of illumination of the visual field and
target and, in particular, the degree of muscle relaxation.
Whatever the level of acceleration, vision is not disturbed
until some five seconds after the beginning of the exposure.
At moderate levels of acceleration, the intensity of the visual
17/11/2015 15:39

symptoms often decreases 8–12  seconds after the onset of
the acceleration. This improvement is due to compensa-
tory cardiovascular responses described above, restoring
the flow of blood to the retina. During exposure to +5 Gz,
blackout may occur after six seconds but some vision may
be restored six seconds later. Normal vision usually returns
three to five seconds after the manoeuvre ends.
Figure  7.5  illustrates these changes as recorded in an
experimental subject seated in a centrifuge and exposed to
+4.2 Gz for 15 seconds. This shows an initial fall in arterial
blood pressure at head level (recorded using a non-invasive
blood pressure monitor in the finger held at eye level) fol-
lowed by an obvious tachycardia and partial recovery in
blood pressure. Peripheral vision was monitored using a
subject operated tracking device and closely mirrors the
blood pressure changes, with blackout occurring a few sec-
onds after the point of lowest pressure.
The visual disturbances produced by +Gz accelera-
tion are caused by retinal ischaemia. The various degrees
of grey-out are due to progressive reduction in the flow of
blood to the retina; complete cessation of the flow causes
blackout. The eye has an internal (intraocular) pressure of
around 10–20  mmHg, so the pressure in the central reti-
nal artery must exceed 20 mmHg, otherwise blood flow will
be compromised. Blackout occurs during +Gz acceleration
when the systolic arterial pressure at eye level falls below
20  mmHg. Using an ophthalmoscope, the retinal arteries
and arterioles can be seen to be empty when the arterial
pressure is less than 20 mmHg (Duane 1954).
Figure 7.5 demonstrates that there is an interval of four
to six seconds between the cessation of retinal blood flow
Acceleration = 4.2 Gz
100
blood pressure (mmHg)
Head-level arterial
0
15 s
Figure 7.5  Effects of a 15-second exposure to +4.2 Gz on head-level arterial blood pressure and peripheral vision. Note that periph-
eral vision is lost progressively as arterial blood pressure falls, with blackout (zero peripheral vision) occurring some six seconds after
the point of lowest pressure. Thereafter, both blood pressure and vision recover as compensatory reflexes develop.
K17577_C007.indd 139
Exposure to +GZ acceleration  139
and loss of vision. It is generally believed that the time
delay relates to metabolism of local oxygen in the blood
and tissues. Thus, retinal function decays when local ‘func-
tional reserves’ of oxygen have expired. Similarly, on recov-
ery, the return of vision is delayed for a few seconds after
the arterial pressure at eye level has risen above 20 mmHg.
This delay is due to the time taken to regenerate the tis-
sue oxygen levels and thereby raise the oxygen tension in
the retina above the minimum required for normal func-
tion. Despite the blackout, consciousness is usually pre-
served until the cerebral arterial pressure is reduced to
0–10 mmHg.
The peripheral distribution of the loss of vision in
grey-out (or coning of vision) has been explained by the
vascular anatomy of the retina. This explanation relies
on the assumption that the retina has a single blood sup-
ply from the central retinal artery, which is an end artery
that penetrates the globe at the optic disc and forms mul-
tiple branches, becoming more numerous and smaller in
diameter towards the periphery. A reduction in central
retinal artery pressure will cause blood flow in the periph-
eral retinal vessels to be overcome first by intraocular pres-
sure, as the peripheral vessels have the lowest pressure. The
explanation is probably somewhat oversimplified, as it does
not address blood supply to the fovea, which is avascular
and nourished by the choroidal circulation. Moreover, the
hypothesis does not explain the alternative, more uniform
pattern of visual loss seen in some individuals. Due to the
technical difficulties involved, a thorough understanding
of the basis of visual symptoms under increased accelera-
tion has not yet been gained.
100
Peripheral vision (%)
17/11/2015 15:39
 140  Long duration acceleration
G-Induced loss of consciousness
Exposure to +Gz acceleration greater than that required to
produce visual blackout may result in G-LOC. As conscious-
ness is lost, there is usually total loss of muscle tone, so that
the head and body slump. During recovery, in the few sec-
onds following acceleration exposure, clonic muscle activity
may occur, which may be due to differences in cerebral acti-
vation as blood flow returns to the brain. This is not epilep-
tic in nature and is not known to be of clinical significance,
except that it may be useful in identifying a G-LOC episode.
Furthermore, it is possible that an aircraft control or switch
could be operated inadvertently during this activity.
Incapacitation due to G-LOC can be divided into two
periods: a period of absolute incapacitation, lasting on aver-
age around 9–10  seconds (Whinnery and Forster 2013),
during which the individual is unconscious, and a period
of relative incapacitation lasting for 30  seconds or more,
during which the individual is conscious, but suffering
from confusion and disorientation, such that he or she is
unable to control the aircraft (Whinnery et  al. 1987). The
total incapacitation time, which could be a minute or lon-
ger, is sufficient for a fast-moving aircraft to impact with
the ground. In the period 1982–2001, the United States Air
Force (USAF) lost 29 aircraft to G-LOC (Lyons et al. 2004a).
In the hours following G-LOC, G tolerance may be
reduced and certain psychological effects may persist.
Therefore, aircrew are recommended to terminate the
flight and not to fly for the remainder of the day following a
G-LOC episode. Physiological amnesia in up to 50 per cent
of cases following G-LOC may mean that aircrew may be
unaware of having had a G-LOC episode. Confidential sur-
veys from various armed forces around the world suggest
that 10–20 per cent of all military fast jet pilots have suffered
from G-LOC at least once. However, considering that some
individuals may have suffered from post G-LOC amnesia,
this may be an underestimate. G-LOC occurs more com-
monly in training aircraft, although the resulting accident
rate is higher in single-seat fighters (Lyons et al. 2004b).
The syndrome of ‘almost loss of consciousness’ (A-LOC)
has also been described. This is a rather loose collection
of signs and symptoms of a physiological, emotional and
cognitive nature. Features include sensory abnormalities,
amnesia, confusion, euphoria, paralysis and reduced audi-
tory acuity. One particularly notable feature is the apparent
disconnection between the desire and the ability to perform
an action. Certain features (e.g. tremor) may persist for
some time after the acceleration exposure has ceased. The
underlying mechanism is thought to be similar to that of
G-LOC, and it may be that a brief period of A-LOC pre-
cedes and follows G-LOC episodes. One survey showed that
50 per cent of fast jet aviators had experienced at least one
episode of A-LOC (Rickards and Newman 2005); as far as
the aviator is concerned, the syndrome is as important as
G-LOC, as both A-LOC and G-LOC may potentially result
in loss of control and midair collision or ground impact.
K17577_C007.indd 140
Effects of +Gz acceleration on the cerebral
circulation
The hydrostatic effect of exposure to +3.5  Gz reduces the
arterial pressure at the level of the brain to a value that,
under normal gravity, would be less than that required to
maintain an adequate cerebral blood flow. Similarly, expo-
sure to +4.5  Gz reduces the arterial pressure at head level
to virtually zero. Furthermore, exposure to +Gz accelera-
tion sufficient to induce blackout (when the arterial pres-
sure at eye level is less than 20 mmHg) does not necessarily
result in loss of consciousness. Although reflex compen-
satory changes partially restore arterial pressure at brain
level 6–12 seconds after the onset of acceleration, the inci-
dence of G-LOC is much lower than would be expected.
Several mechanisms are responsible for the continued flow
of blood through the brain during exposure to +3 to +5 Gz,
even though the arterial pressure at head level is only
0–20 mmHg:
●● The cerebral vessels and brain are enclosed in a rigid
bony box and surrounded by cerebrospinal fluid. The
pressure of the cerebrospinal fluid falls, owing to hydro-
static effects, in parallel with the reduction of vascular
pressure at head level, so that the pressure difference
across the walls of the intracranial vessels remains close
to normal and the vessels remain open.
●● There is active vasodilation of the arterioles of the cere-
bral circulation, so that the resistance to flow through
them is reduced.
●● The column of blood in the upper part of the veins in
the neck creates a siphon effect, which maintains the
cerebral circulation for as long as the column remains
unbroken. A pressure difference between the arterial
and venous sides of the cerebral circulation of the order
of 50–60 mmHg is maintained at an acceleration of
+4 to +5 Gz due to a subatmospheric pressure in the
jugular bulb of –50 mmHg.
At higher levels of acceleration, however, further lower-
ing of the pressure within the upper part of the jugular veins
causes these vessels to collapse completely, increasing the
venous resistance, and thereby breaking the siphon. Blood
then ceases to flow through the brain, and unconsciousness
supervenes in a few seconds. As the siphon breaks, the cere-
bral vessels are emptied of blood, so that only the oxygen
stored as dissolved gas in the cerebral tissue is left to main-
tain aerobic metabolism. This store is exhausted in some
three to five seconds.
Effect of +Gz acceleration on skin capillaries
The high vascular transmural pressure across the walls
of the capillaries in the skin of dependent parts produced
by exposure to increased +Gz acceleration not only gives
17/11/2015 15:39

rise to transudation of fluid but also may cause rupture
of these vessels, with the formation of petechial haem-
orrhages. It is not unusual to find multiple petechiae on
the foot, leg, buttocks and forearm after repeated or pro-
longed exposures to accelerations greater than about
+6  Gz. This appearance is commonly termed ‘G-measles’.
Occasionally, a larger vessel (usually a small vein or ven-
ule) may rupture, leading to a subcutaneous collection of
blood. This usually occurs at higher acceleration levels in
unsupported areas such as the popliteal fossa; although
sometimes it is painful, the condition generally resolves
without complication.
Effect of +Gz acceleration on cardiac rhythm
Benign cardiac dysrhythmias have been observed in cen-
trifuge studies during and immediately following expo-
sures to high sustained +Gz acceleration (Shubrooks 1972).
Dysrhythmias have also been observed in flight (Zawadzka–
Bartczak and Kopka 2011) but no clinically significant
episodes in flight have been reported. Most common are
premature ventricular contractions, which tend to occur
during the acceleration exposure itself, although occa-
sionally premature supra-ventricular contractions are also
observed. Sinus bradycardia and brief atrioventricular dis-
sociation may occur after acceleration exposure has ended.
These changes are probably related to the profound changes
in heart rate induced by autonomic imbalance during and
following G-exposure. It is generally considered that these
rhythm changes represent a normal physiological response
to acceleration stress.
Hormone response to +Gz acceleration
Acceleration stress induces a specific endocrine response
with increases in serum cortisol, adrenaline and nor-
adrenaline levels (Mills 1985). The cortisol response
is too slow to have an effect on tolerance to an acute
exposure to acceleration, but it may be significant in
prolonged or repeated exposures. The acute release of
catecholamines and vasopressin (antidiuretic hormone)
may also enhance G tolerance by increasing peripheral
resistance. Indeed, the first exposure to +Gz acceleration
of a series has been shown to produce visual symptoms
at a lower acceleration level than subsequent exposures
– the so-called ‘first-run effect’. A rise in plasma renin
has also been observed following exposure to +Gz accel-
eration; this promotes salt and water retention via angio-
tensin II and hence aldosterone secretion. It is possible
that increased circulating angiotensin II levels may also
contribute directly to acceleration tolerance by promoting
peripheral vasoconstriction. Aircrew are encouraged to
conduct at least two moderate G turns of at least 10  sec-
onds duration before starting high G manoeuvring, to
take advantage of short term G tolerance improvement
by catecholamines. This ‘G warm up’ may also be used to
K17577_C007.indd 141
Exposure to +GZ acceleration  141
check personal G tolerance, and practice anti-G straining
in a controlled  setting.
Tolerance to +Gz acceleration
‘G tolerance’ can be defined in a number of ways: grey-out,
blackout or physical exhaustion can be used – the most
appropriate end-point depends on the rate of application and
duration of the accelerative stress. The time from the onset
of the acceleration to the appearance of grey-out, blackout
or G-LOC is a function of the rate at which the accelera-
tion is applied, particularly when this is less than 1 G/s. This
means that the level of acceleration at which blackout occurs
is, on average, 1 G higher with a rate of onset of 0.1 G/s as
compared with an onset rate of 1 G/s. In most fast-jet avia-
tion, the rate of onset of acceleration for peak accelerations
above +4 Gz generally is much greater than 1 G/s, and the
duration of exposure is usually defined as the total time for
which the acceleration exceeds +1  Gz. During prolonged
G exposure, e.g. during air combat manoeuvring, fatigue
becomes an important factor and time to physical exhaus-
tion is sometimes used as a measure of tolerance under
these circumstances. As there is a large variation in G tol-
erance between individuals, using this information mean-
ingfully can be difficult – in one series of experiments, the
acceleration required to produce blackout varied between
subjects from +2.7 Gz to +7.8 Gz (mean value +4.7 Gz with
a standard deviation of ±0.8 G). It is important for aircrew
and medical personnel to recognize this wide variation in
G tolerance in the aviator community, and note that while
some aircrew have very good G tolerance, equally there is a
proportion of the population for whom good G protective
measures are crucial.
With these limitations in mind, a compilation of cen-
trifuge data on tolerance to +Gz acceleration in relaxed
unprotected subjects is presented in Figure  7.6  (after Stoll
1956). The end-points are unconsciousness or blackout,
whichever occurred first. The increase in tolerance beyond
ten seconds is due to the operation of compensatory car-
diovascular responses. Figure 7.6 shows that, theoretically,
a subject could be taken to +14 Gz and brought back to +1 Gz
without any visual loss if the acceleration exposure were
completed within a few seconds. However, if the subject
remained at +14  Gz for more than a few seconds, uncon-
sciousness would occur without any preceding grey-out,
since the oxygen reserves of the eye and the brain become
exhausted at about the same rate. A very slow onset of accel-
eration allows cardiovascular reflexes to develop, and the
trough seen in Figure 7.6 may then be avoided, so that toler-
ance to +Gz acceleration at an onset rate of 0.1 G/s is about
1 G greater than at an onset rate of 1 G/s. When using this
curve, it should be noted that it represents individuals who
are not using any anti-G protective systems, and does not
take account of preceding G exposure which may alter G
tolerance. The effect of G onset rate on tolerance is summa-
rized in Figure 7.7.
17/11/2015 15:39
 142  Long duration acceleration

16 Factors affecting tolerance to +Gz

Endpoint acceleration
14 Grey-out
Blackout In the avoidance of G-LOC, it is very important that aircrew
12 Unconsciousness maintain good ‘G awareness’. In addition to knowing about
G-LOC and how it may manifest itself, G awareness com-
Maximum acceleration (G)

10 prises a good knowledge of those factors that could make G

tolerance worse in an operational setting.
8
TEMPERATURE

6
Exposure to heat reduces tolerance to +Gz acceleration.
A 1°C rise of deep body temperature reduces the level of
acceleration at which blackout occurs by 30–40  per cent
4
(Howard 1965). The reduction in tolerance is due to cutane-
ous vasodilation and the shift of blood to the periphery that
2
occurs in response to a rise of body temperature. The lower
peripheral resistance and reduced central blood volume
0
0 5 10 15 20 25 30 35 then enhance the reduction of arterial pressure produced by
Total time from onset of acceleration to end point (s) the acceleration. Exposure to increased temperature is often
an inescapable fact in fast jet aviation.
Figure 7.6  Compilation of centrifugal data on tolerance
to +Gz in relaxed seated subjects (without the use of any BLOOD GLUCOSE CONCENTRATION
protective device). The endpoints are blackout or uncon- Tolerance to positive acceleration is reduced by a falling
sciousness, whichever occurred first. The results plotted blood glucose concentration. A 50  per cent reduction of
in this figure were obtained with a variety of rates of onset the glucose concentration below the resting value reduces
of acceleration. The increase in tolerance beyond ten
the blackout threshold by about 0.6  G (Howard 1965).
seconds is due to compensatory cardiovascular changes
(after Stoll 1956). Nutritional status is important for aircrew, and consider-
ation should be given to those foods that provide a sustained
14 rise in blood glucose, rather than those which provoke a
rapid rise then fall in glucose level.
12 B ALCOHOL
Ingestion of alcohol reduces tolerance to +Gz acceleration.
10 Loss of consciousness A dose of 110 mL of whisky was found to reduce the grey-
out threshold by 0.1–0.4 G (Howard 1965). It is likely that
+Gz acceleration

this effect is due to alcohol-induced vasodilation and also

8
to depression of central responses. Dehydration associ-
C ated with alcohol consumption may also have an effect on
6 G tolerance, even when blood alcohol level has returned to
ms
ympto zero. Psychomotor performance impairment from alcohol
Visual s
A
4 consumption is much more likely to be a contributory fac-
D tor in aircraft accidents and incidents than any effect on
G tolerance.
2
HYPERVENTILATION AND HYPOXIA
0 5 10 15 20 25 30
Time (s) Hyperventilation markedly reduces tolerance to +Gz accel-
eration. Reduction of the arterial carbon dioxide tension to
Figure 7.7  Tolerance to +Gz acceleration and effect of the order of 2.6–3.3 kPa (20–25 mmHg) by two minutes of
onset rate. A brief rapid-onset exposure to +12 Gz (10 G/s) vigorous hyperventilation reduces the grey-out threshold by
can be tolerated without visual loss (A), but if this is pro- about 0.6 G (Howard 1965). Moderate hyperventilation was
longed for more than four seconds (B), loss of conscious- found to precipitate unconsciousness in some individuals
ness may occur without visual warning. Even a moderately exposed to +3  Gz. Hyperventilation may be a feature in a
fast rate of onset (C) outpaces the cardiovascular reflexes,
poorly performed G straining manoeuvre, or due to anxi-
although loss of consciousness will then be preceded
by symptoms of grey-out and blackout of retinal origin. ety. The increase in cerebral vascular resistance produced
A slow (0.1 G/s) rate of onset (D) allows compensatory by hypocapnia accentuates the reduction in blood flow
reflexes to develop during the application of the stress, through the brain caused by a fall in arterial pressure at
symptoms now appearing at a higher G level. head level under increased +Gz acceleration. Studies have

K17577_C007.indd 142 17/11/2015 15:39


found that breathing five to ten percent carbon dioxide in
air causes a significant increase in G-tolerance but the asso-
ciated headache makes its use impractical.
Hypoxia also reduces tolerance to +Gz acceleration. A
reduction in blackout threshold of 0.5 G has been demon-
strated when breathing air at the equivalent of 10 000 feet,
which is usually regarded as an altitude below which sup-
plementary oxygen is not required. Reduction of arterial
oxygen tension to 9.3 kPa (70 mmHg) reduces the thresh-
old for blackout by 0.6  G, and more severe degrees of
hypoxia (inspired oxygen tension 7.3 kPa, 55 mmHg) have
been shown to reduce the blackout threshold by 0.8–1.2 G
(Howard 1965). Hypoxia should not be an issue with a cor-
rectly functioning life support system, but system failures
and hose disconnections have sometimes been discovered
through a reduction in G tolerance.
DISTENSION OF THE STOMACH
Distension of the stomach increases tolerance to +Gz accel-
eration. The ingestion of 1.5 L of water has been shown to
increase the threshold for blackout by 0.6–1.3 G. This effect
may be due in part to the distended stomach reducing the
descent of the diaphragm and heart during the exposure,
but it may also be related to a central reflex elevation of arte-
rial blood pressure.
ACTIVE INFECTION
Active infection, such as an upper respiratory tract infec-
tion, reduces tolerance to +Gz acceleration. This is par-
ticularly true if body temperature is raised, although it is
possible that there is also some reduction in the effective-
ness of central mechanisms that usually elevate arterial
blood pressure under acceleration stress.
HYDRATION
The fast jet cockpit environment may lead to significant
dehydration during a flight, particularly if this involves
performance of the physically demanding anti-G straining
manoeuvre (see below). The effects of heat on aviators are
discussed more fully in Chapter 12. It is known that dehy-
dration can reduce endurance to G exposure, e.g. during air
combat, which is likely to be related directly to the reduc-
tion in circulating volume. It is important to emphasize to
aircrew that deliberate dehydration, e.g. to avoid the poten-
tial problems of in-flight urination, may have a detrimental
effect on G tolerance.
GENDER AND BODY MORPHOLOGY
No difference has been demonstrated in G tolerance
between men and women either in relaxed G tolerance
(Wiegman et  al. 1995) or time to fatigue in air combat
manoeuvring (Heaps et al. 1997). It might be expected that,
as average female stature is less than male stature, a smaller
hydrostatic gradient between heart and head would result
in improved tolerance to +Gz acceleration. However, offset
against this, the female resting blood pressure is often lower
than that of males, and also the relationship between stature
K17577_C007.indd 143
Exposure to +GZ acceleration  143
and head-to-heart distance may be different in both sexes.
It is recognized anecdotally that squat individuals tend to
have better G tolerance than tall people, but this not a reli-
able predictor, as a multitude of other factors, including age,
blood pressure and diet, may also have influence.
TIME OFF FROM FLYING
It is known that time off from flying for more than a few
days can result in reduced G tolerance on return to the
cockpit. This is sometimes termed ‘G layoff’. As a conse-
quence, aircrew should be advised to take care when pulling
G during their first few flights after a break in flying. The
physiological basis of this effect has been discussed above
(see ‘Baroreceptor reflex’).
PRECEDING –GZ EXPOSURE
Exposure to –Gz (footwards) acceleration reduces tolerance
to a following +Gz exposure. This is sometimes called the
‘negative-to-positive G’ or ‘push–pull’ effect. The physiolog-
ical basis of this effect is explained below (see ‘Exposure to
–Gz acceleration’).
VESTIBULAR INFLUENCE
Pilots sometimes report that their G tolerance appears to
be worse when they are suffering from motion sickness and
this is supported by the observation that motion sickness
appears to lower the tolerance to acceleration (Eiken et al.
2005). This has implications not only for flight training, but
also G training conducted on a human centrifuge.
Pulmonary effects of +Gz acceleration
PULMONARY VENTILATION AND LUNG VOLUMES
In trained aircrew, pulmonary ventilation tends to fall when
exposed to +Gz acceleration, the increase in respiratory rate
being more than offset by a decrease in tidal volume. This
effect is exaggerated by inflation of the abdominal blad-
der of an anti-G suit. The total lung and vital capacities
are unaffected by accelerations up to +3  Gz, but exposure
to +5  Gz reduces them by about 15  per cent. Exposure to
+Gz acceleration causes descent of the abdominal contents
and diaphragm, thereby increasing the functional residual
capacity (FRC). The FRC is increased by about 500  mL at
+3 Gz. The descent of the diaphragm produced by +Gz accel-
eration is greatly reduced, or even reversed, by inflation of
an anti-G suit (Glaister 1970).
REGIONAL LUNG VENTILATION
Exposure to +Gz acceleration accentuates the regional dif-
ferences in the distribution of ventilation that are present
in the lungs of an upright individual at +1 Gz. The increased
weight of the lung magnifies the pressure gradient down the
pleural cavity, which amounts to about 0.2 cm H2O per 1 cm
of lung per G. At +5 Gz, the pleural pressure at the base of the
lung is 30 cm H2O greater than that at the apex. The larger
gradient of pleural pressure induces greater differences in
17/11/2015 15:39
 144  Long duration acceleration

the distension of alveoli down the lung. Alveoli at the api-
ces are more distended, while those at the bases are closer
to their minimum volumes as compared with their sizes at
+1 Gz. These changes accentuate the differences in alveolar
ventilation down the lung (ventilation per unit alveolar vol-
ume) (Figure  7.8). This results in a gradient of ventilation
down the lung at +3  Gz that is three times that present at
+1 Gz.
4
Ventilation
At higher G levels, alveolar volumes decrease down the
lung to such an extent that alveoli at the lung base reach
their minimal volume and their associated airways close.
The lung volume (on breathing out from total lung capac-
ity) at which this closure can first be detected is termed
the ‘closing volume’ of the lung and increases linearly with
acceleration. Closure of terminal airways in dependent lung
tissue occurs whenever the actual lung volume is less than
the closing volume. Alveoli downstream of the closed air-
ways will contain only a residual volume of trapped gas and
are unable to take part in ventilation. Since inflation of the
abdominal bladder of an anti-G suit raises the diaphragm
and reduces the FRC, its use markedly increases this effect

(Figure 7.9).
2
3G
REGIONAL PULMONARY BLOOD FLOW
1G
0 The distribution of blood flow through the lung is affected
Apex Base greatly by +Gz acceleration, because the pressure in the pul-
monary circulation is relatively low. The mean pulmonary
4 artery and pulmonary venous pressures at the level of the
junction of the middle and lower thirds of the lung are typi-
cally around 15  mmHg and zero, respectively. The vascu-
Perfusion

3G
2 lar pressures above and below this level are determined by
1G hydrostatic forces so, even at +1 Gz, the mean arterial pres-
sure falls to zero 20 cm above the junction of the middle and
0
Apex Base
100
4
1G 3G

80
Ventilation/perfusion ratio

3
Lung volume (% TLC)

60 CC
B
2 TV

40

1 A
FRC
20

0
Apex Base 0
Distance down lung 1 3 5 7
+Gz

Figure 7.8  Vertical distributions of alveolar ventila-

tion, perfusion and ventilation/perfusion ratio in the
upright lung of an individual exposed to +1 Gz and +3 Gz
expressed relative to values that would exist if gas and
blood were distributed uniformly. Exposure to +3 Gz
increases the gradient of ventilation per unit of alveolar
volume down the lung three-fold over that which exists at
+1 Gz. Blood flow to virtually all the upper half of the lung
ceases at +3 Gz and the gradient of flow per unit alveolar
volume is tripled in the lower half. The volume of lung
tissue that is ventilated but not perfused (that which has a
ventilation/perfusion ratio of infinity) is increased mark-
edly by exposure to +3 Gz which also increases the spread
of ventilation/perfusion ratios in the lower portion of the
lung and produces a region of perfused but non-venti-
lated alveoli at the extreme base.
Figure 7.9  Effect of +Gz acceleration on functional
residual capacity (FRC) and closing capacity (CC)
expressed as a percentage of total lung capacity (TLC)
for a subject wearing an anti-G suit that starts to inflate
at +2 Gz. The combination of acceleration and anti-G suit
inflation causes a reduction in FRC and tidal volume (TV).
With increasing acceleration, terminal airways in the lung
bases will start to close at end-expiration at point (A) but
reopen in the ensuing inspiration until point (B), remaining
closed thereafter. By increasing the FRC and TV, the per-
formance of an anti-G straining manoeuvre or breathing
under positive pressure will move points (A) and (B) to the
right and thus increase the level of +Gz at which accelera-
tion atelectasis (absorption of alveolar gas trapped by
airway closure) may develop.

K17577_C007.indd 144 17/11/2015 15:39


lower thirds, which is just at the apex of the lung. At +4 Gz,
the mean pulmonary artery pressure is zero only 5 cm above
the junction of the middle and lower thirds and, as a conse-
quence, mean pulmonary artery pressure is zero throughout
the upper half of the lung. Therefore, the proportion of the
lung that is not perfused increases with increasing accelera-
tion from the uppermost 1 or 2 cm at +1 Gz to the whole of
the upper half of the lung at +4 to +5 Gz. The progressive rise
in the pulmonary artery pressure and pulmonary venous
pressure below the junction of the middle and lower thirds
of the lung results in a corresponding increase in regional
blood flow (see Figure 7.8). The rise in blood flow with dis-
tance down the lung increases with increasing acceleration.
However, blood flow decreases in the most dependent part
of the lung because the rise of interstitial pressure is trans-
mitted to the alveolar gas when terminal airways close, thus
increasing the local resistance to blood flow.
PULMONARY GAS EXCHANGE AND ARTERIAL
OXYGEN SATURATION
As we have seen, exposure to +Gz acceleration accentu-
ates the increases in ventilation and blood flow with dis-
tance down the lung that occur under normal gravity. The
magnitude of the changes in ventilation and blood flow
down the lung differ, so that +Gz acceleration accentu-
ates the ventilation–perfusion inequalities that are pres-
ent in the normal erect lung (see Figure 7.8). In particular,
with increasing +Gz acceleration, there is a progressively
larger volume of the upper lung that is ventilated but not
perfused, which amounts to about one-half of the lung at
+5 Gz. There is also a progressively larger volume of basal
lung that is perfused but not ventilated (due to airway clo-
sure) and so has a ventilation/perfusion ratio of zero. The
ventilated but non-perfused region at the top of the lung
simply adds to the respiratory dead space and does not,
in practice, interfere with the oxygenation of the arte-
rial blood. The perfused but non-ventilated alveoli in the
lowermost part of the lung can significantly impair the
oxygenation of the arterial blood. The oxygen tension of
the gas trapped in the non-ventilated alveoli falls within
a few seconds, by absorption of oxygen into the blood, to
equal that of the mixed venous blood. The blood flowing
through these alveoli thereafter constitutes a right-to-left
shunt. The proportion of the cardiac output shunted in
this manner increases with acceleration and at +5 Gz may
amount to 50  per cent (Glaister 1970). This right-to-left
shunt reduces markedly the oxygen saturation and tension
of the systemic arterial blood. Desaturation of the arterial
blood becomes apparent at +3 Gz, and sustained exposure
to +5 Gz for one minute reduces the arterial oxyhaemoglo-
bin saturation to about 85  per cent (mean arterial oxygen
tension 6.9  kPa, 52  mm Hg). Inflation of an anti-G suit
increases the fall of the oxygen saturation of the arterial
blood produced by +Gz acceleration, since elevation of the
diaphragm and fall in FRC increases the number of alveoli
that are perfused but not ventilated.
K17577_C007.indd 145
Exposure to +GZ acceleration  145
ACCELERATION ATELECTASIS
As discussed above, the terminal airways of the basal
alveoli close on exposure to +Gz acceleration, so that ven-
tilation of their alveoli ceases, although they continue to
be well perfused. The closed airways will open again as
soon as the exposure to acceleration ends and ventila-
tion resumes. Since these non-ventilated alveoli are well
perfused, gaseous exchange continues between the gas
trapped in them and the mixed venous blood flowing
through their septa. This blood absorbs the trapped gas
from the alveoli at a rate limited by the rate at which the
least soluble gas, usually nitrogen, is removed. However,
if little or no nitrogen is present when the acceleration is
applied, as will be the case if 100 per cent oxygen has been
breathed before the exposure, then the trapped gas will be
absorbed very rapidly and many alveoli will be rendered
gas-free. High surface-tension forces will then hold the
walls of the gas-free alveoli closed, and the affected part of
the lung will remain collapsed (atelectatic) after the accel-
eration exposure has ended. It then takes the relatively
high pressure created in the collapsed lung by a deep inspi-
ration or cough to separate the septal walls, reopen the
alveoli and allow ventilation to resume.
Exposure to sustained acceleration above about +3  Gz
produces acceleration atelectasis when a high concentration
of oxygen has been breathed for about 15  minutes before
the exposure and an anti-G suit has been used during the
exposure. The condition can arise without an anti-G suit,
but the severity of lung collapse is then considerably less.
There is a wide individual variation in susceptibility, both
in the level and duration of acceleration required to pro-
duce atelectasis and in the magnitude of the effect. The
symptoms, which usually are not apparent until after the
exposure, or even after the flight in which the exposure
occurred, consist of a dry cough, with or without substernal
discomfort or pain, which is exacerbated by a deep inspi-
ration. Chest radiographs reveal atelectatic bands at both
lung bases (radiographic signs of collapse can occur in the
absence of symptoms, but X-rays are not usually needed
in the management of the condition). The symptoms and
radiographic signs usually clear completely after several
deep inspirations, which often provoke bouts of coughing.
In the absence of deep breathing, however, basal collapse
may persist for 24 hours or more. The vital capacity may be
reduced by up to 60 per cent of the normal value, but the
volume of lung collapsed is considerably less than this and
the limitation of deep inspiration is largely reflex in origin.
The lung collapse induced by several exposures to moderate
levels of +Gz acceleration while breathing 100 per cent oxy-
gen produces a right-to-left shunt of the order of 20–25 per
cent of the cardiac output, sufficient to reduce the arterial
oxygen tension to 8 kPa (60 mmHg). In order to reduce the
risk of significant acceleration atelectasis, designers attempt
to ensure that the minimum concentration of nitrogen in
the gas breathed before exposure to acceleration is around
40 per cent.
17/11/2015 15:39
 146  Long duration acceleration
EXPOSURE TO –GZ ACCELERATION
Flight conditions that give rise to –Gz (footwards) accel-
eration (‘negative G’) are outside loops and spins, simple
inverted flight, and ‘unloading’ of G to gain energy during
air combat. Tolerance to –Gz acceleration is much lower
than that for +Gz acceleration, and the symptoms produced
by even –2 Gz are unpleasant. Although military fast jet air-
craft are often stressed to withstand up to –3 Gz, aircrew are
not often exposed to high negative G due to the limited tac-
tical use of such manoeuvres. Higher levels of negative G are
encountered briefly during some civilian aerobatic flights.
Confusion sometimes arises concerning accelerations that
are less than +1 Gz but not truly negative (i.e. greater than
zero). These accelerations still have a physiological effect
and can be thought of as ‘relatively negative G’. Usually the
most important aspect of negative G is the effect of reduced
G tolerance on pulling positive G immediately afterwards
(the ‘push–pull’ effect, named after the aircraft control
input required, see below).
Physical effects of –Gz acceleration
The feeling of heaviness and the interference with move-
ment in the limbs produced by exposure to –Gz accelera-
tion are similar to those experienced with +Gz exposure.
The unpleasant symptoms associated with –Gz acceleration
occur primarily in the head. Sustained exposure to –1  Gz
produces a sense of fullness and pressure in the head which
worsens at –2 Gz and may result in a persistent headache. At
–2.5 to –3 Gz the eyes become uncomfortable and feel as if
they are ‘popping out of the head’. There is marked vascular
congestion which can produce oedema of the eyelids, sub-
conjunctival haemorrhage and petechial haemorrhage in
the skin of the face and neck if –G is sustained. Congestion
of the mucosal lining of the air passages may cause difficulty
in breathing and epistaxis may occur. ‘Redout’, a redden-
ing of vision sometimes described by pilots, may possi-
bly be caused by ascent of the lower eyelid over the pupil.
Exposure to acceleration of greater than –4  to –5  Gz for
more than about six seconds can cause mental confusion
and unconsciousness.
Cardiovascular effects of –Gz acceleration
The immediate hydrostatic effect of –Gz acceleration is to
increase the vascular pressure in the regions anatomically
above the heart and to decrease pressure below this level.
The arterial pressure at head level is immediately increased
by the additional pressure exerted by the column of blood
between the aortic valves and the head. The mean arterial
pressure at eye level increases immediately by 20–25 mmHg
per G, so that it becomes 170 mmHg on exposure to –3 Gz.
The venous pressure at head level takes several seconds to
rise to a plateau level, as blood has to flow through the capil-
lary bed to fill the capacity vessels before the venous pres-
sure attains an equilibrium value. The venous pressure at
K17577_C007.indd 146
eye level at –3  Gz rises to above 100  mmHg, the effective
length of the venous column being from the level of the dia-
phragm to the head.
The rapid increase of arterial pressure in the neck stim-
ulates the baroreceptors of the carotid sinus. The intense
stimulation of the carotid baroreceptors causes a large dis-
charge of vagal efferent impulses, which, in turn, produce
bradycardia and may cause a variety of cardiac dysrhyth-
mias, ranging from simple prolongation of the P–R interval
to complete atrioventricular dissociation, with ectopic beats
and asystole (periods of asystole of five to seven seconds are
not uncommon at –2.5  Gz). The bradycardia and general-
ized arteriolar vasodilation cause mean arterial pressure
at head level to decline after the initial increase caused by
the acceleration.
The increase in pressure in cerebral vessels produced
by –Gz acceleration exposure generally is balanced exter-
nally by similar increases in the pressure of the cerebrospi-
nal fluid, such that there is no rise in transmural pressure
and little risk of rupture of vessels within the skull. After
a few seconds, cerebral blood flow becomes increasingly
compromised and mental confusion and unconsciousness
may result due to the reduction of cardiac output produced
by stimulation of the carotid sinus. Immediate loss of con-
sciousness on exposure to high levels of –Gz acceleration
is usually related to a prolonged cardiac asystole or a slow
ectopic rhythm.
Pulmonary effects of –Gz acceleration
Exposure to –Gz acceleration produces a headward dis-
placement of the diaphragm and reduces the vital capacity
and the functional residual capacity. It also reduces pulmo-
nary ventilation. The regional distribution of ventilation
and blood flow within the lung are changed by –Gz expo-
sure in the same way as those produced by +Gz accelera-
tion, but anatomically reversed. Since the level within the
lung at which pulmonary vascular pressures are unchanged
by acceleration is at the junction of the middle and basal
thirds, most of the lung remains perfused under –Gz accel-
eration. Closure of terminal airways occurs, trapping gas
in the apical regions, and the continuing flow of blood
through unventilated alveoli constitutes a right-to-left
shunt and arterial oxygen desaturation as with +Gz accel-
eration. Acceleration atelectasis produced by –Gz exposure
(when breathing 100 per cent oxygen) occurs at the apices of
the lungs, and as the functional residual capacity is reduced
by –Gz exposure, atelectasis occurs more readily than with
+Gz acceleration and without the intervention of an inflated
anti-G suit.
Tolerance to –Gz acceleration
–Gz acceleration is not tolerated well. The limit is set by
discomfort in the head, oedema of the soft tissues of the
face, petechial and subconjunctival haemorrhages and
loss of consciousness. The maximum acceleration that
17/11/2015 15:39

can be tolerated is around –5  Gz for 5  seconds. A level of
−3  Gz can be tolerated by most individuals in the seated
posture for 10–15 seconds, while –2 Gz can be tolerated for
several minutes. A degree of adaptation may develop with
repeated exposures, and experienced aerobatic display com-
petitors may tolerate brief exposure to up to –9 Gz without
immediate problems.
Importantly, exposure to –Gz acceleration reduces tol-
erance to a following +Gz exposure (‘push–pull’ effect),
since cardiovascular reflexes and the distribution of blood
volume have been reset by the negative G exposure, to a
lower baseline. Figure  7.10, recorded in a centrifuge fitted
with a three-axis gondola control, illustrates this situation.
Following a period at rest, exposure to –1.8 Gz caused a pro-
nounced bradycardia and a gradual fall in blood pressure at
heart level. An immediate reversal in acceleration vector to
+2.4 Gz then caused a profound fall in blood pressure, and
vision was lost before tachycardia led to a recovery in blood
pressure. A control exposure to +2.4 Gz without preceding
negative G produced a much smaller fall in blood pressure
without visual symptoms.
EXPOSURE TO GX ACCELERATION
In early space flights, the acceleration needed to achieve the
velocities required for orbit or escape from Earth’s gravi-
tational field were such that they could be tolerated by the
occupants of space vehicles only if the inertial forces were
applied in the +Gx axis. Typical launch and re-entry pro-
files for current vehicles such as Soyuz and space tourism
vehicles involve exposure to around +4 to +6 Gx, although
this can rise to as much as +8 Gx under certain conditions.
As vision of the external world and instruments and the
operation of controls are much easier when the individual
lies supine rather than prone, prolonged transverse accel-
eration is almost always experienced in the +Gx direction.
Acceleration
1.1 G
–1.8 G
ECG
200
Head level arterial blood
pressure (mmHg)
150
100
50
0
10 s
Figure 7.10  Recording of electrocardiogram and non-invasive measure of heart level arterial blood pressure in a subject in
a human centrifuge exposed to –1.8 Gz for 30 seconds followed immediately by a +2.4 Gz exposure.
K17577_C007.indd 147
Exposure to Gx acceleration  147
Gross effects in the systemic circulation do not occur with
Gx exposure, and the major physiological disturbances
occur in the respiratory system, which limit tolerance to
this form of acceleration stress. Exposure to significant lev-
els of Gx acceleration is unusual in aviation, and is usually
confined to catapult launch, rocket and jet-assisted takeoff
and carrier landings. The forces are small relative to human
tolerance and do not give rise to specific problems.
Physical effects of +Gx acceleration
Increase in the weight of the limbs becomes apparent at
+2 Gx, with difficulty in breathing usually noted at +3 Gx.
At and above +5 Gx there is a consistent ache in the chest,
which is generally most severe at the lower third of the ster-
num or epigastrium and which frequently radiates along
the costal margins. The pain is aggravated by inspiration,
which becomes progressively more difficult and shallow
with increasing acceleration until around +9 to +12 Gx, at
which point there is severe difficulty in breathing. At about
+15 Gx, inspiration is extremely difficult and there is a severe
vice-like pain in the chest. The limbs cannot be lifted at
+8 Gx, although with the forearms supported fine controlled
movements of the wrist and fingers are possible up to and
above +15 Gx. Lifting the head is impossible at +7 to+9 Gx, or
less when heavy headgear is worn. Petechial haemorrhages
may occur in the unsupported regions of the posterior sur-
face of the body.
Cardiovascular effects of +Gx acceleration
Since the hydrostatic pressure gradient produced by +Gx
acceleration is much smaller than that produced by +Gz
acceleration, there are less pronounced effects on the car-
diovascular system. The pressure in the right atrium is
raised by +Gx acceleration to about 20  mmHg at +5  Gx.
2.4 G
17/11/2015 15:39
 148  Long duration acceleration
This increase is due to blood displaced to the thorax from
the lower limbs and, to some extent, the abdomen when the
legs are elevated. There is a similar rise in venous pressure
throughout the body at the horizontal level of the heart.
Visual disturbances do not occur when the body is
truly supine, and arterial pressure in the brain usually is
increased by exposure to +Gx acceleration. However, it is
unusual for the long axis of the body to be completely hori-
zontal in situations in which exposure to +Gx occurs. The
respiratory discomfort produced by +Gx is minimized when
the trunk is inclined slightly (15–25  degrees) towards the
acceleration vector, and the head is frequently flexed on the
trunk to improve all-round vision. In these circumstances,
a small but important component of +Gz is created that may
result in loss of vision and unconsciousness due to the ver-
tical distance (parallel to the acceleration vector) between
the heart and the head. With trunk and head elevated to
25 degrees, blackout occurs at about +10 Gx and conscious-
ness is lost at +14 to +16 Gx. When the angle of the back to
the horizontal is only ten degrees, blackout does not occur
until +16 Gx, and consciousness is not lost until the accelera-
tion exceeds +20 Gx.
Heart rate is usually reduced by +Gx acceleration when
the body is fully supine. Slight flexion of the trunk, with the
associated introduction of a small +Gz component, results
in an increase in heart rate. Cardiac dysrhythmias, consist-
ing mainly of premature atrial and ventricular contractions,
are commonly seen on exposure to +Gx acceleration above
+6 to +8 Gx. These disturbances of rhythm, which disappear
on cessation of the exposure, are probably due to distension
of the right atrium.
Pulmonary effects of +Gx acceleration
The increase in weight of the abdominal contents under
increased +Gx acceleration displaces the diaphragm
towards the chest. Inspiratory capacity becomes restricted
and expiratory reserve volume is reduced. At +5  Gx, the
vital capacity is reduced by 75 per cent and the expiratory
reserve volume falls to zero, so that the functional residual
capacity becomes equal to the lung’s residual volume. The
residual volume is unaffected by +Gx acceleration. The
vital capacity becomes progressively smaller with increas-
ing acceleration until at about +12 Gx, it equals the reduced
tidal volume. However, the falling tidal volume is more
than offset by an increase in the respiratory frequency, so
that the pulmonary ventilation is actually increased. As
described above, the magnitude of the disturbances to
breathing and the chest discomfort can be reduced by rais-
ing the back to about 25  degrees to the horizontal which
reduces the displacement of the abdominal contents
towards the thoracic cavity.
The distribution of inspired gas within the lung in the
supine posture is controlled by the same factors as in the
upright lung, and so exposure to +Gx progressively reduces
the ventilation of the alveoli at the back of the lungs, while
ventilation of the front of the lung remains fairly uniform.
K17577_C007.indd 148
At +5  Gx, the alveoli in the posterior third of the lungs
are unventilated.
Pulmonary artery pressure at the anterior surface of
the lung is reduced to zero by +4 Gx due to the hydrostatic
gradient. The absence of perfusion in the very anterior part
of the lung, and the increased spread of ventilation/perfu-
sion ratios produced by +3 to +4 Gx exposure produce only
minor disturbances of the overall gas exchange between
inspired gas and blood. However, the unventilated but per-
fused alveoli in the posterior part of the lung form a right-
to-left shunt, such that exposure to +6 Gx when breathing
air reduces the arterial saturation to 80–87 percent, while
exposure to +8 Gx reduces it to 72–82 percent. Acceleration
atelectasis of the posterior part of the lung occurs during
exposure to +Gx acceleration when 100  percent oxygen is
breathed before and during the exposure. The mechanism
of this collapse is the same as that responsible for the lung
collapse that occurs on exposure to +Gz acceleration of sub-
jects breathing 100 percent oxygen. Breathing 100 percent
oxygen before and during exposure to +6 Gx for two to three
minutes produces a 40 percent reduction of the vital capac-
ity, and the associated right-to-left shunt of blood through
the collapsed lung reduces the saturation of the oxyhaemo-
globin of the arterial blood to about 75 percent.
Tolerance to +Gx acceleration
Tolerance to +Gx acceleration is set primarily by the
increased difficulty of breathing produced by the increased
weight of the anterior chest wall and abdominal contents.
The maximum voluntary tolerance for periods of exposure
between 5 and 150 seconds is of the order of +14 to +15 Gx,
although above +12 Gx tolerance depends much on motiva-
tion and training. The chest pain and difficulty in breathing
are reduced by elevating the trunk, but tolerance is then low-
ered by the occurrence of visual symptoms. Breathing under
a positive pressure of 0.7 kPa/G (pressure of 4.9–5.6 kPa at
+7 to +8 Gx) balances the extra weight of the anterior chest
wall and restores functional residual capacity, vital capacity
and tidal volume to near-normal +1 Gz levels. Additionally,
the rise in intrathoracic pressure increases arterial blood
pressure to a comparable degree and enhances G-tolerance.
Under these conditions, an acceleration of +10 Gx has been
tolerated for 30  seconds with little decrement of vision or
psychomotor performance. Even without positive pressure
breathing, an acceleration of +8 Gx can be tolerated for at
least six minutes with the trunk elevated by ten degrees.
Tolerance to –Gx acceleration
Tolerance to –Gx acceleration is influenced considerably by
the support provided to the front of the body. In a seated
attitude, support comes from the restraint harness, whereas
in the fully prone position, the body is usually supported by
a specially contoured couch. With –Gx acceleration induced
by an aircraft in a flat spin, operation of the ejection seat han-
dle is difficult and the effectiveness of the restraint harness’s
17/11/2015 15:39

automatic shoulder retraction is reduced, so compromises
ejection safety. The inertial force displaces blood from the
trunk into the head and the limbs, and the rise in vascular
pressures and distension of the vessels in the head and limbs
causes pain and petechial haemorrhage. Tolerance to sus-
tained –Gx acceleration with a conventional restraint har-
ness is of the order of ten seconds at –5 Gx and five minutes
at –3  Gx. When the head and limbs are restrained so that
the seated posture is maintained, tolerance is increased to
around 30 seconds at –8 Gx.
When the body is supported in the prone position by a con-
toured couch, exposure to –Gx acceleration causes difficulty
in breathing, nasal drip, salivation, sagging of the lower eye-
lid and petechial haemorrhage. As with +Gx acceleration, the
major physiological disturbances occur in the respiratory sys-
tem. The reduction of vital capacity and the functional resid-
ual capacity produced by –Gx acceleration is markedly less
than that produced by +Gx acceleration, as the inertial forces
pull the abdominal contents and diaphragm away from the
thoracic cavity. The proportion of anterior lung alveoli that
are not ventilated during –Gx exposure is correspondingly
less than at a comparable level of +Gx which results in an arte-
rial oxyhaemoglobin saturation of 94 per cent on exposure to
–6 Gx compared with 80 per cent at +6 Gx. The head and the
chest may be raised from the horizontal positioning order to
improve forwards vision, adding a small +Gz component, but
even with the chest and head elevated to an angle of 25 degrees
from the horizontal, vision is unimpaired on exposure to
–12 Gx. Tolerance to sustained –Gx acceleration by a person
supported by a couch in the prone or semi-prone position is in
excess of five minutes at –5 Gx and two minutes at –10 Gx.
EXPOSURE TO GY ACCELERATION
Significant Gy (lateral) acceleration does not occur under
normal fast jet flight conditions, although forces around
±2 Gy may be generated by some high performance aircraft
during roll manoeuvres at high angles of attack, or in air-
craft featuring thrust vectoring. This level of Gy acceleration
has little effect, but may impede head mobility and increase
the risk of neck injury, and possibly spatial disorientation.
At ±3 to ±4 Gy or more, there are profound effects on pul-
monary function due to the weight of the mediastinal con-
tents acting on the dependent lung to induce airway closure,
right to left shunting and susceptibility to atelectasis.
PROTECTION AGAINST LONG DURATION
ACCELERATION
In civilian aerobatic aircraft and military fast jets, the
object of G protection is to minimize the fall in head-level
blood pressure that would otherwise occur on exposure to
increased +Gz acceleration. Robust protection against long
duration acceleration is only needed if G exposure is sus-
tained: for example, the G profile of most rollercoasters is
such that the brief excursions to +Gz acceleration can be
tolerated without protection as they lie within the cerebral
K17577_C007.indd 149
Protection against long duration acceleration  149
oxygen reserve time. Similarly, pilots of civilian high perfor-
mance aerobatic aircraft may tolerate exposures up to +12 Gz
with minimal G protection, due to the inability of the air-
craft to sustain high G. To protect humans against sustained
acceleration, two approaches are taken: voluntary actions
taken by the aircrew to enhance G tolerance, and G protec-
tive systems provided with the aircraft or spacecraft. Of the
latter, the most widely used is the anti-G suit, which has been
in regular use since the 1950s; with the advent of high per-
formance fast jet aircraft, additional measures such as pres-
sure breathing for G protection (PBG) have been added.
Anti-G straining manoeuvre
Symptoms of visual disturbance and, rarely, loss of
consciousness were experienced by aircrew as early as
1918  (Head 1920). Although these observations initially
were regarded as a curiosity, the onset of the Second World
War and the requirement for tactical superiority in air
combat led to intensive efforts by both sides to improve air-
crew G tolerance. In an attempt to minimize the effects of
acceleration, a number of voluntary manoeuvres were per-
formed; some of these survive, in an altered form, to the
present day. Hunching forward in the cockpit was found to
improve G tolerance by as much as 1 G, because the heart
to brain distance was reduced. When used in combination
with elevation of the legs, by means of an accessory rudder
bar to reduce venous pooling, the Germans claimed that up
to 2 G improvement in tolerance could be gained. However,
hunching is of limited use in practice, as vision from the
cockpit is severely limited. Shouting and generalized muscle
tensing were successful, and have been adapted to form the
anti-G straining manoeuvre (AGSM) used today.
MUSCLE-TENSING
Experiments conducted in aircraft during the Second
World War demonstrated that generalized sustained con-
traction of skeletal muscles could increase G tolerance by
2 G or more. The beneficial action of this manoeuvre is due
to a combination of several factors:
●● Increased tissue pressure applies mechanical pressure
to arteries and arterioles, causing a reduction in vessel
diameter. The associated rise in peripheral resistance
leads to an increase in arterial blood pressure, because
blood pressure is equal to the product of cardiac output
and total peripheral resistance.
●● Increased tissue pressure applies mechanical pressure
to veins, limiting venous pooling and possibly causing
a shift of blood to the thorax. In this way, venous return
is preserved.
●● Increased intra-abdominal pressure helps to prevent
descent of the diaphragm under increased +G accelera-
tion, which would otherwise increase the heart to head
distance and so reduce head-level blood pressure.
●● There is a slowly developing reflex induced rise in
blood pressure.
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 150  Long duration acceleration
VALSALVA MANOEUVRE
The Valsalva manoeuvre, or forcible exhalation against a
closed glottis, improves G tolerance in a similar manner to
shouting. Intrathoracic and intra-abdominal pressures are
increased, and the pressure increase is transmitted directly
to the heart and great vessels, raising systemic arterial blood
pressure at the level of the aortic valve. Under increased
+Gz acceleration, this minimizes the reduction in head-
level blood pressure that would otherwise occur due to the
hydrostatic gradient, so maintaining cerebral perfusion.
However, the protective effect of this manoeuvre is short
lived. When the manoeuvre is started, blood pressure is ele-
vated, but after only a few cardiac cycles, pulse and systolic
arterial pressures begin to drop, often to lower than the rest-
ing value. This is because the elevated intrathoracic pressure
leads to a reduction in venous return from the periphery
and, hence, a decrease in cardiac filling and stroke volume.
Therefore, if a Valsalva manoeuvre is prolonged for more
than three to four seconds under increased +Gz accelera-
tion, G tolerance may be reduced.
PERFORMANCE OF THE AGSM
The AGSM is a combination of continuous muscle tensing
and a Valsalva manoeuvre sustained in three to four second
segments. Muscle tensing should be sustained throughout
the acceleration exposure and not relaxed during breathing.
Exhalation and subsequent inhalation should be performed
as rapidly as possible (ideally, in less than one second), as
blood pressure falls precipitously during this phase. There
is some evidence to suggest that the negative intrathoracic
pressure generated during brisk inhalation may augment
venous return and so improve cardiac output. Various
forms of the manoeuvre exist and some nations teach that
no breath in or out is taken, but rather just a brief interrup-
tion of Valsalva effort is made.
The manoeuvre forms the mainstay of G protection for
civilian aerobatic pilots and is employed in combination
with anti-G trousers by the great majority of military fast
jet aircrew. The AGSM can provide more than 3 G improve-
ment in G tolerance if it is performed correctly. When used
in combination with a standard anti-G suit (which tends to
enhance AGSM performance), it should enable most aircrew
to tolerate +9 Gz for at least ten seconds. When performing
the manoeuvre under increased +Gz acceleration, it should
be emphasized that head-level arterial blood pressure is not
normal; on the contrary, it is usually of just sufficient mag-
nitude to provide adequate cerebral perfusion, which, at
very high accelerations, may be as low as 30 mmHg systolic
and 0 mmHg diastolic.
The AGSM has the advantage of being a simple proce-
dure that can be used in any aircraft without the installa-
tion of special equipment and can be combined with other
methods of enhancing G tolerance (such as an anti-G suit)
with additive effect. However, the manoeuvre is physically
exhausting and fatigue may lead to reduced effectiveness.
The manoeuvre may distract from the primary task of flying
K17577_C007.indd 150
the aircraft and engaging in air combat; equally, the flying
task may distract crews resulting in an inadequate strain. In
all these circumstances, it is possible that an inadequate G
strain will lead to G-induced loss of consciousness (G-LOC).
Speech is difficult, if not almost impossible, while perform-
ing AGSM at high +Gz levels, and so the manoeuvre may
have a profound effect on communication. Although the
AGSM is used widely, other straining manoeuvres do exist.
The Qigong manoeuvre has been shown to provide similar
improvements in G tolerance to the AGSM, but with less
fatigue (Zhang et al. 1991).
G-PROTECTIVE SYSTEMS
Abdominal belts
The first attempts to produce a G-protective garment came
with the development of abdominal belts in the 1930s and
1940s. It was believed that use of the belt would prevent
blood pooling in the abdomen under increased +Gz accel-
eration. Belts of various types were produced, including
inelastic, elastic, water-filled and air-filled. Work was dis-
continued, as the G protection provided by these garments
was poor in comparison to that of a garment that included
coverage of the lower limbs.
Arterial occlusion
At around the same time, arterial occlusion suits were
investigated, in which the flow of blood into all four limbs
was prevented under increased +Gz acceleration. Although
the suit gave excellent protection, the major limiting factor
was ischaemic pain, which developed when acceleration was
sustained over long periods. This method of protection was
abandoned in favour of the anti-G suit.
Water immersion
The principle of a rigid suit filled with water had been sug-
gested as a method of G protection by the Germans in 1934.
The hydrostatic pressure developed by the suit opposes simi-
lar forces on the cardiovascular system such that vascular
transmural pressures tend to remain unchanged but total
water immersion including the head and neck is required
for truly effective protection. Breathing is difficult with total
water immersion, and the equipment required is cumber-
some, but in centrifuge experiments, accelerations of up to
+31 Gz (Gray and Webb 1961) have been sustained for five
seconds without visual symptoms developing. The start-
ing point for the development of the present day pneumatic
anti-G suit was the water-filled suit designed by Franks in
Canada and used in the early years of the Second World
War. The suit provided blackout thresholds of +6.2 Gz and
+7.7  Gz in air tests (Brook 1990) but was bulky and cum-
bersome. The final demise of the water-filled anti-G suit
came when it was demonstrated that the protection given
by the suit when inflated with air to a pressure of 6.9 kPa
17/11/2015 15:39
 G-protective systems  151

(1 lb/in2) per G was equal to or greater than that of the same

suit filled with water. Although some water filled suits have
been developed since, air-filled suits have generally been
found to be more practical, and are in virtually exclusive use.

Pneumatic five bladder anti-G suits

The first true operational pneumatic anti-G suit was
Professor Cotton’s pneumatic flying suit. This three blad-
der graded pressure suit, developed in Australia in 1940,
had limited use by aircrew in the Pacific Campaign during
the Second World War. Graded pressure suits, in which the
pressure was highest in the calves and reduced proximally,
were developed by Clark, Baldes and Wood in the USA, and
the same team investigated arterial occlusion suits and cap-
stan suits. Capstan suits were designed to be less bulky and
offer less thermal stress than standard suits and worked by
tensioning the fabric over the limbs by inflation of a sepa-
rate inflatable tube.
The most widely used anti-G suit in use today is the
standard five bladder suit, which arose as a result of the
requirement for good mobility and comfort in the garment
(Figure  7.11). The garment is trouser-like, cut away at the
crotch and knees to permit greater mobility and to reduce
heat load. It consists of an outer restraining layer made
of a non-stretch material containing five interconnect-
ing non-circumferential bladders. The bladders and their
outer restraining coverings fit over the abdomen and wrap
around the thighs and calves of the wearer; the girth of the
outer restraining layer may be adjusted by means of lacing
cords. The suit inflates to a uniform pressure throughout,
Figure 7.11  Standard Royal Air Force anti-G suit. The
through a flexible hose connected to the aircraft anti-G sys- bladders over the abdomen, thighs and calves are inflated
tem. The maximum improvement in relaxed G-tolerance and deflated through the flexible hose attached to the
that has been claimed for a suit of this type is around 2 G, abdominal bladder.
but in practical use, when laced to a comfortable tension,
the improvement is more usually in the region of 1 to 1.5 G. Full coverage anti-G suits
When used together with the AGSM, aircrew tend to per-
ceive a greater improvement in G tolerance than this, pos- Aircraft with modern flight control systems are able to gen-
sibly due to the synergy between the two approaches. erate rapidly and sustain high +Gz forces, over a wide range
The anti-G suit increases tolerance to +Gz acceleration in of air speeds and altitudes. The risk of G-LOC is greater
the following manner: because there are no premonitory visual symptoms at high
G onset rates, and the ability to sustain high +Gz levels for
●● Mechanical tissue compression maintains peripheral a considerable period of time may lead to aircrew fatigue
vascular resistance and reduces venous pooling in the if performing the AGSM. In order to address these issues,
lower limbs, in a similar manner to skeletal muscle improvements to the G protection offered by five bladder
tensing. There may also be a headward shift of blood, trousers and AGSM have been required.
returning blood to the thorax, helping to maintain In order to provide more counter-pressure to the lower
cardiac output. To ensure that this is fully effective, the limbs, at greater mechanical efficiency, the area of cover of
inflation of the anti-G suit must be rapid and is usually the anti-G suit can be extended (Figure  7.12). Full cover-
specified to be 90 per cent complete within one second age suits utilize circumferential bladders, which improve
of reaching the peak G level. venous return to the thorax under increased +Gz accelera-
●● The abdominal bladder of the suit supports the tion. Peripheral vascular pooling is reduced, and the fall
abdominal wall and reduces the amount by which in cardiac output is minimized, resulting in an increase in
the diaphragm is displaced downwards. This tends to relaxed G tolerance of 2–2.5 G compared with the unpro-
prevent the increase in the vertical distance between the tected individual. A common problem with these garments
heart and brain that is normally caused by increased is the reduction in mobility and increase in thermal bur-
+Gz acceleration. den that are imposed by the extended bladder coverage.

K17577_C007.indd 151 17/11/2015 15:39

 152  Long duration acceleration
Careful suit design, combined with an appropriate choice
of materials, is required to minimize these effects. A larger
range of garment sizes is required to encompass the
anthropometric range.
Full coverage anti-G suits provide improved G protec-
tion at minimal financial cost and without the need for
major aircraft modification. Consequently, it is a relatively
simple process to retrofit them into existing aircraft types.
However, due to their increased inflated bulk, care must be
taken to avoid cockpit interactions (e.g. with the control
column or the ejection seat path). Furthermore, the perfor-
mance of the anti-G valve should be considered, as the infla-
tion rate of extended-coverage suits may be slower because
of their larger inflated volume.
Anti-G valve
The anti-G valve controls the flow of gas, usually air from
the engine compressor, into the anti-G suit. The valve, which
may be mechanical or electronic, senses the prevailing +Gz
acceleration and supplies the required pressure accordingly.
Mechanical valves are generally more common and consist
of an orifice, the opening of which is controlled by a mass,
supported by a spring and a diaphragm, which is exposed
to the pressure in the suit. The increase in the weight of the
Figure 7.12  Example of a full coverage anti-G suit. The cir-
cumferential bladders cover over 90 per cent of the lower
limbs, providing greater G protection than the standard
anti-G suit.
K17577_C007.indd 152
control mass that occurs on exposure to acceleration opens
the orifice and allows air to flow into the suit until the pres-
sure in the latter, acting on the diaphragm of the valve,
balances the increase in force exerted by the control mass.
As the applied acceleration is decreased, the suit pressure
opens the orifice and the suit deflates.
With the introduction of aircraft with very rapid rates of
onset of G, valves have been introduced that provide higher
gas flows in order to minimize inflation delays. Many of
these are mechanical, but electronic anti-G valves are also
in service. Although electronic valves are principally used
for better reliability, they have the potential to anticipate
gas flow requirements by sensing both instantaneous G
and the rate of onset of G. Pre-inflation of the anti-G suit to
around 1 kPa can hasten inflation, as the volume of gas sub-
sequently needed to achieve maximum pressure is reduced,
but many people find the pre-inflated anti-G suit cumber-
some and uncomfortable in the cockpit. Most anti-G valves
supply a pressure that increases linearly with acceleration,
of approximately 10 kPa (1.5 lb/in2) per G. Inflation pressure
schedules above this tend to cause discomfort. Typically, the
anti-G valve is designed so that garment inflation does not
start until the acceleration exceeds +2 Gz in order to avoid
unnecessary and distracting anti-G suit inflation under
conditions of turbulence and during gentle turns.
Positive pressure breathing for G protection
(PBG)
The effective automation of the Valsalva manoeuvre by
the addition of PBG raises intrathoracic pressure and can
reduce the respiratory fatigue associated with the AGSM.
Positive pressure breathing has been used for many years as
an emergency measure for high-altitude protection, but PBG
takes advantage of a different physiological consequence of
breathing at increased pressure, and has been introduced
for aircraft such as Eurofighter Typhoon, F-22, F-35  and
Gripen. The elevation of intrathoracic pressure acts directly
on the heart and great vessels to increase blood pressure on
a virtually one-to-one basis but is mirrored by a rise in cen-
tral venous pressure, compounding the decrease in venous
return to the thorax caused by exposure to increased +Gz
acceleration. It is essential, therefore, that there is adequate
support of venous return, and this can best be provided by
extended coverage anti-G trousers. The combination of PBG
and extended-coverage garments enables most individuals
to maintain clear vision at +9 Gz with only moderate strain-
ing effort. When matched for age and height, there is little
evidence to show any sex difference in the G-protection pro-
vided by such systems.
Breathing against PBG does not require the same physi-
cal effort as pressure breathing at +1  Gz as exhalation is
assisted by the increased weight of the chest wall. Studies
have shown that although a chest counter-pressure garment
is usually required to protect against lung over-distension
when pressure breathing at above 4  kPa (30  mmHg), this
garment is not needed for PBG because the increased weight
17/11/2015 15:39

of the chest wall and the aircrew clothing alone effectively
prevent lung over-distension.
PBG is supplied by a modified breathing regulator, driven
by a control signal from the anti-G valve, to provide a schedule
of pressure that increases with increasing +Gz acceleration.
This arrangement prevents the activation of PBG without
anti-G suit inflation, which would severely compromise the
circulation. A typical pressure breathing schedule cuts in at
+4 Gz and increases linearly at 1.6 kPa (12 mmHg) per G to
a peak pressure of 8 kPa (60 mmHg) at +9 Gz (Figure 7.13).
An effective oronasal mask seal must be achieved to prevent
distracting mask leakage when using PBG, preferably with
some means of automatic mask tensioning. The stability of
helmet-mounted display images must be ensured, as PBG
and mask tensioning can displace the helmet on the head, so
moving the displayed image out of the visual field.
With the hands placed on stick and throttle, the hydro-
static pressure gradient at high G causes high vascular
pressure in the forearms. PBG increases this yet further
and aircrew may experience deep, poorly localized pain,
which is probably due to vascular over-distension. This pain
appears to be worse when experienced in the environment
of a human centrifuge rather than in the air, possibly due to
the distraction provided by the flying task and short dura-
tion at peak +Gz acceleration during operational flying.
There is evidence that some adaptation to high G arm pain
occurs with regular exposure.
HIGH G TRAINING
The requirement for centrifuge-based high G training was
identified after the G-LOC surveys conducted during the
1980s and most major military forces around the world now
provide centrifuge training programmes for their fast jet
aircrew. It is methodologically difficult to demonstrate the
effect of high G training on accident rates: in the USAF, a
decrease has been shown in the G-LOC accident rate from
the pre-G-LOC awareness and centrifuge training era
70
60
Breathing pressure (mmHg)
50
40
30
20
10
0
1 2 3 4 5 6
Acceleration (+Gz)
Figure 7.13  Typical positive pressure breathing for
G-protection schedule. Positive-pressure breathing is
supplied above +Gz to enhance G tolerance, usually in
combination with extended-coverage anti-G trousers.
K17577_C007.indd 153
Musculo–skeletal injury  153
(1982–84) to the post-training era (1985–94) (Lyons et  al.
2004), but no statistically significant reduction in G-LOC
accident rates could be demonstrated over the whole period
(1982–2001). As G tolerance varies quite widely in aircrew,
for many individual cases of low G tolerance, training has
been effective and has allowed such aircrew to continue fly-
ing high performance aircraft.
High G training consists of briefings on the physiologi-
cal basis for acceleration induced visual disturbance and
loss of consciousness; a demonstration of a good anti-G
straining manoeuvre; and individual centrifuge experience.
Centrifuge acceleration onset rate should be rapid, and ide-
ally representative of the aircraft type flown. Most current
centrifuges provide around 6 to 8 G/s, and although more
rapid onset rates are possible, they may cause excessive dis-
orientating effects. Centrifuge acceleration profiles may take
the form of simple exposures to a single +Gz level for a pre-
set duration of time or more complex simulated air combat
manoeuvres, in which the +Gz level is varied in a manner
akin to that of an aircraft engaged in air combat. Flight simu-
lation within the centrifuge can enhance training realism
and aircrew acceptability through the use of aerobatics, tail-
chasing and air combat against a simulated aircraft target.
The objectives of any high-G training programme should
include the following:
●● To promote aircrew awareness of the potential for
G-LOC.
●● To enhance aircrew anticipation of circumstances that
might result in G-LOC and to recognize the symptoms.
●● To develop an efficient and effective AGSM.
●● To learn how to best use the anti-G system fitted to the
aircraft (e.g. PBG).
●● To develop confidence in the ability to sustain high
+Gz acceleration.
MUSCULO–SKELETAL INJURY
High +Gz acceleration combined with high Gz onset rate is
associated with musculo–skeletal injury in aircrew. Most
commonly, this takes the form of neck and back injury,
which is made more likely by the use of heavy flying hel-
mets with an unfavourable centre of mass often higher and
more anterior than that of the head. Increased head-borne
mass is becoming more prevalent with the proliferation of
night-vision equipment and helmet-mounted display sys-
tems. Neck and back pain can be experienced in many air-
craft types, and often in helicopters due to their ergonomics.
With G exposure even in moderately manoeuvrable aircraft
such as jet trainers, there can be substantial morbidity,
7 8 9
and the incidence is often higher in highly agile aircraft.
Instructors and non-pilot aircrew such as navigators and
weapons operators can be at risk of injury from sudden
unexpected manoeuvres. In reality, there is a continuum
between acute episodes of pain experienced in flight and
chronic background neck pain or discomfort, although the
two can be separated for discussion purposes.
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 154  Long duration acceleration
Acute in-flight neck pain
Acute in-flight pain is most commonly caused by ligamen-
tous injury or muscle strain. Between 70–90 per cent of all
fast jet pilots have experienced acute flight-related neck
pain at some point in their career. The neck is particularly
vulnerable when at the extremes of extension and rotation,
which is, unfortunately, a common position for aircrew to
adopt as they pull G, e.g. during a ‘check six’ manoeuvre,
in which the aircrew turn to look over their shoulders for
aircraft following them. Cervical disc protrusion and even
annular tears in the discs have sometimes been reported,
particularly in the region of C3–4 (Hamalainen et al. 1994).
Some of these protrusions have extended far enough to
cause spinal-cord compression. At least one episode of acute
cervical compression fracture has been noted in flight in an
F16 pilot (Andersen 1988), and there have also been reports
of fractured spinous processes and facet joint dislocation.
Chronic flight-related neck pain
Although some pilots go on to experience background neck
pain for a number of years, a few studies have suggested
that there is evidence of increased prevalence of degenera-
tive changes in the spine of fast jet aviators, usually taking
the form of disc degeneration with osteophyte formation.
Unfortunately, there is a high prevalence of spinal abnor-
malities on MRI and cervical radiography of asymptomatic
individuals, which makes analysis of +Gz acceleration-
related changes difficult. Evidence remains limited as stud-
ies have been of small size and have produced mixed results
(Landau et al. 2006; Sovelius et al. 2008).
PHYSICAL CONDITIONING
The AGSM is a fatiguing manoeuvre and exhaustion is
likely to limit the total time for which high +Gz acceleration
can be tolerated. Moreover, the fast jet cockpit is a physically
demanding environment, with movement to conduct look-
out required against the force environment. Although there
is no good evidence to suggest that absolute G tolerance can
be improved by physical conditioning, some studies have
shown that whole-body strength training can significantly
increase endurance at sustained high +Gz acceleration. For
example, a centrifuge exposure that consisted of alternating
15-second periods at +4.5 and +7 Gz could be tolerated for
longer (411  seconds instead of 232  seconds) – an increase
of 77 per cent – following weight-training (Epperson et al.
1985).
A balance of aerobic and anaerobic fitness is generally
advocated, although the supporting scientific evidence is
weak (Bateman et  al. 2006). Anecdotal evidence suggests
that excessive aerobic fitness may be deleterious to G toler-
ance, since it induces an imbalance between sympathetic and
parasympathetic activity. Excessive vagal tone has occasion-
ally led to bradycardia or even asystole and subsequent loss of
consciousness. Therefore, it is generally recommended that
K17577_C007.indd 154
fitness training should not be pursued so far as to cause the
resting heart rate to fall below 55 beats/min, although aircrew
with a heart rate below this often have normal G tolerance.
The evidence that neck muscle strength training pro-
vides protection against flight-related neck pain is limited
due to the difficulties involved in conducting such studies
(Ang et  al. 2009; Kikukawa et  al. 1994; Jones et  al. 2000),
although conditioning programmes are offered for many
military aircrew. Compliance with these programmes is
sometimes difficult due to aircrew availability, and studies
on their efficacy on neck and back pain continue.
OTHER METHODS TO IMPROVE G
TOLERANCE
Posture
Any measure that reduces the vertical distance between the
heart and brain will provide a degree of protection against
acceleration. This approach to G protection has never been
adopted fully in operational aircraft because a seat reclined
to greater than 65 degrees is required to improve G tolerance
significantly (Glaister and Lisher 1977). In this position, it
is impossible to gain a 360-degree view from the cockpit,
as the head cannot be rotated adequately, and this is com-
pletely unacceptable for a fighter aircraft in a combat situa-
tion. In aircraft with reclined seats, such as F16 and Rafale,
the seat-back angle is approximately 30 degrees, which adds
about 0.5 G improvement to G tolerance at +9 Gz compared
with a conventional seat, although the principal benefit is in
terms of seat comfort. Elevation of the legs in this position
also helps to discourage peripheral venous pooling.
Pharmacological means
A number of attempts have been made to improve G toler-
ance with drugs that increase vasomotor tone. In all cases,
the pharmacodynamics of these agents, and their side effects,
have proven to be incompatible with use in the aviation
environment. Hypertensive drugs such as catecholamines,
amphetamine and even inspired CO2 have been investigated
with little success and, at present, there does not appear to be
any drug that is suitable to improve G tolerance.
FUTURE G PROTECTION
With the advent of remotely piloted combat vehicles, it
is unlikely that future combat aircraft will be developed
with a requirement for protection to even higher G levels.
However, G-LOC still occurs in current aircraft types, and
there remains scope to improve G protection. The risk of
death from G-LOC is likely to be mitigated by aircraft fit-
ted with automated terrain avoidance systems in future,
although these are not yet in widespread use. The need for
acceleration protection for the passengers of space tourist
vehicles is still not fully defined, and acceptable approaches
have yet to be determined.
17/11/2015 15:39

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Short duration acceleration
MATTHEW E. LEWIS
Introduction 157
Short-duration versus long-duration acceleration 157
Mechanics of impact 158
Impact: the physical basis of injury 159
Human tolerance and velocity change 159
Factors affecting human tolerance to short-duration
acceleration 160
Human tolerance: acceleration magnitude and direction 160
INTRODUCTION
Short-duration accelerations resulting in injury or death can
be inflicted not only on the occupants of vehicles involved
in crashes, but also on pedestrians, sports participants,
people falling from heights and those exposed to explosions
and bomb blasts. Injuries may be received when someone in
motion comes into collision with a solid object or when an
object or missile strikes a stationary person. Irrespective of
the circumstances surrounding the accident, injury occurs
when a person is exposed to forces of a critical magnitude
for a brief period of time, and the degree of injury is related
to the magnitude and duration of the applied forces. The
study of impact injury can be summarized as what we hit,
how we hit it, how long we hit it for, how many times we
hit it, and which part of the body is hit. Before introducing
injury-reduction programmes, it is necessary to understand
how accidents cause injuries, the nature of the forces con-
tributing to the injuries, and the characteristics of the type
of accident under consideration.
SHORT-DURATION VERSUS LONG-
DURATION ACCELERATION
When assessing injuries incurred during aviation or auto-
motive accidents, we encounter occupants who have been
exposed to high forces for very brief periods of time. The
time course of an impact event is extremely short, usually
K17577_C008.indd 157
8
Anatomical and physiological aspects of impact
tolerance 161
Occupant characteristics and tolerance to impact 162
Impact testing and anthropomorphic test devices 163
Thresholds for injury 163
References 164
Further reading 164
0.1–0.5  seconds. Experiments carried out on human and
animal subjects have demonstrated the essential features
in the study of the effects of impact accelerations to be the
magnitude of the peak acceleration, the duration of expo-
sure, the momentum change, the jolt, the nature of the
forces of inertia and the site of application to the body.
The effects of short-duration accelerations are related
principally to the structural strength of the part of the body
on which they act and to the overall velocity change induced
in the body. In contrast, intermediate-duration accelera-
tions are forces that persist for 0.5–2 seconds, such as during
ejections from aircraft, catapult launches and deck landings.
Human tolerance to intermediate-duration accelerations
depends not only on the overall velocity change induced,
but also on the time taken to reach peak acceleration and
on the peak acceleration level attained. Long-duration
acceleration, which can be experienced in various aircraft
manoeuvres, imposes forces that last more than two sec-
onds and have a duration of perhaps minutes. Human toler-
ance to sustained acceleration depends principally on the
plateau level of the acceleration imposed on the body, as the
response to long-duration acceleration is due to the effects
of physiological changes arising from hydrostatic pressure
gradients and from alterations in the flow and distribution
of blood and body fluids.
An alternative way of distinguishing long- and short-dura-
tion acceleration can be by the response of the human: with
long-duration acceleration, the stresses can be considered as
157
17/11/2015 15:39
 158  Short duration acceleration
mainly physiological and sustained; with short-duration (or
impact) acceleration, the stresses are considered as mainly
mechanical and transitory. For example, events such as
unconsciousness may arise in both, but the causations dif-
fer: unconsciousness following impact acceleration is caused
mainly by physical trauma, while with long-duration accel-
eration it is usually caused by reduced cerebral perfusion.
A human tolerance curve in which peak acceleration is
plotted against the length of time for which it may be toler-
ated has the form illustrated in Figure  8.1. For whole-body
impacts, each point on the 45-degree sloping left-hand part
of the graph represents a combination of acceleration (a)
and time (t), which gives a constant velocity change (v = at),
while the right-hand horizontal part indicates sensitivity to
a constant plateau acceleration. The intersection of the two
lines may show a dip, as indicated by the dotted line, where
dynamic overshoot caused by body-resonance effects ampli-
fies the transmitted forces and causes a reduction in tolerance.
MECHANICS OF IMPACT
The profile of acceleration forces acting on an aircraft dur-
ing a crash is determined by the manner in which the air-
craft decelerates as its velocity is resisted by friction with
the ground or by collision with stationary objects. When an
aircraft impacts the ground during an accident, the aircraft
experiences an opposing force of very short duration. This
force decelerates the aircraft, reducing the initial speed to a
final speed, which eventually will be zero. The peak mag-
nitude of this opposing force will depend on the length of
time for which the force acts. If the time is short, then a
higher peak force will result compared with when the time
available is longer. The aircraft, by virtue of its mass (m) and
velocity (v), will have kinetic energy (KE) as follows:
100
Pulse amplitude for equal dynamic response
Velocity change
10
1 reach the occupant. Crashworthy design features can be used
0
0.01
Figure 8.1  Effect of pulse duration (expressed as a
fraction of the natural period of oscillation of a simple
dynamic system) on the amplitude of the triangular
impact pulse needed to give an equal dynamic response.
Shaded areas indicate transitions between the three
zones in which the dynamic response (acceleration toler-
ance) depends primarily on velocity change, pulse length
or peak acceleration.
K17577_C008.indd 158
1
KE = mv 2
2
If the structure of a crashing aircraft is crushed or
deformed progressively, then much of the kinetic energy of
the crash is absorbed, and the overall deceleration profile is
relatively smooth. If parts of the crashing aircraft plough into
the ground, however, the aircraft velocity is reduced more rap-
idly and peaks of abrupt decelerations of high magnitude are
produced, with the highest peak values occurring when the
aircraft strikes solid objects, such as rocks or buildings. When
an aircraft ditches, the forces acting on the airframe reflect not
only the speed of the aircraft and its angle of incidence with the
water but also the orientation of the aircraft with respect to the
wave front and the sea state at the time of the accident. There
is often little attenuation from airframe deformation during
a planned ditching, as water tends to produce a uniform load
distribution across the lower surfaces of the fuselage.
The velocity of an aircraft before a crash may be known
with some accuracy from in-flight data recording, or it may
be estimated from the resulting structural deformation.
However, the deceleration depends on the nature of the ter-
rain struck and, in particular, on the distance (s) over which
the vehicle is brought to rest. Assuming a constant decelera-
tion, this can be calculated from the pre-impact velocity in
G units from the equation
G = v2/2gs
In practice, the crash-deceleration pulse is more likely to
approximate to a triangle or saw-tooth, in which case the
peak deceleration will be twice that calculated above, but at
least an approximation will be obtained of the magnitude of
the forces imposed on the vehicle’s occupants.
Although information on the crash pulse of the aircraft can
be determined from analysis of the impact dynamics, it is the
Response magnitude of the forces acting on the occupant that is more
dependent on
important. In certain circumstances, the forces reaching the
Pulse Peak
length acceleration occupant of a crashing aircraft may be significantly less than
those occurring in the aircraft structures immediately sur-
t
rounding the person. This is due to the surrounding structures
collapsing and crushing, and thus absorbing part of the kinetic
energy and attenuating the severity of the force before it can
to allow the structures to collapse progressively in a controlled
manner and so increase the chances of human survival. The
magnitude of the forces on the occupant may also be well in
0.1 1 10 100 excess of those occurring in the surrounding structures. In
Pulse length/period such crashes, the occupant, by virtue of inadequate restraint
or poor seat design, experiences little deceleration during
the early part of the impact. Inevitably, at some later point in
the crash, the occupant will strike the aircraft or come to full
harness extension and thereby be decelerated suddenly to the
vehicle’s velocity in a very short time.
As with sustained acceleration, the direction in which an
impact force acts on a human being is described by a three-
coordinate system in which the x-axis describes forces acting
17/11/2015 15:39

in the fore and aft direction at right angles to the longitudinal
axis of the body, the y-axis indicates laterally applied loads,
and the z-axis describes accelerations in the long axis of
the body. It is important to distinguish between the applied
force and the resultant inertial force, as these act in oppo-
site directions. For example, the deceleration of a crashing
car (backwards acceleration) displaces the driver’s internal
organs forwards; this resultant (inertial) force is called −Gx.
The tolerance to backwards acceleration of the occupant of
an aircraft or vehicle seat depends critically on the effective-
ness of the support provided to the front of the body by a
restraint harness. If no obstacles are present within the flail
envelope, then the head will be flung down on to the chest,
and the arms and legs will be thrown forwards at right angles
to the body. Without restraint, the occupant will simply con-
tinue forwards at their initial velocity until they strike a solid
object such as an instrument panel or bulkhead.
Significant lateral (±Gy) accelerations do not occur under
normal flight conditions. However, in crashes, significant
±Gy accelerations can occur, particularly to the seated occu-
pants of sideways-facing crew positions or passenger seats
in military fixed-wing and rotary-wing aircraft. In these
crashes, the severity and type of injury sustained by the
occupant is dependent on the restraint provided, the nature
of any contact with airframe structures, and the displace-
ment of the body, especially the head, neck and limbs.
Significant +Gz acceleration can occur in crashes associated
with a high sink rate, particularly in helicopters. Tolerance
to accelerations in this axis is influenced by the seat-back
angle, the sitting platform and the posture of the occupant.
Headwards (+Gz) acceleration is reacted primarily through
the buttocks and spinal column, and the posture of the occu-
pant and the effectiveness of any restraint harness provided
influence the incidence of spinal column injury. Footwards
(−Gz) accelerations are reacted through any restraint harness
and may occur during inverted crashes or following a rollover.
IMPACT: THE PHYSICAL BASIS OF INJURY
Impact injury refers to structural disruption of biological tis-
sue as a result of a short-duration physical event and causes
tissue disruption by placing stress on the tissue. Tissues can
be stressed in different ways. Forces that tend to compress tis-
sues produce compression stress; the opposite of compression
stress is tension, produced by forces that tend to pull tissues
apart. A positive or negative single number can, therefore, be
used to describe compression-tension stress. Axial compres-
sion or tension stress is not the only kind of stress that can be
placed on tissues, and mathematically a total of six numeri-
cal values are required for a complete description, namely:
Compression–tension load.
Fore–aft bending.
Left–right bending.
Fore–aft shear.
Left–right shear.
Clockwise–anticlockwise torsion.
K17577_C008.indd 159
Human tolerance and velocity change  159
Bending of a tissue structure results in a number of inter-
nal stresses and will place one side in tension and the other
in compression. Shear stress is produced by a non-aligned
force couple, which, if aligned, would have produced com-
pression or tension. Since the force is non-aligned, it tends
to produce slip. Torsion is produced by axial torque and can
produce locally in the tissue tension, compression and shear.
Injury mechanisms are descriptions of the process by
which an injury occurs. Defining the mechanism of injury
ultimately involves specifying the principal stresses that
produce an injury. Since injury is simply strain beyond
the yield point, where strain is defined as the change in a
dimension divided by the original dimension, the preven-
tion of injury requires limiting strain to the recoverable
portion of a load–deformation curve. Limiting the strain
can be achieved by limiting the applied force that produces
it and/or applying the force over a larger or more tolerant
part of the body.
Visco-elasticity is a material property whereby a change
of stress occurs under constant deformation or a change
in deformation occurs under constant load. All biological
tissues, including hard tissues such as bone, have the prop-
erty of visco-elasticity and will break under different loads,
depending on the rate of application of the load, the nature
of the force and the time over which the force is applied.
Human bones may sustain without breaking a higher force
applied rapidly and withdrawn, but may break when a lower
force is applied more slowly. As biological tissues are visco-
elastic, the rate of loading and the strain rate are critical
to the production of injury; the faster the load is applied,
the stiffer the material behaves. At some discernible level of
deformation magnitude and rate, the tissue will not be able
to recover, and damage to the tissue or injury will occur.
This level of response is the injury threshold and indicates
the tolerance of the body organ or tissue to impact.
HUMAN TOLERANCE AND VELOCITY
CHANGE
Defining human tolerance levels to short-duration accelera-
tions is not a simple task, due to the variability of individual
response and the need to state the level of injury that is con-
sidered acceptable. Short-duration acceleration forces can
be separated into three broad categories: tolerable, injurious
and fatal. In this classification, tolerable forces may produce
minor superficial trauma, such as bruises and abrasions,
which do not incapacitate; injurious forces result in moder-
ate to severe trauma, which may or may not incapacitate;
and fatal injuries result in death. These distinctions are
important, since research data are often based on the results
of voluntary exposures to impact, while in accidents, sur-
vival without permanent injury may be a necessary com-
promise in vehicle design.
In a vehicle crash, the instantaneous change in velocity,
Δv, is a good predictor of injury severity. The probability of an
occupant receiving injury or death increases with increasing
Δv, although the relationship between Δv and injury severity
17/11/2015 15:39
 160  Short duration acceleration
is non-linear and influenced by physiological and anatomi-
cal variabilities of the vehicle occupant. This relationship is
ill-defined in aircraft accidents, due to the relatively small
number on which full crash analyses have been carried out,
but extensive data have been derived from car-crash stud-
ies. Figure 8.2 was derived from the United States National
Accident Sampling System (NASS) data for the decade
1982–1991 and relates to the probability of car-driver injury
or fatality against Δv (Evans 1993). A database of more than
22  000 crashes in which Δv either was known or could be esti-
mated from vehicle deformation allows a clear relationship
to be seen. From such data, the influence of driver character-
istics, seatbelt systems, air bags and so on can be determined,
provided that numbers are adequate for statistical analysis.
FACTORS AFFECTING HUMAN
TOLERANCE TO SHORT-DURATION
ACCELERATION
Magnitude and duration of applied force
In general, under similar conditions, the longer the dura-
tion of the impact pulse, the lower the acceleration level that
can be tolerated. This follows simply from the sensitivity of
injury tolerance to the induced velocity change.
1.0
Probability of fatality, all drivers
0.8
0.6
0.4
0.2
0
0 20 40
∆ν (mph)
1.0
Probability of injury, all drivers
0.8
0.6
0.4
0.2
0 standing subjects exposed to a vertical force vector, with an
0 20 40
∆ν (mph)
Figure 8.2  Relationship between the probability of a car
driver being killed or injured and the velocity change (Δv)
incurred in the crash (from Evans 1993).
K17577_C008.indd 160
Rate of onset of applied force
If the conditions of the impact are the same, then the slower
the rate of onset of the acceleration, the better the impact
will be tolerated. For example, if the rate of onset of the
acceleration is 1000 G/s in a given −Gx impact, then signs of
injury may be evident; however, these signs could be absent
if the rate of onset is slowed to 60 G/s. The effect of rate of
onset of acceleration is related to the natural resonant fre-
quency of the whole body, or of individual organs, and to
the compliance, that is, the ability of the mechanical sys-
tem of the visco-elastic components of the bones, joints and
ligaments, to respond to an applied force.
Direction of applied force
The body can withstand much greater forces applied in the
+Gx axis due to the larger supported surface area of the body
in this orientation. The same applies to the −Gx axis given
optimum support and head restraint. Accelerations in the
±Gz axis place greater strain on the organs suspended in
the body cavities, and the tolerance to impact is reduced.
The limited research on the effects of ±Gy impacts indicates
these to have the lowest tolerance limits, especially when the
head is unrestrained. In this situation, neck pain caused by
this force imposes a voluntary limit of some ±8 Gy.
Site of application of acceleration
In general, some parts of the body, such as the back and but-
tocks, are more able to withstand a given force than other,
more vulnerable parts, such as the limbs and head. For this
reason, restraint systems should be designed so as to apply
loads to the body’s strong points, such as the pelvic bones
rather than to the abdomen.
HUMAN TOLERANCE: ACCELERATION
MAGNITUDE AND DIRECTION
60 80 100 120
Figures 8.3 and 8.4 are presented as an attempt to amplify
Figure  8.1  and to bring in the influences of posture and
restraint. The graphs underline the enormous range of
accelerations that may or may not be tolerable and show the
futility of trying to answer the apparently simple and fre-
quently asked question – how much G can the body stand?
Since tolerance to impact forces depends on the imposed
Δv and tolerance to long-duration forces depends on the pla-
teau level of acceleration imposed, a tolerance plot should be
comprised of two connected lines – one for impact having a
45-degree slope connecting points of equal Δv and the other
horizontal and set at a given acceleration level (Figure 8.1).
Figure 8.3 illustrates tolerance curves for lying, seated and
60 80 100 120
idealized rectangular pulse form and with acceleration and
timescales being plotted on logarithmic scales, a form of
presentation made essential by variations in input data of
several orders of magnitude. The greatest tolerance is seen
when the forces are distributed most widely, i.e. when lying
17/11/2015 15:39

1000
Plateau (average) acceleration G
25
100
10
10
t
1
0.001 0.01
Figure 8.3  Tolerance to whole-body impacts in the pos-
tures and restraints indicated by the stick figures and for
a downward acting inertial force vector. Inset numbers
indicate tolerable velocity change (Δv) for brief impacts
and tolerable G for somewhat longer impacts.
100
Plateau (average) acceleration G
2.5
10
1 of the body or to the soft tissues and internal organs.
t Skeletal injury
0.1
0.001 0.01
Figure 8.4  Tolerance to whole-body impacts plotted as
for Figure 8.3, but for horizontally acting force vectors.
supine on a form-fitting couch or when falling on to a con-
forming surface, such as soft snow. The least tolerance is seen
when free-standing, as in a falling lift. Note that the two
lower curves cross over, since a knees-bent posture attenu-
ates the transmission of forces to the upper body, but cannot
sustain prolonged loads. The other curves in Figure 8.3 refer
to impacts with the differing postures and restraints illus-
trated by the stick figures. The seated figure with torso
restraint represents the case of ejection from an aircraft and
illustrates the trough in tolerance caused by a resonance
overshoot for an impulse lasting about 200  ms. The final
curves illustrate the lower tolerances of unrestrained bod-
ies, which will slump forwards, and to −Gz impacts, with the
forces acting through shoulder and lap restraints.
Figure 8.4 is a similar plot, but for horizontal force vec-
tors. It illustrates the very wide range in tolerance caused
by diverse postures and tolerance criteria. The upper curve
is the same as the upper curve in Figure  8.3, but turned
K17577_C008.indd 161
Anatomical and physiological aspects of impact tolerance  161
through 90°, and could represent a passenger in a rear-
facing aircraft seat (with lap-belt to prevent rebound) or
feet/s
80
Inertial force
in a forward-facing seat with full-body restraint. Note the
vector provision of adequate head fixation and the assumption
15
20
G that the seat itself is capable of withstanding 40 G without
40
failure. The tolerance criterion in these accident situations
20 is survival without incapacitating injury. The lowest curve
is for a person stepping on to a moving walkway, where
4 5 the much gentler tolerance criterion is the requirement to
2.5 remain upright even if aged and encumbered with luggage.
2 The intermediate curves illustrate forward-facing aircrew
0.1 1 with five-point harnesses, and a lateral impact with uni-
Pulse duration t (s) form body support; a forward-facing airliner or car passen-
ger with seatbelt, and the unlikely assumption of adequate
free space in front to preclude injury to the flailing head and
limbs; an unbelted car driver attempting to support them-
selves on the steering wheel; and a passenger jumping on to
a moving bus fitted with a grab handle (as in the old London
double-decker buses).
feet/s
80 G ANATOMICAL AND PHYSIOLOGICAL
30 40 ASPECTS OF IMPACT TOLERANCE
15
20
6
15 Injury can result from a direct blow to the body by a solid
8 object or from an indirectly transmitted force, such as when
4 the humerus or clavicle is fractured from an impact trans-
mitted up the outstretched arm during a fall. Either mecha-
Inertial force nism of injury can result in damage to the skeletal framework
vector
0.3
0.11
Damage to the bony skeleton of the body, including the
0.1 1
joints, is the most common injury seen in the crash environ-
Pulse duration t (s)
ment (Baker 2009). Injuries to the upper and lower extremi-
ties are particularly common, and these may not be reduced
by the provision of effective restraint harnesses, chiefly due
to the presence of solid objects within the flail envelope. The
direction of the forces and the rate at which they are applied,
together with an estimation of the loads involved, may be
obtained from an examination of the fracture type.
Joints
Joint disruption can result in an unstable joint or a joint in
which the range of movement has become either restricted
or more than normally mobile. The application of a force that
stresses a joint beyond its normal range of motion results in
the failure of the ligaments, tendons and the joint capsule.
Abdominal cavity
The abdominal cavity reacts to an impact as would a fluid-
filled or hydraulic cavity. The force of a blow to any part
of the abdomen is transmitted to all organs and structures
within the abdominal cavity virtually unchanged. Hence,
a potentially rapidly fatal rupture of the diaphragm, liver
17/11/2015 15:39
 162  Short duration acceleration
or spleen can occur from blunt trauma to any part of the
abdomen. Some damping of the pressure waves generated
by an abdominal impact occurs through compression of the
air and gas in the intestines and stomach, and some occurs
through the action of the muscles of the abdominal wall and
the muscular layers of the various viscera. Blunt trauma can
result in abdominal injury by several mechanisms, such as
pressure-wave transmission, compression and shear forces.
The visco-elastic properties of the individual organs influ-
ence the tolerance to impact and blast. However, it would
appear that intestinal injury in vehicle crashes occurs
mainly in response to submarining, i.e. bending the torso,
under a lap-belt.
Chest
In vehicle trauma, the chest is the most commonly injured
part of the body after the head and limbs. Impact injuries
to the chest are often rapidly fatal, as all the major contents
of the chest are vital to life. Major life-threatening injuries
to the chest compromise the respiratory and circulatory
systems and can result in hypoxic brain damage or death.
Severe decreases in the amount of oxygen available for
transport by an intact circulatory system can result from
impaired breathing mechanics following damage to ribs
and diaphragm, as well as from the alterations associated
with pneumothorax, haemothorax and lung contusions.
Disruption of the circulatory system, with potentially fatal
decreases in the blood volume available for oxygen trans-
port, can be the result of blunt trauma to the chest. Non-
penetrating cardiac injuries (ruptures of the myocardium,
cardiac septa, pericardium and valvular apparatus) and
rupture of the aorta are frequently seen at post-mortem
examinations of the victims of vehicle trauma.
Head and face
The head is the most frequently injured region of the body in
vehicle crashes in which the occupants have been restrained
by a three-point belt. Such injury is the predominant cause
of death in vehicle crashes. The definition of head-injury tol-
erance is fraught with difficulty and still requires clarifica-
tion. In pursuing the study of head and brain injury, some
researchers have equated head injury with brain injury,
while others have related head injury to fracture of the
skull. As it is possible to have brain injury without a skull
fracture, and skull fracture without brain injury, difficul-
ties arise in the correlation of the results of observations
and experiments.
Spine
Back injuries incurred during an aircraft crash may involve
the musculoskeletal structures of the vertebral column
and/or the spinal cord itself. When considering the evi-
dence for the mechanism of injury to the vertebral column,
consideration must be given to the fact that post-accident
K17577_C008.indd 162
appearances will not indicate the maximum deformation
that occurred at the time of maximal loading. The deter-
mination of the mechanism for vertebral column injury in
any one accident is complicated further by the variation in
response to identical applied loads that arise from individ-
ual anatomical and physiological characteristics. The pat-
tern of injury will depend on which of the elements in the
vertebral column is the weakest link in a particular indi-
vidual, such as when intervertebral disc lesions are affected
by the degeneration of the disc that occurs with increasing
age. Injuries from the same applied loads may be modified
in different individuals by the action of the vertebral mus-
cles, especially if pre-tensioning of the vertebral muscles has
taken place before the impact.
The movement of the spine is complex and occurs as
coupled motions. Lateral bending involves rotation about
the horizontal and vertical axes, as well as translation per-
pendicular to the horizontal plane; hence, lateral bend-
ing may cause any combination of transverse shear in the
horizontal plane, rotational shear about the vertical axis,
and tensile and compressive stresses in the vertebral bod-
ies. Furthermore, similar injuries may be produced by a
number of different mechanisms. The tolerance of the ver-
tebral column to impact is not uniform down its length,
with, in general terms, fractures of the cervical verte-
brae being less stable than those of the lumbar vertebrae.
Stability of the vertebral column following impact injury
is paramount in determining the overall survival of the
casualty. High cervical fractures with instability of the
neck are likely to result in injury or transection of the spi-
nal cord, and high spinal cord injuries are often fatal or
result in quadriplegia.
The majority of the injuries to the vertebral column aris-
ing from vehicle accidents involve the thoracolumbar spine.
The response of the thoracic vertebrae to impact is modified
by the presence of the ribs, whereas the increasing size of
the lumbar vertebrae and the orientation of the joint fac-
ets of the lumbar vertebrae lead to increased stability of the
lower vertebral column. The forces required to cause frac-
tures or fracture dislocations of the thoracolumbar spine
are very large due to the size of the vertebral bodies and
supporting ligaments.
An awareness of the most likely sequence of events in
a particular accident, with some assessment of the prob-
able kinematics of the occupant, will allow the determina-
tion of the most likely mechanism of a spinal injury (Rao
2014). Consideration must be given to the type of restraints
employed as the different belt configurations are associated
with characteristic injuries such as hyperflexion over a lap-
belt or rotation and hyperflexion over a three-point harness.
OCCUPANT CHARACTERISTICS AND
TOLERANCE TO IMPACT
The limiting factor of all methods of emergency escape
and crash survival protection is the tolerance of the occu-
pant to acceleration and applied forces. The current state of
17/11/2015 15:39

knowledge concerning human impact tolerances is incom-
plete. While most human volunteer studies have been con-
ducted on young healthy male subjects under controlled
conditions, they have been terminated voluntarily at levels
below that of irreversible injury. Few experimental data are
available for females. Due to the range of human variabil-
ity, data derived from volunteer male subjects must be used
with caution in other applications. Animals have been used
to obtain physiological data at impact levels above those
injurious to human volunteers, and cadavers offer a means
of determining structural limits of tissues but cannot pro-
vide the physiological information that must be obtained on
living systems.
Human beings can be grouped by gender, each with its
own set of related characteristics, but also they are infinitely
variable in age, race, build, fitness, genetic predisposition
and freedom from disease. Attempts to quantify impact tol-
erance limits result only in approximations and generaliza-
tions, making it necessary in any one accident to analyze
occupant injury mechanisms individually. Furthermore,
individual variability must be considered, for tolerance
under identical test conditions may vary in the same indi-
vidual as well as from person to person. Accidental free­falls
provide the means of determining human tolerances to
extreme impacts beyond those to which human volunteers
may be subjected. Other estimates of impact tolerances are
obtained from clinical studies of impact trauma and from
reconstruction of automotive and aircraft accidents.
The tolerance limits for fatality and injury have been
derived from research carried out in a variety of institutions
using a multiplicity of experimental devices and techniques.
The limited numbers of impacts using scarce resources and
the variability of the subjects themselves have allowed only
an approximation of tolerance limits. The utilization of
anthropomorphic test devices (ATDs), or crash-test dum-
mies, to provide repeatable impact conditions has suffered
from the employment of a number of different types of
ATD, each with its own characteristic responses and limi-
tations. The protocols, measurements and recording tech-
niques employed in these research programmes have been
many and varied, making it extremely difficult to compare
the results obtained either with other ATD tests or with
tests using biological subjects.
IMPACT TESTING AND
ANTHROPOMORPHIC TEST DEVICES
Any attempt to standardize human tolerance limits from
actual accidents where so many variables exist needs to be
circumspect and confined to broad limits only. Researchers
in the fields of human bioengineering and medicine
have been seeking alternative sources of information on
human impact tolerances. The development of increas-
ingly sophisticated ATDs and recording devices able to
withstand repeated impacts has continued to provide a
tool for research into the effects of short-duration acceler-
ations but, as with live data, the ‘human tolerance limits’
K17577_C008.indd 163
Thresholds for injury  163
derived from ATD impact research must be treated with
some circumspection.
ATDs have been developed for use in the automobile and
aviation industry. They were manufactured to improve the
biofidelity and injury-prediction measurements for human
models in automotive occupant-restraint testing. The prin-
cipal design attributes required of an ATD to serve as an
effective human surrogate are anthropometry (similar
shape, mass distribution and joint articulation as that of a
human), biofidelity (be able to duplicate the biomechani-
cal responses of a human exposed to identical impact con-
ditions), repeatability (a similar response is obtained for
repeated tests), reproducibility (different ATDs will give
the same responses for similar impacts), durability (ATDs
should not break after each impact), measurement capabil-
ity (ATDs should be instrumented to measure the required
parameters), sensitivity (ATDs should not be sensitive to
extraneous conditions), simplicity and ease of use (ATDs
should be easy to operate, maintain, calibrate and repair).
In practice, compromises between several different require-
ments are made to produce the final dummy design.
One significant deficiency of most ATDs in their use for
ejection testing and for vertical impact analysis is the lack
of a flexible spine: the lumbar and thoracic spines of ATDs
are relatively rigid. During a live ejection, the seat occupant
is forcibly flexed forward within the seat harness, with the
spine usually pivoting around the thoracolumbar junction.
The forces appear to be maximal in this region, and this is
where classically the majority of spinal injuries occur. The
ATD’s inability to reflect accurately the true movement of the
ejection-seat occupant significantly compromises the data
obtained from such tests. Modifications are being made to
develop an ATD with a flexible spine, but a number of techni-
cal difficulties need to be overcome before such an ATD will
become available for widespread use (Dmitriy 2013).
THRESHOLDS FOR INJURY
The potential for aircrew to sustain injuries during impact
or ejection can be determined by comparing the data mea-
sured from the ATD load cells and accelerometers recorded
during accident simulations with the forces above which
injury is likely to occur: comparisons with the accident test
simulation data give an indication of the potential for injury
in the test impacts.
The injury thresholds or injury assessment reference
values (IARVs) refer to a human response level below
which a specified significant injury is considered unlikely
to occur for the given size of individual. If a response
measurement is below its corresponding IARV, then the
occurrence of the associated injury for that size occupant
is considered unlikely for the accident environment being
simulated. However, being below the specified IARV does
not assure that significant injuries will not occur, since
IARVs are not specified for all of the injury types that an
occupant might experience; in addition, the ATD is instru-
mented to measure only a limited set of responses. Also,
17/11/2015 15:39
 164  Short duration acceleration
exceeding an IARV defined in the ATD does not neces-
sarily imply that its human counterpart would experience
that injury if exposed to the same test conditions. In many
cases, the difference between an IARV and its correspond-
ing injury threshold level is not known because the biome-
chanical data do not exist to define accurately the injury
threshold level.
No experimental programme will be able to repro-
duce fully the conditions met in an accident, and data
from all experimental programmes require validation
against known injuries from the analysis of real acci-
dents. Mathematical models are being developed to assist
the understanding of the nature of the forces encountered
during accidental impact, and although these and the new
generation of ATDs are becoming more biofidelic, they are
not human beings. Neither mathematical models nor ATDs
break in an impact, but they lack the internal structure of
the human body and are unable to mimic realistically the
result of impact accelerations on organs and body tissues. In
the long term, finite element mathematical models are likely
to be the main tools used in impact analysis, but their use
will depend on proper validation and continual updating
from accident-derived data.
Finally, an accident may be considered survivable in
terms of the injuries recorded as a result of accelerative
forces, but death may ensue from another cause, such as
a penetrating injury or internal or external haemorrhage.
A survivable accident may become unsurvivable in the
presence of a minor head injury causing a short period of
unconsciousness and the failure to escape a post-crash fire
or effect an underwater escape. Relatively minor but inca-
pacitating limb injuries similarly can prevent survivors of
the initial event surviving the post-crash sequelae. In other
words, the outcome of any accident will depend not only
on the nature of the injuries directly resulting from the
body’s response to impact but also on complicating fac-
tors arising from any injury caused by the deformation of
the airframe, penetrating injuries, environmental factors
such as fire or water, and the rapidity with which emer-
gency services can respond, and the provision of expert
medical care.
REFERENCES
Baker SP, Brady JE, Shanahan DF, Li G. Aviation-
related injury morbidity and mortality: data from
US health information systems. Aviation, Space, and
Environmental Medicine 2009; 80: 1001–5.
Dmitriy K. Comparative Analysis of THOR-NT ATD vs.
Hybrid III ATD in Laboratory Vertical Shock Testing. US
Army Research Laboratory, ARL-TR-6648, September,
2013.
Evans L. Driver injury and fatality risk in two-car crashes
versus mass ratio inferred using Newtonian mechanics.
Accident Analysis and Prevention 1993; 26: 609–16.
K17577_C008.indd 164
SUMMARY
●● In long-duration acceleration, the stresses can be
considered as mainly physiological and sus-
tained, and in short-duration acceleration the
stresses are considered as mainly mechanical
and transitory.
●● Human tolerance to short duration acceleration
depends on the structural strength of the body
and the overall velocity change.
●● Human tolerance to intermediate-duration accel-
eration depends on the overall velocity change,
the time taken to reach peak acceleration and the
magnitude of the peak acceleration.
●● The kinetic energy of a crashing aircraft can
be absorbed by crushing and deforming of the
aircraft structure.
●● Impact injuries can occur by: compres-
sion–tension load, fore–aft bending, left–right
bending, fore–aft shear, left–right shear and
clockwise–anticlockwise torsion.
●● Injury can result from a direct blow to the
body by a solid object or from an indirectly
transmitted force.
Rao RD, Berry CA, Yoganandan N, Agarwal A. Occupant
and crash characteristics in thoracic and lumbar spine
injuries resulting from motor vehicle collisions. Spine
Journal 2014; 14(10): 2355–65.
FURTHER READING
AGARD. Anthropomorphic Dummies for Crash and Escape
System Testing. AGARD-AR-330, Neuilly-sur-Seine,
France: AGARD/NATO, 1996.
Backaitis SH. Biomechanics of Impact Injury and Injury
Tolerances of the Head–Neck Complex. Warrendale,
PA: Society of Automotive Engineers, 1993.
Backaitis SH. Biomechanics of Impact Injury and Injury
Tolerances of the Abdomen, Lumbar Spine and Pelvis
Complex. Warrendale, PA: Society of Automotive
Engineers, 1995.
Backaitis SH, Hertz HJ. Hybrid III: The First Human-
like Crash Test Dummy. Warrendale, PA: Society of
Automotive Engineers, 1994.
Nahum AM, Melvin JW. Accidental Injury: Biomechanics
and Prevention, 2nd edn. New York: Springer, 2002.
Nigg BM, Herzog W. Biomechanics of the Musculo-
Skeletal System, 3rd edn. Hoboken, NJ: John Wiley &
Sons, 2007.
Schmitt K-U, Nieder PF, Cronin DS, Muser MH, Walz F.
Trauma Biomechanics: An Introduction to Injury
Biomechanics, 4th edn. New York: Springer 2014.
17/11/2015 15:39

Head injury and protection
MATTHEW E. LEWIS
Introduction 165
Principles of head injury 165
Mechanics of head injury 166
Head injury tolerance 167
INTRODUCTION
Head injury is common in all forms of accident trauma.
Surveys carried out on aircraft accidents have shown that
40  per cent of injuries sustained are craniofacial, and
14–20 per cent of all fatalities resulting from aircraft crashes
are due to serious head injury.
Interest in the special need for head protection in the
military pilot resulted from changes in the design and role
of aircraft. Heavy jet-powered aircraft, introduced in the
1950s, tended to sink rapidly when power was lost and many
aircrew perished because they were unable to escape from
crashing aircraft as a result of a relatively minor head injury
with disturbance of consciousness. Also, as the speed of
aircraft increased and operational requirements demanded
flight at low level in turbulent conditions, it was feared that
both aircraft and occupant might be lost if the pilot lost con-
sciousness as a result of his or her head striking cockpit struc-
tures. Consequently, protective helmets were developed for
use by aircrew. Since the introduction of such helmets into
military aviation there has been a marked reduction in the
incidence of head injury and in many cases the wearing of a
protective helmet has proved to be life-saving.
This chapter is concerned with the mechanics of head
injury, the principles of head protection and the design and
specification of aircrew protective helmets.
PRINCIPLES OF HEAD INJURY
The principles of head injury described by Cairns and
Holbourn (1943) have commonly been taken to be the
K17577_C009.indd 165
9
Methods of preventing head injury 169
References 174
Further reading 174
mainstays of the descriptive reports on brain injuries. The
clarification of the mechanism of head injury upon impact
is crucial in trying to find appropriate measures for modi-
fications of the impacting object to reduce the severity of
injuries. The nature of head injury depends on various
impact conditions, but, despite extensive work being carried
out, the mechanisms have not been clarified sufficiently. It
is particularly important in the aviation environment to
determine what kinds of mechanisms and observations are
important, what parameters are required to measure in the
experimental and accident reconstruction environment and
what types of head injury occur.
From a clinical view, head injuries can be classified into
three categories: skull fractures, focal injuries and dif-
fuse brain injuries. Head injuries from these three clini-
cal categories can be produced from very specific forms of
mechanical input. Characteristics of the mechanical input,
such as the direction, magnitude, application rate, duration
and point of action of the force, contribute to the type and
severity of the head injury. The complex mechanical load-
ing experienced by the head can be either static or dynamic.
Static loading implies that the force is applied to the head
slowly, typically over periods greater than 200 milliseconds
(ms). Events such as earthquakes, avalanches and slowly
moving vehicles that trap the head against solid struc-
tures produce these events. In aviation, static loading is
seen rarely. Dynamic loading is the more common type of
mechanical loading and is characterized by an input applied
rapidly to the head. Dynamic loading can be of two types:
impulsive and impact. Impulsive loading occurs when the
head is set in motion or the moving head is arrested without
165
17/11/2015 15:40
 166  Head injury and protection
being struck or impacted. It is the inertial forces produced
by the way in which the head moves that cause the result-
ing head injury. Impact loading is the more frequent type
of dynamic loading and usually results in a combination of
contact forces and inertial forces. The inertial force compo-
nent can be minimal in certain impact situations, such as if
the head is prevented from moving when struck. The result
is that most of the energy is delivered to the head as a con-
tact force. The force applied to any tissue results in strain,
which can be considered as the amount of deformation that
the tissue undergoes as a result of the applied mechanical
force. Depending on the direction of the applied force, the
resulting strain can be tensile, compressive or shear. Since
the brain is virtually incompressible in vivo, and has lower
tolerance to tensile and shear strain, the latter two types of
strain are the usual mechanical causes of brain damage.
Unfortunately, brain deformation or strain is almost impos-
sible to measure in impacts, particularly in vivo, and hence
input variables such as head acceleration are used as alter-
native parameters to characterize the injury mechanisms.
MECHANICS OF HEAD INJURY
Skull injury
A number of injuries can occur as the result of the unpro-
tected head striking a hard object or an object striking the
head. When the human head is subjected to a heavy blow
the bones of the skull, which break in a characteristic way,
absorb much of the energy of impact. The outer table of the
skull gives way over an area corresponding closely with the
shape of the object striking it. It is thrust into the diploe,
which is compressed and shattered. The force of the blow
now spreads into surrounding bone and is borne by the
inner table, which first bulges and then gives way over an
area somewhat larger than that of the outer table. Secondary
fissures radiate outwards into surrounding bone along lines
dictated by the architecture of the skull.
Broad impacts to the vault of the skull send multiple
fissures radiating away from the site of the blow. As these
reach the sides of the vault, they turn downwards towards
the base of the skull and are directed into channels between
the thicker buttresses and the floor of the skull. A very heavy
blow directed from underneath the occupant may lift the
upper cervical spine with such violence that it breaks away
from its ring-base attachments. With skull fractures, the
brain and its covering membranes are commonly injured.
The skull is also flexible enough under certain conditions of
impact to be dented transiently by 10 mm or so; underlying
brain damage is then produced in the absence of skull frac-
ture. Contusions or lacerations of the brain surface under-
lying the site of skull deformation or fracture are known
as coup type contusions and occur at the point of primary
impact. The break strength of the facial and cranial bones
was determined from impacted cadaveric specimens and
the resulting head accelerations (G) were measured at the
point of failure. Results depended very much on the site of
K17577_C009.indd 166
impact and ranged from 30 G for the nose, 40 G for the jaw
and 50  G for the zygomatic arch to 100  G for front teeth,
50–100 G for the temporoparietal bone and 100–200 G for
the frontal bone.
Membrane and vascular injury
Whether or not fracture of the skull takes place, an impact
to the head may tear membranes and cause intracranial
haemorrhage. Blood accumulates in the epidural, subdural
or subarachnoid spaces according to its source. Epidural
bleeding normally follows rupture of the middle or poste-
rior meningeal arteries by violent transmitted force. The
dura is lifted locally by the haemorrhage, bulges into the
interior of the skull cavity and displaces brain tissue. After
a latent period during which blood accumulates, the injured
person may appear dazed or temporarily concussed but
soon lapses into unconsciousness as intracranial pressure
increases. Subdural bleeding is often associated with sub-
arachnoid bleeding and develops by leakage from torn per-
forating dural veins. Escaping blood may remain localized
or may spread slowly across the brain by its own pressure
and by gravity. Symptoms may be quite slow to develop.
Brain injury
Inertial loading of the head, whether from impact or from
impulsive loading, causes such rapid movement of the head
that resultant injuries are due only to the manner in which
the head moves. Head motion results in strains within the
brain tissue, which can cause either functional or struc-
tural damage by two possible mechanisms. Differential
movement of the skull and brain can be produced by
head acceleration. A relative movement occurs because
the brain is free to move to some degree within the skull
and because, due to inertia, the brain movement momen-
tarily lags behind the skull movement. In combination,
these factors allow the skull and dura to move relative to
the brain surface, causing localized strain there. The para-
sagittal bridging veins, which are particularly susceptible
to localized strain, may tear if the vascular strain toler-
ance is exceeded. A relative displacement in excess of some
10  mm stretches these vessels beyond their elastic limit,
with resulting rupture and haemorrhage. Furthermore,
when a head strikes an object or the ground, the skull
decelerates rapidly while the semi-fluid brain continues
moving towards the point of impact. Severe contusions
in the area opposite the point of impact can occur where
the brain glides over the irregular, jagged contours of the
skull’s inner surfaces. These so called contra-coup injuries
can be more severe than the corresponding coup-type con-
tusions, and it is thought that the movement of the brain
away from the skull creates regions of low pressure that
may also be involved in the causation of contra-coup con-
tusions. Head motion is also injurious as it produces strain
within the brain parenchyma, leading to classical cerebral
concussion, diffuse axonal injury and associated tissue-tear
17/11/2015 15:40
 Head injury tolerance  167

injury. Data suggest that the different densities of the white
and grey matter result in different velocities of propagation
of the mechanical impact wave through the brain paren-
chyma, thereby causing stress and strain. In each type of
injury, the acceleration or movement of the head causes
either a functional or a structural failure of neural or vas-
cular structures, where the severity and extent of disrup-
tion are linked to the magnitude, rate, duration, direction
and types of inertial loading.
Impact acceleration can be made up of two components:
translational and rotational acceleration. Translational
acceleration occurs when the centre of mass of the head is
moved (accelerated) in a straight line; rotational accelera-
tion occurs when the head is rotated around its centre of
mass. With the exception of horizontal plane movements,
pure translational acceleration is uncommon. As the head
is anchored by the neck, the usual acceleration is angular
acceleration, whereby the head centre of mass angulates
about a point typically in the mid or lower cervical region.
Pioneering workers in the field of head injury attributed
intracranial damage to deformations and accelerations of
the skull and pressure gradients caused by skull deforma-
tions and acceleration due to direct impact. Translational
acceleration initially was considered to be the most impor-
tant mechanism, while rotational acceleration was thought
to be of minimal significance. However, later research indi-
cated that inertial rotation alone could not produce the
levels of injury caused by direct impact, and about twice
the rotational velocity was required to produce cerebral
concussion by indirect impact (or whiplash) (Ommaya
et  al. 1966). Furthermore, it was suggested that rotation
could account for approximately half of the potential for
brain injury, while the remainder was attributed to direct
impact. Other researchers demonstrated that translation
of the head in the horizontal plane produced only focal
effects, resulting in well-circumscribed cerebral contu-
sions and intracerebral haematomas, and diffuse injuries
were seen only when a rotational component was present
HEAD INJURY TOLERANCE
The impact response of the head has been studied, and
the forces needed to fracture the skull are reasonably well
known; however, the mechanical response of the brain is
difficult to quantify. Pioneering work on linear skull frac-
tures using cadavers and anaesthetized animals led to the
development of the Wayne State tolerance curve (WSTC)
(Figure 9.1). The WSTC is a plot of effective head accelera-
tion against impact duration and is based on a mixture of
data from human cadaver drop tests, animal experimenta-
tion involving frontal hammer blows and airblasts to the
exposed brain, and human volunteer sled tests. It cannot
be considered definitive, as there was a considerable degree
of scatter in the data, but a hyperbolic tolerance curve was
drawn through the data points.
The WSTC indicates that high head accelerations are
tolerable, provided that the duration is short. The WSTC
utilized the peak value of the acceleration encountered,
but this was subsequently changed to ‘effective’ accelera-
tion, which is interpreted as the average acceleration of the
impact pulse. The procedure for deriving the curve exhib-
ited a number of deficiencies, including:
●● Poor definition of the type of acceleration parameter
to be utilized and failure to address the presence of
acceleration spikes.
●● Lack of applicability to blows other than those used in
its construction.
240
220
200
180
160
Acceleration (G)

(Gennarelli et al. 1972, 1996). It is believed that the princi- 140

pal mechanism of pure translation appears to be a pressure 120
gradient, while that of pure rotation appears to be shear
stress. Angular acceleration was proposed as the cause of 100
gliding contusions resulting from excessive strain in cere- 80
bral vessels, and the site of maximum shear occurred at a
constant distance from the surface of the brain. It has also 60
been shown that the deeper parts of the brain could be 40
injured while the surface was uninjured and that the zone
of maximum shear became deeper as the angular accelera- 20
tion pulse duration increased. Further work investigated 0
the role of rotational acceleration in causing brain injury in 0 5 10 15 20 25 30 35 40 45
Time (ms)
live primates and physical models (Gennarelli and Thibault
1982; Gennarelli et al. 1981, 1982; Thibault and Gennarelli
Figure 9.1  Tolerance of the human brain to impact
1986). This work established that angular acceleration is
acceleration. The curve was developed at Wayne State
the most injurious in the production of concussive injuries, University and describes the time for which a given accel-
diffuse axonal injury and subdural haematomas and that eration must be applied to produce cerebral concussion.
virtually every known type of head injury can be produced The four dots, reading from left to right, represent veloc-
by angular acceleration. ity changes of 4, 5, 9 and 20 m/s, respectively.

K17577_C009.indd 167 17/11/2015 15:40

 168  Head injury and protection
●● Inadequate correlation of data with living humans.
●● Initial acceleration measurement at the contra-coup
position, which may require modification due to skull
resonances and vibrations.
Nevertheless, the WSTC represents one of the corner-
stones for biomechanical injury criteria serving as a com-
parison for more recently derived models.
Gadd (1966) used the WSTC curve to derive a means of
assessing the likelihood of sustaining a head injury from the
acceleration–time curve of an impact. He analyzed the pulse
duration of an impact in its entirety rather than just the peak
acceleration and determined that between 4 and 50 ms on
the acceleration–time curve the WSTC is almost a straight
line with a slope of –2.5 if plotted logarithmically. This he
represented mathematically as the Gadd severity index
(GSI), where a tolerance level of less than 1000 was stipulated
as acceptable and was considered to be the median point
between those occupants who survived and those who did
not. A concern with the GSI is that it can give unrealistically
high values for impacts that typically have much longer pulse
duration. Examples of this are impacts with automobile air-
bags or padded surfaces that are known to be less injurious,
but the GSI would predict that injuries would occur despite
accident and experimental evidence to the contrary.
The GSI had been developed further into the head injury
criterion (HIC), which is the current standard for the Federal
Motor Vehicle Safety Standard 208. The HIC is a linear head
injury model developed for use in the automotive industry
to assess impacts of anthropomorphic test dummy heads on
to the interior structures of automobiles. The formulation of
the HIC is similar to that of the GSI, but the mathematical
process calculates the maximum value of the HIC over only
a part of the acceleration pulse and considers only the more
injurious portion of the impact pulse around the peak of the
acceleration waveform.
An HIC of less than 1000  is considered to be an
acceptable level, as at this value there is a 16 per cent risk
of life-threatening brain injury (Figure 9.2). However, one
of the difficulties with this formula is that it ascribes to
the entire event a level of severity that is based on only
part of the impact event. Furthermore, it contains no ref-
erence to rotational kinematics and is a poor approxima-
tion of the empirical data on which the WSTC was based.
As a result, the formulation produces numbers that are
too high when impacts last longer than 20  ms. Rather
than correcting a fundamentally unsound equation, the
current approach is to limit the time interval to the 15 ms
around the peak acceleration. This has the effect of keep-
ing the HIC artificially low in order to correspond better
to reality.
Since the recognition that rotational motion may be
more likely to correlate with brain injury, a number of
studies have attempted to set limits for angular accelera-
tion and angular velocity. A scaling relationship was used
for the animal data to extrapolate them to adult humans.
Rotational movement of the head provides far more
K17577_C009.indd 168
99
98
95
Risk of life-threatening brain injury (%)
90
80
70
60
50
40
30
20
10
5
2
1
0 500 1000 1500 2000 2500 3000
HIC
Figure 9.2  Probability of injury risk curve for head injury
criterion (HIC) for peak acceleration duration of 15 ms
(after Mertz 1994).
opportunity for the brain to move relative to the skull
and to distort than does linear motion. Rotational motion
probably results in more significant shear strains leading
to tissue disruption, but the rotational accelerations alone
do not provide a complete description of events to pro-
vide a satisfactory correlation with injuries. New data may
suggest that measurement of strain and strain rate, and
in particular the strain/strain rate product, may be bet-
ter predictors of injury outcome. However, as yet, this has
limited practical significance, as strain and strain rate can
be measured only on cadavers using radio-opaque markers
inserted into the brain tissue.
Alternative surrogates for brain injury research are
finite-element computer models. Ever increasingly sophis-
ticated computer models are starting to provide informa-
tion that is useful in the investigation of human injury
due to impact. The use of such models allows the brain’s
response in the form of acceleration, strain, stress and
pressure to be calculated. In particular, the models should
be able to relate the degree and severity of the physiologi-
cal changes and/or structural failure for a given mechani-
cal input. A number of injury mechanisms have been
postulated for brain injury, and experimental and compu-
tational modelling data are being used to investigate how
the human brain is injured by rotational kinematics. The
cumulative strain damage measure (CSDM) computational
model has been developed and this, in turn, has been used
to derive the brain injury criteria (BRIC) for anthropo-
morphic test dummies which can be used to determine the
probability of diffuse axonal injury in impacts (Takhounts
et  al. 2011). BRIC is not a universal head injury criterion
as it only correlates to traumatic brain injury from head
17/11/2015 15:40

rotations. A human head rarely experiences just rotational
or just translational motion; most head injuries result from
a combination of linear and rotational accelerations. The
HIC is a translational injury criterion (calculated using
translational accelerations only) and appears to be a valid
tolerance criterion. Potentially, combining the two crite-
ria may offer better insight into future protection for all
head injuries.
Impact energy and protection
To consider methods of head protection, a clear under-
standing of the human tolerance to each potential injury
mechanism is essential. The relationships between veloc-
ity, acceleration and stopping distance on head impact
can be made clear by means of an example. Assume that
a human head weighing 5 kg and travelling at a velocity of
10 m/s strikes a solid wall. The frontal bone fractures and
is depressed to a depth of 20 mm (0.02 m). Then, from the
laws of motion, v2 = 2as where v is the velocity (in m/s), a is
the acceleration (in m/s2) and s is the stopping distance
(in meters).
Then,
10 2
a= 2500 m / s 2 = 255 G
(2 × 0.02)
The force (F) acting on the head (or wall) is given by mass
multiplied by acceleration:
F = 5 × 225 G, or 1275 N
The kinetic energy (KE) of the head before impact is
given by 1/2mv2:
KE = 1/2 × 5 × 102 = 250 J
If a constant deceleration of the head is assumed, then
the duration of the impact (t) is given by the velocity divided
by the acceleration:
10
t= = 0.004s = 4.0 ms
2500
It should be noted that if the skull had not fractured,
then the stopping distance would have been much less
(perhaps only 3 mm). In that case, the deceleration would
have been 1700  G, the force 8.5  kN and the duration
0.6 ms. The input energy would still have been 250 J. This
example emphasizes the profound importance of stopping
distance on the forces imposed by a given head impact. It
also shows how the skull and soft tissues can, as a result of
a certain amount of deformation, protect the brain from
excessive acceleration. The relationship between stopping
distance, impact velocity and acceleration is shown in
Figure 9.3.
K17577_C009.indd 169
Methods of preventing head injury  169
50 G 100 G 200 G
25
20
Stopping distance (mm)
300 G
15
500 G
10
5
0
1 2 4 6 8 10
Velocity (m/s)
Figure 9.3  Relationship between velocity change and
stopping distance for five levels of uniform deceleration.
For example, a velocity change (dv) of 7.5 m/s requires
10 mm of theoretically perfect padding to stay within
300 G.
METHODS OF PREVENTING HEAD INJURY
The problem of preventing head injury on impact may be
approached in a number of ways. Restraint harnesses can do
much to prevent contact of the head with surrounding struc-
tures. However, even with acceptable harness restraint, there
may be multidirectional flailing of the head, arms and legs. A
more effective means of preventing contact of the head with
surrounding structures during crash deceleration is by pro-
vision of a suitable head-restraint system, such as an airbag.
The provision of adequate space in the cockpit within
the occupant’s immediate environment helps to reduce
the injury associated with flailing of the head and contact
with surrounding structures. Space is usually at a premium,
however, and it is not always possible to site structural parts
of the aircraft at a sufficient distance.
Where it is not possible to design the cockpit in such a
way that the occupant’s head is prevented from striking sur-
rounding objects, it may be possible to treat surfaces in order
to minimize injury. Injurious surfaces or projections within
the head’s flail envelope may be constructed from deform-
able material to provide a measure of energy absorption,
and control knobs and switches may be made to preferen-
tially fracture if impacted – so-called de-lethalization of the
cockpit. Although many aircraft cockpits are designed fol-
lowing this principle, the structures and equipment used are
far from ideal. However, some, for example the parachute-
containing headbox on ejection seats, have been shown to be
effective energy absorbers and are designed to improve head
protection in high-speed ejections without any increase in
helmet mass. Although the primary aim should always be
to eliminate potentially lethal head impacts, in practice it
is usually necessary to resort to personal head protection.
Thus, the provision of a protective helmet for aircrew is now
the standard method of reducing the risk of serious head
injury in aircraft operations.
17/11/2015 15:40
 170  Head injury and protection
Mechanics of helmet head protection
DISTRIBUTION OF IMPACT LOAD AND PREVENTION
OF SKULL DEFORMATION
There are several possible mechanisms whereby a helmet can
protect the head during impact. It can distribute the impact
load so as to prevent or reduce soft-tissue injury. Similarly, it
can prevent deformation of the skull and so increase toler-
ance to linear acceleration to the 300 G level. In either case,
the requirement is for a strong, inflexible shell. However, if
the shell is separated from the skull by an appropriate dis-
tance, then some flexion or distortion of the shell becomes
acceptable. In this case, the load has to be transmitted to
a large area of cranium by a suitable suspension system or
padding. A measure of the potential benefit afforded by a
rigid helmet shell is given by a simple example.
A light aircraft makes a controlled wheels-up landing
on a rough field and slows to rest at a modest 5 G, a level
of acceleration that would be readily tolerated in terms of
whole-body response. However, at 5 G, the pilot is unable
to prevent his head and upper torso being thrown forwards
inertially, and his head travels some 30 cm before striking
the top edge of the instrument panel. In the time taken for
the head to cover this distance, the aircraft velocity will have
decreased by 5.4 m/s, and it is at this relative velocity that
the head strike will occur (assuming no resistance to head
motion from the neck musculature). Taking head mass as
5 kg, the impact energy will be 73.5 J. Without head protec-
tion, the 3 mm stopping distance offered by the soft tissues
of the scalp will give an average deceleration to the head
of 500 G. Acting over a small area, this greatly exceeds the
strength of the frontal bone, so that a fracture will occur,
with damage to the underlying brain tissue.
The same head, but wearing a well-designed protective
helmet, would impact at the same velocity, but the impact
energy would actually be increased by the added helmet
mass to some 100  J. However, by distributing the impact
over a greater area, skull distortion and fracture are pre-
vented. In addition, the protective padding component of
the helmet (see below) affords an additional 15 mm of stop-
ping distance. The available 18 mm now allows the head to
be brought to rest at an average 83 G, well below the injury
threshold. Thus, not only will there be no brain damage,
but also the avoidance of even transient concussion allows
the pilot to extricate himself promptly in the event of a
post-crash fire.
PROVISION OF FINITE STOPPING DISTANCE
The provision of a finite stopping distance by a protective
helmet can reduce the peak acceleration imposed in a given
impact. Since the velocity change will be unaltered, the
reduced acceleration will be applied for a longer time. In the
example given above, a six-fold increase in stopping distance
(from 3 to 18 mm) afforded a six-fold reduction in average
deceleration (from 500  to 83  G), although the duration of
the impact event was also increased by a factor of six (from
1.1 to 6.7 ms). In practice, the maximum stopping distance
K17577_C009.indd 170
that can be built into a protective helmet is about 25 mm –
more than this and the device becomes unacceptably bulky.
Even this theoretically available 25  mm is reduced by the
relatively inefficient energy-absorbing materials that can be
integrated into a practicable helmet, and only some 15 mm
is actually available in which to reduce the relative velocity
between head and struck object to zero before the material
bottoms out and the transmitted force rises.
There are two basic energy-absorbing systems that can
be used in protective helmets. Certain helmets employ a
fibre-glass shell that breaks up on impact. The impact load
is transmitted to the head and distributed widely by means
of a suspension harness, which initially provides an air gap
of about 25 mm. Each time a glass fibre ruptures or is pulled
out of its resin matrix, energy is absorbed inelastically. This
technique requires a strong rigid shell. A second technique
makes use of a layer of rigid foam beneath the shell, which
crushes on impact to about 40 per cent of its initial thick-
ness. In this design, a lighter shell can be employed.
An important consideration of helmet design is to tune
the padding material to human tolerance levels, such that
the material crushes at a level of transmitted force that is
just tolerable. Such padding will appear very hard and will
not crush to any significant extent in a minor impact. For
comfort, a double layer of padding is desirable, the inner
layer of which is more yielding. In any event, all materials
used should be energy-absorbing; this principle can also be
applied to other helmet components such as ear cups. The
hard outer shell with a crushable liner system is used widely
for helmets produced in large numbers, e.g. in protective
helmets for motorcyclists, as the major components can
be produced cheaply and effectively by injection moulding
using thermoplastics. Hybrid designs are available that use a
combination of frangible shell, energy-absorbing foam and
harness suspension, although the reduced air gap means
that the harness is used mainly for fitting the helmet to
individual heads rather than for energy absorption. Other
helmets use a frangible shell and energy-absorbing padding,
with additional comfort foam pads for individual sizing.
This system, with its reduced air space, may incur a greater
heat load, and its frangible shell is more liable to damage in
routine use. Newer state-of-the-art helmets employ form-
fit liners, which are custom-fitted to the individual aircrew
member’s head size and shape. In a helmet in which energy
is absorbed elastically (as occurs to a certain extent with a
thermoplastic shell and padding), the helmeted head will
rebound on impact, and the impact energy will be increased
by the addition of a post-impact head velocity. This effect is
minimized with the low coefficient of restitution afforded
by a frangible shell.
PROTECTION AGAINST ROTATIONAL
ACCELERATION
A very heavy helmet could reduce head angular accelera-
tion by increasing the rotational inertia of the whole head,
but only at the expense of excessive weight and an increased
risk of neck injury. Hence, this mechanism has never been
17/11/2015 15:40

employed deliberately in the design of aircrew protective
helmets. If a helmeted head strikes a surface at an acute
angle, then the head may either slide or roll along the sur-
face, depending on friction at the contact area. If the helmet
shell is made smooth and external protuberances reduced
to a minimum, then the tendency to slide is increased and
rotational acceleration is reduced. For the same reason, any
essential projections should be fared or designed to break
away at a non-injurious force level. Helmet designs for
motorcyclists can now incorporate multidirectional impact
protection systems consisting of lubricated flexible mem-
branes which can slide over the outer shell. On impact, the
membrane glides over the underlying shell layer thereby
decreasing the friction of the helmet against the road sur-
face which reduces the rotational accelerations and veloci-
ties imparted on the brain. Such devices have been shown
to reduce the rotational acceleration by over 60  per cent.
However, such a system is currently not incorporated into
any aircrew helmet designs.
EXTENT OF HELMET PROTECTION AND RETENTION
All of the mechanisms for protecting the head that have
been discussed above protect only the area actually covered.
Overall protection is compromised by the need to provide an
adequate field of vision and head mobility. Helmets must be
retained following an impact so that protection is available
in the event of a repeated insult. Investigations of aircraft
accidents have shown that multiple impacts are not uncom-
mon. During the ejection sequence, the head could strike
canopy fragments and the seat headbox, then strike against
the separating seat and then sustain a final ground strike on
landing. Furthermore, aircraft crashes rarely impose a sin-
gle axis of deceleration and multiple head impacts are likely
to occur. Despite careful fitting and the use of a chinstrap
and an adjustable neck strap, helmet losses may still occur,
especially during high-speed ejections, as a result of high
aerodynamic lift forces.
WINDBLAST PROTECTION
In high-speed ejection, the body is suddenly thrust into an
airstream that can exert a windblast pressure as great as
60  kPa at 600  knots. This pressure on the face may cause
petechial and conjunctival haemorrhages and, if the mouth
is open and unprotected, blast damage to the lungs. If, due
to the initial posture, or as a result of the ejection forces, the
head is not in contact with the headbox, then the head will
be forced back by the windblast with a potentially injuri-
ous impact. Face protection in high-speed ejection is essen-
tial. The protection can be provided by an oxygen mask
and visor of adequate strength to be retained during the
ejection sequence.
Tests for helmet protection
No dedicated helmet standard for civilian aviation use was
forthcoming until the 1990s (British Standards Institution
2012). Unlike earlier specifications, which defined helmets
K17577_C009.indd 171
Methods of preventing head injury  171
in terms of their materials, dimensions and production,
the later performance standards defined helmets largely in
terms of their function, i.e. instead of describing the hel-
mets, the standards defined how to test the helmets. The
standards served two immediate purposes: tools for the
evaluation of existing helmet designs and guides for the
development of new headgear.
In the UK, some of the military aircrew helmets still in
use are based on design standards of motorcycle helmets. In
the past, there was no specific standard for military aircrew
helmets. The Mk4 helmet used in rotary-wing aircraft and
in fixed-wing aircraft for certain roles is tested against BS
2495, while the Mk10 or ALPHA helmet is used in aircraft
fitted with ejection seats and is tested to BS 6658. Both stan-
dards were developed for the evaluation of motorcycle hel-
mets; with the introduction of a new European standard, EN
regulation 22, these earlier motorcycle standards have been
superseded. EN regulation 22  is the culmination of many
years of analysis of motorcycle helmet impact data, with
the standard better reflecting the threat seen in motorcycle
accidents. As a result, it made its use in the procurement
of aircrew helmets less tenable and made the development
of helmet test standards specifically for aircrew helmets
all the more important. In the UK, a helmet standard has
been developed specifically for aircrew helmets and, as
with all helmet design standards, it originally covered three
major aspects: resistance to penetration, shock absorption
and retention.
The standard was developed from the findings of
research programmes that included assessment of existing
equipment and the cockpit environment, detailed review
of aircrew accident statistics including impact events and
injury outcomes, impact test methodology and evaluation
techniques for damaged helmets. Two types of helmet are
specified: Type E for use in aircraft fitted with ejection seats
and Type S for aircraft fitted with static seats.
Since its introduction as a Defence Standard in 2004 it
has undergone a further review and, in 2014, revised impact
test standard requirements were developed. Table 9.1 pres-
ents the shock attenuation test requirements for MAHIS
together with representative test velocities for shock attenu-
ation tests for other protective helmet standards.
SHOCK ABSORPTION
The test helmet is mounted on an instrumented head-
form and dropped in guided freefall on to either a flat or a
hemispherical anvil. A typical helmet impact test tower is
illustrated in Figure 9.4. The headform and its supporting
carriage have a combined mass of 5 kg; the impact veloci-
ties, measured just before impact are given in Table 9.1. Each
impact is followed by a second impact at the same site but
at half the energy; on no occasion must the acceleration of
the headform exceed 300  G. Helmets may be impacted at
any point of the crown as well as laterally and posteriorly
down to within about 40 mm of a basic plane defined as that
passing through the external auditory meatus and inferior
margin of the orbit.
17/11/2015 15:40
 172  Head injury and protection

Table 9.1  Representative impact velocities for shock-attenuation testing for various protective helmet standards.

Helmet standard Impact criteria Pass/fail criteria

Military Aircrew Helmet Impact Standard,
Defence Standard 05-102, 2015
Aircrew Integrated Helmet System Fabrication
Specification, US Army Aviation and Troop
Command, 1680-ALSE-101, 1995
Helmets for Airborne Sports, British Standards
Institute, BS EN 966, 2012
Protective Helmets For Vehicle Users, British
Standards Institute, BS 6658, 1985
Uniform Provisions Concerning The Approval Of
Protective Helmets And Their Visors For
Drivers And Passengers Of Motor Cycles And
Mopeds, ECE Regulation 22, Revision 4, 2002
Type E helmet; flat and hemi anvil – 6.0m/s <300G
then 4.3m/s
Type S helmet; flat and hemi anvil – 7.0m/s
then 5.0m/s
Flat anvil – 6m/s except crown where 4.88 m/s <175G except crown
<150G
Flat and kerbstone anvils –5.4m/s 250G
Type A helmet; flat anvil – 7.5m/s then 5.3 m/s, <300G
hemi anvil – 7m/s then 5 m/s
Type B helmet; flat anvil – 6.5m/s then 4.6 m/s,
hemi anvil – 6m/s then 4.3 m/s
Flat and kerbstone anvil – 7.5 m/s <275G, HIC <2400

PENETRATION RESISTANCE
To evaluate a helmet’s resistance to penetration, a test hel-
met is mounted on a rigid headform and struck by a coni-
cal striker with a 0.5  mm radius tip. The striker weighs
1.8  kg, and the striker is dropped in guided freefall from
the required height dictated by the particular test standard.
A test failure occurs by detecting penetration by transient
electrical contact between the tip of the striker and a soft
metal insert at the top of the headform. However, recent
reviews of UK and US accident damaged helmets have dem-
onstrated that the penetration impacts during accidents
are very unlikely. The penetration test and the hemispheri-
cal anvil impact test drive the design of helmet shells to be
stiffer than they would otherwise need to be to meet flat
anvil impact requirements; a consequence of this, together
with the provision that the hemi-spherical anvil test is
retained, has resulted in the penetration test requirement
for MAHIS to be removed.
HELMET RETENTION
In this test, the helmet is mounted on a rigidly fixed head-
form and the chinstrap is preloaded through an artificial
chin from which hangs a vertical bar at the lower end of
which there is a stop. A magnetically released mass of 10 kg
can be dropped 0.75  m down the bar, so as to impact the
stop and produce a sudden jerk load. A 7 kg preload takes
the slack out of the system, and maximum displacement cri-
teria ensure that a peak force of the order of 3–4 kN must
be withstood without failure or excessive stretch, either of
which could result in helmet loss.
Assessment of protection
Aircrew helmets that have been involved in an ejection or
crash should be examined and assessed for the protection
afforded to the wearer. Close examination can reveal any
impact damage and witness marks may indicate the nature
of the object struck. In suitable cases, impact tests should be
conducted against a representative anvil using undamaged
helmets to assess the impact forces involved in the accident;
these are then compared with known human tolerance lev-
els and the actual outcome of the accident.
Other functions of protective helmets
Apart from providing protection against impact accel-
erations, protective helmets fulfil other major functions
in aviation. They are mentioned here only briefly. Helmets
contribute towards achieving high levels of speech intel-
ligibility and preventing hearing loss by reducing noise
that gains access to the ear through the helmet structure.
The predominant factor is the performance of the ear cup
and the seal that it provides to the skin around the ear. If
the ear cup is constructed from crushable materials, it can
offer additional impact protection without any increase in
helmet weight.
For aircrew, an antiglare filter is essential for flight. The
neutral-density filter is placed as close to the eyes as possible
and is adjustable so that it protects from glare but still allows
the pilot to see the instruments. The antiglare visor must
be as light as possible so as to stay in place during high-G
manoeuvres and to keep the total mass of the helmet as low
as possible.
Nuclear explosions may result in flash-blindness or reti-
nal burns from the fireball directly or indirectly from atmo-
spheric scatter. Protective headgear may include, or be worn
with, devices that protect against nuclear flash. Similarly,
headgear may also be required to integrate with chemical
defence respirators or other devices worn by aircrew to pro-
tect against chemical and biological agents.

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Figure 9.4  Helmet impact drop test rig, with a monorail
tower on to which the headform and helmet are attached
and dropped under guided freefall on to the test anvil.
The impact accelerations are measured by accelerometers
mounted in the headform.
The hazard of bird-strike is always present during low
level flight. To protect the eyes from splinters of broken
transparency and bird remains, the helmet must carry a
visor made of polycarbonate (3 mm thick), which covers the
area of the face and eyes. The lower edge of the polycarbon-
ate visor must abut closely (a gap less than 5 mm) against
the oronasal mask and it must be possible to lock down the
visor in order to protect against windblast. In addition to
supporting the visor, the helmet also acts as a platform from
which to suspend an oxygen mask.
An extension of the head-up display principle with an
aircraft-mounted collimator is to project the display infor-
mation on to the inside surface of the helmet visor, where
it may be viewed independently of head position. Similarly,
a sight can be placed over a target by moving the head
and an appropriate aim angle computed from measured
head orientation. Either device requires helmet-mounted
(or helmet-integrated) electronic and optical components,
which will add to its mass and need to be mounted so that
the centre of gravity of the helmeted head is not unduly
displaced from its normal position. Heavier objects, such
as night vision goggles, which must be mounted in front
of the eyes, may be counterbalanced by placing other com-
ponents, such as batteries, to the rear of the helmet; pro-
vision may also be made for the goggles to separate from
the helmet before ejection or impact, so as to reduce forces
imposed on the neck.
K17577_C009.indd 173
Methods of preventing head injury  173
Helmet comfort
As with other items of personal equipment, headgear should
not be uncomfortable or impair the efficiency with which
the wearer can perform duties inside or outside the cockpit.
This is difficult to achieve, particularly if the helmet is heavy,
poorly balanced, or required to keep the eye fixed in rela-
tion to helmet-mounted optics. A helmet must not impair
the wearer’s ability to board the aircraft, strap in securely or
egress in an emergency.
When the helmet is worn in aircraft frequently exposed
to sustained accelerations or vibrations, the total weight
of the entire headgear ideally should not exceed 1.7  kg.
The weight of the helmet and components should be well
distributed over the head, and the centre of gravity of the
headgear–head combination should be as close as possible
to that of the head alone. The increase in the moment of
inertia of the head due to the headgear should also be kept
as low as possible. Since the weight of the headgear is dis-
tributed around the circumference of the head, its angular
inertia (proportional to the square of the radius) increases
to a greater degree than its weight. Even a simple full-face
motorcyclist’s helmet doubles the angular inertia of the
wearer’s head. The helmet should be as compact as pos-
sible to keep it away from the cockpit structure, seat, can-
opy and other items of aircrew personal flying equipment,
to improve effective vision and to allow free movement of
the head. The outer surface of the helmet should be kept as
smooth as possible in shape and texture. Any components
mounted on the outer shell of the helmet should be con-
toured smoothly to reduce the effects of glancing blows and
to avoid snagging hazards, such as with the parachute risers
following ejection.
The weight of the helmet should be distributed over as
large an area of the head as possible. The wearer should
be able to alter the distribution and magnitude of any
local pressure points and have some range of adjustment
during wear (e.g. by altering tension in the chinstrap).
The headgear may have to be worn for several hours at a
time, and pressure points that are tolerable initially can
become highly distracting, annoying and fatiguing with
prolonged wear.
To be effective, the helmet must be clasped firmly to the
head. It should not move when the head is moved volun-
tarily or involuntarily as a result of vibration or sustained
accelerations; this is particularly important when the head-
gear includes sights and displays. A stable fit depends on
good initial adjustment of the webbing harness, so that it
fits snugly around the head. The chinstrap and an oxygen
mask help to keep it in place, and the ear cups can provide
additional sideways stability.
The user should be able to put on and take off the hel-
met easily and without assistance and to put on or remove
parts of the assembly or the mask in the narrow confines of
a cockpit.
The helmet should not impose any visual restriction.
The wearer should not need to carry out excessive head
17/11/2015 15:40
 174  Head injury and protection
movements to see above or behind in combat or to see
essential cockpit instruments. The lower part of the helmet
should not produce any significant restriction of head move-
ment, either by preventing full neck mobility or by coming
up against items of personal equipment worn on the upper
trunk (e.g. a life preserver or other floatation device).
SUMMARY
●● Head injuries can be classified into three catego-
ries: skull fractures, focal injuries and diffuse
brain injuries.
●● Mechanical loading of the head can be static or
dynamic with dynamic loading being of two
types: impulsive and impact.
●● Impact loading is the more frequent type of
dynamic loading and usually results in a combi-
nation of contact forces and inertial forces.
●● Impact acceleration can be made up of two
components: translational acceleration occurring
when the centre of mass of the head is accelerated
in a straight line and rotational acceleration when
the head is rotated around its centre of mass.
●● A helmet protects the head by distributing the
impact load so as to prevent or reduce soft-
tissue injury and by preventing deformations of
the skull.
●● Two basic energy-absorbing systems can be used
in protective helmets: a rigid shell that breaks up
on impact and the energy is absorbed inelasti-
cally, and an energy attenuating foam beneath the
shell, which crushes on impact.
REFERENCES
British Standards Institution. Helmets for Airborne Sports,
BS EN 966. London: British Standards Institution, 2012.
Cairns H, Holbourn H. Head injuries in motorcyclists with
special reference to crash helmets. British Medical
Journal 1943; 1: 591–8.
Gadd CW. Use of a weighted impulse criterion for
estimating injury hazard. Proceedings of the 10th
Stapp Car Crash Conference. New York: Society of
Automotive Engineers, 1966; pp. 164–74.
Gennarelli TA, Adams JH, Graham DI. Acceleration
induced head injury in the monkey. I: the model,
its mechanistic and physiological correlates. Acta
Neuropathology 1981; 7 (suppl.): 23–5.
K17577_C009.indd 174
Gennarelli TA, Ommaya AK, Thibault LE. Comparison of
translational and rotational head motions in experi-
mental cerebral concussion. Proceedings of the 15th
Stapp Car Crash Conference. New York: Society of
Automotive Engineers, 1972; pp. 797–803.
Gennarelli TA, Thibault LE. Biomechanics of acute subdu-
ral hematoma. Journal of Trauma 1982; 22: 680–6.
Gennarelli TA, Thibault LE, Adams JH, et al. Diffuse axonal
injury and traumatic coma in the primate. Annals of
Neurology 1982; 12: 564–74.
Gennarelli TA, Thibault LE, Ommaya AK. Pathophysiologic
Responses to Rotational and Translational Acceleration
of the Head. In: Bachaitis S (ed). Biomechanics of
Impact Injury and Injury Tolerances of the Head–Neck
Complex. Warrendale, PA: Society of Automotive
Engineers, 1996; pp. 411–23.
Mertz H. Injury Assessment Values used to Evaluate the
Hybrid III Response Measurements. In: Bachiatis S,
Mertz H (eds). Hybrid III: The First Human-Like Crash
Test Dummy. Warrendale, PA: Society of Automotive
Engineers, 1994; pp. 407–22.
Ommaya AK, Hirsch AE, Martinez JL. The role of whip-
lash in cerebral concussion. Proceedings of the 10th
Stapp Car Crash Conference. New York: Society of
Automotive Engineers, 1966; pp. 314–24.
Takhounts EG, Hasija V, Ridella SA, Rowson S, Duma S.
Kinematic Rotational Brain Injury Criterion (BRIC). 22nd
Enhanced Safety of Vehicles Conference, Paper No.
11-0263. Washington, DC: National Highway Traffic
Safety Administration, 2011.
Thibault LE, Gennarelli TA. Biomechanics of diffuse brain
injuries. Proceedings of the 10th International Technical
Conference on Experimental Safety. Washington DC:
NHTSA, 1986; pp. 79–85.
FURTHER READING
AGARD. Impact Head Injury: Responses, Mechanisms,
Tolerance, Treatment and Countermeasures.
Conference proceedings 597. Neuilly-sur-Seine,
France: AGARD/NATO, 1997.
Cooper GJ, Dudley HAF, Gann DS, et al. Scientific
Foundations of Trauma. Oxford: Butterworth-
Heinemann, 1997.
Schmitt K-U, Niederer P, Muser M, Walz F. Trauma
Biomechanics: Accidental Injury in Traffic and Sports,
3rd edn. New York: Springer, 2010.
Yoganandan N, Pintar F, Larson S, Sances A. Frontiers in
Head and Neck Trauma. Amsterdam: IOS Press, 1998.
17/11/2015 15:40

Restraint systems and escape from aircraft
MATTHEW E. LEWIS
Restraint systems 175
Escape from aircraft 177
RESTRAINT SYSTEMS
The function of a restraint system in flight is to keep the
individual within their workspace so that control of the
aircraft and equipment is maintained. During an impact,
the restraint system must maintain the individual within a
known volume, so that the crash dynamics are attenuated
and movement of the occupant restricted to avoid impacts
with aircraft structures. In a crash, the occupants will stay
at rest or move with uniform velocity unless acted upon
by an external force. When a moving vehicle decelerates,
the occupants tend to continue in a straight line along the
path of original motion. The restraint system resists this
motion to decelerate the occupant. The system must apply
this deceleration in the most appropriate direction and at
sites over the human body that are most suitable to take
the load.
A restraint system must be comfortable to wear, have
easy adjustment and must protect the occupant from injury
arising from multi-directional forces. Although harnesses
will be designed with particular impact dynamics in mind,
it should protect the occupant under all foreseeable impact
conditions. The harness must provide the response require-
ments for the expected dynamics and the anchor points
should be capable of taking the maximum expected loads.
The system should provide maximum distribution of the
forces over the body and should not lead to harness-related
injury. It should not allow relative movement between the
restraint system and the human body.
The system must be easy to put on and release should be
as simple as possible. A single-point mechanism is desirable
K17577_C010.indd 175
10
References 186
Further reading 187
and it should be possible to operate with restricted vision,
such as in a smoke-filled cabin. The loads required to
operate the mechanism should prevent inadvertent opera-
tion, single-handed operation should be possible, and two
sequenced operations should be incorporated to avoid acci-
dental opening. The system should allow enough move-
ment for the occupant to carry out all tasks and should be
designed to perform regardless of whether the occupant is
sitting back, leaning forward or reaching for equipment.
Active or inflatable restraint elements systems should oper-
ate without causing injury.
The ideal restraint system would distribute uniform forces
over the whole of the body and so eliminate the possibility
of concentrated forces. Conversely, poor restraint occurs
from concentrated loads, either from a poorly designed or
poorly fitted restraint system or due to twisted straps.
The seat itself should be regarded as integral to the
restraint and should be borne in mind when designing air-
craft seating, as this will affect the transmission of impact
energy to the body. A soft cushion may appear to attenuate
impact energy, but when the cushion is compressed to its
maximum extent, it may impart greater peak accelerations
than would have been experienced if the person was sitting
on a rigid seat. The effectiveness of a restraint system must
be considered in context with the other elements that affect
the crashworthiness, such as the occupiable space, environ-
ment, energy absorption and post-crash survival aspects,
which are summarized by the acronym CREEP: container,
restraint, environment, energy absorption and post-impact
factors. Compromise of any of these aspects will affect the
chance of survival.
175
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 176  Restraint systems and escape from aircraft

Lap-belts and diagonal straps
The simplest type of restraint system is the lap-belt
(Figure 10.1). It is typically used in most passenger aircraft
and requires two anchorage points, positioned on both sides
of the body on the seat or the floor. This harness provides
minimum restriction to the occupant, but the restraint is
poor and to increase survivability a brace position is required
to minimize forward flail. Unless the head and chest trajec-
tory is free of obstruction significant injuries may occur on
impact. If the belt rises up over the iliac crests across the front
of the abdomen, then abdominal and lumbar spine injuries
may occur. Continued use in passenger aircraft owes much
to simplicity and usefulness in providing restraint in tur-
bulence. Moreover, typical aircraft passenger seats are inca-
pable of taking 3, 4 or 5-point harness restraint systems, as
they are not stressed to take higher loads.
The diagonal belt (Figure  10.2) has the advantage of
remaining a simple system, but as the pelvis is not restrained
the occupant tends to rotate out of the harness during
impact. This can lead to a fatal whip action on the neck or
internal chest injuries. This type of restraint is rarely used.
to the seat at the midline between the legs and joins the cen-
tre of the harness, preventing distortion of the harness. It is
useful during negative-G aerobatic manoeuvres, which can
separate the occupant from the seat. This negative-G strap is
also important during impact as it prevents pelvis rotation and
forward sliding under the lap straps (so-called ‘submarining’).
Multiple-point harnesses can be integrated into the seat,
so that one harness per seat is required, or issued personally,
in which case at least one harness per person is necessary (to
account for clothing assembly and repair). The latter is usu-
ally an individually fitted four-point harness and referred
to as a ‘torso harness’. The choice of torso harness or seat-
mounted harness has logistical implications and also gives
rise to differences in performance under dynamic stresses
in the aviation environment.

Multiple-point harnesses
The most widely used restraint is the typical automobile
three-point harness (Figure 10.3). It provides good restraint
for frontal impacts, but restraint during vertical impacts is
only moderate, and restraint in lateral impacts is poor. It is
important that this type of harness is fitted correctly and the
seat cushion is reasonably stiff, so that the lap-belt cannot slip
over the iliac crests, with the possibility of abdominal injuries.
The four-point harness involves lap restraint and a strap
across each shoulder (Figure 10.4). It provides better restraint
than the three-point harness, due primarily to the larger
spread of loading. The five-point harness additionally pro- Figure 10.2  Shoulder strap.
vides a negative-G strap (Figure 10.5). This strap is attached

Figure 10.1  Lap-belt. Figure 10.3  Three-point harness.

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Figure 10.4  Four-point harness.
Figure 10.5  Five-point harness.
Airbags
Airbags can be either cockpit mounted or integral to the
straps of the restraint harness. Cockpit mounted airbags
operate in a similar manner as automobile airbags. Gas gen-
eration from small explosive devices inflate the bag, provid-
ing a soft structure that absorbs energy as the seat occupant
flails into the airbag. Harness mounted airbags inflate in
a similar manner and can provide a similar approach to
energy absorption as cockpit mounted airbags; however,
they can also be used as an augmentation to the restraint
provided by the harness to fix the seat occupant rigidly in
the seat thereby preventing forward flailing.
ESCAPE FROM AIRCRAFT
Although it could be possible to provide all aircraft with the
capability to absorb the energy of impacts it becomes more
problematic in fighter aircraft. Combat aircraft are likely to
impact the ground at high velocities; the structural strength
and energy absorption necessary to permit the aircrew to
K17577_C010.indd 177
Escape from aircraft  177
survive would result in an extremely heavy aircraft, with an
inevitable decrease in agility and aircraft performance. For
aircrew to survive and escape from a disabled aircraft with
limited crashworthiness, they have to parachute from the
aircraft before ground impact. Initially simple bailout was
the only method used, but as aircraft speeds increased this
became increasingly dangerous and hence, ejection seats
were developed.
The need to escape from an aircraft may arise on the
ground or during flight. The means for escape must be
available at all times and must take account of the forces
that may be operating on the aircraft. Most high-perfor-
mance military aircraft have assisted escape systems, which
use mechanical and explosive power for aircrew to leave
the aircraft. Assisted escape systems must have sufficient
thrust to eject the occupant clear of the aircraft structure at
all speeds and provide sufficient ground clearance to enable
full deployment and inflation of the main parachute before
ground impact. After initiation of the ejection sequence the
system should be fully automatic, relieving the occupant of
any action, other than preparing for the parachute landing,
and it should restrain the occupant sufficiently and modu-
late any forces of the body, so that the risk of injury is mini-
mized. Modern ejection systems enable either aircrew of a
twin-seat aircraft to initiate the ejection despite the other
crew member being totally unprepared for ejection. Thus,
the system has to pre-position the aircrew in the ejection
seat by a harness retraction system while canopy jettison
or canopy fragmentation devices are clearing the ejection
path. Ejection systems have now been developed which can
automatically eject the aircrew with the decision to eject
being made by on-board aircraft computers outside the con-
trol of the pilot.
Ejection sequence
The principal method of assisted escape is the ejection seat.
Ejection sequences vary slightly with aircraft and ejection
seat type, but all assisted escape systems have broadly simi-
lar modes of operation (Figure  10.6). The seat consists of
a sitting platform that is attached to the aircraft structure
with one or more set of rails, which provide guidance for the
initial part of the trajectory. The top of the seat is attached
to a catapult or gun-propulsion system, with the base of this
catapult attached to the aircraft. In most systems, the cata-
pult consists of a series of telescopic tubes that contain one
or more explosive gas-generating cartridges, which provide
and sustain the thrust as the seat leaves the aircraft. Some
ejection seats have a rocket motor fitted to the base of the
seat-pan to augment the thrust of the catapult to increase
the escape velocity. This motor may also be used to ensure
divergence for the seats, so that front and rear seats travel in
different directions and aid aircraft tail-fin clearance.
On most current ejection seats, escape is initiated by
pulling the seat firing handle, which can be centre mounted
on the seat-pan between the aircrew’s legs or side mounted
forming part of the seat’s thigh guards. Activation of the
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 178  Restraint systems and escape from aircraft

5
1. Firing handle initiates escape
Harness retracts
4 Canopy jettisons
Ejection gun seat withdrawn
3 Ejection gun fires
2. As seat rises:
Limb restraint lines operate
Personal equipment connector disconnects
2 Emergency oxygen trips on
Drogue gun and barostatic time-release seats
withdrawn
3. Remote rocket firing unit operates
1 7
Rocket motor ignites
4. Drogue gun piston fires
5. Drogue parachute stabilizes seat
6. Below 10000 ft:
Barostatic time-release unit operates
Main parachute deploys
Automatic man/seat separation occurs
7. Normal parachute descent

Figure 10.6  Sequence of events in a typical high speed, low level ejection from a fast jet aircraft.

seat firing handle fires the initiation cartridge and from this
point onwards the ejection sequence progresses automati-
cally with no further inputs required by the aircrew. Gas is
piped from the initiation cartridge to:
●● Activate a harness retraction system, which pulls the
seat’s occupant into the correct ejection posture to align
the aircrew’s spine with the thrust of the ejection gun.
●● The ejection gun primary cartridge to activate the
ejection catapult.
●● The command ejection selector valve, hence firing the com-
mand ejection cartridge (if fitted in a twin seat aircraft).
●● The gas pathway or mechanical linkage to initiate the
canopy clearance mechanism.
The gases from the ejection gun primary cartridge initiate
upward seat movement, and unlock the seat from the aircraft
structure. As the seat accelerates up the guide rails the ejec-
tion gun secondary cartridges fire in turn, these increase
the ejection thrust to increase the seat’s upward velocity to
give sufficient velocity to clear the aircraft tail-fin. The seat’s
emergency oxygen supply is selected automatically, the regu-
lator is set to 100 per cent O2 and seat is disconnected from
the aircraft’s main oxygen supply. The leg and arm restraint
lines are activated and the rocket motor initiator cartridge is
fired. Rocket initiation is timed to occur immediately prior
to gun separation from the aircraft, so that the seat continues
to accelerate away from the aircraft.
The rocket motor is designed to deliver sufficient height
for the main parachute canopy to deploy in ejections occur-
ring at zero forward speed and zero altitude, so called zero–
zero ejections. Without a rocket pack, zero–zero ejections
could only be achieved by delivering very high peak and
high onset rate accelerations from the ejection catapult.
As the seat separates from a moving aircraft, it will still
have a high forward speed which must be slowed down before
the main parachute can be deployed safely. Furthermore,
the seat has poor aerodynamic properties and needs to be
stabilized in the windblast. The drogue parachute system
stabilizes and decelerates the seat to a safe speed for main
parachute canopy deployment. Drogue extraction is timed
to fire after the seat has cleared the cockpit structures.
Following a possible short time delay, if the ejection occurs
above the height set by the altitude sensor of the barostatic
time release unit (BTRU) the locks securing the occupant’s
harness to the ejection seat are released automatically. On
some systems the pull of the drogue is transferred from the
ejection seat to the parachute withdrawal line, producing
parachute extraction and deployment, and separation of the
man from the seat. On other systems the ejection seat head-
box can be fired off the seat to deploy the main parachute.
Once the main parachute canopy is deployed the aircrew
are decelerated rapidly to descend beneath the parachute
canopy. Shortly after man–seat separation the survival pack
will deploy automatically (if an automatic deployment unit is
fitted, otherwise the pack has to be released manually) and it

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will fall away from the stowed position to be retained by an
approximately 6 m long lanyard and lowering line attached
to the aircrew. The pack, therefore, lands on the ground first
followed by the aircrew. On landing, the parachute should
collapse and the aircrew can then release himself from the
parachute harness by unfastening the quick release fitting.
Aircraft cockpit canopy
Cockpit canopy removal or destruction is a critical part of
the escape process and may be cleared by physical removal,
fragmentation of the canopy itself, or using the seat and
occupant to punch a path through the structure. Traditional
canopies have been made from stretched or cast acrylic but,
in an attempt to increase strength and reduce weight, com-
posite or sandwich materials are now being used in order to
enhance protection against the effects of bird strikes. These
have increased structural strength and resilience, but can be
more difficult to break. The escape path clearance method
will be determined by the canopy material composition,
shape and strength.
The most reliable method for escape path clearance for
minimizing injury is canopy jettison. The canopy and its
frame are detached from the aircraft and separated using
removal rockets or explosive charges. Forced removal is usu-
ally necessary as aerodynamic forces alone may not lift the
canopy. Under certain circumstances, such aerodynamic
forces may keep the canopy in place. Typically, 0.3 s is allowed
in the escape sequence for the removal of the canopy.
Another method of clearing the escape path is to frac-
ture the canopy. This uses an explosive energy (either stored
thermal or kinetic) system to fracture the canopy into small
pieces. The fracture pattern depends on the canopy shape,
material properties and expected forces. For example, a
material such as stretched acrylic, which is resilient to
secondary crack propagation and breaks into large knife-
edged pieces, will be broken in two or only weakened to
allow the seat and occupant to push the resultant pieces
out of the way. Other materials that fracture easily may be
broken into small pieces to minimize injury. Depending
on the form and power of the fragmentation device, prob-
lems may occur from the detonation of the canopy minia-
ture detonating cord (MDC) or linear cutting charge. The
explosive charges of these devices are typically sheathed
with lead and, on detonation, this lead sheath melts. As a
consequence molten lead droplets can fall on the aircrew
causing superficial lead splatter burns to exposed skin and
aircrew equipment assemblies. These burns can look dra-
matic in the first 24–48 hours post‐ejection but usually heal
well with no long-term problems. A more serious conse-
quence is that if aircrew eject with their helmets’ visors in
the raised or stowed position then molten lead can penetrate
the eye. Occasionally, lead splatter can affect the eyes even
if the visors are in the locked down position at ejection; for
this reason, all aircrew who eject from aircraft fitted with
an MDC system should have an ophthalmic examination
post ejection.
K17577_C010.indd 179
Escape from aircraft  179
Ejection systems sometimes rely on the seat and occu-
pant forcing their own path through the canopy. This is
referred to as ‘through-canopy ejection’ and should not be
used except where unavoidable, such as a backup system
through the thinnest of canopies.
Ejection envelope
Ejection seats are designed to function within certain cri-
teria which include maximum and minimum altitude, air
speed, pitch, roll and descent rates. Each ejection seat oper-
ates within its own specifically designed performance lim-
its. If the ejection takes place within such limits then the
ejection is said to have occurred within the safe ejection
envelope and the aircrew should survive. Ejections occur-
ring outside the safe ejection envelope are likely to result
in very severely or fatally injured aircrew. Examples include
ejections in which there was an adverse angle of bank at low
altitude and the aircrew impacted the ground before sepa-
ration from the seat, or where the main parachutes had had
insufficient time (because of low altitude) to deploy fully.
The aircrew involved in out of envelope ejections tend to
sustain severe multiple injuries with gross skeletal disrup-
tion because the impact velocity may be excessive.
Ejection injury
The use of ejection seats is generally lifesaving; however,
their use exposes aircrew to forces that may be at the limits
of human tolerance. The ejection sequence occurs extremely
rapidly with the complete sequence, from initiation to being
suspended on a fully deployed canopy, taking only approxi-
mately 2.5 s. Each phase of the ejection sequence can result
in aircrew sustaining specific injuries through the normal
operation of the system (Table  4.1). These injury patterns
are relatively predictable, but once a failure of an element
of the ejection sequence has occurred the injury pattern can
become more variable and random.
Ejection survivability
The literature on ejection survivability indicates that
between 91 per cent and 97.5 per cent of aircrew will sur-
vive a within envelope ejection, but only approximately
24 per cent of aircrew will survive an out of envelope ejec-
tion. Where fatalities have occurred within envelope ejec-
tions, there appears to be no common pattern to the cause
of death. Drowning has been cited in accident reports as
a possible cause of death, but many of the fatalities have
specific causes of death which were unique to the circum-
stances of the particular accident. Often the individual-
ity of these accidents precludes realistic improvements in
survivability from being made and cases of failure of the
ejection sequence are rare. Fatality rates for fast jet aircraft
accidents where no ejection occurred, so-called controlled
flight into terrain accidents and mid-air collisions, are high,
ranging from 70.5 per cent to 100 per cent. This high fatal-
ity rate is not surprising as the accidents involve aircraft
17/11/2015 15:41
 180  Restraint systems and escape from aircraft

Table 10.1  Typical injuries which may be sustained during impart a sudden high-energy force, resulting in a very high-
the phases of the ejection sequence on escaping from a amplitude, short-duration impact, which may cause injury.
fast jet aircraft. Ideally, the seat and occupant should be attached rigidly to
each other, so that the coupling moves as a single mass. This
Phase Injury
is impractical; therefore, invariably, a well-damped thin
Phase of ejection Possible injuries occurring during foam pad is used between the occupant and the seat.
sequence each phase of the ejection Studies have analyzed the incidences of spinal injuries
sequence following ejection and the results have consistently shown
Escape pathway MDC splatter burns a peak incidence of fractures at the T10 to L2 level. There is
clearance Canopy jettison rocket motor flash a peak incidence of spinal fractures at the thoraco–lumbar
burns junction, but spinal injuries can occur at any level through-
Cervical spine, head, shoulder, out the spine (Yoganandan 2013). It is difficult to say at what
sternum and limb injury resulting precise time spinal fractures have occurred, whether it was
from through canopy ejection on firing of the seat or on landing. Historical data showed
Ejection gun Spinal compression fractures that an increase in the ejection gun velocity and gun thrust
firing/rocket Femoral fracture from contact with correlated with an increase in the percentage of aircrew
motor firing seat pan who sustained spinal fractures, which would indicate that
Seat separation Windblast flail injuries the fractures occur at the time of gun firing. Comparisons
from aircraft Impaired consciousness from of the incidence of parachutists’ spinal fractures with those
helmet/headbox impact of ejectees have shown that spinal fractures resulting from
Drogue parachute Spinal injury from drogue parachute ejection can be typically distributed throughout the whole
deployment opening shock loads of the thoracic and lumbar spine. By contrast, in parachut-
Main parachute Spinal injury from main parachute ing injuries the fractures were predominantly at the level
canopy opening shock loads of the thoraco–lumbar junction. The difference in distribu-
deployment Head/cervical spine injury from tion of the fractures is thought to result from forced forward
helmet and parachute rigging line flexion of the spine from the acceleration of the ejection
interaction gun, a movement not encountered by parachutists who only
Parachute landing Lower limb fractures experience axial compression from the parachute landing.
Spinal injuries
Appearance of spinal lesions
which have impacted terrain at high velocities or have been
involved in mid-air collision where the closing velocities Spinal fractures can be classified and organized according
resulted in decelerations well in excess of the thresholds to the mechanism of the injury and the resulting fracture
both for human tolerance and the structural strength of pattern. Several types of fracture may occur following ejec-
the airframe. The forces involved invariably lead to massive tion, but by far the most common is the anterior wedge com-
destruction of both aircrew and aircraft. pression fracture, caused by axial compression and forward
flexion (Lewis 2006, Manen 2014). Anterior wedge com-
Spinal injury pression fractures reduce the anterior height of the vertebral
body. One or several vertebrae may be affected. Lateral x-ray
Emergency escape from combat aircraft expose aircrew views are the most appropriate and will define the degree of
to vertical accelerations that approach, and may exceed, compression. In most cases, the loss of vertebral height is
vertebral compression failure limits. The problem of ver- slight, but on occasions this may be greater. Frontal x-rays
tebral compression fractures was first observed on early can show widening of the vertebral body and occasionally,
German ejection seats. Versions of these seats produced an element of lateral compression may be present with the
peak accelerations of 12 G and rates of rise (jolt) of 1100 G/s. anterior-posterior x-rays showing asymmetry of the verte-
Although the value of 12  G is known to be comfortably bral height in the frontal plane. In a number of cases, the
within the limits of human tolerance, the figure of 1100 G/s anterior superior corner is torn away and the line of fracture
is now regarded as extremely hazardous and unaccept- is visible as an irregular or serrated edge with the anterior
able. Ejections from current aircraft usually apply accelera- border of the vertebral body deformed to an obtuse angle.
tions in excess of 12 G, typically 12–17 G, for up to 500 ms, UK ejection data of rocket-assisted ejection seats have
with an acceleration onset rate up to 300 G/s. The restraint shown a reduction in spinal injuries compared with previ-
system, therefore, is of vital importance, as it retains the ous studies where non-rocket-assisted ejection seats were
position of the escapee. A properly-fitted restraint system used. In non-rocket-assisted seats between 39–69 per cent
increases the coupling with the seat and should minimize of ejectees sustained spinal fractures. Analyses of rocket-
the possibility of ‘dynamic overshoot’. This can occur when assisted seats demonstrate that the modification of the
a person sits on an elastic cushion; as the seat accelerates, the acceleration profile by the addition of the rocket motor has
cushion depresses, until it is fully compressed. The seat can decreased the number of aircrew who have sustained spinal

K17577_C010.indd 180 17/11/2015 15:41

 Escape from aircraft  181

fractures to between 25 per cent and 30 per cent, depending
on the seat type. The diagnoses of spinal fractures should be
made from radiological findings and must include magnetic
resonance (MR) or computerized tomography (CT) scans.
Accident investigations have highlighted the limitations of
plain radiographs as a means of identifying minor spinal
fractures as initial plain x-rays did not reveal the fractures
in approximately 44 per cent of the aircrew who were subse-
quently shown to have sustained spinal fractures on MR or
CT imaging. The UK military currently has a policy that all
aircrew who eject, or have been subjected to a high vertical
deceleration, will have MR scans of their spines performed.
Evidence suggests that minor spinal compression fractures
were not diagnosed on plain radiographs and could suggest
that the reported spinal fracture rate would have been much
higher in those ejections, before MR scans were available.
Thus, it is possible that the number of aircrew who sustained
spinal fractures from non-rocket-assisted seats, although
high, were even higher as some compression fractures could
have been undiagnosed due to the limited radiological tech-
niques available at the time.
Factors affecting the incidence of spinal
injury during ejection
PILOT’S POSTURE
The position of the pilot during ejection is a critical factor
in causing spinal fractures. An inappropriate sitting posi-
tion will further lead to relative weakness in the vertebral
column and can give rise to lesions when the acceleration
would otherwise be tolerable. Factors that modify the posi-
tion of the pilot are numerous. The attitude of the aircraft at
the time of the ejection is important as it alters the relation-
ship between the seat and the pilot. In a nose-down ejection,
the pelvis is necessarily separated from the seat even if the
harness is properly tightened. Similarly, in ejections from a
INCLUDED ANGLE
The major component of the ejection acceleration is in the
long axis of the spine; however, significant flexion forces are
present and arise because the line of seat thrust does not
coincide with the long axis of the spine. The included angle
is the angle between the axis of the spine and the line of
thrust and large values favour the development of fractures
of the vertebral column by hyperflexion (Figure 10.7). Even
when sitting in the correct ejection posture, the geometry of
the seat structure, the moulded back pad and aircrew equip-
ment assemblies prevent the spine from aligning with the
axis of thrust.
THROUGH CANOPY EJECTION
Ejection through an intact canopy has been phased out as
the primary method of ejection path clearance. Compared
with ejections with canopy jettison or canopy fragmentation
as the method of pathway clearance, three hazards arise:
●● Modification of the acceleration profile for the seat and
the seat occupant causes greater accelerations at the
level of the seat and of the body segments represented
by the pelvis, thorax and head. This produces greater
compression of the vertebrae.
●● Impact between the canopy and the head, shoulders
and knees.
●● Tearing of protective clothing, damage to survival
equipment and laceration to underlying tissue may be
produced by fragments of Perspex which have pierced
various layers of clothing.
Centre of gravity
Line T1
of thrust T2
T3
T4
T5

steeply-banked aircraft there is lateral flexion, which is all T6

T7
the greater if the harness is poorly adjusted. T8
T9

RESTRAINT SYSTEM T10

T11
A very slack harness gives greater freedom of movement of T12
the trunk, which bends considerably during ejection. In the L1
earlier ejection seats fitted with a face blind firing handle, L2

forward flexion of the trunk was limited by retention of the L3

L4
head behind the face blind and, with regard to ejection seats L5
fitted with seat pan firing handles, evidence suggests that
forward flexion is more pronounced in tall subjects with
a long thorax and short arms. However, many pilots, irre-
spective of anthropometric size, cannot completely support Included angle
their spines against the seat during initial seat movement.
Vertical Reaction to
One analysis of spinal injury rates has shown that the use component acceleration
of the seat pan firing mechanism is associated with more
spinal fractures than initiation with the face blind, but
another study did not show any difference in the incidence Figure 10.7  The line of thrust of an ejection seat in rela-
of spinal fractures in relation to the position of the ejection tion to the long axis of the spine. The centre of gravity is
initiation mechanism. that of the upper torso (above T12).

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 182  Restraint systems and escape from aircraft
At the onset, the acceleration of the seat is moderately
high and then decays rapidly as the seat-mounted canopy
breakers come into contact with the canopy and retard seat
movement. During this time, the acceleration at the pelvis
of the seat occupant progressively increases and the occu-
pant continues on his upward path, despite the retardation
of the seat, as if the occupant had parted company with the
seat. When the canopy breaks, the seat accelerates again, at
first slowly during the disruption of the canopy, then more
rapidly for a very short period when there is no longer an
obstacle to its passage. Finally, the seat catches up with the
occupant, producing a secondary acceleration of the occu-
pant and a deceleration of the seat. Thereafter, the accel-
eration curves of the seat and the occupant follow almost
identical paths.
As mentioned above, the development of stronger and
thicker canopy transparencies, in particular to protect the
aircrew from bird strike, has led to the use of stretched
acrylic instead of the earlier Plexiglas and cast acrylic. The
fragmentation characteristics of the transparency mate-
rials differ and, instead of a large number of small blunt-
edged fragments resulting from the break up of cast acrylic
canopies, stretched acrylic breaks into a small number of
larger pieces with razor sharp edges capable of inflicting
serious injury to aircrew and damage to aircrew equipment
assemblies. The physical characteristics of stretched acrylic
alter with temperature: an increase in temperature causes
stretched acrylic to become more malleable and resist pen-
etration as it stretches and balloons over the emerging seat.
The higher the airspeed, then the higher is the temperature
of the canopy and the higher the resistance to penetration.
Hence, penetration through stretched acrylic will cause
more severe acceleration injuries and injuries arising from
contact with heavier, larger and sharper canopy fragments.
An analysis of Royal Air Force (RAF) accident records
from through canopy ejections shows an incidence of ster-
num fractures that is unique to through canopy ejection.
The fractures occur from forcible contact with the chest,
either by the chin (as the forward flexed head comes in to
contact with the transparency) or when the chest is struck
by a piece of detached canopy.
Spinal injury prediction models: Dynamic
Response Index
Mathematical models, which are mechanical system ana-
logues of the dynamic response characteristics of the human
body, were developed to allow predictions to be made of the
percentage of aircrew who would sustain spinal fractures
from ejection seat test data, and to provide a method of
estimating the acceptability of accelerations in an escape
system without having to wait for injury data to accrue. A
number of complex models were initially explored, but sim-
ple single-degree-of-freedom, lumped parameter models
were initially believed to be adequate to explain the limited
available test data applicable to escape systems.
K17577_C010.indd 182
The model developed to the most satisfactory degree
was the Dynamic Response Index (DRI). It was developed
to estimate the probability of sustaining compression frac-
tures in the lower spine due to accelerations acting along the
long axis of the spine. The model was verified by comparing
the response of the model to ejection catapult accelerations
with the operational injury rates associated with specific
ejection systems. After operational and test data verification
it was incorporated into multinational ejection seat specifi-
cations and standards.
The DRI is representative of the maximum dynamic
compression of the vertebral column; however, it does not
attempt to predict the location or severity of the spinal
injury and it cannot be used to predict injury in the cervical
or upper thoracic spine or injury resulting from parachute
opening shock. The DRI is calculated by describing the
human body in terms of an analogous, lumped parameter,
mechanical model consisting of a mass, spring and damper.
The application of the model facilitates assessment of the
response of the human body to accelerations having irregu-
lar waveforms. The DRI is calculated from the equation:
ω n 2δ max
DRI =
g
δ is the compression of the spring.
ωn is the undamped natural frequency of the model.
g is gravitational acceleration.
The DRI model, however, is not ideal and makes a series
of assumptions:
●● The spine is treated as a simple mass spring damper
system with known natural frequency and damping
characteristics that are invariant.
●● The acceleration waveforms are considered as tri-
angular or trapezoidal and successive pulses are
treated independently.
●● The impact is applied to a healthy young male, seated on
an inelastic cushion, adequately restrained by an inex-
tensible harness and wearing a protective helmet.
●● The tolerance for acceleration in the +Gz axis is known
with confidence.
The DRI can be related to the probability of spinal
injury as depicted in Figure  10.8, providing the resultant
acceleration vector is parallel to the spinal column (within
±5°). Figure 10.8 is based on a large number of operational
experiences with different escape systems. The probability
of spinal injury considered acceptable for a certain emer-
gency escape system must be selected based on operational
and technical considerations for the aircraft in question. In
general a DRI value corresponding to a mean probability of
spinal injury of 5 per cent or less is considered acceptable.
Actual spinal injury rates have been compared with the
predicted injury rates from the DRI for rocket-assisted seats
17/11/2015 15:41

50
40
30
Spinal injury rate (%)
20
10
5 early, but this can risk interference with the tail of the air-
2
1
0.2
0.1
12 14 16 18 20
Dynamic response index
Figure 10.8  Distribution of spinal injury rate for dynamic
response index values.
which showed that the predicted injury rates are an under-
estimate. Although current RAF ejection seats are designed
to a DRI which gives a predicted injury rate of 4–5 per cent,
the actual injury rates were between 25 per cent and 30 per
cent. Why the DRI should underestimate for rocket-assisted
seats is not readily apparent, but may be due to the inherent
flaws in the DRI mathematical model. The injury analysis
data would suggest that the DRI is not a successful predic-
tor of injury and probably should only be used as a tool for
comparative tests for design assessment of the dynamics of
ejection seats.
As the DRI only considers accelerations in one direc-
tion (Gz), the DRI has been further developed to charac-
terize the DRI in multiple axes. The Multi-Axial Dynamic
Response Criteria considers the DRI in the Gx, Gy and Gz.
Computation of these criteria assign injury-risk levels to
the acceleration-time pulse of the ejection. These injury-
risk levels are characterized as high, moderate and low
with respective dynamic response values of 22.8, 18  and
15.2. The high-risk levels were determined by calculating
the maximum dynamic response values for acceleration
conditions known to cause major injuries or potentially
serious sequelae. The low-risk levels were estimated on the
basis of the calculated maximum dynamic response values
for acceleration conditions where only minimal injuries
such as bruises, abrasions and muscle or ligament strains
have occurred. The moderate-risk levels were estimated
using the assumption that the probability of injury would
have a normal statistical distribution between the low- and
high-risk levels.
Seat stabilization
Ejection seats are not aerodynamically stable in high speed
airflow. A seat can rotate and tumble in the airflow and
on main parachute deployment hazardous opening shock
loads can be applied to the aircrew. Lateral loads of more
K17577_C010.indd 183
Escape from aircraft  183
than 12 G applied to the head and neck carry a high risk of
injury. To overcome this problem, passive means of stabiliz-
ing an ejection seat aerodynamically have been developed.
The primary technique is to attach a drogue parachute so
the seat is either held upright and facing into the airflow or
facing vertically downward. The drogue must be deployed
craft, hence, to overcome this and provide early yaw con-
trol, aerodynamic plates can be incorporated as an addition
to the seat. In flight, the plates would be stowed and only
deployed as the seat leaves the aircraft.
A problem with the use of a drogue is the need to deploy
it early in the sequence when the airspeed may be high. To
avoid excessive decelerations, the size of the drogue should
22 24 be small, but then, apart from the limited effect which a
small drogue will have, as the airspeed decays the drogue
will be less effective in slowing the seat. Hence, it will take
longer to reach a safe condition for main parachute deploy-
ment and the margin for safe escape will be reduced. Ideally,
a variable sized drogue, or reefed drogue, is required. With
such variably controlled drogue systems, deceleration peaks
are reduced by allowing the drogue to open progressively
so the velocity decays in stages, thereby the man and seat
are decelerated more consistently and more rapidly. When
used in a low speed ejection, the system would be config-
ured automatically to deploy the drogue in a more fully-
open state, while below a particular threshold airspeed the
drogue is dispensed with, allowing the main parachute to be
deployed directly.
Windblast
Ejections from aircraft flying at high speed are associated
with injuries different from those found in ejections occur-
ring at low speed and these injuries are related to the aero-
dynamic forces experienced immediately on entering the air
stream. As the cockpit canopy is cleared from the aircraft,
the occupant is subjected to windblast. Within 0.2 s of the
seat’s first movement, the seat and occupant are subjected to
the full blast of the air while still travelling at approximately
the same speed as the aircraft. The magnitude of this force
(Q) is expressed as:
Q = 1/2 ρ v2
Where Q = dynamic air pressure (N/m2)
ρ = air density (kg/m3)
v = velocity (m/s)
Two different injury patterns have been attributed to
Q forces. The first is characterized by soft tissue injury
resulting from localized dynamic air pressure and turbu-
lence, producing surface burns, ecchymosis, oedema and
petechial haemorrhages of the exposed skin. The effect of
the windblast is due to the sudden application of force to
the chest and abdomen. The subject is ‘winded’ in mild
cases but, in cases of high pressure, an arterial pulse may
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 184  Restraint systems and escape from aircraft
be generated, which leads to the subconjunctival haemor-
rhages. Theoretically, very high blast pressures could lead to
rupture of internal organs and death. The second and more
significant injury pattern is flail injury, which results from
the summation of force over larger areas producing differ-
ential decelerations of the head and extremities relative to
the torso. These result from drag forces according to the
following relationship:
Drag force
Deceleration (G) =
Weight
N
Dynamic pressure ( 2
) × Drag coefficient × Frontal area (m 2 )
= m
Weight (kg)
The greater frontal area to weight ratio for the extremi-
ties relative to the torso will result in a more rapid decel-
eration of the extremities and, if the area to weight ratio is
further reduced, as occurs by the addition of the ejection
seat, the relative deceleration of the extremities will be even
greater. Flail injury results when the decelerating head or
limb impacts the ejection seat or when the limb exceeds the
limits of motion of a particular joint.
During ejection, the limbs and head may be subjected to
severe windblast and unrestrained legs may be forced over
the side of the seat-pan, resulting in fracture or dislocation
of the hip. At low speeds, the hands may be able to hold on
to the firing handle but, at higher speeds, the force of the
windblast may tear them free, with the arms flailing out-
wards, upwards and backwards. Therefore, limb restraints
are required to prevent injury. Although it is recognized
that limb restraint is a significant problem at ejection speeds
above 300  knots, UK experience has demonstrated that
windblast limb injuries have occurred at ejection speeds
as low as 200 knots. Unless the head is located positively, it
too may flail, and, for this reason, neck protection devices
involving inflatable airbag collars are being incorporated
in ejection seats and are useful in preventing head and
neck injuries in aircrew, particularly while wearing heavy
helmets with integrated display systems. Injury analyses
have shown that the percentage of aircrew who sustained
arm flail injuries on ejecting with an ejection seat with arm
restraints was significantly lower than in those who ejected
with an ejection seat not fitted with arm restraints.
Parachute opening shock
Escape system parachutes are, generally, either round or
aeroconical. They are designed to withstand high opening
speeds, to open quickly, and to operate across a large range
of aircrew masses. They are also stable during descent and
easy to control, since the ejectees are not usually experi-
enced parachutists. The main parachute canopy deploy-
ment may be delayed or may open immediately depending
on the altitude of ejection. At a low ejection altitude, any
delay is unacceptable and the interval between initiation
K17577_C010.indd 184
of ejection and parachute deployment should only be
long enough to allow adequate clearance from the air-
craft structure. At higher altitudes, in excess of 10 000 feet,
deployment of the main parachute canopy is delayed as
high parachute opening shock forces can occur and, addi-
tionally, the ejectee is exposed to potentially hypoxic and
hypothermic conditions. At these higher altitudes, man/
seat separation is prevented. The man and seat configura-
tion is in free fall, but stabilized by the drogue parachutes
to 10 000  feet when activation of the BTRU initiates the
sequence of events which releases the parachute from its
container so the aircrew separates from the ejection seat
and main parachute canopy deployment occurs. During
the free falling of the aircrew, two forces act on the body:
first, that exerted by gravity and, second, the drag due to
air resistance which opposes the gravitational accelera-
tion. If the time between ejection and parachute deploy-
ment is sufficiently long, equilibrium between these forces
is reached and the speed of descent at this time is the ter-
minal velocity. The magnitude of this velocity is in part
dependent on the altitude, because at greater altitude the
density of the air decreases and the component of drag is
smaller: air resistance is therefore reduced and the termi-
nal velocity is correspondingly greater. The extraction of
the main parachute canopy and its subsequent inflation
decelerate the man further, and eventually he will reach
a descent velocity which is termed the reduced terminal
velocity. This velocity depends on a number of factors,
which include the diameter and shape of the parachute and
the characteristics of its fabric.
Opening shock will be greatly increased if the para-
chute is operated at a speed greater than the free fall ter-
minal velocity at the altitude of escape. For a 90 kg man at
10 000 feet, the terminal velocity is approximately 52 m/s. In
such circumstances, the body is rapidly decelerated at a rate
that varies with the square of the velocity and the density
of the surrounding air. Time should be allowed for decel-
eration of the seat to occur, otherwise the very high forces
at parachute opening could cause the parachute to fail, or
could injure the ejectee. When deployment is carried out
at high altitude, owing to lower air density, the canopy will
inflate more quickly than at lower altitudes. The size of the
canopy also has an effect, as larger canopies are associated
with smaller opening shocks because the time needed for
their deployment is greater and the deceleration is spread
over a longer period. This is critical for ejectees, as emer-
gency escape parachutes generally have smaller diameter
parachute canopies than those used by military airborne
forces. A smaller canopy is required in escape parachutes
because of the size and weight constraints of fitting it into
the headbox container. A quickly opening parachute is also
required as ejections may occur near to or on the ground
and so the time to become suspended on a fully deployed
parachute should be short to increase survival. Although
there remains a theoretical risk of parachute opening shock
injuries there are very few confirmed cases of such injuries
in the literature.
17/11/2015 15:41

With ‘canopy first’ parachute deployment the canopy
is extracted from the ejection seat headbox first, followed
by the parachute rigging lines. As the canopy clears the
headbox it immediately starts to inflate, thus, the canopy
rigging lines become taut after the main canopy has par-
tially inflated. This deployment method can cause severe
parachute opening shock forces. With the ‘rigging lines
first’ parachute deployment, the parachute is deployed out
of the ejection seat headbox contained in a deployment bag.
The bagged parachute is towed away from the seat by drogue
parachutes and, once the parachute lines are fully deployed,
the bag is pulled from the main parachute by the continuing
action of the drogue parachutes. Hence, the main parachute
canopy only starts to inflate once the rigging lines become
taut, reducing the parachute opening shock load.
Parachute landing injury and parachute rate
of descent
The final phase in the ejection sequence where there is as
risk of injury is the parachute landing. Of concern is the
higher rate of parachute descent with a heavier occupant
and the increased risk associated with a touch down at a
high velocity. If the kinetic energy absorbed at touch down
is a measure of the risk of parachute landing injury then
the risk is dependent on the parachute-borne mass and the
square of the landing velocity. Although other factors, such
as surface wind velocity and landing terrain, influence the
incidence of landing injuries, it is the descent velocity which
is most critical.
Parachutes which have no steering lines fitted may result
in the ejectee having difficulty in controlling his glide path
to avoid collision with ground obstacles. In the absence
of steering lines, aircrew can attempt to manoeuvre the
parachute by pulling down forcefully on the lift webs but,
when using the lift webs, the canopy is slow to respond and
enormous amounts of effort are required to cause a change
in direction. With steering lines fitted, a parachute can be
turned easily into wind to cause a decrease in the horizontal
velocity. Any decrease in the horizontal velocity is advanta-
geous, especially in the presence of a high surface wind, and
will assist in minimizing landing injuries.
Concern has been expressed over the possible increase
in descent velocity and hence, increases in landing injuries
when steering lines are used. This is probably unfounded as
the use of steering lines allows a more rapid correction of
direction and the loss of height in the turn is significantly
less than when a turn is induced by pulling on the lift webs.
Although there is a small increase in vertical sink rate when
the steering lines are operated, it is not excessive, ceases
once the steering lines are released and can be used effec-
tively if there is a need to land short of an obstacle. Analysis
of UK ejections demonstrated no landing injuries attribut-
able to the use of the steering facility, but there were a num-
ber of cases where injuries could have been prevented had
the parachute used been fitted with steering lines and the
aircrew had been able to steer away from ground objects.
K17577_C010.indd 185
Escape from aircraft  185
Typical parachute landing injuries include fractures of
the femur, fibula and tibia (including the medial and lat-
eral malleoli and shaft), and soft tissue injuries of the ankle
and knee (ligament, tendon and menisci tears). UK ejection
data has shown that approximately 18  per cent of aircrew
who ejected have some degree of parachute landing injury;
approximately half of these injuries were fractures with
soft tissue injuries making up the remainder. The causa-
tion of parachute landing injuries is not solely due to the
absolute parachute descent and impact velocities, but time
on parachute is also critical and accident data evidence sug-
gests that the lower the altitude and the shorter the time on
parachute the more likely it is the aircrew would sustain
landing injuries.
During landing, the adoption of a good parachute land-
ing fall should help minimize any injuries. The hands and
arms should be positioned over the head, which should
be tucked well into the chest. The feet and legs should be
together and the knees slightly bent to cushion the impact of
landing. The landing shock should be spread over as long a
time and as large an area as possible by allowing the body to
collapse in the direction of motion as soon as the feet touch
the ground and rolling from thigh to buttock to shoulder.
During the roll, the legs must be kept in apposition.
After landing, the parachute must be collapsed or
released as soon as possible in order to avoid dragging and
the risk of injury from rough terrain. If the descent is made
into water, then there is the possibility of being dragged
with the head below water level. To avoid this hazard, some
parachutes are fitted with water pockets, which collapse the
canopy. The parachute harness’s quick release fitting can be
fitted with a water activated release system which will auto-
matically release the harness on its activation by immersion
in water. This type of system is particularly advantageous if
the aircrew or parachutist had been injured during the air-
craft escape, and these automated release systems have been
shown to decrease the risk of drowning.
Escape from helicopters
Although considerable effort has been spent on ejection
seats for fixed-wing aircraft, there has been no parallel evo-
lution of escape systems for helicopters. Fitting ejection
seats to rotary-wing aircraft has been considered, but the
weight penalty and the problems associated with escape
from helicopters have meant that autorotation is regarded
as the preferred option. An exception being the Kamov
Ka-50  ‘Hokum’ attack helicopter, which is fitted with an
ejection seat; before ejection occurs, the rotor blades are
removed by explosive charges and the canopy is jettisoned
to permit a clear ejection pathway. The safety of helicop-
ters has increased over the years and, in the case of power
loss, the possibility to autorotate usually exists. Loss of con-
trol does not have an escape possibility, and so improved
crashworthiness is regarded as the most practical option.
Nevertheless, at high altitude, the bailout option exists if the
dynamics allow egress.
17/11/2015 15:41
 186  Restraint systems and escape from aircraft
Unassisted escape and parachuting
The precise procedure to be used will vary with the con-
figuration of hatches, and type and role of aircraft, but
certain general principles should be observed. The first
requirement is that the aircrew are fitted correctly with
appropriate equipment and understand its operation and
use. They must be familiar with the escape sequence and
know the location and method of egress from emergency
exits, escape hatches, tunnels or chutes. Unless these drills
are practised, an escapee may not only prejudice their own
chances of escape, but also impede the progress of oth-
ers. It is important for the escapee to enter the airstream
without striking the aircraft. This means that careful con-
sideration must be given to the design and training in the
use of the escape system. The exit routes must cater for the
full physical strength ranges and anthropometric varia-
tion of aircrew with all of their escape and survival equip-
ment. These issues must be taken into consideration when
the aircraft is moving under any aerodynamic, inertial or
vibration influences, as well as when it is stationary. Some
degree of assistance may be incorporated into the system,
e.g. explosive bolts and cutting charges to remove doors
and escape hatches.
Escapees must usually propel themselves through the
escape exit with as much force as possible and then assume
a compact shape without trailing arms or legs. To escape
from a side door, the escapee crouches, holding both sides
of the door, and heaves themselves outwards and down-
wards, folding their arms across their chest. Where practi-
cal, the escape system should assist the escapee in directing
the separation from the airframe. This may be with the use
of aerodynamic windbreaks or even a scoop.
After successful separation from the aircraft, the escapee
may either fall freely for a while or open the parachute
immediately. At altitudes below 500 feet, any delay is unac-
ceptable and sufficient time should be allowed only to clear
the aircraft structure. At altitudes below 200  feet, success
will be problematic under the best of circumstances, as 3 s
or less is available for the operation of the parachute. Escape
at altitudes below 100 feet is invariably fatal, as the height
lost during the parachute inflation is too great.
At altitudes between 2000  and 15 000  feet, the escapee
should wait for some seconds before initiating the para-
chute, in order to ensure that they are clear of the air-
craft and have lost some of the forward velocity. In this
way, the parachute is not subjected to an airspeed that
would create shocks beyond its structural strength.
In unretarded descent, the escapee will fall approxi-
mately 1000  feet in the first 10  s of leaving the aircraft.
The descent rate will then start to stabilize. At altitudes
above 15 000  feet, factors such as high parachute opening
shocks, hypoxia and low temperatures make it impor-
tant to delay the deployment of the parachute. Free fall is
advised from these altitudes, with some stabilization (with
either clothing design or a small drogue), until the para-
chute can be deployed.
K17577_C010.indd 186
The design of a parachute depends on many fac-
tors, including the range of speeds at which it will be
expected to work and the weight range of the person-
nel. Emergency escape parachutes tend to be smaller
and produce a higher descent rate than military para-
trooper canopies, because the rate of exposure is lower
and the requirement for paratroopers is usually a ‘fit-
to-fight’ rather than ‘fit-to-survive’ capability. Modern
parachute designs have increased performance, reduced
shock loading and greater stability than their prede-
cessors. Some parachutes are designed to take a degree
of damage during inflation by using stretch materials
and sacrificial gores for high-speed deployments with-
out a dramatic increase in descent rate. Parachutes are
designed with drive, which is achieved by allowing slots
in the rear of the parachute to spill air and push the
canopy forward, increasing parachute stability. Steering
of emergency escape parachutes can be a problem, espe-
cially for inexperienced parachutists, therefore, wher-
ever possible, training in the use of a parachute should
be provided. The issue of gliding and high-performance
ram-air parachutes to inexperienced personnel is not
recommended, because the chance exists of a very high
descent rate and, they may have restricted operating
ranges compared with round or aeroconical parachutes.
SUMMARY
●● A restraint system maintains the individual
within a known volume, so that the crash
dynamics are attenuated and movement of the
occupant restricted to avoid impacts with aircraft
structures.
●● A restraint system must be comfortable to wear,
have easy adjustment and must protect the occu-
pant from injury arising from multi-directional
forces.
●● Aircraft assisted escape systems must eject the
occupant clear of the aircraft at all speeds and
provide sufficient ground clearance to enable full
deployment and inflation of the main parachute
before ground impact.
●● Ejection seat exposed aircrew to forces that may
be at the limits of human tolerance.
●● Injury prediction models provide a method of
estimating the acceptability of acceleration in an
escape system.
REFERENCES
Lewis ME. Survivability and injuries from use of rocket-
assisted ejection seats: analysis of 232 cases. Aviation,
Space, and Environmental Medicine 2006; 77(9):
936–43.
17/11/2015 15:41
 Further reading  187

Manen O, Clément J, Bisconte S, Perrier E. Spine inju- FURTHER READING

ries related to high-performance aircraft ejections:
a 9-year retrospective study. Aviation, Space, and NATO Research and Technology Organization. Injury
Environmental Medicine 2014; 85(1): 66–70. Prevention in Aircraft Crashes: Investigative Techniques
Yoganandan N, Stemper BD, Baisden JL, et al. Effects and Applications. Lecture series 208. Neuilly-sur-Seine,
of acceleration level on lumbar spine injuries in France: NATO AGARD, 1998.
military populations. Spine Journal 2013; 26 pii:
S1529-9430(13)01448-4.

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K17577_C010.indd 188 17/11/2015 15:41

Human physiology in the thermal environment
GRAEME MAIDMENT AND MICHAEL TIPTON
Thermoreception 190
Heat exchange: The heat balance equation 191
Human thermal responses 192
Heat illness and cold injury 193
Humans are homeotherms, meaning that they attempt
to control their deep body temperature within close lim-
its in the face of wide variations in their activity and their
environment. Maintenance of a relatively stable internal
temperature allows the body’s enzymes, nerves and cell
membranes to perform optimally. When the stresses of the
environment exceed what the individual can cope with, the
individual becomes susceptible to thermal strain, which
may become manifest as an effect on their performance,
or more extremely as a variety of heat or cold related ill-
nesses or injuries. It is important to appreciate thermal
issues in the context of aviation for a number of reasons.
Thermal stress in the aircraft may have an adverse effect
on aircrew performance and hence potentially affect flight
safety or mission effectiveness. The ground crew who ser-
vice the aircraft may have to work outdoors in hot or cold
environments, and may be at risk from the effects of those
environments. Finally, there is always the potential that a
flight may suffer an emergency, and that the occupants
may be faced with surviving in whatever environment the
aircraft was flying over at the time; in these days of long-
distance flights, that could potentially include cold-water,
arctic, desert and jungle environments in a single flight.
This chapter considers the fundamentals of how individu-
als exchange heat with their environment, and their physi-
ological responses to thermal challenges. Chapter 12 more
specifically considers the sources of thermal stress in the
aviation environment, and the ways of potentially amelio-
rating its effects.
It is important to have a clear understanding of the dif-
ference between the terms heat and temperature. Heat is a
K17577_C011.indd 189
11
Water immersion 194
Acclimatization 196
References 196
Further reading 197
form of energy, associated with vibrational movement of
atoms or molecules; the SI unit of energy is the joule (J),
although heat may also be quantified in calories (cal). In
thermal physiology we are more usually concerned with
rates of heat production or exchange, and this is normally
expressed in watts (W); 1W = 1J/s. Temperature is measured
on a variety of linear scales (Celsius, Fahrenheit or Kelvin)
and is commonly thought of as a measure of ‘hotness’ or
‘coldness’, but is really a measure of the average kinetic
energy of a sample of particles in a particular substance; the
relationship between temperature and heat varies for dif-
ferent substances, according to their specific heat capacity,
which is defined as the amount of energy required to raise
the temperature of a unit mass of the substance by 1 degree
Kelvin. One important manifestation of the Second Law of
Thermodynamics is that heat will only flow from an area
of higher temperature to one of lower temperature, some-
times referred to as flowing down a temperature gradi-
ent; this concept is critical to an understanding of human
heat exchange.
It is a useful simplification when considering thermal
physiology to think of the body as being composed of a
‘core’ and a ‘shell’. The core consists of the deep body tissues,
principally the vital organs that are necessary for the main-
tenance of life. In humans the temperature of the core is
normally maintained at approximately 37°C ± 1°C across a
wide range of environmental temperatures, although there
is some variability in the temperature with time of day, the
menstrual cycle, activity and ingestion of food. Excursions
outside of this range may still be considered normal (e.g.
a higher core temperature following strenuous exercise)
189
17/11/2015 15:42
 190  Human physiology in the thermal environment
providing it does not cause symptoms of heat illness, it is
being regulated and it returns to normal on cessation of
exercise. In reality, no single core temperature exists; a core
temperature may be measured at a variety of sites includ-
ing the oesophagus, auditory canal and rectum. These all
vary slightly for different reasons; sublingual or axillary
measurements can be a much less accurate reflection of a
true core temperature. The shell is composed of the more
peripheral tissues, including the skin, subcutaneous fat
and muscles; the temperature of the shell fluctuates much
more widely than that of the core, both with changes in
the environment and changes in blood flow. In most situa-
tions a mean skin temperature of 32–34°C will be perceived
as comfortable, but there is much regional, temporal and
inter-individual variation.
THERMORECEPTION
The body is endowed with a rich supply of specialized
temperature-sensitive nerves called thermoreceptors.
While the conduction rate of all nerves is to some degree
dependent upon their temperature, thermoreceptors show
specific changes in their rate of discharge in predictable
ways in response to static temperatures, but importantly
they also exhibit highly sensitive dynamic responses in
their discharge rates to changes in their temperature. The
direction of these dynamic responses allows the distinc-
tion of two classes of thermoreceptor, known as warm
and cold receptors. Thermoreceptors are found centrally,
principally within the hypothalamus but also elsewhere in
the central nervous system and other central sites. They
are also widespread peripherally within the skin, where
they are able to sense rapid changes in the skin tempera-
ture and the environment. Their distribution in the skin
is non-uniform; cutaneous cold receptors outnumber
warm receptors by three to four times, and are located
more superficially in the skin than are warm receptors,
and they tend to be concentrated on the peripheries and
the face. Five times more cold points per square centi-
metre have been found on the fingers than on the broad
surfaces of the body, and four times more on the lips than
on the fingers. How the body transduces temperature
into nervous impulses is at present incompletely under-
stood, but is thought to occur via the transient recep-
tor potential (TRP) family of proteins; for example cold
reception is thought to be mediated at least in part by the
TRPM8 ionic channel. The afferent signals thus generated
are carried by both myelinated and unmyelinated fibres
to the spinal cord, and then relayed centrally, principally
via the contralateral spinothalamic tract to the thalamus
and other central sites, including some projections to the
somatosensory cortex. Integration of inputs from the cen-
tral and peripheral thermoreceptors appears to take place
principally within the hypothalamus.
The exact nature of what the body is attempting to con-
trol remains somewhat contentious. The most straight-
forward model is that of a homeostatic feedback loop,
K17577_C011.indd 190
whereby deviation in the core temperature or mean body
temperature from a set point (nominally 37°C for deep
body temperature) triggers effector responses which aim to
stabilize it at the set point. While this model may suffice
for many practical purposes, there are various observa-
tions that it is unable to explain. Far from being ‘set’, the
normal core temperature is quite variable, and in some
circumstances, such as fever, it deviates quite markedly
from 37°C. No anatomical structure has ever been identi-
fied that could serve as a set point reference, this model
ignores the importance of peripheral sensory inputs and,
perhaps most telling, it is unable to account for those sce-
narios where effector responses are brought into play that
are contrary to what changes in the core temperature
alone should dictate. Examples of such occurrences are
the observations that on sudden exposure to cold air, the
core temperature will often initially rise while at the same
time the individuals will exhibit responses appropriate to
the cold such as shivering, or that those with a core tem-
perature of 35°C will immediately stop shivering if placed
in water at 40°C, due to their raised skin temperature.
While a number of modifications have been proposed to
the simple set point model, including variability of the
set point, integration of peripheral and central inputs
and multiple set points, the model is still not universally
accepted. An alternative model proposes that reciprocal
inhibition of interneurons, as seen in other physiological
systems, between the sensory warm and cold inputs and
the heat-gaining or heat-losing effector pathways produces
a null zone of core temperature stability, without the need
for reference to a separate set point.
An alternative and fundamentally different model sug-
gests that the body is actually attempting to regulate its
heat content rather than its mean body temperature, and
that deep body temperature stability is a secondary effect of
this, rather than being the primary controlled variable. This
model suggests that the body uses feedback from heat flow
across the skin, as sensed by the integration of inputs from
thermoreceptors at different depths in the skin, and possi-
bly feedforward signals of metabolic heat production. While
this model is not widely accepted, it is able to explain the
time course of some observations that current temperature-
based models cannot.
While for many practical purposes the details of ther-
moreception and temperature control are not of great sig-
nificance, an understanding of the principles can be vital
to the appropriate design of cooling or heating garments or
developing strategies for cooling heat casualties. One such
principle is that core temperature usually takes precedence
over local shell temperature with regard to the control of
thermoregulatory effector responses. This enables, for
example, the cooling of a hot individual by hand immersion
in cold water (as blood flow to the hands is maintained by
vasodilatation), but not the rewarming of cold individuals
by immersion of the hands in hot water (as reduced blood
flow due to vasoconstriction prevents redistribution of heat
to the core).
17/11/2015 15:42

HEAT EXCHANGE: THE HEAT BALANCE
EQUATION
The human body is continually producing heat as a by-
product of metabolism. At rest, the basal metabolic rate for
most adults is in the range 60–100 W. Muscles are mechani-
cally inefficient, with approximately only 20–25 per cent of
their metabolic energy requirement being converted into
mechanical work, the remainder being liberated as heat; as
a consequence, physical activity can dramatically increase
heat production to well in excess of 1000 W. If the body’s
mean temperature is to remain constant, then its heat con-
tent must also be constant, and therefore its intrinsic heat
production must be balanced against heat exchange with
the environment. This concept is embodied in the heat
balance equation:
M ± W = E ± R ± C ± K ± S (all in Watts)
where M is metabolic energy utilization, W is external work,
R, C, K and E are the rates of heat exchange with the envi-
ronment by the mechanisms of radiation, convection, con-
duction and evaporation, respectively, and S is the rate of
heat storage in the body; homeothermy basically attempts
to modify the terms in this equation to make S equal to zero,
and therefore maintain a stable temperature.
Conduction refers to the transfer of heat energy within
or between solids, or at a solid–fluid interface, and reflects
transfer of heat energy between the constituent particles of
the material. Its magnitude is determined by the conduc-
tivity (or its inverse, insulation) of the material in question,
its surface area and thickness and the temperature gradi-
ent. In most circumstances it plays a small role in human
heat exchange, as the temperature gradient and surface area
involved are both usually small, but there may be some cir-
cumstances where this is not the case, such as immersion,
survival settings when the individual may be lying on cold
ground, or contact with very hot or cold surfaces which may
cause thermal injuries.
Convection is the exchange of heat by molecular mass
transfer in fluids; in contrast to conduction where heat is
transferred between particles, in convection the particles
move in response to heat-induced changes in the density of
the fluid, and carry the heat with them. As with conduction,
the thermal gradient and surface area are key determinants
of heat transfer by convection, as are the nature of the fluid
and its rate of movement. Two separate types of convection
are recognized: free (or natural) and forced convection. Free
convection occurs in still air, and is a consequence of the
heat from the body surface being transferred to the cooler
air immediately adjacent to it; this warmed air rises up over
the body, forming a boundary layer of rising but warmed air,
which carries heat upwards away from the body, while also
providing a degree of insulation. Forced convection occurs
when there is relative movement between the body and the
surrounding fluid; this may be the result of movement of
the fluid, for example wind in air or water currents during
K17577_C011.indd 191
Heat exchange: the heat balance equation  191
immersion, or may be the result of movement of the indi-
vidual through the air, for example flying in an aircraft with
an open cockpit or by running. Convection can be a major
pathway of human heat exchange, and in practice free and
forced convection often co-exist; the magnitude of forced
convection increases with the square-root of air velocity,
and becomes the dominant factor with wind-speeds greater
than 0.1–0.2 m/s.
All objects radiate heat in the form of a wave of energy
containing particles (photons) in the red–infrared range of
the electromagnetic spectrum, the exact wavelength being a
function of the temperature of the object. The energy from
these particles may be absorbed by the atoms of the sur-
faces they come into contact with, or they may be reflected,
depending on a property of the surface known as emis-
sivity; matt black surfaces tend to absorb radiation, while
light or shiny surfaces will reflect it. Radiation can occur
in a vacuum, and is therefore the only means of heat trans-
fer in space. The direction and magnitude of radiant heat
transfer depends on the temperature gradient between the
body and the surrounding mean radiant temperature of the
environment, and also the surface area available for radiant
heat transfer. It can be a potent pathway for heat gain or loss
in humans; in bright sunlight a significant amount of radi-
ant heat will be absorbed both directly from the sun and
reflected from surfaces, but on a cold clear night heat will
be lost by radiation.
Conduction, convection and radiation are sometimes
grouped together in the term ‘dry heat exchange’, and
they share the property that heat transfer by any of these
mechanisms takes place along a temperature gradient;
they can all therefore be pathways of human heat loss or
gain, depending on the relative temperatures of the skin
surface and the surrounding environment. In contrast,
evaporation is purely a method of heat loss and does not
directly depend upon a temperature gradient. Heat is
required for the process of converting a liquid into vapour
without changing its temperature; this heat is known as
the latent heat of vapourization, and for water is 2.4 kJ/g
(0.576 kcal/g). Humans use evaporation of sweat as a
potent means of losing heat, and as the process does not
rely on a temperature gradient, it is the only means of heat
loss open to the body when the environmental tempera-
ture exceeds the skin temperature. The rate of evaporation
is determined by the vapour pressure gradient between
the skin and the air, the latter being a function of the air
temperature and humidity. Air movement also plays a role,
as still air at the skin surface will become saturated with
water vapour and thus inhibit evaporation. The surface
area and degree of skin wetness are also determining fac-
tors. To remove heat, the sweat must evaporate; if it runs
off the skin, or is wiped off, it will not contribute to heat
loss. In addition to the skin, heat is lost by evaporation in
the respiratory tract, even in the cold, as the relatively dry
inspired air is brought up to body temperature and satura-
tion levels during inspiration, and then exhaled, resulting
in both heat and water loss.
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 192  Human physiology in the thermal environment
HUMAN THERMAL RESPONSES
While the physiological thermal responses of the body
are of importance and will be considered in some detail,
by far the greatest impact on human thermoregulation is
achieved by behavioural responses. These include a wide
variety of conscious actions that alter heat exchange, and
include such things as changing the amount of clothing
being worn, adjusting posture (and therefore effective sur-
face area for heat exchange), seeking shelter, or turning on
heating or air conditioning systems. What allows humans
to make these responses is their conscious perception of
their thermal comfort, particularly in dynamic (chang-
ing) environments. In contrast to most other autonomically
regulated body functions, we are conscious of our degree of
thermal comfort, and this allows us to initiate appropriate
behavioural responses.
Skin, fat and unperfused skeletal muscle are all good
thermal insulators, and transfer of heat from the body core
to the skin surface occurs much more quickly by forced con-
vection in the blood stream than by conduction through the
tissues. The body uses these facts to regulate heat exchange
by altering skin blood flow; the range of temperatures over
which thermoregulation is achieved solely by this means,
and thus without recourse to energy or fluid-expending
mechanisms, is known as the ‘thermoneutral’ or ‘vasomo-
tor’ zone. During cold exposure, as a result of falling skin
temperature, augmented by falling deep body temperature,
the hypothalamus triggers a noradrenergic sympathetically
mediated peripheral vasoconstriction, which dramatically
reduces skin blood flow to as little as 20 mL/min. Peripheral
blood flow is also reduced due to a cold-induced increase
in blood viscosity. The skin temperature falls towards the
environmental temperature, thus reducing the thermal gra-
dient between the skin and the environment, and hence the
rate of heat loss from the body. In this way the body will
‘sacrifice’ the extremities that are dependent on blood flow
to maintain their function, in order to preserve and pro-
tect deeper, more critical tissues. The effective interposition
of the insulating tissues of the shell offsets the increased
thermal gradient between the core and the skin. While the
insulation provided by fat, which generally has minimal
vasculature, remains relatively constant, approximately
70 per cent of the insulation of the shell at rest is provided by
unperfused skeletal muscle. As muscle blood flow increases
dramatically with muscle activity, including both exercise
and shivering, the effective insulation provided by muscle
decreases in these circumstances.
On exposure to a warm environment, the converse occurs.
A reduction in sympathetic stimulation and active vasodila-
tory mechanisms cause peripheral vasodilatation, resulting
in an increase in skin blood flow, potentially up to 3 L/min.
The extremities are richly endowed with specialized arte-
riovenous anastomoses, whose opening greatly increases
blood flow through the limbs. Vasodilatation allows blood
to bypass the insulating shell tissues, and the blood trans-
ports heat from the body core by forced convection to the
K17577_C011.indd 192
skin. The skin temperature rises, and providing the air tem-
perature is below the body temperature, this increases the
temperature gradient for heat loss from the body surface
to the environment. High skin blood flow places a strain
on the cardiovascular system and is associated with pool-
ing of blood in the skin and subcutaneous vascular beds.
This results in reduced cardiac filling and stroke volume,
and consequently a higher heart rate is required to maintain
cardiac output. The redirection of blood from the viscera to
the skin and muscles during exercise in the heat can con-
tribute to the development of heat illness.
On sudden exposure of the peripheries to a cold environ-
ment, vasoconstriction causes the exposed skin tempera-
ture to fall exponentially to approximate the environmental
temperature. However, in most individuals after a period
of time the peripheral skin temperature paradoxically rises
temporarily, potentially by as much as 10°C, before falling
again, and the cycle repeating. This oscillation of periph-
eral skin temperature in the cold was first described by
Lewis (1930), and is sometimes described as the ‘hunting
response’ bearing his name, although it is now more usually
referred to as cold-induced vasodilatation (CIVD). CIVD
helps to maintain digital sensitivity and possibly manual
dexterity, and affords some protection to the extremities
against the development of cold injuries; this is of course
traded off against the fact that with each wave of vasodila-
tion, increased amounts of heat will be lost from the body.
The arteriovenous anastomoses appear to be the primary
structures underlying the phenomenon of CIVD, although
the exact mechanism remains incompletely understood;
various proposed mechanisms include axon reflexes, the
action of local vasodilatory substances, changes in local
sensitivity to noradrenaline or cold-induced fatigue of the
smooth muscle of the arteriovenous anastomoses, but none
of these mechanisms in isolation is able to account for all
the observed features of CIVD.
If the body’s temperature moves outside the range that
can be controlled by changes in blood distribution, active
fluid and substrate-dependent mechanisms are brought
into play. Sweating is the principal physiological method
by which humans attempt to dissipate excess heat in these
circumstances. Sweating relies on heat loss by evapora-
tion, and sweat is simply a means of wetting the skin, to
increase the vapour pressure gradient between the skin
and the environment. Sweat is produced in specialized
eccrine sweat glands; humans possess about 2.5  million
sweat glands, more than any other mammal, and the rela-
tive lack of body hair in humans makes heat loss by sweat-
ing more efficient. The sweat glands are distributed in
densities of 100 to 600 per square centimetre, with marked
regional variation between different skin sites, the great-
est densities being found on the palms and the soles. They
consist of a coiled gland situated deep in the dermis, which
is connected to a pore on the skin surface by a duct. Sweat
is formed in the coiled gland by diffusion of fluid from the
interstitial fluid into the duct; at this stage, sweat is approx-
imately isotonic with interstitial fluid.
17/11/2015 15:42

Within seconds of the commencement of exercise or
exposure to the heat, the hypothalamus stimulates the
sweat glands via cholinergic sympathetic efferents. The
sweat gland is surrounded by myoepithelial cells, and their
stimulation causes sweat within the gland to be propelled
through the duct to the skin surface. The cells lining the
duct have sodium–potassium exchange pumps within their
membranes, similar to those found in the renal tubules, and
as sweat transits through the duct to the skin, these pumps
actively withdraw sodium from the sweat so that it becomes
relatively hypotonic by the time it is secreted onto the skin
surface. As the sweat rate increases, the transit time in the
duct decreases, and so less sodium is reabsorbed, leading
to relatively greater sodium losses with high sweat rates.
Saturation of the skin leads to local inhibition of sweating, a
phenomenon known as hidromeiosis, most likely mediated
by osmotic occlusion of the sweat pores. Sweat rates of up to
about 2 L/hr can be attained, but a more realistic sustainable
sweat rate is about 1 L/hr. The latent heat of vapourization of
water means that if all the sweat were to evaporate, a sweat
rate of 1 L/hr would have the potential of removing approxi-
mately 700 W of heat from the body; as discussed, the rate
of evaporation is dependent on a number of environmen-
tal variables, and also critically on the nature of any cloth-
ing that is being worn, so this theoretical rate of heat loss
through sweating is unlikely to often be attained in practice.
The mechanical inefficiency of muscle has already been
mentioned; the body uses and accentuates this inefficiency
as a means of generating heat in the cold by shivering.
Shivering is the automatic asynchronous rhythmic contrac-
tion of muscle motor units; as little external work is done
in shivering, most of the energy expended by the muscle
is liberated as heat. The mean frequency of contraction is
approximately 9 Hz, similar to that of physiological tremor
of the extremities. Skin temperature plays a major role in
initiating shivering, explaining why it is seen early in the
response to cold exposure. Frank shivering is preceded by
an increase in muscle tone, which itself increases metabolic
heat production. As cold exposure continues, true shiver-
ing develops, starting in proximal muscle groups such as the
masseters, trapezius and pectorals before extending to the
muscles of the trunk and finally the limbs; it has been sug-
gested that this pattern of recruitment may maximize heat
production in the trunk while minimizing heat loss from
the limbs. Shivering is initially intermittent but later, as
deep body temperature falls, becomes continuous. Maximal
shivering can increase metabolic heat production to five or
six times the resting rate, but shivering at this intensity is
uncomfortable, fatiguing and is likely to interfere with vol-
untary movements, which may be critical in a cold survival
setting. With more profound falls in core temperature the
central drive for shivering is attenuated, possibly related to
glycogen depletion. Cessation of shivering in a hypothermic
individual who remains exposed to the cold heralds a rapid
and potentially fatal phase of body cooling.
A separate mechanism of physiological heat production
is termed non-shivering thermogenesis. This refers to heat
K17577_C011.indd 193
Heat illness and cold injury  193
production in a specialized form of fat, known as brown
adipose tissue. The pathway of oxidative phosphorylation in
brown adipose tissue is modified such that heat is generated
rather than adenosine triphosphate being synthesized, and
brown adipose tissue can therefore be regarded as a specific
heat-generating tissue. It is of definite thermoregulatory
importance in small mammals and neonates; its amount
decreases with age, and its significance in adult humans is less
clear, although small amounts of active brown adipose tissue
have been demonstrated in adults (Tews & Wabitsch 2011).
HEAT ILLNESS AND COLD INJURY
When the stress of the thermal environment exceeds what
the combination of available behavioural and physiological
responses can counteract, the body runs the risk of being
subject to a variety of pathological processes. In the heat,
these may take the form of local effects, such as sunburn or
the rash of miliaria (‘prickly heat’), but of greater concern
is the spectrum of conditions generically termed heat ill-
nesses. These conditions go under a variety of names, and
essentially form a continuum from relatively innocuous
heat cramps and heat syncope, through heat exhaustion to
potentially life-threatening heat stroke. Brief summaries of
these conditions are presented in Table 11.1, but it is beyond
the scope of this text to go into their specific treatment; for
more information the reader is referred to the further read-
ing section at the end of this chapter.
Cold environments pose a threat both of localized cold
injury and of generalized heat loss from the body, poten-
tially leading to hypothermia. Hypothermia is defined as a
core temperature of less than 35°C; as the deep body tem-
perature drops, cellular metabolism, blood flow and neural
activation are all affected. The early signs and symptoms
of mild hypothermia are mainly related to changes in ner-
vous system function, and include ataxia, dysarthria, lack
of coordination and subtle changes in personality; the
individual may fumble, mumble, stumble and grumble. As
hypothermia becomes more profound shivering ceases, the
level of consciousness decreases and respiratory and heart
rates slow. Most deaths result from spontaneous ventricular
fibrillation, but the reduction in metabolism associated with
hypothermia can, depending on the rate of cooling and the
maintenance of cardiac and respiratory function, provide
some protection from the effects of hypoxia, and even very
profoundly hypothermic individuals may recover with
appropriate treatment; the case of a hypothermic casualty
who made a full recovery from a core temperature of 13.7°C
has been reported (Gilbert et al. 2000). This mechanism may
also explain some of the ‘miraculous’ recoveries of individ-
uals, usually children, submerged for up to one hour under
water (Tipton & Golden 2011).
Peripheral cold injuries may be either freezing or non-
freezing in nature. Human tissue freezes at around –0.55°C,
and true freezing of the tissues is termed frostbite; a freez-
ing cold injury that resolves with no residual symptoms
within 30 minutes of commencing rewarming is known as
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 194  Human physiology in the thermal environment

Table 11.1  Spectrum of heat illnesses

Condition Description
Heat cramps Usually occur in the specific muscles exercised due to an imbalance in fluid and electrolyte
concentrations and low energy stores. Core temperature remains normal. Can be prevented by
appropriate rehydration strategy, and treated by stretching and massage
Heat syncope Faint caused by a combination of lowered circulating blood volume as a consequence of dehydration
and increased thermal demand for peripheral blood flow. Can be exacerbated by venous pooling in
the lower limbs due to being stationary and upright. Heart rate increases, but cerebral blood flow
falls, leading to syncope. Casualty should be kept horizontal, removed to a cool environment and
rehydrated
Heat exhaustion Defined as an inability to continue exercising in the heat. Usually seen in unacclimatized individuals.
Caused by ineffective circulatory adjustments and reduced blood volume. Characterized by
breathlessness, hyperventilation, weak and rapid pulse, hypotension, dizziness, headache, flushed
skin, paradoxical chills, irritability and restlessness. Deep body temperature is raised but sweating
persists and there is no organ damage. Heat-exhausted individuals should stop exercising, lie down
(ideally out of the heat), control breathing if hyperventilating and rehydrate. Heat exhaustion can
progress to more severe heat illness
Heat stroke Medical emergency resulting from thermoregulatory failure due to a very high deep body
temperature (usually >40.5°C), with associated central nervous system dysfunction. Characterized
by confusion, absence of sweating with hot, dry skin and circulatory instability. Death can occur
from circulatory collapse and multi-organ failure. Along with maintenance of the airway, breathing
and circulation, immediate cooling is the main priority of treatment, as mortality is related to
degree and duration of hyperthermia

frostnip. The tissue damage of freezing cold injuries is pro-
duced by a combination of ice crystal formation, which can
produce direct mechanical damage to the cell (rapid freez-
ing) or exert osmotic effects on intracellular and extracel-
lular fluid balance (slower freezing), and a reduction in local
blood flow, with the potential for thrombosis and ischaemia.
Frostbite cannot occur in air temperatures above freezing,
and the risk is low above an air temperature of –7°C, irre-
spective of wind-speed, but it increases dramatically below
this temperature. Direct skin contact with metals or with
fluids with low freezing points can produce freezing cold
injuries in a matter of seconds.
Non-freezing cold injury represents a spectrum of con-
ditions, ranging from the severe injury that is sometimes
known as trench foot to conditions such as perniosis and
chilblains. Non-freezing cold injury is caused by prolonged
exposure to cold temperatures (0  to approximately 15°C);
concomitant exposure to wetness is common, but is not a
prerequisite. The risk is increased with coexistent dehydra-
tion and factors that diminish peripheral blood flow such
as tight footwear, prolonged upright posture and stress. The
underlying pathology appears to be related to prolonged
vasoconstriction causing endothelial damage to the vessels
which supply peripheral nerves or the microvasculature.
Typically the condition passes through four clinical phases,
principally comprising loss of sensation, cyanosis, painful
hyperaemia and finally a phase characterized by persistent
cold hypersensitivity, pain and increased sweating (hyperhi-
drosis) in the injured area. Again the reader is referred to the
further reading section for recommendations regarding the
management of hypothermia and peripheral cold injuries.
WATER IMMERSION
Flying over water always carries the potential risk that an
emergency may result in the occupants having to survive in
the water, and therefore it is appropriate to consider the spe-
cific physiological challenges associated with water immer-
sion. Some of these relate to the thermal properties of water,
while others are a consequence of the hydrostatic pressure it
generates, or of its motion.
Head-out immersion in water, regardless of its tempera-
ture, causes profound cardiovascular effects, due to the
density of water and the hydrostatic pressure that it exerts
on the immersed body. As the airway is in continuity
with the air at atmospheric pressure, the squeezing effect
of water on the thorax produces a negative transthoracic
pressure of approximately 14.7 mmHg, resulting effec-
tively in negative pressure breathing. Combined with the
hydrostatic pressure of the water preventing venous pool-
ing in the lower limbs, this results in a central redistribu-
tion of the circulating blood volume, which can increase
by 700 mL within a few heart beats following immersion.
This enhances diastolic filling and raises right atrial pres-
sure; there is a consequent increase in cardiac output of
32–66 per cent. The body senses this central shift in blood
as representing fluid overload, and initiates a number of
renal responses, including diuresis, natriuresis and kali-
uresis. Diuresis is usually manifest by the first or second
hour of immersion, and can result in urine output reaching
350  mL/hr, with the potential to exacerbate dehydration
or, if the individual is forced to void their bladder while
wearing an immersion suit, degrade the insulation of their

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clothing. Cold-induced peripheral vasoconstriction can
also cause a profound diuresis, by a mechanism similar to
perceived fluid overload.
Air and water have markedly different thermal charac-
teristics. Because of differences in the specific heat capac-
ity and density of the two mediums, water has a very much
greater cooling power than air; at 37°C the volume-specific
heat capacity of water is 3431  times that of air. In resting
individuals, the mean thermoneutral temperature for air
averages approximately 26–28°C, compared with 35°C for
water. Core temperature falls approximately two to five
times faster during cold-water immersion compared with
air at the same temperature, and the rapid fall in skin tem-
perature associated with cold-water immersion can elicit
various reflexes which are not seen with cold air exposure.
It should be noted that there is no universally accepted
definition as to what temperature constitutes ‘cold’ with
regard to water; 10°C or 15°C have both been suggested.
It is helpful to consider the physiological responses
to sudden immersion in cold water as occurring in four
phases, related to the duration of immersion (Golden &
Tipton 2002). The initial phase occurs in the first two to
three minutes following immersion, and can be thought of
as a ‘cold shock’ response, elicited by the rapid fall in tem-
perature of the peripheral thermoreceptors, principally
those of the torso. The response is multifaceted, and con-
sists of a profound inspiratory gasp, during which the indi-
vidual may inhale substantial quantities of water if their
head is submersed, uncontrollable hyperventilation (which
may induce hypocapnia), hypertension and increased
cardiac workload.
Cold stimulation of the face, particularly the skin
around the eyes, can induce a separate vagally mediated
reflex known as the diving reflex. This is characterized by
bradycardia and apnoea, and thus opposes the effects of the
cold shock. It has been postulated that the conflicting sym-
pathetic and parasympathetic responses of the cold shock
and diving reflexes (‘autonomic conflict’) may be capable
of inducing arrhythmias which may be incapacitating, thus
increasing the risk of drowning, or may indeed be fatal in
their own right.
The second phase of responses to cold immersion is char-
acterized by increased cooling of the tissues of the shell, and
in particular the nerves and muscles of the limbs, which are
particularly prone to cooling both as a result of peripheral
vasoconstriction and due to their cylindrical shape hav-
ing an inherently high surface area-to-volume ratio. Nerve
conduction is slowed by 10 m/s per 10°C fall in local tem-
perature, and maximum muscle power falls by 3  per cent
per 1°C fall in muscle temperature. These effects combine
to reduce manual dexterity, speed of movement, strength
and mechanical efficiency. Manual tasks which may be
essential for survival may become impossible within as
little as 10  minutes of immersion. Furthermore, while the
intense hyperventilation of the cold shock response sub-
sides over the first few minutes of immersion, breathing
tends to remain erratic, and if the individual is not wearing
K17577_C011.indd 195
Water immersion  195
a buoyancy aid, but is relying on the active movements of
swimming or treading water to remain afloat, the effects
of cooling on the limbs make it increasingly difficult to
coordinate these movements with the pattern of breath-
ing, making inhalation of water more likely. Shivering may
also interfere with purposeful swimming movements. The
posture of the individual is likely to become more upright,
increasing their sinking forces, and potentially inducing a
vicious circle of panic and purposeless movements that can
ultimately end in drowning. It is likely that the majority of
cold-water immersion deaths occur during these first two
phases of immersion.
The third phase, which generally does not become sig-
nificant until at least 30 minutes of immersion, is associated
with progressive cooling of the body core and ultimately
with the effects of hypothermia. The rate of body cooling
is largely dependent upon the water temperature and the
individual’s insulation, which includes both the intrinsic
insulation provided by the tissues of their shell and the
external insulation of the clothing they are wearing, but a
large number of other factors come into play including their
sex, posture, the sea state and exercise. It has long been advo-
cated that movement in the water, while generating heat by
metabolism, will increase the rate of fall of core temperature,
both due to a reduction in the insulation of muscles as they
are perfused and increasing convective heat loss from the
body by the agitation of the water. While this may be true for
some minimally clothed individuals, recent evidence sug-
gests that it may not be the case for all individuals (Tipton
& Bradford 2014), and especially those wearing appropriate
immersion protective garments in very cold water (Faerevik
et al. 2010). If exercise is necessary it is best to use leg-only
exercise as the arms are particularly susceptible to heat
loss in cold water. Other possible adverse effects of longer
durations of immersion include diuresis, non-freezing cold
injury and motion sickness due to the motion of the sea. The
mechanisms of motion sickness are discussed in Chapter 52,
but from an immersion survival standpoint it can produce
adverse effects, including peripheral vasodilation which will
increase heat loss, vomiting which may contribute to dehy-
dration and electrolyte disturbances, and a deleterious effect
on morale and the will to survive.
The final phase to consider is what may be termed the
‘circum-rescue’ phase. For centuries, instances have been
recognized of individuals surviving in the water, only to
collapse and possibly die at or around the time they are
pulled from the water. There are a number of possible physi-
ological explanations for this phenomenon. Two mecha-
nisms may account for collapse immediately prior to rescue.
If a survivor is hypothermic, the associated bradycardia
and increased blood viscosity may result in poor coronary
artery perfusion; increased physical activity, for example to
aid their rescue, may increase the cardiac work rate, leading
to coronary insufficiency. Conversely, relief at the anticipa-
tion of imminent rescue may lead to a reduction in sympa-
thetic drive, causing a fall in blood pressure and a reduction
in coronary perfusion.
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 196  Human physiology in the thermal environment
Perhaps of more importance is the collapse that can be
seen when the survivor is pulled from the water. The tra-
ditional method of winching immersion victims from the
water was by means of a strop placed under their armpits,
such that they were winched up in a vertical posture. The
transition from a horizontal or oblique posture in the water
to a vertical one, combined with the sudden loss of the
hydrostatic compression of the lower body and re-introduc-
tion of the full effects of gravity as the individual is winched
out of the water, can result in a reduction in venous return
and cardiac output, a situation that may be compounded by
cold-induced blunting of the baroreceptor reflex. The hazard
is ameliorated by ensuring that survivors are winched out
of the water in as close to horizontal a posture as possible,
particularly for long-duration lifts such as into a helicopter
or a high-sided ship, and that they are then transported in a
head-down posture (e.g. head-forward in a rescue helicop-
ter and head-aft in a fast rescue craft). Collapse following
rescue could be caused by alveolar damage due to aspiration
(previously called ‘secondary drowning’), peripheral dila-
tion during rewarming causing a relative hypovolaemia, or
haemorrhage from internal trauma which has previously
been masked by cold exposure.
ACCLIMATIZATION
Exposure to a hot environment induces a number of physi-
ological changes that potentially reduce the degree of heat
strain experienced by an individual in that environment
and improve their physical performance. These changes
are termed acclimatization and include increased sweat-
ing, a decreased temperature threshold for the initiation
of sweating, decreases in the concentration of sodium
and chlorine in the sweat, an increased circulating blood
volume and a reduction in heart rate. Acclimation is the
term used when similar changes are induced by artificial
manipulation of the body temperature, such as in a labora-
tory setting. It should be noted that acclimatized individu-
als will produce more sweat than unacclimatized people
in the same environment, and that therefore their require-
ment for water to maintain fluid balance will be increased
rather than decreased compared with their unacclimatized
peers. The majority of the improvement in performance is
attained during the first seven days of exposure to the hot
environment, with the maximum improvement occurring
10–14  days after the commencement of exposure; a few
days less time is required for those with higher aerobic fit-
ness. Physical exercise in the heat optimizes the develop-
ment of acclimatization, but is not an absolute prerequisite.
Unless the individual continues to be exposed to activity
in the heat, their changes of acclimatization will start to be
lost after about a week, and will be fully lost by a month
(Pandolf 1998).
While the changes of acclimatization to the heat are rela-
tively well characterized, the existence of true cold acclima-
tization is rather more contentious; indeed the ingenuity
of humans is such that normally, if possible, they do not
K17577_C011.indd 196
allow themselves to be exposed to the cold environment
for prolonged periods at all. There are broadly three pos-
sible mechanisms of potential whole-body cold acclimatiza-
tion, namely tolerance of a lower body temperature thereby
reducing heat loss, enhancing insulation, or increasing
metabolic heat production. While there is some evidence
of cold adaptation in some specific populations, the results
are not compelling. Repeated cold exposure does appear to
be able to enhance the CIVD response, and the cold shock
responses and shivering during cold-water exposure can be
attenuated by a relatively small number of short cold-water
immersions (Tipton et al. 2000).
SUMMARY
●● Humans attempt to maintain their deep body
temperature around 37°C over a wide range
of environments. However, the core tem-
perature is not a fixed constant, and devia-
tions from 37°C may in some circumstances be
physiologically normal.
●● The body exchanges heat with the environment
by conduction, convection, radiation and evapo-
ration; the first three mechanisms rely on a tem-
perature gradient, but evaporation is driven by
a vapour pressure gradient. To maintain a stable
mean body temperature, the body must balance
its metabolic heat production with heat exchange
with the environment.
●● The physiological mechanisms of heat regulation
include metabolic heat production, shivering,
non-shivering thermogenesis, sweating and regu-
lation of blood flow, but behavioural responses
have a much greater impact on heat balance than
physiological ones.
●● Significant imbalances between heat production
and heat exchange can lead to a spectrum of heat
illnesses, cold injuries or hypothermia.
●● Exposure to a hot environment can induce physi-
ological changes of acclimatization which reduce
thermal strain and improve physical perfor-
mance, but which do not reduce the requirement
for water to maintain fluid balance.
●● Immersion in cold water imposes a number of
potentially deleterious physiological effects on
the body, and heat losses in water are very much
greater than in air at the same temperature.
REFERENCES
Faerevik H, Reinertsen RE, Giesbrecht GG. Leg exercise
and core cooling in an insulated immersion suit under
severe environmental conditions. Aviation, Space, and
Environmental Medicine 2010; 81(11): 993–1001.
17/11/2015 15:42

Gilbert M, Busund R, Skagseth A, Nilsen PA, Solbø JP.
Resuscitation from accidental hypothermia of 13.7°C
with circulatory arrest. Lancet 2000; 355: 375–6.
Golden F, Tipton M. Essentials of Sea Survival.
Champaign, IL: Human Kinetics; 2002.
Lewis T. Observations upon the reactions of the human
skin to cold. Heart (British Cardiac Society) 1930; 15:
177–208.
Pandolf KB. Time course of heat acclimation and its decay.
International Journal of Sports Medicine 1998; 19:
S157–S160.
Tews D, Wabitsch M. Renaissance of brown adipose tis-
sue. Hormone Research in Paediatrics 2011; 75: 231–9.
Tipton MJ, Bradford C. Moving in extreme environ-
ments: open water swimming in cold and warm water.
Extreme Physiology & Medicine 2014; 3: 12.
Tipton MJ, Golden FStC. Decision-making guide for the
search, rescue and resuscitation of submerged (head
under) victims. Resuscitation 2011; 82: 819–24.
K17577_C011.indd 197
Further reading  197
Tipton MJ, Mekjavic IB, Eglin CM. Permanence of the
habituation of the initial responses to cold water
immersion. European Journal of Applied Physiology
2000; 83: 17–21.
FURTHER READING
Armstrong LE (ed). Exertional Heat Illnesses. Champaign,
IL: Human Kinetics; 2003.
Cheung SS. Advanced Environmental Exercise Physiology.
Champaign, IL: Human Kinetics; 2010.
Giesbrecht GG, Wilkerson JA. Hypothermia, Frostbite and
Other Cold Injuries. Seattle, WA: The Mountaineers
Books; 2006.
Ministry of Defence, UK. Climatic Illness and Injury in the
Armed Forces: Force Protection and Initial Medical
Treatment. Joint Services Publication 539; September
2012.
Parsons K. Human Thermal Environments, 2nd edn.
Oxford: Taylor and Francis; 2003.
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Thermal protection and survival
MICHAEL J. A. TRUDGILL AND GRAEME MAIDMENT
Heat stress 199
Cold stress 204
Fire protection 205
The aviation environment provides some thermal
aspects which, if not absolutely unique, can be extremely
challenging for the aviator. Aviation is a global activ-
ity, and spans the full range of climatic conditions.
Furthermore, as one ascends, the air temperature gen-
erally falls at a rate of approximately 2°C per 1000  feet,
up to the isothermal layer of the atmosphere. Exposure
to cold at altitude can thus be a very significant prob-
lem for the occupants of aircraft with open cockpits or
helicopters that are required to fly with their doors open
for operational reasons, and for high-altitude balloonists
or parachutists. However, heat stress is a more common
problem than cold stress, as a result of hot operating
environments, the various sources of heat in the cockpit
and the many layers of specialized clothing that military
aviators may have to wear. The ground environment may
be a source of heat stress not only for the ground sup-
port personnel, but also for the aircrew during their pre-
flight preparations and standby. The high-speed nature
of modern flight means that in a matter of hours indi-
viduals may be transported from one thermal environ-
ment to a completely different one, to which they may
not be acclimatized. Finally, if an emergency occurs in
flight, the aircraft occupants may be faced with having
to survive in whatever environment the aircraft was fly-
ing over at the time of the emergency.
This chapter considers the sources of heat and cold stress
in aviation, the means of quantifying their effects and the
various ways of attempting to combat them, both during
routine and emergency situations.
K17577_C012.indd 199
12
General survival principles 206
References 211
HEAT STRESS
Sources of heat stress in aviation
Heat in the cockpit may be derived from the metabolic heat
production of the occupants, from the aircraft, or from the
environment; the relative contribution of these different
sources will depend upon the nature of the external envi-
ronment, the type of aircraft, the phase of flight and the
nature of the activities of the occupants.
Metabolic heat production at rest for most individu-
als is approximately 60–100 W. Any physical activity will
increase this level of heat production. Donning military air-
crew flying clothing, which can be heavy, stiff and awkward
to get into, is a physically demanding procedure and has
been shown to increase oxygen uptake (a surrogate for met-
abolic rate) potentially by more than three times the resting
level (Withey 1974). Walking to the aircraft in flying cloth-
ing produced an oxygen uptake of 19–28  per cent greater
than the equivalent activity wearing normal outdoor cloth-
ing, and climbing into the cockpit and strapping-in also
generate significant amounts of heat. Once airborne, fly-
ing straight and level requires little more than basal energy
expenditure, but flying a fast jet in turbulent air at low level
and, more particularly, performing air combat manoeuvres,
with the associated requirement to maintain a comprehen-
sive look-out and perform anti-G straining manoeuvres,
very significantly increases aircrew heat production. The
energy expenditure of helicopter pilots is relatively modest
during flight, with studies showing figures between 67 W
199
17/11/2015 15:45
 200  Thermal protection and survival
at rest to up to 320 W flying in the hover (Staab et al. 1998).
However, many helicopter crew members, particularly
rear crew personnel, may be required to perform physical
tasks both within the aircraft and while dismounted on the
ground; a recent study of helicopter crew personnel operat-
ing in hot environments showed peak energy expenditure
of up to 1750 W during such activities (Tharion et al. 2012).
Clearly, the ambient environment is a potential source of
heat stress, particularly in those aircraft such as helicopters
where the occupants may be directly exposed to the envi-
ronment. In bright sunlight, or when flying above cloud,
radiant heating through the cockpit transparency can be a
potent source of heat, which is exacerbated by the so-called
greenhouse effect. Radiant heat from the sun is able to pen-
etrate through the cockpit transparency, and heat up the
structures within the cockpit; these structures also radiate
heat, but at much longer infrared wavelengths, which are
unable to pass through the transparency, thus effectively
trapping the heat within the cockpit.
Movement of the aircraft through the air generates fric-
tional heating of the surface of the aircraft; the greater the
speed and the denser the air, the greater this aerodynamic
heating will be. As an extreme example, the SR-71  flying
at Mach 3  could attain surface temperatures in excess of
400°C. Some of the heat from the frictional heating of the
airframe will be conducted to the cockpit, where it has the
potential to add to the thermal burden of the aircrew.
The aircraft engines may in some circumstances provide
a direct source of heat. For example, in some helicopters, the
loadmaster operating at the open door may be subjected to
heat from the engine outlets.
Modern aircraft contain many heat-generating avionic
systems, which are also a potent source of heat. In certain
circumstances, the total thermal burden in the fast-jet cock-
pit can exceed 12 kW. The relative lack of vapour permeabil-
ity of some items of flying clothing may restrict the ability of
aircrew to lose heat by evaporation, and ensuring adequate
fluid intake may be difficult during flight, adding further to
the potential for heat strain. In fast-jets, the most thermally
stressful part of the sortie is often the preflight phase, and
particularly the phases of taxiing and cockpit stand-by on
the ground, when the canopy is closed but the cabin con-
ditioning system, which usually relies on the engines oper-
ating at higher power settings, may be relatively inefficient.
Quantification of the thermal environment
Consideration of the heat balance equation, discussed in
Chapter 11, reveals that six fundamental parameters com-
bine to determine how thermally stressful an activity will
be in a particular environment. Four of these relate to the
environment itself; these are the ambient temperature of
the air, the wind speed, the mean radiant temperature of
the environment and the humidity of the air. The other two
parameters are particular to the individual and consist of
the metabolic heat production of the individual (which is
largely a function of their activity or workload) and the
K17577_C012.indd 200
nature of the clothing they are wearing. Whether the indi-
vidual is acclimatized to the environment may also need to
be considered.
The way in which these parameters combine is com-
plex. Furthermore, the definition of what is acceptable to
the individual is wide and could range from thermal com-
fort (or perhaps more specifically the absence of a percep-
tion of thermal discomfort) through to limiting the time of
exposure to an environment which has the capacity to cause
severe heat illness. In order to aid in the assessment of par-
ticular environments, a wide variety of heat-stress indices
have been developed. These are mathematical equations,
models or algorithms that take some or all of the six funda-
mental parameters as their inputs, and generate a single fig-
ure output which indicates the degree of heat strain likely to
be experienced by an individual. A very wide variety of such
indices, of greatly varying complexity, has been derived,
and each has its strengths and weaknesses for particular
situations. It is beyond the scope of this text to attempt to
describe the full range of heat stress indices that exist, but
a small number which are of greatest relevance to aviation
will be discussed.
Perhaps the most widely applied heat stress index is
the wet-bulb globe temperature (WBGT) index (Yaglou &
Minard 1957). This was originally designed in an attempt
to reduce the number of heat-related casualties during mili-
tary training. The WBGT is derived as the weighted mean
of the wet-bulb (Twb), globe (Tg) and dry-bulb (Tdb) tempera-
ture measurements of the environment:
WBGT = 0.7Twb + 0.2Tg + 0.1Tdb
The dry-bulb temperature is the ambient air temperature,
as measured by a traditional thermometer. The wet-bulb
temperature is measured by a thermometer whose mer-
cury reservoir, or bulb, is covered by a wetted wick; water
will evaporate from this, dependent upon the vapour pres-
sure of the ambient air, and will cool the bulb, producing a
depression in the wet bulb temperature compared with the
dry bulb, as a function of the humidity of the air. In the
WBGT, the wet bulb is natural, or unventilated. This means
that the air is not blown over it artificially by a fan, as occurs
with some temperature measuring devices, and therefore
the wet-bulb temperature will be affected by the wind speed
as well as the humidity of the air. The globe temperature is
measured by a thermometer at the centre of a matt black
15 cm hollow copper sphere and provides an indirect mea-
sure of the radiant temperature of the environment. Thus,
the WBGT includes terms which are affected by all four of
the fundamental environmental parameters.
The measurements that allow calculation of the WBGT
are made in the environment in which the activity will
take place. The equation does not take into account either
the metabolic workload of the individual or their cloth-
ing, or indeed the acclimatization status of the individual,
and hence to be meaningful the WBGT value must be
interpreted in the light of these variables. ISO 7243 (1989)
17/11/2015 15:45

tabulates WBGT reference values for various metabolic
rates. In the United Kingdom defence services, Joint
Services Publication 539 provides a table of WBGT thresh-
olds for assorted military ground tasks for acclimatized or
unacclimatized individuals, based on individuals wearing a
single layer uniform with their sleeves rolled up and with-
out helmets, which are valid for one hour exposures with
30 minutes of rest after the activity. The quoted threshold
values for acclimatized individuals range from a WBGT
threshold of 34 for low intensity work to a WBGT of 20 for
extreme activity, and are correspondingly lower for unac-
climatized individuals. A shortcoming of the WBGT is that
it relies heavily on the ability of the individual to evaporate
sweat, and therefore it is less applicable when vapour-imper-
meable clothing is being worn. Since this includes many
of the specialised garments military aviators may have to
wear, such as anti-G trousers, chest counter-pressure gar-
ments, body armour or chemical, biological, radiation or
nuclear protective garments, the applicability of the WBGT
in the military cockpit may be questionable. Furthermore,
the WBGT is ineffective when the dry bulb temperature
exceeds 40°C and, while integrated measuring devices are
available, the requirement for a globe temperature reading
can make assessment cumbersome. It has been proposed
that the modified Discomfort Index correlates very closely
with the WBGT, and is easier to use in practice (Epstein &
Moran 2006). It is calculated by the equation:
DI = 0.5Twb + 0.5Tdb
An index that was specifically derived for use in military fast
jets is the fighter index of thermal strain (FITS) (Nunneley
& Stribley 1979). FITS was designed to predict the thermal
strain that would be experienced in a fast jet cockpit during
low-level flight from measurements made on the ground at
the airfield from which the aircraft is operating. It thus dif-
fers significantly from the WBGT in that measurements are
not actually made in the specific environment of interest,
namely the cockpit. FITS was derived on the assumption
that there is a predictable first-order relationship between
the WBGT in the cockpit during low-level flight and the
WBGT on the ground and that in full sunlight the globe
temperature exceeds the dry-bulb temperature by 10°C,
both in the cockpit and on the ground. FITS is calculated as:
FITS = 0.83Tpwb + 0.35Tdb + 5.08
Tpwb being the psychometric, or artificially ventilated, wet
bulb temperature. A separate equation for FITS in overcast
conditions has also been derived.
Values of FITS between 32 and 38°C place the index in
the caution zone, in which it is advised that ground opera-
tions (including preflight inspections and cockpit standby)
be limited to 90 minutes, that aircrew are allowed at least
two hours recovery time post-sortie and that adequate
hydration is available during recovery. A FITS greater
than 38°C is regarded as being in the danger zone, and
K17577_C012.indd 201
Heat stress  201
recommendations include cancelling low-level flights, lim-
iting ground operations to 45 minutes and, if possible, hav-
ing fluids available in flight.
Effects of heat stress on performance
With the exception of loadmasters and helicopter crews
performing physical work, aircrew are unlikely to expe-
rience any of the severe manifestations of heat illnesses
mentioned in Chapter 11, but heat stress has the potential
to have effects on their performance which may impact on
flight safety or mission effectiveness. The literature on the
psychological effects of heat stress is somewhat conflicting,
but a meta-analysis revealed that while environments with a
WBGT within the range 21.1–26.6°C had little effect on per-
formance, a WBGT in excess of 26.7°C was associated with
negative effects on attentional, perceptual and mathemati-
cal processing tasks and that pre-task exposures to the envi-
ronment of more than 60 minutes resulted in a substantial
decrement in performance (Pilcher et al. 2002). Froom et al.
(1993) reported a study that showed a relationship between
ambient temperature and helicopter accidents and incidents
due to pilot error, with the risk being greatest at ambient
temperatures above 35°C.
Heat strain in the cockpit also has the potential to pro-
duce adverse physiological effects on the flying task; for
example, the combined effects of peripheral vasodilata-
tion and fluid loss due to sweating in the heat can reduce
tolerance to long-duration acceleration by around 1G. It is
clearly desirable to reduce aircrew heat strain as much as
is practicable.
Preflight solutions
When considering potential solutions to the problem of heat
stress in aviation it is convenient to think of those things
that can be done in the preflight phase, and those things
that are specific to flight. The physiological benefits of accli-
matization have been discussed in the previous chapter and
if aircrew are operating in a hot environment it is clearly
advantageous if they are fully acclimatized to that envi-
ronment. Aircrew should commence the sortie adequately
hydrated, particularly if access to fluids during flight will
potentially be limited. As urination may not be convenient
during the sortie, aircrew may be reluctant to drink ade-
quately before flying. However, dehydration during flight
not only runs the risk of exacerbating the problems of heat
stress but may also reduce G-tolerance. It is stressed that
being heat acclimatized does not reduce the requirement for
adequate fluid intake.
Other strategies are aimed at reducing the heat-load-
ing of either the aircrew or the cockpit prior to the sortie.
Preflight heat strain should be minimized as far as possible,
for example by air-conditioning of aircrew accommodation
and providing air-conditioned facilities for preflight plan-
ning and donning of flying clothing. Adequate time between
sorties should be scheduled to allow aircrew to recover and
17/11/2015 15:45
 202  Thermal protection and survival
offload excess heat from their previous sorties. The need for
aircrew having to walk to their aircraft in the heat should
be minimised, possibly by the provision of air-conditioned
vehicles. Some aircrew may allow trusted colleagues to per-
form some or all of the preflight walk-round checks of the
aircraft. Heat soaking of parked aircraft should be avoided,
ideally by parking the aircraft in hangers or other forms of
shelter. Alternatively, mobile shades can be placed over the
cockpit to prevent direct radiant heating of the cockpit if
the aircraft has to be parked in direct sunlight. Mobile air-
conditioning units may be used to pump cold air into the
cockpit before ingress of the crew. Wetting or spraying the
canopy may, in some environments, increase evaporative
cooling of the cockpit.
Aircraft environmental conditioning
Most aircraft incorporate a system that is, at least in part,
designed to control the thermal conditions within the cock-
pit. Such systems are generally known as environmental
conditioning systems (ECSs), and in addition to thermal
conditioning of cockpit air, they provide other essential
functions, such as cabin pressurization and air supply,
cooling of the avionics systems of the aircraft and fire sup-
pression. In military aircraft they may also provide air for
on-board oxygen generating systems, pneumatic cockpit
seals, canopy demisting, and pressurized gas for anti-G
suits and chest counter-pressure garments. Given the mul-
tiplicity of tasks which a single system is required to fulfil,
it is not surprising that the systems vary quite dramatically
between aircraft in their effectiveness at providing a ther-
mally comfortable environment for the occupants.
While system designs vary, most systems in fixed-wing
aircraft take bleed air from the compressor stage of the
engines; the temperature and pressure of the bleed air will
vary with the altitude and power setting of the engines, but
both will generally be high, so the ECS functions to reduce
the temperature and the pressure of the air to usable levels
for cabin conditioning. The temperature is reduced by pass-
ing the hot air through ram air heat exchangers, where it is
brought into close proximity to the ambient air and loses
heat to the ambient air down the temperature gradient, and
also by use of a cold air unit (CAU). In the cold air unit, the
air is compressed (which raises its temperature and pres-
sure), is passed through a secondary ram air heat exchanger,
where the increased temperature gradient between the con-
ditioned air and the ambient air increases loss of heat from
the conditioned air. This then expands in a turbine, which
reduces both its pressure and temperature and also uses
energy from the expanding air to drive the compressor stage
of the cold air unit. The cycle of compression and expan-
sion of the air in the cold air unit dramatically increases
the cooling of the air, potentially allowing it to cool below
the outside air temperature. Water is separated from the air
and a comfortable cabin temperature is achieved by mixing
the cold conditioned air with hot engine bleed air which by-
passes the cold air unit.
K17577_C012.indd 202
The effectiveness of ECSs in their ability to maintain a
comfortable temperature varies quite dramatically between
aircraft. In most modern passenger-carrying aircraft, the
systems are effective at maintaining a comfortable shirt-
sleeve environment in both the cockpit and the passenger
cabin. The same cannot necessarily be said for all military
transport aircraft, fast jets or helicopters. As systems rely on
bleed air from the engines they decrease engine effective-
ness, and in some aircraft they may be particularly ineffec-
tive on the ground with the engines at low power, this being
one factor that tends to make the cockpit stand-by and taxi-
ing phases of a sortie the most thermally stressful. Indeed,
some aircraft require the temperature conditioning to be
turned off for take-off, to maximize engine performance.
The systems also add weight to the aircraft, and this will
cause a trade-off in performance, range or payload capacity.
Some systems may not totally remove water from the con-
ditioned air, so that at low temperatures there may be the
potential for ice to be blown into the cockpit. As the systems
are attempting to condition a relatively large volume of air
in the cockpit, very cold air may be required to attain a com-
fortable temperature overall; if this very cold air is directed
directly at the occupants, this may paradoxically produce
localised cold discomfort. The design of the distribution
pipes and air outlets is of great importance in this regard.
Personal conditioning garments
If the combination of the effects of the environment and the
activity and clothing of the aircrew is such that the aircraft
ECS is unable to prevent the aircrew from experiencing det-
rimental thermal strain, then an alternative approach is to
provide them with personal conditioning garments. Personal
conditioning garments for use in aviation have been in exis-
tence for many decades, but while their concept is simple
and they have gained widespread use in other occupational
settings, their practical application in the operational avia-
tion environment has proved to be surprisingly difficult. The
concept of personal conditioning is that a garment is worn
which by means of air, liquid or a phase-changing substance
removes heat directly from the wearer. In cold environments,
some types of garments may also be used to supply heat. The
conditioning garment is worn next to the skin; the layers of
clothing that are worn over the conditioning garment, which
may otherwise be imposing heat stress because of their insu-
lation, effectively increase the efficiency of the personal cool-
ing garment by insulating it from the environment.
Air-conditioned garments work by pumping air over
the skin of the individual; the air may either be ambient
air, or may be cooled in some way. Cooling of an individ-
ual by an air-conditioned garment may take place by con-
vection or evaporation, and systems can be optimized for
either of these, although in practice often both will coexist.
Convective systems rely on a temperature gradient from the
skin to the air, and will therefore be ineffective if ambient
air is used which exceeds skin temperature. Conversely,
evaporative cooling relies on a vapour pressure gradient
17/11/2015 15:45

between the skin and the air, and therefore dry air will pro-
duce more cooling than humid air. Convective systems are
dependent upon the mass of air which flows through them,
and will therefore be affected by the change of air density
with altitude; this does not affect evaporative systems, as it
is the volume of air which can accept water vapour rather
than the number of air molecules which are present which
is important. Ideally, convective systems direct most of the
airflow to the limbs rather than the torso, to maintain the
normal comfortable temperature difference between the
torso and the slightly cooler peripheries. This is not so much
of an issue with evaporative cooling and hence the airflow in
these systems can be more uniform over the body surface.
While air is the natural milieu for humans, it does have
some disadvantages for personal conditioning. In the mili-
tary aviation setting, the principal drawback is the need to
filter the air if operating in a contaminated chemical, bio-
logical, radiation or nuclear environment; furthermore, the
thermally stressful protective clothing that needs to be worn
in a chemical, biological, radiation or nuclear environment
makes it one of the scenarios where personal conditioning is
most beneficial. While filtering the air is not impossible, it is
an engineering challenge, and the focus of most nations has
been on liquid-cooled garments, which, as they are closed
systems, do not run the risk of contamination inherent in
air-ventilated systems. Air-ventilated garments require
means of venting the air, which may also be challenging in
the aviation environment, where multiple external layers of
flying clothing may be worn.
Liquid-cooled garments for aviation were first produced
in the 1960s and the concept has changed little since then.
They consist of stretchable garments incorporating a net-
work of plastic tubing, which is designed to be held in con-
tact with the skin, and through which is pumped coolant,
usually either water or a water/glycol mix. While water has
a much higher specific heat capacity than air, and therefore
theoretically could extract much more heat from the body
than an air-cooled garment, this is somewhat offset by the
fact that the water is contained within the tubes, whose walls
have a finite insulation; the heat must cross the walls of the
tubing, and this may be a limiting factor in heat extraction
from the body. Another downside to liquid-cooled systems
is that direct heat transfer only occurs at the site where the
tubing is in contact with the skin, which is a relatively small
percentage of the body surface area. A whole-body liquid-
cooled suit can potentially extract approximately 400W of
heat from the wearer. In the aviation environment, vests
which cover only the torso are more common and these are
capable of extracting approximately 150 W of heat.
The rate of cooling by a liquid-cooled garment is a func-
tion of the temperature of the coolant (normally quoted at
the point it enters the garment, known as the inlet tempera-
ture), and the rate at which the coolant is pumped around the
tubing. While the theoretical lower limit of the inlet temper-
ature is dictated by the freezing point of the coolant, physi-
ological considerations mean that maximal cooling occurs
with a much higher inlet temperature. Cooling is optimized
K17577_C012.indd 203
Heat stress  203
when body heat is brought to the skin surface by convection
in the blood, and therefore inlet temperatures that induce
peripheral vasoconstriction may be counterproductive. It is
difficult to be absolutely prescriptive about the temperature
at which this will occur, as it is a function both of the periph-
eral and the deep body temperatures, but generally an inlet
temperature below 15°C is not recommended. Increasing the
flow rate increases heat extraction, but only up to a plateau
value, due to the finite insulation of the tubing. For a garment
containing 20 m of tubing, this plateau flow rate is approxi-
mately 300 mL/min, rising to approximately 600 mL/min
for a suit containing 50 m of tubing. The wearer should have
manual control of the inlet temperature or coolant flow
rate, or both, to allow them to control the degree of cooling
according to their personal perceived comfort. Increasing
the length of tubing increases the potential heat extraction,
but this is offset by the greater resistance to coolant flow, and
therefore requires greater force to pump the coolant around
the garment; this can, to a certain extent, be mitigated by
arranging the tubing in a parallel manifold rather than hav-
ing a single continuous loop of tubing. Liquid-conditioned
garments have the advantage that they may also potentially
be used for heating in cold environments.
The limited degree of vasoconstriction that occurs in the
scalp has meant that cooling of the head by means of liquid-
conditioned cowls has been investigated; these can improve
thermal comfort during heat stress, although over-cooling
of the head can produce marked localized thermal discom-
fort. Their use in aviation, while superficially appealing,
has a number of problems. This is true particularly with
regard to their integration in helmets, as this can give rise
to leakage and mean that the essential stability on the head
for impact protection and as a mounting point for masks
and assorted visual interfaces is disrupted. As a result, liq-
uid cowls in aviation have not been widely used, but some
modern helmet designs do incorporate air ventilation sys-
tems and with the increasing use of heat-generating head-
mounted avionics which are a feature of many modern
military helmets, the requirement for some form of head
cooling may become important.
While personal cooling garments have been widely used
in many occupational settings, the major challenge to their
use in the aviation environment has been in providing a
sustainable method of cooling the fluid. Cooling systems
may be either intrinsic to the aircraft or man-mounted, the
latter giving the wearer the ability to move around while
still using the garment, which is advantageous in rotary or
transport platforms. A variety of cooling solutions have been
suggested, including thermoelectric units, vapour-cycle
refrigeration and heat exchangers, either as a part of the air-
craft’s ECS, or as a bolt-on to the cockpit cold air outlets.
Until recently, the power requirements of aircraft-mounted
systems have precluded their regular incorporation into air-
craft designs, but many fourth-generation fighter aircraft
are designed to use personal conditioning systems (PCSs),
although in some cases their ECSs are of such efficiency that
PCSs may not be needed in most operating environments.
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 204  Thermal protection and survival
The simplest system to have been used widely is man-
mounted, and consists of a two-litre plastic bottle contain-
ing ice which is worn by the individual. A battery-powered
pump circulates the ice-water through the cooling garment,
with the flow rate being adjusted manually by the wearer.
When the system was first fielded in rotary wing operations
it was hailed as a great success, but in recent operations its
use has become less widespread. The main problem is the
duration of the ice, which must be replenished when it has
melted, which provides a logistic challenge. In common
with all PCSs, when coolant is no longer circulating, for
whatever reason, the garment merely becomes an extra layer
of insulation, and will therefore add to the thermal burden
that it was designed to alleviate. Other disadvantages in the
aviation setting are the fact that the umbilicals from the
PCS must pass through the external clothing layers, poten-
tially creating a breach in chemical, biological, radiation or
nuclear protective garments or immersion suits. Also, as the
garments are designed to be worn next to the skin they must
be regularly laundered, which is not easy given their com-
plexity and potential fragility. Leakage from a garment may
at best be a nuisance, but if fluid were to leak into aircraft
systems it may produce a flight safety hazard.
An emerging technology which may find an aviation
application is that of phase-change materials. These are
materials that can produce cooling by means of the latent
heat associated with their change from the solid to the liq-
uid phase, and they include organic compounds, such as
paraffin and fatty acids, and inorganic salt hydrates. They
have been used in cooling garments for a variety of occu-
pational and sporting applications, but their logistic con-
straints are similar to the use of ice as a coolant in liquid
conditioned systems, and they have yet to find widespread
application in aviation, although their incorporation in air-
crew clothing or indeed aircraft seats may provide an ave-
nue for future development.
One aspect of personal cooling concerns ascertaining
what constitutes a significant improvement in thermal strain,
which is an important driver in deciding whether systems
should be procured and used. In some instances, field or lab-
oratory studies may demonstrate that certain items of equip-
ment clearly either cause or relieve significant heat strain and
the benefit or otherwise may be clear-cut; nonetheless the
results may be highly dependent upon the particular task
and environmental variables chosen in the study. It may not
necessarily be appropriate to read the results across to other
scenarios. More commonly, studies may show a small, albeit
statistically significant, change in some of the measured
physiological variables, such as core or skin temperature, or
in subjectively assessed thermal comfort or fatigue. Deciding
at what point these statistically significant results translate
into practically significant ones can be difficult.
COLD STRESS
Aircraft operations in cold regions of the world run the
risk of subjecting both the ground crew and aircrew to the
K17577_C012.indd 204
potential hazards of cold stress. While cold stress is not usu-
ally a problem in the fast jet cockpit, that is not necessarily
the case in transport aircraft or with helicopters that may
have to operate with their hatches or doors open, subjecting
the occupants not only to the temperature of the outside air,
but also to increased convective cooling due to the airspeed
of the aircraft. Ground operations in the cold may be haz-
ardous because of slippery surfaces. Cooling of the periph-
eries may reduce manual dexterity and sensitivity, making
manual tasks more difficult and potentially more danger-
ous. Prolonged exposure to the environment runs the risk
of non-freezing cold injury, but in extreme environments
only relatively short exposures could produce frostbite, and
this can occur in a matter of seconds if there is direct con-
tact between the skin and cold metals or liquids, such as
fuels or lubricants, whose freezing point is below 0°C. The
bulky clothing that is often needed to combat the effects of
the cold can itself produce problems, making physical tasks
more difficult, and it may paradoxically become a potential
source of heat stress. Cold air is usually dry and can lead to
water loss from the skin, potentially producing chapping and
cracking; large amounts of water can be also be lost through
the respiratory tract, potentially causing dehydration.
Cold indices
The potential effects of a cold environment may be predicted
by means of a cold index; in contrast to the heat, relatively
few cold indices exist, but two important ones are the wind
chill index and required clothing insulation (IREQ) index.
The wind chill index is designed to take account of the
increased convective cooling produced by wind in a cold
environment. It was originally derived by timing how long
it took for cylinders of water to freeze in the Antarctic, and
determining the combinations of temperatures and wind
speeds that produced an equivalent rate of cooling. The
main purpose of the index is to quantify the risk of frost-
bite in the exposed skin of clothed individuals exposed to
the environment. However, a passive cylinder of water is not
a particularly good surrogate for a heat-producing clothed
human and as a consequence, the original wind chill index
tends to overestimate the risk of freezing of human skin. A
new wind chill index was developed in 2001 and has now
become the generally accepted standard; it can be quoted as
a wind chill equivalent (WCE) temperature, which is calcu-
lated by the equation:
WCE = 13.12 + 0.6215T – 11.37V0.16 + 0.3965T(V0.16)
where T is the ambient temperature in degrees Celsius and
V is the wind speed in km/h at a height of 10 m.
Charts of the potential risk of frostbite related to the
equivalent chill temperature are widely available. It is
important to appreciate that while wind increases the rate of
cooling and the perception of how cold it feels, it is still the
temperature gradient between the skin and the air which
determines whether heat will be lost. The skin temperature
17/11/2015 15:45

will not fall below the air temperature, regardless of how
strong the wind is.
While the wind chill index is useful for predicting frost-
bite risk, other approaches need to be adopted to predict
the risk of hypothermia, or to determine adequate levels
of clothing insulation. One of the more potentially useful
indices is the IREQ index (Holmér 1984). The IREQ index
is based upon the heat balance equation and calculates, for
any given activity and environment, the amount of cloth-
ing insulation that should be worn to achieve either thermal
neutrality (IREQneutral) or a reduced but acceptable mean
body temperature (IREQmin). If the conditions are such that
the required level of insulation cannot be provided, IREQ
can be used to calculate an acceptable time of exposure to
the environment, the duration limited exposure.
Clothing
The ideal approach to cold environments is to avoid exposure
to them, but if this is not feasible, then clothing provides the
mainstay of protection. Cold-weather clothing serves prin-
cipally to reduce heat loss from the body, by providing insu-
lation between the skin and the surrounding air. Most of the
insulation in clothing is provided by the air that is trapped
within it; this needs to be trapped in relatively small spaces,
to prevent internal convection currents building up, which
would decrease the effective insulation. Ingress of wind also
increases convective heat exchange within clothing, and so
an outer windproof layer is needed to optimize insulation.
Air provides much greater insulation than water, so if the
air is displaced by water, either from the environment or as
a consequence of sweating, the insulation will be markedly
degraded. The outer layer should therefore be waterproof
and, ideally, vapour permeable to allow sweat to evaporate
rather than accumulate in the clothing. While the fibres of
the material may contribute relatively little to the insulation
of the clothing, their nature can have a profound impact on
its performance. They will determine the robustness and
weight of the garments, how effectively sweat is wicked from
the skin to the clothing surface, whether water accumulates
within or between the fibres (and therefore how easily the
clothing will dry if it becomes wet), how easily wind pen-
etrates the clothing and its fire-retarding properties.
Cold-weather clothing should be worn in layers. Not
only does the air between the layers potentially enhance the
overall insulation, but wearing multiple layers allows the
wearer to adjust their insulation, by taking layers off or put-
ting them on. This is particularly important during physi-
cal activity in the cold, where sweating should be avoided
if at all possible, as it will degrade clothing insulation, pro-
moting undue body cooling once physical activity ceases.
The design of collars, cuffs and closures is important; these
should prevent wind ingress but should be capable of being
opened to aid ventilation.
The insulation afforded by clothing ensembles can be
measured in a variety of ways, including the use of heated
manikins of varying degrees of sophistication, or by means
K17577_C012.indd 205
Fire protection  205
of human trials. The usual unit of measurement of cloth-
ing insulation is the clo; this corresponds to the amount of
clothing insulation required to maintain thermal comfort in
a normal room environment (21°C. 0.1 m/s air movement),
and in terms of heat transfer, it equates to an insulation of
0.155 °C m2 W–1. An ensemble incorporating underwear, a
shirt and a light business suit has an insulation of approxi-
mately 1 clo. An alternative unit, which is more commonly
applied to materials and bedding rather than clothing ensem-
bles, is the tog, which equates approximately to 0.645 clo.
The insulation value of individual garments can be looked
up in a variety of tables (e.g. ISO 9920), and the insulation of
the overall ensemble may be estimated by adding together the
insulation of the component garments; it may be necessary
to multiply the total by a factor to take into account the effect
of compression of the underlying garments by those which
are worn over them, which may reduce the amount of air
trapped within them, effectively reducing their insulation.
As increasing thicknesses of clothing are worn, the bulk
effectively increases the total surface area available for heat
exchange; in the cold this will be predominantly heat loss,
which will to some degree offset the benefit of the increased
insulation provided by the clothing. This phenomenon
is of greatest significance with hand wear; the cylindrical
shape of the fingers means that this trade-off of increased
surface area with increasing thickness of insulation is rap-
idly attained, and consequently when the air-temperature
is below approximately –10°C the use of mittens should be
considered, as it may be impossible to provide adequate
insulation with fingered gloves.
Metalized layers can be incorporated into clothing, or
can be used in their own right in a survival setting, in the
form of a so-called space blanket. The rationale for metal-
ized layers is that they will reflect radiated heat from the
body. However, radiant heat loss from cold skin in most cir-
cumstances is relatively small. In clothing or sleeping bag
assemblies, the metallized layer is at its most effective as the
outermost layer of a low-density insulating ensemble. The
thermal advantages of using a space blanket in a cold sur-
vival setting compared with using a strong wind-proof and
waterproof plastic bag are debatable.
FIRE PROTECTION
Aircrew are exposed to the risk of fire during flight opera-
tions. The magnitude of this risk is variable between plat-
forms and, indeed, roles of individual aircraft. Currently,
the greatest risk exists in military rotary-wing aircraft where
post-crash fires occur following 16% of accidents. Aircraft
fires may be electrical, mechanical, munitions related or of
a fuel origin and the durations and intensities of these fires
vary enormously. Some causes of aircraft fires are shown in
Table 12.1.
A hierarchy of controls is employed to manage the risk of
fire, but a sizeable residual risk has led to the adoption of
personal protective equipment for some aircrew. The role
of this equipment is two-fold: firstly it reduces the risk of
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 206  Thermal protection and survival
Table 12.1  Summary of helicopter fire characteristics
Fire source Frequency Location Duration
Electrical Common Avionics Short lived
Mechanical Rare Gearbox or Localized but
engine spreads
Fuel Uncommon, Fuel tanks and Widespread and
usually lines. Often uncontrollable
post-crash becomes
or refuelling widespread
Oil Rare Hydraulic lines Short lived
Munitions Uncommon Anywhere Short duration
Explosion
PPE, personal protective equipment.
burns and secondly it allows crews to tackle the fire or to
continue to operate in a burning environment. This aspect
may be essential in recovering a damaged aircraft or assist-
ing in the evacuation of an aircraft that has crashed.
Fire-protective equipment for aircrew provides insu-
lation from the thermal insult. This insulation increases
the bulk of clothing, reduces mobility of the wearer and
increases the thermal burden. These factors, individually or
collectively, will reduce efficiency and increase the risk of
other hazards, such as entrapment during escape, control
restriction or distraction. The selection of protective equip-
ment in this safety-critical environment therefore requires
careful balancing of protection and burden in order that the
overall risk to the user is minimized.
When selecting fire-protective equipment it is important
to understand the intensity and duration of flame that pro-
tection is required from. For example, a crewman on a large
aircraft may be required to carry out emergency firefighting
duties during flight. In this scenario breathing apparatus as
well as flame-protective clothing would be required. By con-
trast, cabin crews in commercial aircraft are not provided
with flame-protective clothing, as it is believed that the risk
of fire has been reduced to a level where this is unnecessary.
Generally, in higher risk areas of aviation such as military or
display flying, fire-resistant clothing is worn.
Fire-protective clothing insulates the wearer from the
hostile thermal environment outside. In so doing it slows
the rate of skin heating and thus the perception of pain and
the development of burns. The level of protection required
will dictate the materials and amount of insulation that an
ensemble has. Most of the insulation is provided by trapped
air within the clothing layers. For aircraft fires, fire fight-
ing suits are heavyweight silvered garments that will pro-
vide complete protection, if worn with breathing apparatus,
for over 10 seconds. The more usual Nomex aircrew flying
coverall will protect for about 4 seconds, whereas everyday
clothing will ignite and burn to destruction after approxi-
mately two seconds. Protection to the head and neck can
be provided by the aircrew helmet and visors and these
assemblies are remarkably resilient to a survivable flame
K17577_C012.indd 206
Intensity Control measures
Localized Design, training
Localized Design, training
Localized but spreads with Design, training, PPE
increasing intensity
Localized, and can result Design, PPE
in short duration
explosive fireball
High intensity PPE
exposure, providing good protection to the underlying
skin. Uncovered areas of the face and neck are, however,
vulnerable and in some aircraft this has been addressed by
the addition of a face shield or by wearing a fire-retardant
balaclava or head-over. The hands are exquisitely sensitive
to heat and protection is provided by gloves manufactured
from leather or synthetic fire-retardant fabrics. The thermal
protection provided by gloves is compromised in order that
sufficient tactility and mobility is maintained to operate
aircraft controls.
GENERAL SURVIVAL PRINCIPLES
Following an aircraft emergency, the occupants of the air-
craft may be faced with surviving in whatever environment
the aircraft was flying over at the time. The nature of that
environment will pose potential threats to their survival
and whether or not they survive will depend upon the
equipment available to them and their actions; these actions
may not always be intuitive and prior training in emergency
procedures, survival techniques and the use of survival
equipment greatly enhance the chances of survival.
The priorities of the survivor should be the same, regard-
less of the environment in which they find themselves, and
can be summarized as protection, location, water and food,
in that order (although first aid treatment of any injuries
sustained in the emergency may be required before any
of these can be addressed). Protection incorporates those
things that mitigate the adverse effects of the environment;
in water or on cold land, the survivors may succumb to the
effects of hypothermia in a matter of hours, and therefore
protection from heat loss is a high priority, but protection
may also incorporate such things as impact protection and
floatation devices. In most settings individuals may survive
for a number of days without water and potentially a num-
ber of weeks without food, so these things take lower prior-
ity, but are nonetheless essential. However, the survivor will
ideally be rescued before water provision becomes critical,
and therefore equipment and actions to aid their location
assume a high priority.
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Protection
Protection from the thermal effects of the environment
consists primarily of clothing and shelter. The clothing and
equipment available to the survivors of an aircraft accident
will depend on both the nature of the aircraft and the emer-
gency. The pilot of a military fast-jet who ejects will have
only the clothing he was wearing in the cockpit, plus what-
ever survival equipment is in the personal survival pack
incorporated into his ejection seat. In contrast, the occu-
pants of a passenger-carrying or transport aircraft may be
able to access whatever additional clothing or equipment
was being carried in the aircraft.
PROTECTION FROM IMMERSION
As discussed in Chapter 11, the physical properties of water
mean that heat loss from the body of an immersed individ-
ual is very much greater than it would be in air at the same
temperature. As a consequence, immersion poses a much
greater risk to survival than does the land environment, so
for any flight that includes flight over a significant body of
water the aviator should dress and be equipped for the pos-
sibility of having to survive in the water.
The primary requirement is to prevent drowning, which is
achieved by the provision of a life-preserver. Life-preservers
have been available for aviators since the early days of flight.
Indeed, the Royal Aero Club mandated their use for flight
beyond three miles of the shore in 1912. Early life preserv-
ers were little more than a bicycle inner tube worn bando-
lier-style across the chest. However, they soon evolved into
kapok filled jackets and later the iconic Mae West.
During the Battle of Britain, loss of aircrew to drown-
ing became so critical that RAF aircrew were forbidden
from straying out over the sea. Inevitably, this stimulated
research, which was conducted at the RAF Physiological
Laboratory at Farnborough by Mackintosh and Pask. Key
principles of life preserver design were defined including
the concept of freeboard, flotation angle and self-righting.
●● Freeboard: This is the distance from the water surface to
the corner of the mouth. The European Aviation Safety
Agency and many other standards require this to be
a minimum of 120 mm in order that the mouth and
airway do not fill with water if the supported survivor
is unconscious.
●● Flotation angle: This is the angle that the main axis of
the body floats relative to the horizontal. Most stan-
dards agree that this should be between 30° and 60° (i.e.
45° ±15°). If the body floats in a more horizontal posi-
tion, then self-righting is impaired, whereas moving to
the vertical makes the survivor more liable to bobbing
up and down; 45° is the most stable wave-riding angle.
Recent advances in fabric technology have produced
light-weight immersion suits that are truly dry suits.
This has the advantage of keeping the survivor dry
and well insulated but has led to a greater suit buoy-
ancy and almost horizontal floatation of the survivor.
K17577_C012.indd 207
General survival principles  207
In one sense this is advantageous as they are less likely
to become hypothermic but on the other hand the
self-righting capability is impaired. Some regulatory
authorities have accepted this for helicopter survival
suits and it is likely that others will follow.
●● Self-righting: Life preservers are designed with their
flotation distributed asymmetrically on the torso such
that the greater buoyancy is on the front of the chest.
This ensures that an unconscious survivor will always
float face up and, if turned over by a wave, self-righting
will occur. The standard for self-righting requires this to
occur in still water within five seconds.
Most aircrew life-preservers are inflated by a small gas cyl-
inder that is backed up by an oral inflation valve. Fast jet
aircrew wear life-preservers with water-activated automatic
inflation systems; these have been introduced to protect air-
crew that have been rendered unconscious during an ejec-
tion. In rotary and wide-bodied aircraft, manual inflation
systems are used because an automatic system could trap
a survivor in a water-filled cabin following ditching. Many
other features are incorporated into some life preservers
and they are often a hybrid life-preserver/survival vest.
Notwithstanding this, the fit is critical as a loose, poorly
adjusted jacket will fail to meet the performance criteria
previously mentioned. Location of survivors is often dif-
ficult and life-preserver stoles are therefore manufactured
from high visibility orange or yellow fabrics. A sea light
and whistle are also standard. Where location beacons are
carried by the crew, the aerials are often mounted on the
life-preserver stole. For ease of use and comfort, the bulk of
life-preservers is minimized, and they are often contained
within a robust stole cover that can withstand the rigours of
daily use, escape and, potentially, ejection.
IMMERSION SUITS
Immersed survivors will lose heat at a rate that is largely
determined by the water temperature, which at low tem-
peratures can be rapid; if rescue is not prompt, these
individuals will be at risk of succumbing to the effects of
hypothermia. When clothing becomes wet during immer-
sion, the insulating air within it is replaced by water, and the
clothing effectively loses most of its insulation. To preserve
its insulation, the clothing must be kept dry, and this is the
primary function of an immersion suit. An immersion suit
is a special type of waterproof dry suit that is designed to
protect the wearer from hypothermia if immersed in cold
water. Immersion suits will also to some extent ameliorate
the physiological effects of the cold shock reflex that is expe-
rienced on sudden immersion in cold water. Aircrew suits
are fitted with neoprene or butyl neck and wrist seals and
either boots or socks for the feet. Entry into the suit is either
via a diagonal chest zip or a horseshoe-shaped zip on the
upper chest.
Immersion suits have been worn by aircrew since
WW2 when Sea Hurricane pilots, launching from Q ships,
could only ditch in the sea for recovery. These early suits
17/11/2015 15:45
 208  Thermal protection and survival
were made from a finely woven cotton fabric called Ventile
that swelled and became waterproof on immersion. Their
air permeability when dry allowed trapped air to venti-
late as altitude increased. However, they are heavy, not
fire-retardant and susceptible to leakage. These suits have
largely been superseded by suits manufactured from mod-
ern trilaminate fabrics using a moisture vapour permeable
membrane. These modern suits are true dry suits, offering a
light-weight, fire-retardant garment. They do, however, trap
air so effectively that flotation when wearing a life-preserver
is affected (the legs are more buoyant and hence the survivor
floats in a more horizontal position reducing the self-right-
ing ability of the life-preserver). The other disadvantage is
ballooning caused by trapped air expansion on rapid ascent
to altitude. This has been minimized by tailoring the suit
or incorporating a more vapour permeable fabric patch
or valves.
Some aircrew who regularly enter the water (e.g. heli-
copter winchmen) wear a heavier weight immersion suit.
Originally these were made from heavy-weight nylons, but
being non-fire retardant and relatively stiff they too have
been replaced by trilaminate fabrics. Immersion suits can
also be provided for passengers and these tend to be bulkier
and more robust. Depending on the environment, they may
also incorporate additional survival features such as a hood
and gloves.
Current UK military flying regulations mandate that air-
crew flying over water below a minimum temperature must
wear an immersion suit, but the amount of insulation that is
worn under the immersion suit is a matter for the individual.
There is often a balance to be struck between wearing suffi-
cient insulation to promote survival in the unlikely event of
immersion and the risk of increasing heat strain within the
cockpit, which may impair performance and paradoxically
potentially increase the chances of an accident happening. It
is helpful for the aviator to be provided with guidance as to
what they should wear under their immersion suit.
Computer-based mathematical models, which predict
both the physical heat exchange and the physiological
responses of the individual, have been used to generate sur-
vival time predictions in water. Models of varying sophis-
tication have been used over the years and many of these
models have evolved with time, so that a variety of different
survival time predictions exist. It is possible, up to a point,
to validate the output of these models, either by compar-
ing the results with data from real-life disasters, or with
data from human physiological experiments, although for
ethical reasons the latter will be confined to non-hazardous
temperature ranges and therefore may not accurately reflect
genuine survival scenarios.
The output of these models may be used in a variety of
ways, the most common being presentation of curves which
plot the predicted time to a set end-point (usually a particu-
lar core temperature) against water temperature, for a vari-
ety of different immersed clothing insulations. Often these
curves will be drawn for the worst-case of someone with a
low body mass, as they will have relatively little intrinsic
K17577_C012.indd 208
subcutaneous insulation and will therefore tend to cool
more rapidly. Care should be exercised in being clear what
the end-point represents; this could be chosen as a core tem-
perature representing death, loss of useful consciousness or
onset of hypothermia, which are all clearly very different
end-points.
Aviators flying over water are able to consult the survival
curves and determine their required immersed clothing
insulation for a given water temperature and likely maxi-
mum rescue time. The immersed insulation of a variety of
aircrew clothing ensembles is tabulated, allowing the avia-
tor to choose the most appropriate combination of insulated
garments. It is important that immersed rather than dry
air insulation values are used, as the effective insulation of
clothing will decrease in the water, due to the hydrostatic
pressure of the water compressing it, even if it is kept dry by
an effective immersion suit.
LIFE RAFTS
Life rafts are provided for the protection of survivors in all
aircraft that fly over the sea. Sufficient rafts are carried for
all passengers and crew and designs vary from single seat
life rafts for crews of military combat aircraft to large multi-
seat life rafts in passenger aircraft. Many design features
are shared between these types. Weight and volume are
kept to a minimum and life rafts are generally constructed
from synthetic high-visibility fabrics. Gas cylinders pro-
vide inflation and on larger rafts these may be multiple.
Buoyancy chambers form the raft structure and in larger
rafts these may be separate, to provide some redundancy. A
canopy and floor are also provided and where this is inflat-
able it provides additional insulation for the occupants.
Access, stability and protection from the environment are
key requirements and the rafts are designed accordingly.
Boarding ramps and steps are incorporated into larger rafts,
whereas single seat designs have handles to assist boarding.
Stability is enhanced by the shape, water pockets and sea
anchors and in the event of capsize, righting aids are also
provided. Protection from cold or the heat of the sun may
be equally important and as such the canopy is designed so
that it can be securely closed or opened providing shade but
allowing air movement. Study of the MS 10 life raft shown in
Figure 12.1 will allow the reader to appreciate these features.
HELICOPTERS
When a helicopter ditches in a controlled manner, the com-
bination of its high centre of gravity, wave actions and the
precession effect of the rotors means that commonly the
helicopter will roll into an inverted attitude. It may or may
not then float, and some helicopters are fitted with floata-
tion devices to promote this, but either way the occupants
will face the prospect of being under water and inverted,
and will have to attempt to escape from the aircraft in this
hazardous and disorienting environment. Ensuring that
the helicopter is crashworthy is the first step to survival.
Provision of escape doors and hatches that are easy to oper-
ate is important, as is lighting of the escape routes by a
17/11/2015 15:45

Light-reflective
strips
Rainwater
catchment
Rainwater
collector tube
Canopy
Inflation manifold
General purpose
pocket
CO2 cylinder
Entrance cover
closing cords
and buttons
Inflatable floor
Figure 12.1  MS10 multi-seat life raft.
means which attempts to make them visible through tur-
bid and agitated water. Training of helicopter occupants in
the techniques of underwater egress aids survival, as does
the provision of a supplemental air supply for emergency
underwater use. It is important that life preservers for use
in helicopters do not automatically inflate on immersion, as
an inflated life jacket will impede the wearer and perhaps
others in their attempts to escape from the inverted aircraft.
Helicopter Underwater Egress Training is provided to
offshore oil and gas workers and military personnel who
are regularly transported in helicopters over water. The
purpose is to prepare them for emergency exit in the event
of a ditching. During these accidents, crew and passengers
often panic and become disorientated, delaying escape and
increasing the risk of drowning. The training involves sim-
ulating a ditching where students are strapped into a heli-
copter module that enters the water, rotating and sinking.
Students learn to adopt a brace position, orientate them-
selves, and identify primary and secondary escape routes
and escape.
Research has shown that breath-hold times required to
escape from a ditched helicopter are usually inadequate.
This, coupled with the cold shock of water immersion, has
led industry to adopt a range of adjuncts to assist breathing
during escape.
These are:
●● Short-term air supply systems (STASS or PSTASS): This
is in effect a small scuba set comprising a lightweight
cylinder of compressed air with regulator and self-
purging mouth piece attached. This is small enough to
be mounted on the life preserver but requires training.
As this system uses compressed air, there is a theoreti-
cal risk of pulmonary barotrauma if the user does not
breathe out on ascent.
K17577_C012.indd 209
General survival principles  209
Beacon/aerial
retainer
Flashing-beacon
retainer
General purpose
pocket
Exterior and
interior light
Seat
Seat-ring
Rescue line and
quoit stowage
Bailing device
Buoyancy chambers
Knife pocket
Lifeline
Battery stowage
(ext./int. lights)
Inner entrance
cover retainer
Boarding ramp
●● Rebreather apparatus: This is a torso-mounted reservoir
of air with a mouthpiece that is inflated by the survi-
vor prior to immersion. This requires the survivor to
anticipate immersion and may impede egress as it will
inevitably generate bulk and buoyancy.
●● Hybrid rebreather: This is a rebreather apparatus
as described above, but with an additional charge
of breathing gas provided by a small cylinder. This
removes the requirement for the user to inflate prior
to immersion but suffers the same problems of bulk
and buoyancy.
Within the UK, guidance following recent ditchings favours
the adoption of STASS or PSTASS.
PROTECTION FOR COLD LAND SURVIVAL
When a sortie involves flight over both cold land and water,
the aviator should always dress for the possibility of water
immersion, which represents the worst case in terms of
threat to life. Sea-survival clothing will provide reasonable
protection for land survival, but the converse is not true. An
immersion suit will be waterproof and largely windproof;
however, its design is not optimized for comfort or mobility
on land and accumulation of sweat may occur in the under-
garments. Ventilation can be increased by cutting the neck
and wrist seals once immersion is no longer a possibility.
In deciding what to wear when flying over cold land, the
aviator is again faced with the balance between dressing for
the potential of having to survive in the cold and not unduly
adding to the burden of heat stress in the cockpit. In larger
aircraft it may be possible to stow additional clothing and
survival aids where they can be accessed if needed, but fast-
jet pilots will have to survive in whatever they were wearing
to fly the aircraft, plus the limited amount of survival equip-
ment in their personal survival pack. Attempts have been
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 210  Thermal protection and survival
made to predict survival times on land to aid in the aviator’s
decision making; the approach has been to use computer
modelling to produce predictions similar to those for sea
survival, but the situation on land is very much more com-
plex than in water. In the latter situation heat loss is essen-
tially only by conduction and convection (if one ignores
heat exchange from the head and respiratory tract), whereas
on land, all four pathways of heat exchange come into play,
as a complex interaction of the different components of the
thermal environment. The responses of the individual are
also much more variable than in water. Providing that the
individual is conscious and not severely injured, in most
settings it would be expected that they would perform vari-
ous actions to aid their own survival. Foremost among these
would be to find or construct some form of shelter from the
environment. As with most aspects of survival, the ability to
construct an adequate shelter is something which benefits
greatly from previous training and its difficulty should not
be underestimated.
Location aids
Life rafts and aircrew life-preservers carry aids to assist the
rescue organizations in their task of locating survivors from
crashed aircraft. These aids may be electronic, pyrotechnic,
visual or audio, and the combination of aids carried will
depend upon the space available for carriage and the geo-
graphical area over which the aircraft is operating.
ELECTRONIC AIDS
Location beacons that transmit a distress signal are car-
ried in the life-preserver. These transmit a signal on the
International Distress Frequencies of 121.5  or 406 MHz.
Activation is automatic in ejection seat aircraft and man-
ual for most other aircraft. Modern systems incorporate
global positioning system co-ordinates into a data burst
that is released on activation, whereas the 406 MHz bea-
cons are continuously monitored by satellite. Distress
beacon firing is relayed directly to a rescue coordination
centre and rapid accurate location is possible worldwide.
Beacons are fitted with an aerial and, like any transmitter,
are susceptible to terrain shielding and the limitations of
battery life, although this is usually greater than 48 hours.
Covert beacons are available for military combat opera-
tions and transmit on a secure frequency. In less remote
locations the use of personal mobile phones by survivors
is increasingly common.
PYROTECHNIC AIDS
These include mini flares, rocket flares and smoke flares.
The mini flares, which are carried in the life preserver, fire
a small red distress flare to approximately 200 ft. This flare
can be seen at a range of 1–2 NM by day or up to 5 NM at
night. The rocket flare is larger and carried in life rafts. It
can reach 800 ft and burns for six seconds allowing it to be
seen at 4–5 NM during the day and up to 8 NM at night.
Smoke flares can be carried in the survival vest or the life
K17577_C012.indd 210
preserver and usually generate a thick orange smoke that
can be seen in clear conditions up to 10 NM away.
VISUAL AIDS
These include strobe lights, sea lights and reflective aids.
Miniaturization of light sources and modern battery tech-
nology has generated a huge range of options in this field.
Visible spectrum high intensity strobe lights are carried or
mounted on many life rafts or jackets. Military users may
employ strobes in the infrared spectrum allowing them to
operate covertly but be readily located by friendly forces
using night vision goggles. Water-activated sea lights are fit-
ted to most life preservers and provide a small light source
for at least eight hours. Strobes are visible at up to 7 NM,
whereas sea lights can be detected at 3 NM. Reflective aids
include the heliograph (a mirror with a sighting system that
is remarkably effective and can be seen up to 20 NM away
on a good day) and reflective tapes that are useful when illu-
minated by a searchlight. Finally, it is worth mentioning the
stole colour, that is bright orange or yellow and the whistle
that accompanies every life preserver and is essential in fog!
Water and food
In most survival situations, humans can survive a number
of days without water and a number of weeks without food,
but their provision will at some stage be of importance. In
temperate settings, humans require approximately 1500 ml
of water each day to maintain fluid balance, whereas in some
survival settings a significantly lower amount may be toler-
ated for a period of time. In hot environments where large
amounts of water are being lost by evaporation, the require-
ment may be significantly greater. Water can be carried by
military aircrew operating in hot climates in their survival
packs or on their person in survival waistcoats, but it is
heavy, cumbersome and may be difficult to integrate with
other pieces of equipment. Therefore the volume of water
that can be carried tends to be very limited. Consequently,
during a period of survival, water will need to be obtained
from the environment. Environmental water can be made
potable by use of a reverse osmosis pump, which is now a
common inclusion in aircrew survival packs, but the older
methods of desalination kits and purification tablets may
still have their place. If there is no source of water in the
environment, it may be possible to condense water from
the environment by means of a solar still or vegetation may
provide some water, but again, prior training make success
much more likely.
While humans can survive for prolonged periods with-
out food, they will become debilitated and eventually are
unable to perform the functions needed to promote their
own survival. Military aircrew will generally be provided
with limited survival rations in their personal survival
equipment. This should be primarily composed of carbo-
hydrates, to aid in the maintenance of blood glucose levels,
although the presence of some fat tends to aid satiety. The
digestion of protein increases the metabolic rate, which is
17/11/2015 15:45

disadvantageous in a hot environment, and the elimination
of the breakdown products of protein requires increased
urinary water loss, which will exacerbate dehydration in
those situations where water supply is limited. If the sur-
vival period is prolonged, the survivor will have to attempt
to provide food for themselves; knowledge of the edibility of
local vegetation and prior training in fishing or the build-
ing of traps or snares to catch animals will greatly aid the
survivor’s endeavours.
SUMMARY
●● The likely heat strain produced by an activity in
a particular thermal environment can be pre-
dicted using a wide variety of heat stress indices;
two indices that are particularly applicable to the
aviation environment are the WBGT and FITS.
●● In fast-jet operations, the pre-takeoff phase of the
sortie may be the most thermally stressful, and
efforts should be made to minimize heat strain in
the preflight period.
●● Most of the insulation provided by cold-weather
clothing comes from the air that is trapped
in it, and to optimize insulation the cloth-
ing should be kept dry and be worn in layers;
trapped air also provides important insulation in
fire-protective assemblies.
●● The survival priorities of protection, location,
water and food are generally applicable, with
slight modifications, to any survival scenario.
●● In survival settings, heat loss is always greater
in water than in air, and aircrew should dress
accordingly whenever there is possibility that
they may have to survive in water.
●● Previous training in survival techniques is
extremely beneficial should one be faced with
having to survive for real.
K17577_C012.indd 211
References 211
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Epstein Y, Moran DS. Thermal comfort and the heat stress
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Froom P, Caine Y, Shochat I, Ribak J. Heat stress and heli-
copter pilot errors. Journal of Occupational Medicine
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Holmér I. Required clothing insulation (IREQ) as an analyti-
cal index of cold stress. ASHRAE Transactions 1984;
90: 116–28.
ISO 7243. Hot Environments – Estimation of Heat Stress
on Working Man, Based on the WBGT Index. Geneva:
International Organization for Standardization; 1989.
Nunneley SH, Stribley F. Fighter index of thermal stress
(FITS): guidance for hot-weather aircraft operations.
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Staab JE, Kolka MA, Cadarette BS. Metabolic Rate and
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Vibration
J. R. ROLLIN STOTT
Introduction 213
Principles of vibration 213
Mechanical properties of biological tissues 215
Vibration sources 216
Measurement and analysis of vibration 217
Biomechanical effects of vibration 219
Effects of vibration on vision 220
Cardiovascular effects of vibration 222
Respiratory effects of vibration 222
Neuromuscular effects of vibration 222
INTRODUCTION
Vibration is defined as motion that repeatedly alternates in
direction. The motion of tides and ocean waves, the shak-
ing of the Earth’s crust during earthquakes, the movement
of pistons within the cylinders of engines, the disturbances
generated in aircraft flying through turbulent air, and the
disturbances in vehicles travelling over uneven terrain are
all forms of vibration. They are also examples of vibration
that can be transmitted to the human body and may result in
a range of physiological and psychological effects. Vibration
generally is transmitted to the body through direct contact
with a vibrating structure. In these conditions, significant
levels of vibrational energy can be transferred to the body,
with potentially harmful consequences. Vibration may
also reach the body by transmission through air. Airborne
vibration, if in the appropriate frequency range, is perceived
as sound, but at low sonic and subsonic frequencies it may
exert other physiological effects.
Much of human exposure to whole-body vibration
occurs through transport in vehicles of various sorts.
Although engineering solutions have been found to reduce
the physiological hazards of vibration in many types of
vehicle, undesirably high levels of vibration can be encoun-
tered in helicopters, fixed-wing aircraft during low-level
K17577_C013.indd 213
13
Vibration and motion sickness 223
Alerting effects of vibration 223
Infrasonic vibration 223
Human tolerance to vibration 224
Vibration standards and assessment of vibration
severity 224
Protection against vibration 225
Occupational hazards of vibration 226
References 227
Further reading 228
flight, high-speed sea-going craft and land vehicles travers-
ing rough terrain. Vibration is of operational significance in
aviation because it may, among other things, impair visual
acuity, interfere with neuromuscular control, including
speech, and lead to fatigue. The human body is mechani-
cally complex, and the pattern of vibration to which it is
subjected in, for example, low-level turbulence in an aircraft
or travelling over a rough track in a road vehicle is also com-
plex. Some understanding of the effects of vibration can be
gained by considering the body as an assemblage of simpler
mechanical subunits and by analyzing a complex vibration
waveform in terms of its constituent sinusoidal components.
PRINCIPLES OF VIBRATION
Natural vibration
The most simple example of a vibrating system is provided
by a mass hanging from a fixed point by a spring. When dis-
placed from its rest position, the mass oscillates about this
position for some time before it comes to rest. This vibration
involves a repeated interchange of energy between the mass
and the spring. The mass has gravitational energy when it is
at the highest point of its travel and kinetic energy when it
is in motion. The spring stores energy when it is extended.
213
18/11/2015 14:08
 214 Vibration
If  no energy was lost from the system, then oscillations
would continue indefinitely. In practice, the mass encoun-
ters some resistance to motion from the surrounding air,
and further energy is lost within the spring in the form of
heat. If the displacement of the mass from its rest position is
plotted against time, the resulting graph will be sinusoidal
in shape. Sinusoidal motion can be quantified by two pieces
of information: the frequency, defined as the number of
cycles of oscillation that occur in 1 second (1 cycle/s = 1 Hz),
and the amplitude, which can be defined as the maximum
displacement, measured in metres, from the rest position.
The frequency at which an ideal mass spring system will
oscillate when it is disturbed is termed the natural frequency,
fn (Hz). The natural frequency depends on two quantities:
the size of the mass, m (kg) and the stiffness of the spring,
k (N/m). A greater mass will oscillate more slowly, i.e. at a
lower natural frequency, whereas a stiffer spring will lead to
oscillations at a higher natural frequency. The formula that
links these quantities is as follows:
2π fn = (k / m)
The loss of mechanical energy in a vibrating system as heat,
with consequent decay in the amplitude of oscillation, is
known as damping. As a discrete entity, a damper is exem-
plified by the shock absorber of a car. This typically consists
of a piston in an oil-filled cylinder. A force on the piston
causes it to move at a rate determined by the ease with which
oil is able to flow from one side of the piston to the other,
either through orifices in the piston or through an external
channel connecting one end of the cylinder with the other.
A system that incorporates only a small degree of damp-
ing continues to oscillate for a long time after an initial
disturbance. As the amount of damping is increased, so
the oscillations that follow an initial disturbance decay
more rapidly. With further increases in damping, the mass
returns to its rest position without any overshoot. The mini-
mum degree of damping required to produce this result is
termed critical damping, Cc (kg/s). Its magnitude can be
calculated from the size of the mass, m (kg), and the spring
stiffness, k (N/m), as follows:
Cc = 2 (km)
The amount of damping in a system is commonly expressed
as a proportion of critical damping, termed the damping
factor. Thus, a system that has a damping factor of 1 is criti-
cally damped. If the damping factor is less than 1, the sys-
tem is under-damped; if the damping factor is greater than
1, the system is over-damped.
Forced vibration
The previous section dealt with the behaviour of a mass/
spring/damper system left to vibrate following an initial
mechanical disturbance, so-called natural vibration. It is
K17577_C013.indd 214
necessary to consider how such a system behaves when it
is subjected to an external source of sustained vibration at
various frequencies. Figure  13.1  shows a mass supported
on a vibrating surface through a spring and a damper. The
amplitude of motion of the mass is expressed as a propor-
tion of the motion of the base in the graph. The response
of the mass is determined by the frequency of the imposed
vibration. At low frequencies, the mass and the base share
the same amplitude of vibration (amplitude ratio 1). As
the frequency of vibration is increased, the mass begins
to vibrate to a greater extent than the base. Its vibration
relative to the base reaches a maximum at the resonant
frequency (fo). With further increases in the frequency
of vibration, the relative amplitude of vibration falls until
a frequency is reached above which the vibration of the
mass becomes progressively less than that of the base. At
these frequencies the mass is increasingly isolated from the
source of vibration.
The amount of damping in the system determines the
extent to which vibration is amplified at the resonant fre-
quency. Figure 13.2 shows a family of graphs of the frequency
response of a mass/spring system plotted for different values
of damping. With less damping in the system, the ampli-
fication of vibration at resonance increases. (In theory, it
is infinite if there is no damping at all.) Even with critical
damping, there is some amplification of vibration at the res-
onant frequency. The degree of damping has a small effect
on the frequency at which resonance is at its maximum; the
resonant peak occurs at a somewhat lower frequency in a
more damped system compared with a system with little
or no damping. Above the resonant peak the transmission
of vibration decreases until at a frequency that is a factor
of 2 greater than the un-damped natural frequency, the
response of the mass becomes identical in amplitude with
that of the base, whatever the degree of damping. At this
frequency the graphs cross over each other, indicating that
with a high degree of damping and a consequent low reso-
nant peak there is less vibration isolation at the higher fre-
quencies. A greater degree of damping does not, as the term
Transmission ratio (x/x0)
m x
1.0
k c
x0 0
f0 2f0
Frequency (Hz)
Figure 13.1  A mass/spring/damper system mounted on a
vibrating surface, where m is the mass (kg), k is the spring
stiffness (N/m) and c is the coefficient of damping (kg/s).
The graph shows the ratio of the sinusoidal motion of the
mass (x) to that of the base (xo) as the frequency of vibra-
tion of the base is increased. f 0 represents the resonant
frequency of the system.
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6
0.1
5
4
Transmission ratio
3 0.2
2 0
0.5
1.0
1
0 mass/spring/damper systems, where m is the mass (kg),
f0 2f0 2f0 3f0
Figure 13.2  Graphs showing the response to forced vibra-
tion of a mass/spring system with different degrees of
damping. The figure adjacent to each graph is the damp-
ing factor. f 0 is the undamped resonant frequency.
‘damping’ might suggest, lead to a reduction in transmitted
vibration at the higher frequencies but rather, an increase.
In a system with a low degree of damping, the motion
of the mass at or near the resonant frequency may be many
times greater than that of the applied vibration and may
result in structural damage. However, such a system gives a
high degree of vibration isolation of the mass at frequencies
well above the resonant frequency. In the design of a vibra-
tion isolation system such as the suspension of a motor car,
some compromise level of damping (achieved through the
vehicle’s shock absorbers) has to be found. Damping needs
to be low enough to obtain adequate vibration isolation of
the vehicle at frequencies generated by the normal rough-
ness of the road surface. However, if the degree of damping
is too low, the wheels may bounce should the vehicle hit a
pothole that excites the resonant vibration frequency of the
suspension, leading to a loss of tyre adhesion with the road
surface and possible loss of control. The damping factor that
best achieves this compromise is generally about 0.7, which
limits the amplification at resonance to a factor of about 1.3.
The concept of resonance is particularly important in
understanding some of the harmful effects of vibration
both in engineering structures and in the human body.
The presence of inadequately damped resonances within a
complex structure means that comparatively low intensity
applied vibration can, at certain frequencies, build up to
levels of vibration that generate potentially damaging forces
on component parts of the structure. A large part of vibra-
tion engineering involves the avoidance or the suppression
of resonant vibration.
When a structure contains multiple masses resiliently
coupled together, the behaviour of the system under vibra-
tion is correspondingly complex. Figure  13.3  shows two
masses linked in series by springs and dampers to a vibrating
K17577_C013.indd 215
Mechanical properties of biological tissues  215
m2
Transmission ratio (x/x0)
k2 c2
m1
x 1.0
k1 c1
f1 A f2
x0
Frequency (Hz)
Figure 13.3  Response to forced vibration of two linked
k is the spring stiffness (N/m) and c is the coefficient of
damping (kg/s). The graph shows the ratio of vibration
amplitude of the lower mass (x) with respect to the base
(xo). Two resonances are present, f1 and f2, with attenu-
ation of vibration at an intermediate frequency (A). At
this frequency, the upper mass is resonant relative to the
lower mass.
base. Considering the behaviour of the lower mass, the graph
shows its response as a proportion of the vibration of the base
at different frequencies of applied vibration. Two resonant
peaks are now evident at frequencies that differ from the
resonant frequencies of each individual mass/spring system.
Between these two resonances is a frequency region in which
the vibration of the lower mass relative to the base is much
reduced. At this frequency there is increased vibration of
the upper mass but it occurs in opposite phase to the applied
vibration and thus tends to reduce the amplitude of vibration
of the lower mass. This principle of reducing the vibration of
a mass by coupling to it a second vibration system is used in
the design of the dynamic vibration absorber, a device fitted
to some helicopters. The presence of resonances at frequen-
cies above and below the region of isolation means that such
a system is only of value when the applied vibration is within
a closely defined range of frequencies.
MECHANICAL PROPERTIES OF
BIOLOGICAL TISSUES
Although it is of value to identify mass, elasticity and
damping in a vibrating system, these constituents are better
regarded as properties possessed by the components of the
system rather than as discrete entities. For example, elastic-
ity is the principal property of a steel spring, but the spring
also has mass. Similarly, many springy materials, such as
rubber and connective tissue, possess significant degrees of
damping generated by friction at a molecular level within
the material. In the human body, it is possible, with vary-
ing degrees of precision, to identify mass/spring systems, i.e.
structures that are loosely coupled to the rest of the body by
connective tissue, which, by virtue of its springiness, may
cause the structure to resonate when vibrated at a particular
18/11/2015 14:08
 216 Vibration
frequency. Important in this regard are the vibration of the
head relative to the rest of the body, the shoulder girdle and
the upper limbs relative to the torso, the torso relative to the
pelvis and the liver and mediastinum within the body cavity.
The springiness of connective tissue is not modelled so
easily as that of an ideal spring. The force required to stretch
an ideal spring is proportional to its increase in length. The
spring is said to possess uniform stiffness. The collagen of
tendon and ligament is non-uniform in stiffness. It becomes
stiffer the more it is stretched (Figure  13.4). The implica-
tion for a vibrating system that has collagen as the spring
component is that the resonant frequency depends on the
underlying tension within connective tissue. This connec-
tive tissue tension is determined mainly by muscle activity
and by the weight of tissues that it supports.
Damping occurs by several mechanisms within the
body. In addition to the internal friction within tissue as
it is stretched, there is an important damping effect from
active skeletal muscle. When active muscle is made to
lengthen by the application of an external force, the muscle
generates an opposing force, which, for a given degree of
neural activation, is proportional to its rate of lengthening.
This is the property of an ideal damper. It is, therefore, not
surprising that the state of muscle tension and the conse-
quent body posture are major variable factors governing
the mechanical response of the body to vibration. Increased
tension in muscles has the effect of stiffening the vibrat-
ing system to which the muscles are attached. This tends to
raise the resonant frequency and at the same time, by gen-
erating increased damping, tends to reduce the degree of
resonant amplification.
VIBRATION SOURCES
Vehicles are a major source of human exposure to whole-
body vibration. In most vehicles, there are two principal
sources of vibration to be considered. The first originates
within the vehicle, in particular the engine; the second is
derived from the environment, i.e. the terrain over which the
Steel spring
Force
Tendon
Extension
Figure 13.4  Relationship between force and extension for
a steel spring compared with that for tendon. Stiffness is
given by the slope of the graph. Tendon becomes increas-
ingly stiff as it is stretched.
K17577_C013.indd 216
land vehicle is travelling, the turbulent air through which the
aircraft is flying, or the sea state in which the ship is sailing.
All machinery is liable to generate vibration. In the
internal combustion engine, the impulse as each cylinder
fires and the reciprocating motion of the pistons provide a
source of vibrational energy that is propagated to the vehicle
through the mountings of the engine and gearbox. Gas tur-
bines and electric motors in good condition are inherently
less likely to generate vibration, but any mass imbalance of
a rotating component or looseness in its bearings may result
in significant vibration. The detailed analysis of vibration
records from accelerometers mounted on the fuselage of
a helicopter and the casing of engines and gearboxes is an
important technique for detecting wear in these compo-
nents during their working life.
The vibration generated from an engine is at a fre-
quency that can be predicted from the rotational speed of
the machinery. A piston engine rotating at 60  revolutions
per second (3600  rpm) is likely to propagate vibration at
this frequency (60  Hz). The rotor of a helicopter typically
revolves at four revolutions per second and, therefore,
potentially generates vibration within the helicopter at
4 Hz. However, the intensity of vibration of the helicopter
at this frequency is generally low. This is achieved by accu-
rate matching of the mass of each blade on the rotor and by
aerodynamically trimming the blades so that they rotate in
the same plane. This fundamental rotor frequency is often
referred to as the 1R frequency. Generally, the vibration pro-
duced at the blade-pass frequency is of greater amplitude.
This frequency is the 1R frequency multiplied by the num-
ber of rotor blades and in many helicopters is in the region
of 15–25 Hz. In addition, components of vibration are gen-
erated at higher harmonics (i.e. integer multiples) of the
blade-pass frequency and also at a frequency related to the
tail rotor speed. Figure 13.5 shows the spectrum of vertical
vibration recorded from a Chinook helicopter. The repeti-
tive pattern of vibration gives rise to discrete peaks in the
spectrum. That at 1R (3.8 Hz) is small: the principal compo-
nents are at the blade-pass frequency, 6R (22.75 Hz) and the
first harmonic of the blade-pass frequency, 12R (45.5  Hz).
Other peaks in the spectrum at frequencies unrelated to the
main rotor frequency may originate from gearboxes and
transmission systems within the aircraft.
Helicopter vibration occurs with broadly similar inten-
sity in all three axes of motion, vertical, lateral and fore–aft.
Although there may be large differences in the amplitudes
of specific harmonics in different modes of flight, the over-
all amplitude of vibration tends to increase with airspeed
and with the loading of the aircraft. The level of vibration
also tends to increase during transition to the hover. The
measured levels of vibration may differ quite widely between
helicopters of identical type operating under similar condi-
tions, although the source of these differences is often elusive.
In fixed-wing aircraft, any vibration arising from
the power source tends to be at a higher frequency than
in helicopters. In a propeller-driven aircraft, the blade-
pass frequency is in the region of 100  Hz, although lower
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6R
3 12R
Acceleration (m/s2/Hz)
2 0.1
1 3R
0 Frequency (Hz)
0 20 40 60
Frequency (Hz)
Figure 13.5  Vertical vibration amplitude spectrum of the
Chinook helicopter. Peaks labelled 3R, 6R, 12R are har-
monics of the fundamental rotor frequency at 4 Hz. In this
case, the highest peak occurs at the blade-pass frequency
(6R), but there is much variation in the relative amplitude
of the different harmonics recorded under different
flight conditions.
frequencies of vibration may be generated by the beat-
ing effect of two propellers running at different speeds. A
single-stage turbine of a fixed-wing jet aircraft typically
rotates at about 8000  rpm (130  Hz); the high-pressure
stage of a dual-stage turbine rotates at about 13 000  rpm
(230  Hz). The main source of vibration encountered in
fixed-wing aircraft arises from the atmospheric tur-
bulence through which the aircraft is flying. In conse-
quence, the most severe vibration tends to occur during
storm-cloud penetration or during high-speed low-level
flight (Speakman and Rose 1971; Speakman et al. 1971). It
reflects the random disturbances of turbulent air modi-
fied by the aerodynamic characteristics of the aircraft and
by the control actions of the pilot (Figure 13.6). Most of the
vibrational energy of fixed-wing aircraft is found at low
frequencies in the vertical axis. In atmospheric turbulence,
the vertical vibration of the aircraft at 1 Hz may exceed by
a factor of 100 that at 10 Hz. The sharp peaks that are char-
acteristic of the spectrum of helicopter vibration are not
seen in fixed-wing aircraft, although the vibration spec-
trum may reflect the flexural resonances of the wings and
fuselage by showing broad maxima at these frequencies.
These features are less evident in the spectrum of high-
performance fighter aircraft, whose wings and fuselage are
constructed more rigidly. However, during buffet, which
occurs, for example, in maximum-rate turns that require
the greatest degree of aerodynamic lift from the wings,
vibration is imposed on the airframe over a narrow fre-
quency range that varies according to aircraft type between
about 8 and 20 Hz.
The response of the aircraft as a whole to atmospheric
turbulence is determined by the aerodynamic loading on
the wings. An aircraft with a large wing area relative to its
weight undergoes greater amplitude low-frequency excur-
sions from level flight as a result of turbulence. Such motion
is predominantly in the frequency range of 0.1–1 Hz.
K17577_C013.indd 217
Measurement and analysis of vibration  217
100
Acceleration PSD ((m/s2)2/Hz)
10
1
F-4C
0.01
0.001
B-52
0.0001
0 5 10 15 20
80 100
Figure 13.6  Power spectral density (PSD) of Gz vibration
from two fixed-wing aircraft, the F-4C fighter and the
B-52 bomber, during high-speed low-level flight. Note
the logarithmic scale on the vertical axis, which empha-
sizes the lower vibration amplitudes at the expense of the
higher amplitudes. The levels of vibration are greater at
the low frequencies (<1 Hz) and decline sharply at increas-
ing frequencies. Redrawn from Speakman et al. (1971).
The firing of machine guns from military aircraft trans-
mits to the airframe a series of mechanical shocks. These
may be attenuated to some degree by gun mountings that
allow the gun to recoil. Such shocks vibrate the airframe
not only at the frequency of firing of the gun but also over
a broader range of frequencies. The firing of a missile pro-
duces a single shock disturbance that evokes a transient
vibrational response from undamped resonances within
the aircraft.
MEASUREMENT AND ANALYSIS OF
VIBRATION
The two essential descriptors of vibration are its ampli-
tude and its frequency. Vibration amplitude could be
described in terms of the oscillatory motion, or displace-
ment of the structure undergoing vibration. An alternat-
ing displacement implies a changing velocity which in turn
implies changes in the acceleration of the vibrating object.
Displacement, velocity and acceleration are related math-
ematically. In principle, one may be derived if the others are
known (Figure 13.7). Vibration intensity is most frequently
quoted in terms of the amplitude of the acceleration, partly
because it is convenient to measure vibration using accel-
erometers but also because acceleration is directly related
to the vibrational forces involved. (Newton’s second law
states that for a given mass, force is proportional to accel-
eration, F = m.a.) The unit of linear acceleration is m/s2, but
it may also be expressed in units of G, i.e. multiples of the
acceleration due to gravity (1 G = 9.8 m/s2). For sinusoidal
vibration at a single frequency the measurement of ampli-
tude is straightforward since successive cycles of vibration
are identical and the peak value can be recorded. For a
complex vibration containing multiple frequency compo-
nents, no two peaks in the vibration record are the same
and some measure that takes account of peak amplitudes
18/11/2015 14:08
 218 Vibration
Displacement (m) d the accelerometer. Accelerometers vary from rugged units
1
f=–
T ing an impact to fragile devices that will measure well below
T are insensitive to linear acceleration and respond only to
Velocity (m/s)
v When accelerometers are used on the human body, the
v = 2πf.d
Acceleration (m/s2)
a teeth provide a useful fixation point, and small accelerom-
a = 2πf.v
= (2πf)2.d
Time
Figure 13.7  Relationship between displacement, veloc-
ity and acceleration for sinusoidal vibration. With respect
to displacement, the phase of velocity is advanced by
one quarter-cycle and acceleration by one half-cycle. The
duration of one cycle of motion, T (s), is known as the
period. The reciprocal of the period, 1/T, gives the fre-
quency, f (Hz). The velocity amplitude, v, is obtained from
the displacement amplitude, d, by multiplying by 2πf. The
amplitude of the acceleration, a, is found from the veloc-
ity amplitude by a further multiplication by 2πf.
over a representative time period is required. Typically, the
root mean square (RMS) amplitude is used. This involves
squaring each value in the record so that previously nega-
tive values become positive, calculating the mean of these
values over a particular time period and then taking the
square root of the mean. The RMS value can be considered
as a type of average amplitude for a complex waveform.
If this process were applied to a sine wave at a single fre-
quency, its RMS level would be a factor of 0.707 (1/ 2) of
its half-peak amplitude.
An additional descriptor of a complex vibration wave-
form is provided by the crest factor. If vibration is generated
from an impulsive source such as a mechanical hammer or
from weapons firing in a military aircraft, then the recorded
vibration will show short-duration high peaks of accelera-
tion, termed mechanical shocks, whose presence makes the
perceived severity of vibration much greater than its RMS
level would indicate. The crest factor is defined as the ratio
of the peak acceleration amplitude of a vibration record to
its RMS amplitude. For vibration in which the crest factor
exceeds a value of 6, the RMS level of vibration is a poor
indicator of its subjective severity, and a form of averag-
ing is used that gives extra weight to the peak levels. The
K17577_C013.indd 218
most widely used device in the measurement of vibration is
designed to measure the high accelerations that occur dur-
the threshold of human perception. For the measurement
of angular motion, accelerometers are manufactured that
angular acceleration. Also available are devices that mea-
sure angular velocity, from which angular acceleration can
be derived.
need for high sensitivity and small size are often conflicting
requirements. There are very few places on the body surface
where good fixation of an accelerometer can be achieved
and where the mass of the accelerometer and the springi-
ness of the underlying soft tissue cannot form a resonant
system and, thereby, generate misleading information. The
eters can be mounted on a dental bite to measure accelera-
tions of the head. Elsewhere on the body, unless fixation is
achieved by screwing into bone, accelerometers have to be
strapped to the overlying skin.
It is often desirable to measure the level of vibration at
the point of entry to the body, and this may be achieved in
a seated subject by enclosing small accelerometers in a thin
seat pad on which the subject sits. Accelerometers have a
directional sensitivity. For a full description of the vibra-
tion of a structure, three linear accelerometers are needed,
with their sensitive axes at right angles to each other.
Additionally, if angular motion is to be measured, a further
three angular accelerometers are required.
The direction of vibration accelerations acting on the body
is specified on the same three-axis system with reference to
the trunk as used in relation to long-duration accelerations.
Gx acceleration acts in the antero-posterior direction, Gy in
the lateral direction and Gz in the cranio-caudal direction.
Angular accelerations about these axes are generally referred
to in terms of roll, pitch and yaw respectively.
Complex vibration waveforms can be divided into two
main types: those that have repetitive or periodic features,
typically generated by machinery, and those that are irregu-
lar or aperiodic as a consequence of random disturbances,
such as the vibration of an aircraft in atmospheric turbu-
lence. Any complex vibration waveform can be considered
as the summation of a series of increasing frequency sinu-
soidal components, or harmonics, of appropriate amplitude
and phase relationship. The technique of breaking down a
vibration signal into its constituent frequencies, known as
Fourier analysis, is important since the effects of vibration
on a structure, and in particular the human body, are criti-
cally dependent on the frequency. A plot of the amplitude of
each component versus frequency is known as the vibration
spectrum. Periodic vibration generates a spectrum that has
narrow discrete peaks with little or no activity in the inter-
vening spectral components. Aperiodic, or random, vibra-
tion yields a continuous spectrum that may show broad
peaks in specific regions of the spectrum.
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BIOMECHANICAL EFFECTS OF VIBRATION
Mechanical impedance of the body
In order to transmit vibration to an object, a source of vibra-
tion has to exert an alternating force at its point of contact.
The amount of force that is required to produce a given
vibration response is known as the mechanical impedance.
More specifically, mechanical impedance is defined as the
ratio of the peak oscillatory force exerted on an object by a
vibration source to the resulting peak velocity of vibration
measured at the point of contact. The concept of mechanical
impedance is directly analogous to that of electrical imped-
ance, which relates an alternating electromotive force (volt-
age) to the resulting flow of alternating current in a circuit
component. When the human body is in direct contact with
a source of vibration, mechanical energy is transferred,
some of which is degraded into heat within those tissues
that have damping properties. Mechanical impedance gives
an indication of the capacity of the body to absorb vibra-
tional energy. The mechanical impedance of the human
body is dependent on the frequency of vibration. If the
body were a simple mass, its mechanical impedance would
increase linearly with frequency. For a seated human sub-
ject, this is true only for frequencies of vibration up to about
2  Hz (Figure  13.8). Thereafter, there is a disproportionate
increase in mechanical impedance, which reaches a maxi-
mum at 4–5 Hz. When vibrated at this frequency, a 70-kg
man has an apparent mass of 130 kg. This effect is the result
of a major resonance within the body. Above a vibration fre-
quency of 7 Hz, the impedance of the body falls below that
of a simple mass, indicative of the vibration isolation effects
of compliant body tissues. Of principal importance is the
flexibility of the lumbar spine and, at higher frequencies, the
compressibility of intervertebral discs and the soft tissues of
the buttocks, which allow the upper trunk to be relatively
isolated from the source of vibration. Mechanical imped-
ance diminishes with increasing frequency, but this trend is
interrupted by a second peak at about 12–15 Hz, indicative
6 12–15 Hz is less clear. It has been postulated that this reso-
70 kg pure mass
Mechanical impedance (kN/m/s)
5 nance is the result of axial compression of the torso con-
4 its supporting musculature, although direct experimen-
3
2 transmission of vibration from the seat to the head and the
70 kg man
1
0 vibration of the head is the principal effect (Rowlands 1977).
0 2 4 6 8 10 12 14
Frequency (Hz)
Figure 13.8  Mechanical impedance of a 70-kg seated sub-
ject at vibration frequencies up to 20 Hz. The two peaks in
the curve occur at the frequencies of the first and second
body resonances. Also shown is the impedance of a pure
mass of 70 kg.
K17577_C013.indd 219
Biomechanical effects of vibration  219
of a second resonance. The shape of the impedance curve is
modified by posture, the type of seating and restraint sys-
tem, and G loading. At 3 G, the peak in mechanical imped-
ance is shifted upwards to about 8 Hz (Vogt et al. 1977).
Body resonances
Measurement of mechanical impedance gives little indica-
tion of the body structures that are involved in the principal
resonances. It is likely that several resonances contribute to
the impedance peak at 4–5 Hz. During vertical vibration of
a seated subject, the flexibility of the lumbar spine and its
associated musculature provides a compliant link between
the mass of the torso and the pelvis and, thus, allows reso-
nance of the upper trunk. There is also amplification of
motion in the shoulder girdle at these frequencies. Less visi-
ble, but of greater relevance to human tolerance to vibration,
is the resonance of the liver, diaphragm and mediastinum
within the body cavity. Animal experiments suggest that
this mass moves as one unit against the restraints of compli-
ant connective tissue and of the fluid- and gas-filled abdom-
inal contents. The associated movement of the diaphragm
promotes oscillatory airflow in the respiratory tract as well
as abdominal wall movement (Coermann et al. 1960), and
intra-abdominal pressure changes. All these measures show
a peak at 3–4 Hz in humans.
The additional energy required to vibrate the body
at the frequency of maximum mechanical impedance is
absorbed in the supporting connective tissue associated
with these resonant structures, both by frictional heating
and, under more severe vibration, by mechanical disrup-
tion of tissues. Anaesthetized animals exposed to lethal
levels of vibration (10–15  G) at frequencies in the region
of their internal body resonance developed pulmonary
congestion with haemorrhage and collapse, diffuse intes-
tinal bleeding and, occasionally, superficial brain haemor-
rhage. Electrocardiographic (ECG) changes indicative of
myocardial damage often preceded death (Nickerson and
Paradijeff 1964).
The origin of the second major resonance of the body at
trolled by the elastic properties of the spinal column and
tal evidence for this is lacking. Both the first and second
resonances (4–5 and 12–15 Hz) are evident as peaks in the
shoulders (Figure  13.9). At 4–5  Hz, resonant vibration of
the shoulders predominates, whereas at 12–15 Hz, resonant
16 18 20
The transmission of vertical vibration to the head in seated
subjects is affected by body posture, whether slouched or
erect, and by the configuration of the seat and the degree of
mechanical coupling between the backrest and the trunk.
The presence of a backrest allows vibration to bypass the
vibration-attenuating effect of the trunk and in conse-
quence, the levels of head vibration at around 6  Hz for
18/11/2015 14:08
 220 Vibration
Gx,  Gz, and pitch head movements are increased (Paddan
and Griffin 1988a). In response to vibration in the fore–aft
direction, the presence of a backrest increases vibration
of the head in these axes over a broader frequency range,
4–16 Hz (Paddan and Griffin 1988b).
The mechanical response of the head under vertical
vibration involves not only linear but also angular motion,
particularly in pitch. This occurs because the centre of
gravity of the head lies anterior to the atlanto-occipital
joint and the consequent tendency to forward flexion of the
head, readily observed in somnolent rail passengers, has in
the waking state to be opposed by continuous activity in
the neck extensor muscles. The relationship between head-
pitch acceleration and linear vertical seat acceleration tends
to reach a peak at 5–6  Hz. A further effect often seen in
response to vibration at these frequencies is that the motion
of the head contains components at twice the frequency of
the input vibration. The effect of wearing an aircrew hel-
met is to increase the mass of the head and, in consequence,
the stiffness of the neck muscles that hold the head upright.
Measurement of the motion of a well-fitted aircrew helmet
shows that it remains coupled well to the head at frequen-
cies of vertical vibration up to about 4 Hz, but at 7 Hz the
pitch motion of the helmet can be more than twice that of
the head.
At different frequencies of vibration, other reso-
nances become apparent within the body. Although the
maximum oscillatory airflow is produced by frequen-
cies of vertical vibration around 3–4  Hz, speech is not
impaired at these frequencies unless vibration levels are
severe. From about 6–20  Hz, the oscillatory airflow per-
sists, probably as a result of chest-wall resonance, and
produces loudness modulation of speech. This may give
rise to loss of intelligibility at some frequencies (Nixon
and Sommer 1963) and may pose problems for automatic
speech-recognition systems.
2 in the antero-posterior direction (Gx), some amplification
Head
Transmission ratio
1
Shoulder
0 First, the image formed on the retina must be focused cor-
0 5 10 15 20
Frequency (Hz)
Figure 13.9  Transmission of vibration to the head and
shoulders of a seated subject. Redrawn from Rowlands
(1977).
K17577_C013.indd 220
Subjects vibrated at frequencies between about 2  and
6  Hz experience difficulty in controlling the position of
the outstretched arm. This may pose problems in the
operation of switches and controls in an environment
vibrating at these frequencies. Tracking-tasks in which the
arm is supported and the hand operates a joystick control
are most disrupted by vibration over a somewhat higher
frequency range, 4–8  Hz, reflecting the smaller mass of
that part of the arm that is free to vibrate. As frequencies
of vibration are increased, progressively smaller structural
units in the body may resonate – at the lower frequencies,
4–8  Hz, the muscles of the thigh, at higher frequencies
muscle groups of smaller mass, and at 15–20 Hz the facial
tissues, often accompanied by mild irritation in the skin
of the face.
The possibility of mechanical resonance of the eye has
been investigated. Early experiments showed visual acu-
ity for stationary targets to be impaired under whole-body
vibration in the frequency ranges 20–40  and 60–90  Hz
((Coermann 1940). An indirect method of tracking the
retinal image during vibration applied direct to the head
has also shown resonant peaks at 30–40  Hz (×1.3) and at
70  Hz (×3) (Stott 1984). In practice, whole-body vibration
applied through a seat at these frequencies is much attenu-
ated within the trunk, and relatively little reaches the head.
It seems likely that any resonance of the eye involves intra-
ocular structures rather than movement of the eye globe as
a whole. The effect of vibration on vision is considered in
more detail below.
The response of the body to vibration transmitted
through the feet of a standing subject is little different from
that of a seated subject, the straight legs acting as rigid col-
umns. Flexion of the legs brings into play the compliance
and damping properties of striated muscle and produces
increasingly effective vibration isolation of the trunk to
frequencies above about 5 Hz, a fact appreciated by down-
hill skiers and occupants of rigid inflatable boats moving at
speed over the waves. When vertical vibration is applied to
supine subjects, the attenuating effect of the trunk on vibra-
tion reaching the head is absent. In supine subjects vibrated
of vibration was found at the head at frequencies above
10  Hz and a resonant peak (×2) at 60  Hz. There was also
amplification of vibration at around 8 Hz on the abdomen,
sternum and knee, with attenuation above about 16  Hz
(reviewed in Dupuis and Zerlett (1986)).
EFFECTS OF VIBRATION ON VISION
There are two principal requirements to enable the eye
to view objects with a maximum degree of visual acuity.
25
rectly; second, the eyes should be directed such that the
image remains essentially stationary on the fovea. This
second requirement of a stable retinal image may have to
be achieved either when the object of regard is in motion
or when the head itself is moving. Two important reflexes,
18/11/2015 14:08

the vestibulo-ocular reflex and the pursuit reflex, pro-
mote stability of the retinal image. The vestibulo-ocular
reflex uses sensory information derived primarily from
the semicircular canals to generate angular eye movements
that compensate for head movements. The pursuit reflex
is mediated visually and uses the error of visual fixation
and the velocity of retinal slip to generate eye movements,
which maintain the retinal image on the region of the
fovea. The shortest neural pathway between the vestibular
system and the eye muscles comprises only three neurons
and, consequently, enables the eye to respond rapidly to
changing head movement. By contrast, the pursuit reflex
comprises more complex visual processing and is relatively
slow in response.
Thus, if a stationary subject views an oscillating com-
plex display, the visual acuity for details of the display
will be reduced if this motion exceeds an angular velocity
of 40  degrees per second or if its frequency of oscillation
exceeds about 1 Hz. The subject’s performance at this task is
limited by the pursuit reflex (Figure 13.10). By contrast, if a
subject with normal vestibular function undergoes angular
oscillation while viewing a stationary display, good visual
acuity is maintained up to frequencies of 8  Hz, or more.
That this ability depends on an intact vestibulo-ocular
reflex is indicated by the fact that a subject who lacks vestib-
ular function loses visual acuity when either the subject or
the display is oscillated at frequencies above 1 Hz (Benson
40
Number of digits read in a 10 s period
30
20
10
0 suppressed and may, therefore, contribute to a decrement
0.5 1 2 3 4
Frequency of oscillation (Hz)
Figure 13.10  Comparison of reading performance (mean
of eight subjects) when subjects undergoing sinusoidal
oscillation in yaw were required to read a stationary
numerical display (○–○) and when stationary subjects
were required to read an oscillating display (●–●). The
dotted lines indicate the performance of a subject who
lacked labyrinthine function. Redrawn from Benson and
Barnes (1978).
K17577_C013.indd 221
Effects of vibration on vision  221
and Barnes 1978). It is likely that the vestibulo-ocular reflex
is able to generate eye movements that are compensatory
for angular head movement at frequencies up to 20–25 Hz
(Stott 1984).
Whole-body vertical vibration generates angular move-
ment of the head principally in pitch. The highest angular
accelerations are generated by vertical vibration between
about 3 and 10 Hz. Such angular head movement is within
the frequency range in which the vestibulo-ocular reflex
will promote compensatory eye movements, although
with high intensities of vibration at these frequen-
cies subjects may be aware of some visual instability of
earth-fixed objects.
The pilot of an aircraft undergoing vibration needs to
maintain visual acuity under two principal conditions –
either when viewing the world outside the aircraft or when
looking into the aircraft to read instruments, displays
or charts that are, like the pilot, undergoing vibration.
The outside world is at optical infinity and is space-sta-
ble, although the pilot may need to track objects moving
within it, such as other aircraft. Under these conditions,
the eye is stabilized to angular head movement by the ves-
tibulo-ocular reflex, and purely linear movements of the
head will produce no retinal image motion. Objects, such
as other aircraft, that the pilot wishes to track within this
field of view are unlikely to move so fast that they exceed
the angular velocity limitations of the pursuit reflex. When
viewing objects within the aircraft, however, the pilot may
experience problems. The aircraft vibration will, at certain
frequencies, be amplified at the pilot’s head. In addition, at
frequencies above 1–2  Hz, head motion is likely to be out
of phase with the motion of the instrument panel, owing
to transmission delays through the body. These factors pro-
duce relative linear motion between the eye and the instru-
ment panel which is likely to result in retinal image motion
and degraded visual acuity, since, unlike the outside scene,
the instrument panel is not at optical infinity. Also, in
these circumstances, any eye movements generated by the
vestibulo-ocular reflex in response to angular head motion
may not improve retinal image stability. The mechanism
by which unwanted vestibular-induced eye movements are
suppressed has the same frequency and velocity limitations
as the pursuit reflex. (It is likely that vestibulo-ocular sup-
pression and ocular pursuit involve the same neural path-
ways.) Thus, vestibular-induced eye movements resulting
from head vibration at frequencies above 2  Hz cannot be
6 8 10 in visual acuity when both subject and visual target are
undergoing vibration.
A further circumstance in which the vestibulo-ocular
reflex produces inappropriate eye movements occurs in
the use of helmet-mounted display systems, which gener-
ate images that are coupled to, and, therefore, move with,
the head. The legibility of a helmet-mounted display is
particularly impaired by vibration at frequencies between
4 and 6 Hz (Figure 13.11) but can be improved if the pro-
jected visual image of the display is stabilized by moving it
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 222 Vibration
Increase in reading time (%) 100 (a)
(b)
50
0
0 5 10 15
Frequency (Hz)
Figure 13.11  Effect of vibration on reading performance
from a helmet-mounted display, (a) when the display
image is fixed in position relative to the helmet and (b)
when the image is stabilized in space. Redrawn from Wells
and Griffin (1984).
in anti-phase to the sensed pitch and yaw rotations of the
helmet at these frequencies (Wells and Griffin 1984).
The legibility of flight instruments in helicopters is a sub-
ject that has received insufficient attention. Pilots are often
aware that at certain phases of flight, e.g. transition to hover,
the levels of vibration render instruments difficult to read.
In addition to the relative motion between observer and
visual target produced by vibration, many other factors are
involved in the legibility of symbolic information, including
size, line width, colour, brightness and contrast.
CARDIOVASCULAR EFFECTS OF
VIBRATION
Exposure to moderate levels of whole-body vibration pro-
duces no consistent changes in simple measures of cardio-
vascular function. There may be an increase in pulse rate
at the start of vibration exposure, but this is not sustained.
A rise in blood pressure after periods of vibration lasting
1–2  hours has been reported. In response to whole-body
vibration, there is an increase in muscle activity, both in
order to maintain posture and, possibly, to reduce the reso-
nant amplification of body structures. This is reflected in
an increase in metabolic rate under vibration and a redis-
tribution of blood flow, with peripheral vasoconstriction
(Hood et  al. 1966). More severe levels of vibration have
provoked transient cardiac rhythm changes in humans and
fatal dysrhythmias in laboratory animals exposed to high
intensity vibration.
RESPIRATORY EFFECTS OF VIBRATION
The increase in metabolic rate during vibration is com-
parable with that seen in gentle exercise, and respiration
is increased in order to achieve the necessary increase in
elimination of carbon dioxide. However, true hyperventi-
lation may occur, leading to reduced CO2  tensions within
the body (Ernsting 1961). There are several possible mecha-
nisms. High levels of vibration may give rise to alarm with
consequent hyperventilation. Alternatively, vibration may
stimulate stretch receptors in the lung to promote increased
K17577_C013.indd 222
pulmonary ventilation. Vibration over a wide range of fre-
quencies promotes an oscillating airflow superimposed
on the normal respiratory air movements. The maximum
oscillating volume is found with Gz vibration at 3–4  Hz,
corresponding to the frequency of internal body resonance.
Although this oscillating volume is less than the anatomical
dead space, it has a disproportionate effect on gas exchange
20 25 on account of the convective mixing promoted by vibration
of the air within the bronchial tree. This effect may be maxi-
mal at higher frequencies of oscillatory airflow (George and
Geddes 1985).
Individual differences in the degree of hypocapnia
induced by vibration may be related to the individual’s
responsiveness to CO2. In subjects with a low CO2 respon-
siveness, minute ventilation is regulated less tightly by arte-
rial CO2  levels. It has been suggested that the increased
ventilation provoked by vibration is not compensated in
these individuals by a reduction in CO2-mediated ventila-
tory drive (Lamb and Tenney 1966). Generally, vibration
levels in helicopter operations are insufficient to produce
overt symptoms of hyperventilation, but end-tidal Pco2
levels of 30  mmHg have been measured in the laboratory
during repeated 2-hour exposures to the simulated noise
and vibration environment of the Chinook helicopter
(Figure 13.12).
NEUROMUSCULAR EFFECTS OF
VIBRATION
Vibration in the frequency range 20–100  Hz applied
directly to a skeletal muscle or its associated tendon pro-
vokes a reflex contraction, the tonic vibration reflex,
accompanied by an erroneous perception of increased
muscle stretch. Local vibration can be regarded as a rapid
sequence of mechanical stimuli provoking a succession
of stretch reflexes. The effect is mediated through the
40
End-tidal PCO2 (mmHg)
30
Noise & vibration Noise & vibration Noise & vibration
20
0 1 2 3 4 5 6 7 8
Time (h)
Figure 13.12  Vibration-induced hyperventilation. End-
tidal Pco2 levels measured in one subject during exposure
to laboratory-reproduced noise and vibration from the
Chinook helicopter over an eight-hour period. End-tidal
CO2 levels return to near-normal following each 20-minute
rest period.
18/11/2015 14:08

stimulation of muscle spindles and Golgi tendon organs,
whose receptors are responsible for the sense of proprio-
ception. Thus, vibration applied to the Achilles tendon
or the soleus muscle in a standing subject is perceived
as a lengthening of this muscle, which is interpreted as
ankle dorsiflexion and a forward tilt of the whole body.
The subject, in an attempt to remain upright, generates
an inappropriate backward movement of the body, to the
point where he or she may fall. Similarly, local vibration
applied to the neck extensor muscles provokes an illusion
of forward flexion of the head, and vibration to the rectus
abdominis provokes an illusion of extension of the upper
trunk. When vibration is stopped, there is a transient illu-
sion of motion in the opposite direction. Furthermore,
if during vibration of muscle groups the subject views
a stationary light in the dark, there is a visual illusion of
movement of the light in the direction of the illusory body
motion, and it may be possible to record an associated nys-
tagmus (Lackner and Levine 1979). In contrast to vibration
applied to individual muscles, whole-body vibration pro-
vokes a reflex inhibition of spinal reflexes. The effect seems
to be mediated peripherally, since inhibition of leg reflexes
can be produced as readily when vibration is applied
through the feet of seated subjects (Roll et al. 1980).
VIBRATION AND MOTION SICKNESS
Whole-body vibration at frequencies below 0.8  Hz, and
maximally at frequencies of around 0.2 Hz, can induce the
symptoms of motion sickness in susceptible subjects. In
seated subjects, susceptibility is greater for a stimulus in the
Gx (fore–aft) direction than for the same stimulus applied
in the Gz (cranio-caudal) direction. The effect of a supine
posture is to reduce susceptibility to low frequency oscilla-
tion, but in this posture the effect on susceptibility of stimu-
lus direction relative to the axis of the body is still present
(Golding et  al. 1995). The frequency range over which
motion sickness is provoked lies well below any internal
body resonance, so that there is no direct mechanical cause
for the stomach-awareness that characterizes the onset of
motion sickness.
ALERTING EFFECTS OF VIBRATION
A fighter pilot who wishes to maximize the rate of turn of
the aircraft will put the aircraft into a steeply banked atti-
tude and pull back on the control column to increase the
angle of attack of the wing and thereby increase the aero-
dynamic lift force. Beyond a certain angle of attack, typi-
cally about 15  degrees for a conventional wing, there is a
steep reduction in lift force as the wing approaches the stall.
This change is the result of turbulence affecting the smooth
airflow over the upper surface of the wing and it imparts a
vibration to the airframe. The onset of this vibration, known
as light buffet, can be felt by the pilot and acts as an indica-
tion that maximum lift has been achieved and as a warning
of an incipient stall. It is so important to detect and avoid an
K17577_C013.indd 223
Infrasonic vibration  223
inadvertent stall that most aircraft are fitted with some form
of stall warning, usually auditory but often supplemented
by a device that imposes a vibration to the control column,
known as a stick shaker.
Vibration has also been used as an aid to aircraft orien-
tation by means of tactors, coin-sized electrically activated
vibrating discs that can be arranged in a grid and incorpo-
rated into a vest worn by the pilot. The pattern of activation
can be used to give the pilot a tactile indication of aircraft
attitude or alternatively to indicate to a helicopter pilot
attempting to land in difficult visual conditions either the
presence of drift in the hover or the rate of descent.
INFRASONIC VIBRATION
Aircraft engines and rocket motors generate airborne
vibration over a very broad range of acoustic frequencies.
Airborne vibration is perceived mainly as sound when
it lies within the frequency range of the ear. Acoustic
frequencies below 25  Hz, nominally the low-frequency
threshold of hearing, can still be heard if they are of
sufficient intensity, but the sensitivity of the ear falls off
rapidly in this frequency range. Below a frequency of about
18 Hz, sounds are heard not as a continuous tone but as a
series of pulses. At even lower frequencies (5–10 Hz), pres-
sure pulsations are still sensed by the ear, although pos-
sibly through nerve endings in the tympanic membrane,
which convey a sense of fullness in the ear and of pain if
acoustic vibration is of sufficient intensity (>155  dB at
5 Hz). There is evidence that the feeling of fullness or pres-
sure in the ear is the result of indrawing of the tympanic
membrane. It can be relieved, but only temporarily, by
venting the middle ear using the Valsalva manoeuvre. The
Eustachian tube appears to be acting as a one-way valve,
so that large excursions of the tympanic membrane force
air out of the middle ear more readily than it can be drawn
back in. After exposure to intense infrasound, vascular
injection of the eardrum may be observed and audiometry
may show a small degree of temporary threshold shift (Von
Gierke and Nixon 1977).
Other symptoms reported by subjects exposed to high
intensity infrasound include nausea and impairment of
balance, symptoms that suggest an involvement of ves-
tibular receptors. Vertical nystagmus has been recorded,
its onset related to the frequency, intensity and duration
of infrasonic vibration. No objective evidence of equilibra-
tory disturbance has been obtained. Infrasonic vibration
over the frequency range 2–15  Hz can be felt as pressure
pulsations on the chest and abdomen, sometimes asso-
ciated with a sense of tightness in the chest. Because of
the disparity in density (more strictly, acoustic imped-
ance) between air and body tissues, much of the pressure
wave is reflected and very little movement is imparted to
the chest wall. However, the fluctuating air pressure gen-
erates an alternating mass flow of air in and out of the
chest. If the gas flow is measured at different frequencies
and constant sound pressure level, a peak in flow is seen
18/11/2015 14:08
 224 Vibration
at around  50  Hz, which is indicative of an acoustic reso-
nance of the chest cavity at this frequency. Dogs exposed
to acoustic vibration of 0.5  Hz at 172  dB can cease spon-
taneous respiration without ill effect. Such observations
have led to the use of oscillatory gas flows at frequencies
between 0.5 and 6 Hz as a technique for assisting alveolar
ventilation in patients with respiratory disease. Tiredness
and an inability to concentrate are also symptoms that
may be reported during exposure to infrasound. These
effects are indicative of the psychological stressor effects
of infrasound.
HUMAN TOLERANCE TO VIBRATION
In the investigation of vibration tolerance, animal studies
have yielded information on the anatomical sites that are
vulnerable to vibration, and at what frequencies. Because
of differences in body mass and posture, extrapolation of
the results of animal studies to humans leads to uncertain-
ties. The nearest approach to carrying out a similar experi-
ment in humans required 15  well-motivated volunteers to
submit to steadily increasing amplitudes of vibration until
they thought they would sustain bodily harm by any further
increase (Magid et al. 1960). The results of this experiment
(Figure 13.13) indicate that the human body is least tolerant
of vertical vibration between the frequencies of 4 and 8 Hz.
The main symptoms for which vibration was discontinued
were precordial and central abdominal pain. The accel-
eration levels of vibration that were tolerated at 1 Hz were
roughly twice those at 4–8 Hz. At 1–3 Hz, the main symp-
tom was difficulty in breathing. After 1 minute of exposure
to vibration at 8 Hz, one subject fainted and was found to
9
8 the impairment of manual control, the loss of visual acu-
7 effects, there is a dependence on the frequency of vibra-
6
Acceleration (g)
5
4 frequency-weighting functions. These can be thought of as
3 spectrum of recorded vibration in order to allow through
2
1
0 In the assessment of vibration, the ultimate aim is to
0 2 4 6 8 10 12
Frequency (Hz)
Figure 13.13  Limits of voluntary human tolerance to Gz
sinusoidal vibration at frequencies between 1 and 15 Hz.
The graph shows the mean of the results from ten sub-
jects. Vertical bars indicate the range at each test fre-
quency. Redrawn from Magid et al. (1960).
K17577_C013.indd 224
have developed a nodal tachycardia. The general shape of
the vibration tolerance curve derived from this experiment
has also emerged from psychophysical studies to find the
levels of vibration at different frequencies and in differ-
ent directions that produce equivalent levels of discomfort
(Miwa 1967).
VIBRATION STANDARDS AND
ASSESSMENT OF VIBRATION SEVERITY
The process of standardization seeks to define a termi-
nology and to specify techniques for the measurement
of vibration and procedures for the analysis of recorded
vibration data. More contentiously, it may attempt to
define limits for what is safe or acceptable to humans in
a range of different circumstances. Standards have to be
based on current knowledge and, therefore, may evolve as
new information becomes available. However, a standard
may be more prescriptive than is warranted by the data on
which it is based. An important reason for the recording
of vibration levels in a particular environment is to deter-
mine the likely effect on individuals who have to operate
in that environment. By comparison with the assessment
of a noise environment, the assessment of vibration poses
additional complexities. First, the effect of vibration
depends on its direction relative to the orientation of the
body. Second, different vibration effects may be relevant
to specific circumstances. For example, a vehicle designer
may be concerned with the level of passenger discomfort,
while a designer of high-rise buildings may be concerned
with the likelihood that its upper-floor occupants perceive
any sway of the building in high winds. In more hazardous
environments, the concern may be the effect on physical
health of exposure to whole-body vibration or to hand–
arm vibration from handheld tools. Other effects may be
ity or the development of motion sickness. For all of these
tion; some frequencies are more relevant than others. The
approach taken by the International Organization for
Standardization (1997a) in ISO 2631-1:1997 for whole body
vibration and ISO (1997b)/CD 5349-1:1997  [26], is to use
soft-edged windows that are applied mathematically to the
vibration frequencies to the extent that they contribute
to the effect under consideration. There are six weighting
functions defined for whole-body vibration and one for
hand-transmitted vibration.
14 16 arrive at a single number that represents the vibration
severity, much like the Richter scale for earthquakes or the
dB(A) scale for noise. The first step in this direction is to
measure the vibration at the appropriate location, usually
at the interface between the body and the source of vibra-
tion, and to record from transducers in the appropriate
orientation, which may require up to six transducers to
18/11/2015 14:08

measure linear and, where necessary, angular motion in
the three body-related axes. The duration of recording also
has to be assessed in relation to the variability of vibration
over time. The second step involves the Fourier analysis
of the recorded time histories of vibration acceleration to
convert them to the equivalent frequency spectra and then
to apply a weighting function appropriate to the direction
of vibration, body posture and the vibration effect of con-
cern (hand control, vision, motion sickness, perception,
discomfort, health). The final step is to summate the com-
ponents of the weighted spectrum in order to give a single
figure, the vibration dose value (VDV). The formula for
this is
VDV = [ ∫0T a w 4 (t )dt ]1/4
This formula has two useful properties. It introduces a
dependence of vibration dose on the duration of vibration
exposure that is consistent with experimental data on the
relationship between severity and exposure duration. Also,
if the vibration source contains high-intensity spikes of
acceleration (mechanical shocks), then the summation of
the fourth power of the weighted acceleration aw4 gives an
appropriately greater emphasis to these in the derived value
of VDV.
In 2002, the European Commission issued the Physical
Agents (Vibration) Directive, which came into force in the
UK in July 2005. This document sets out the requirements
for the protection of workers from the adverse health con-
sequences of vibration. The directive requires employers
to assess the levels of vibration to which their employees
are exposed. Employers have a duty, if certain levels are
exceeded, to take steps to mitigate the effects of vibration
either by reducing the levels of vibration at source or by lim-
iting the time for which employees are exposed.
The directive is concerned with both whole-body and
hand-transmitted vibration and lays down two levels of
vibration, the exposure action value and the exposure
limit value, measured in terms of the 8-hour equivalent
weighted RMS level. It could be argued that for certain
types of vibration, the VDV would give a more reliable
measure, but use of the weighted RMS level has the merit
that it is directly analogous to the method for determi-
nation of noise exposure. For whole-body vibration, the
exposure action value is set at 0.5 m/s2 RMS A(8) and the
exposure limit value at 1.15  m/s2  RMS A(8). For hand-
transmitted vibration, the corresponding values are
2.5 and 5 m/s2 RMS A(8), respectively.
These limits are likely to pose problems in relation to
military activities, particularly for personnel in long-range
insertion craft and the crews of tanks. Some helicopter
operations may also exceed the limit. Calculations based
on vibration data recorded in the Chinook helicopter in
cruise show a weighted RMS level of 1.9 m/s2. If continued
for 8 hours, this level of vibration would be well in excess of
the exposure limit value. In fact, this limit would be reached
after about 3 hours of flight.
K17577_C013.indd 225
Protection against vibration  225
PROTECTION AGAINST VIBRATION
The effects of vibration on the body can be reduced by
attention to the source of vibration, by modification of the
transmission pathway, and by alteration of the dynamic
properties of the body. If the source of vibration is turbu-
lent air, this can be avoided by the appropriate routing of
commercial aircraft away from storm-cloud activity or by
choosing a different cruising altitude. Reduction of vibra-
tion emanating from aircraft engines is a task for the design
and maintenance engineers of the aircraft.
Several methods have been used in helicopters to reduce
the vibration reaching the aircrew and passengers. Dynamic
vibration absorbers are fitted to the cockpit floor in the
Chinook helicopter. This device consists of a minimally
damped mass/spring system that is fixed to the airframe
and has a natural frequency that corresponds to the pre-
dominant vibration frequency of the helicopter. Vibration
of the aircraft induces relatively large-amplitude resonant
oscillation in the mass of the dynamic vibration absorber,
which, in consequence, exerts an alternating force tend-
ing to oppose, and thus reduce, the input vibration. Such a
device works only over a narrow frequency range and will
amplify vibration at frequencies immediately above and
below (see Figure 13.3).
Another engineering approach to the reduction of vibra-
tion is by means of vibration isolation of the aircrew seat.
This has been achieved in the Lynx helicopter by connecting
the seat-pan and backrest to the body of the seat through
steel springs. Provided the resonant frequency of the sys-
tem formed by the body mass and the sprung seat is low
relative to the predominant vibration frequency of the air-
craft, increasing attenuation of vibration can be expected at
frequencies greater than 1.4 times the resonant frequency.
However, the apparent mass of the human body when
vibrated at 20 Hz is much less than its static mass, and for
this reason such a seat does not give the degree of vibration
isolation that simple theory would predict. The heavier the
occupant of the seat, the lower is the resonant frequency of
the seat. Therefore, the vibration isolation at higher frequen-
cies is more effective for heavier subjects. In practice, the
seat and its occupant have a resonance at 3–4 Hz, close to
the principal body resonance. Although in flight there is lit-
tle vibration input at these frequencies, in a crash a sprung
seat will amplify the impact forces at these frequencies and,
consequently, may worsen the chances of survival. The same
principle of vibration isolation is used in the civilian pas-
senger-carrying version of the Chinook helicopter, in which
the whole floor of the passenger compartment is mounted
on a spring suspension.
A further technique for the reduction of vibration
is the use of active vibration absorption. This has been
implemented on the Merlin (EH101) helicopter. The tech-
nique involves the use of active struts between the rotor
head and the top of the fuselage. Each strut incorporates a
force-sensing element and an actuator that can apply rap-
idly changing longitudinal forces to lengthen and shorten
18/11/2015 14:08
 226 Vibration
the strut. By this means, vibrational forces generated at
the rotor head can be sensed and actively cancelled out.
This technique is particularly relevant for the attenua-
tion of vibration at the blade-pass frequency, which is not
amenable to reduction by mechanical balancing of the
rotor blades.
Mention has already been made of the effects of pos-
ture and muscle tension on body resonances. Under severe
vibration, muscle tensing is an involuntary response tend-
ing to increase damping within the body and to stiffen the
spring component of vibrating structures and so alter their
resonant frequency. Subjects tend to adopt a posture that
minimizes vibration reaching the head.
The evacuation of casualties by helicopter has the advan-
tage of speed of access to appropriate medical facilities,
which is unlikely to be outweighed by the stress of helicop-
ter vibration. Nonetheless, pre-flight assessment should,
ideally, take account of the effects of vibration and, for
example, ensure adequate analgesia in patients with frac-
tures. A casualty lying on the floor of the aircraft is exposed
to more vibration, particularly to the head, than is a sitting
subject. An air mattress is effective in attenuating vibra-
tion at frequencies above about 5 Hz. A degree of vibration
isolation is also provided by the compliance of the hanging
stretcher mountings installed in some helicopters.
OCCUPATIONAL HAZARDS OF VIBRATION
Apart from the hazards of acute exposure to high lev-
els of vibration, long-term exposure to vibration has been
suspected as a causative factor in a number of conditions.
The causal link between local vibration to the hand and
arm from hand-held vibrating tools and the development
of Raynaud’s disease (‘vibration white finger’) was first
reported in 1911. The condition is not likely to be seen in
aviators, but it may occur in people working in manufac-
turing industries related to aviation, in particular workers
who use handheld grinding and chipping tools for metal-
finishing. Vibration white finger is a prescribed disease.
This means that its occurrence in certain groups of work-
ers can lead to the payment of financial compensation
(Taylor 1985). Vibration to the hand in the frequency range
20–200  Hz is probably most liable to lead to the condi-
tion. Symptoms appear after months or years of vibration
exposure and consist initially of episodes of tingling or
numbness in the fingers. Later, attacks of finger blanch-
ing, usually provoked by cold, occur with increasing fre-
quency. Touch and temperature sensations are impaired,
and the loss of finger dexterity interferes with work and lei-
sure activities. With further vibration exposure, blanching
attacks are replaced by a more continuous dusky cyanosis.
Atrophic changes in the finger pulps may be followed by
necrosis of the skin over the fingertips. Progression of the
condition may be halted by the affected individual ceas-
ing to carry out work involving exposure to vibration, but
the condition can be reversed only if it is detected in its
early stages.
K17577_C013.indd 226
Whole-body vibration has been implicated as a fac-
tor in the development of disorders of the lumbar spine,
particularly in drivers of tractors, earth-moving vehicles
and trucks. Lumbar backache is also a common com-
plaint among helicopter pilots. Direct measurement of the
movements of the lumbar spine in seated subjects during
vertical vibration using markers fixed into the spinous
processes indicates that at about 4  Hz, there is a peak in
amplification not only of vertical motion but also of fore–
aft and rotational motion of lumbar vertebrae. The major
body resonance occurs at this frequency, and therefore
mechanical stress on the lumbar spine is likely to be at a
maximum in this frequency range. The epidemiologi-
cal surveys conducted on drivers of tractors and earth-
moving vehicles (reviewed in Dupuis and Zerlett (1986))
indicate that degenerative disorders of the lumbar spine
occur at an earlier age in these groups of workers and
that vibration is implicated as an aetiological factor. It is
not certain whether the same is true for helicopter pilots.
The predominant vibration frequency of helicopters tends
to be above the major body resonance, and the unvary-
ing slightly bent sitting posture that the disposition of
cyclic and collective imposes on the pilot may be of greater
importance in provoking back pain during flight. Evidence
for the predominant role of posture rather than vibration
as a causal factor in back pain comes from a number of
epidemiological studies. One study found that helicopter
pilots reported back pain six times more frequently than
other crew members (Hansen and Wagstaff 2001). A sec-
ond study concluded that back pain is task-related; preva-
lence was greatest in pilots during instrument flight (72 per
cent) which involved the greatest degree of forward flex-
ion and least in the co‑pilot/instructor role (24  per cent)
(Bridger et  al. 2002). Pilot height has also been shown to
be a predisposing factor to back pain (Orsello et al. 2013).
However, attempts to correlate electro-myographic activity
with back pain have been unsuccessful. The lumbar EMG
recorded from pilots during flight showed no effect of pos-
ture, fatigue or vibration (Bowden 1987). There is also little
evidence for a greater incidence of radiological abnormali-
ties of the lumbar spine in helicopter pilots. Earlier studies
of back pain in helicopter pilots are reviewed by Bowden
(1987).
SUMMARY
●● Vibration is oscillatory motion. It is characterized
by its amplitude and its frequency.
●● The most simple form of vibration consists of
sinusoidal vibration at a single frequency. More
often recorded vibration contains multiple fre-
quencies and either shows repetitive features if it
originates from machinery, e.g. the rotor of a heli-
copter, or random features if it originates from
atmospheric turbulence or a rough road surface.
18/11/2015 14:08

●● An object, if linked to a source of vibration
through springy material, may exhibit resonance.
This means that within a certain range of fre-
quencies its amplitude of vibration can build up
to levels that are greater than the source of vibra-
tion with consequent risk of damage. However, at
higher frequencies the springy material serves to
isolate the object from the source of vibration.
●● Springs are widely used to reduce the transmis-
sion of vibration at higher frequencies but this
inevitably involves resonance at lower frequen-
cies. A damper in parallel with the spring reduces
the resonant peak but renders the spring less
effective in reducing vibration transmission at
higher frequencies.
●● A complex vibration can be broken down into its
constituent frequencies by Fourier transforma-
tion of the time record. This process yields the
vibration spectrum and is important since the
response of the body to vibration is dependent on
its frequency.
●● Whole-body vibration can affect visual acuity,
particularly for objects within the vehicle, e.g. air-
craft instruments, rather than the stable external
world. At certain frequencies vibration may give
rise to problems with motion sickness, neuro-
muscular control and hyperventilation. At higher
intensities there is a risk of damage to internal
body organs.
REFERENCES
Benson AJ, Barnes GR. Vision during angular oscillation:
the dynamic interaction of visual and vestibular mech-
anisms. Aviation, Space, and Environmental Medicine
1978; 49: 340–5.
Bowden T. Back pain in helicopter aircrew: a literature
review. Aviation, Space, and Environmental Medicine
1987; 58: 461–7.
Bridger RS, Groom MR, Jones H, et al. Task and postural
factors are related to back pain in helicopter pilots.
Aviation, Space, and Environmental Medicine 2002; 73:
805-11.
Coermann R. Investigation into the Effect of Vibration on
the Human Body. Library Translation No. 217. London:
Ministry of Defence, 1940.
Coermann RR, Ziegenruecker GH, Wittwer AL, Von
Glerke HE. The passive dynamic properties of the
human thorax–abdomen system and of the whole-
body system. Aerospace Medicine 1960; 31: 443–55.
Dupuis H, Zerlett G. The Effects of Whole-Body Vibration.
Berlin: Springer, 1986.
Ernsting J. Respiratory Effects of Whole-Body Vibration.
RAF Institute of Aviation Medicine Report no. 179.
London: Ministry of Defence, 1961.
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References 227
European Commission. Directive 2002/44/EC of the
European Parliament and of the Council of 25 June
2002 on the minimum health and safety requirements
regarding the exposure of workers to the risks arising
from physical agents (vibration). Official Journal of the
European Communities 2002; L177: 13–19.
George RJD, Geddes DM. High frequency ventilation.
British Journal of Hospital Medicine 1985; 33: 344–9.
Golding JF, Markey HM, Stott JRR. The effects of motion
direction, body axis, and posture on motion sickness
induced by low frequency linear oscillation. Aviation,
Space, and Environmental Medicine 1995; 66: 1046–51.
Hansen ØB, Wagstaff AS. Low back pain in Norwegian
helicopter aircrew. Aviation, Space, and Environmental
Medicine 2001; 72(3): 161–4.
Hood WB, Murray RH, Urschel CW, et al.
Cardiopulmonary effects of whole-body vibration in
man. Journal of Applied Physiology 1966; 21: 1725–31.
International Organization for Standardization. Mechanical
Vibration and Shock: Evaluation of Human Exposure to
Whole-Body Vibration. Part 1: General Requirements.
ISO 2631-1:1997. Geneva: International Organization
for Standardization, 1997a.
International Organization for Standardization.
Mechanical Vibration: Measurement and Assessment
of Human Exposure to Hand-Transmitted Vibration.
Part 1: General Guidelines. ISO 5349-1:1997. Geneva:
International Organization for Standardization, 1997b.
Lackner JR, Levine MS. Changes in apparent body orien-
tation and sensory localization induced by vibration
of postural muscles: vibratory myesthetic illusions.
Aviation, Space, and Environmental Medicine 1979; 50:
346–54.
Lamb TW, Tenney SM. Nature of vibration hyperventila-
tion. Journal of Applied Physiology 1966; 21: 404–10.
Magid EB, Coermann RR, Ziegenruecker GM. Human tol-
erance to whole-body sinusoidal vibration. Aerospace
Medicine 1960; 31: 915–24.
Miwa T. Evaluation methods for vibration effect: part 1.
Measurements of threshold and equal sensation con-
tours of whole-body for vertical and horizontal vibra-
tions. Industrial Health 1967; 5: 183–205.
Nickerson JL, Paradijeff A. Body Tissue Changes in Dogs
Resulting from Sinusoidal Oscillation Stress. Technical
documentary report AMRL-TDR-64-58. Wright-
Patterson Air Force Base, OH: USAF Aerospace
Medical Research Laboratories, 1964.
Nixon CW, Sommer HC. Influence of selected vibrations
upon speech. III. Range of 6 cps to 20 cps for semi-
supine talkers. Aerospace Medicine 1963; 34: 1012–17.
Orsello CA, Phillips AS, Rice GM. Height and in-flight low
back pain association among military helicopter pilots.
Aviation, Space, and Environmental Medicine 2013; 84:
32–7.
Paddan GS, Griffin MJ. The transmission of translational
seat vibration to the head. I. Vertical seat vibration.
Journal of Biomechanics 1988a; 21: 191–7.
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 228 Vibration
Paddan GS, Griffin MJ. The transmission of translational
seat vibration to the head. II. Horizontal seat vibration.
Journal of Biomechanics 1988b; 21: 199–206.
Roll JP, Martin B, Gauthier GM, Mussa Ivaldi F. Effects
of whole-body vibration on spinal reflexes in man.
Aviation, Space, and Environmental Medicine 1980; 51:
1227–33.
Rowlands GF. The Transmission of Vertical Vibration to the
Heads and Shoulders of Seated Men. Royal Aircraft
Establishment Technical Report No. 77088. London:
Ministry of Defence, 1977.
Speakman JD, Bonfili HF, Hille HR, Cole TN. Crew
Exposure to Vibration in the F4C Aircraft during Low
Altitude High Speed Flight. AMRL-TR-70-99. Wright
Patterson Air Force Base, OH: Aerospace Medical
Research Laboratory, 1971.
Speakman JD, Rose JF. Crew Compartment Vibration
Environment in the B52 Aircraft during Low Altitude
High Speed Flight. AMRL-TR-71-12. Wright-Patterson
Air Force Base, OH: Aerospace Medical Research
Laboratory, 1971.
Stott JRR. The vertical vestibulo-ocular reflex and ocular
resonance. Vision Research 1984; 24: 949–60.
Taylor W. Vibration white finger: a newly prescribed
disease (editorial). British Medical Journal 1985; 291:
921–2.
K17577_C013.indd 228
Vogt HL, Coermann RR, Fust MD. Mechanical impedance
of the sitting human under sustained acceleration.
Aerospace Medicine 1968; 39: 675–9.
Von Gierke HE, Nixon CW. Effects of Intense Infrasound
on Man. In: Tempest W (ed). Infrasound and Low
Frequency Vibration. London: Academic Press, 1977;
p. 115–50.
Wells MJ, Griffin MJ. Benefits of helmet-mounted dis-
play image stabilization under whole-body vibration.
Aviation, Space, and Environmental Medicine 1984; 55:
13–18.
FURTHER READING
Boff KR, Lincoln JE. Engineering Data Compendium:
Human Perception and Performance. Wright-Patterson
Air Force Base, OH: Armstrong Aerospace Medical
Research Laboratory, 1986.
Griffin MJ. Handbook of Human Vibration. London:
Academic Press, 1990.
Guignard JC, King PF. Aeromedical Aspects of Vibration
and Noise. AGARDograph AG-151. Neuilly-sur-Seine,
France: AGARD/NATO, 1972.
Mansfield NJ. Human Response to Vibration. Boca Raton,
FL: CRC Press, 2005.
Piersol AG, Paez TL (eds). Harris’ Shock and Vibration
Handbook, 6th edn. New York: McGraw-Hill; 2010.
18/11/2015 14:08

Anthropometry and aircrew equipment
integration
MICHAEL J. A. TRUDGILL AND MICHAEL J. HARRIGAN
Introduction 229
Anthropometry 229
Aircraft design 232
INTRODUCTION
The demands placed upon aircrew are complex. In addi-
tion to the safe conduct of flight, they may be required to
perform a multitude of additional tasks that vary with their
role. These can be as extreme as search and rescue winch-
man duties, operating a door gun, or high-altitude airborne
dispatch while at the other end of the scale steward duties
and monitoring of data feeds are also regularly undertaken.
What unites all of these is that they are conducted in any
climate, by day and night and in all weather conditions.
To safely meet these requirements, complex clothing
and life support systems have been developed. These pro-
tect the individual during normal operations, emergencies
and, in some instances, on the ground if they are required
to escape and evade. The aircraft structure and perfor-
mance requirements often conflict with the demands of a
safe ergonomic working environment and compromises
are inevitable.
All of these competing demands must be accommo-
dated without excessive physical or physiological burden
as this may reduce performance and hence flight safety
and mission success. Fulfilling these demands requires a
suitably designed working environment and equipment
that fits the individual and performs its function without
degrading performance.
The starting point must be knowledge of the likely
sizes and shapes of the aircrew population to enable air-
craft design and the design, sizing and fitting of clothing
and equipment. Finally, the individuals, their clothing and
K17577_C014.indd 229
14
Aircrew selection 234
Aircrew equipment assemblies 235
References 242
equipment must be assessed to ensure that they can be
accommodated in the aircraft while performing their role.
This chapter will briefly outline this complex process,
with sections outlining anthropometry, aircraft design, air-
crew selection, aircrew equipment assemblies (AEA) and
equipment integration.
ANTHROPOMETRY
Introduction
Anthropometry is the study and measurement of the
human body and its segments. This knowledge is a key pillar
in ergonomics and essential to designers that wish to match
equipment, workstations and working environments to the
human user. Anthropometric data is widely applied within
aviation, with many uses that will be considered, the main
ones being:
●● Aircraft design.
●● Aircrew selection.
●● Sizing of aircrew equipment.
Why is anthropometry so important in aviation?
Aircrew must be able to fully utilize the functions of their
aircraft for safe and effective operations. They must be able
to inspect the aircraft before flight, enter unassisted when
necessary, operate all controls needed to start, fly and
land; then they must be able to leave the aircraft. In flight,
they must be able to operate all aircraft systems and, in
229
17/11/2015 15:51
 230  Anthropometry and aircrew equipment integration
emergencies, they must be able to safely escape, whether
through ejection inflight, or landing and exiting via nor-
mal or emergency exits.
These requirements require adequate reach and full con-
trol movements. Someone that is too small will be unable
to reach some controls or even reach the extremes of flying
control movement. Someone that is too large may be able
to reach everything but be unable to achieve full control
movement when their limbs are inhibited by, for example,
armoured seating. Further, if unable to safely clear obstruc-
tions during escape, it may lead to serious injury resulting
in an inability to survive and escape once on the ground.
Numerous measurements of body size have been
described and used by scientists over the years. These vary
from simple measures such as height and weight, to more
specific measures such as popliteal height, vertical func-
tional reach or torso hoop. Some studies have defined as
many as 187  different variables but anyone considering a
survey, or interpreting previous surveys, needs to under-
stand how the information will be used, in order to consider
only relevant measures.
While few practitioners in aviation medicine will ever
be involved in the design of aircraft, it is important to
understand the principles of design because they may
have to advise on aspects of human function that hinge on
anthropometry and the human interface with the machine.
Examples of this include aircrew selection, equipment eval-
uation and airworthiness certification which increasingly
requires medical input to ensure that the operator has ade-
quate equipment and uses the correct functional clothing.
Statistical principles
If large numbers of the same measurement are taken from
individuals within a target population, then the range of
measurements for that variable will tend towards a normal,
Gaussian distribution, with data points clustering around
the midpoint and fewer at the extremes. The larger the num-
ber of values taken, the more representative of the popu-
lation measured the data set will be. However, the usual
descriptors of central tendency, mean, median or mode, are
limited in terms of design due to the wide spread of mea-
surements. For example, designing to the mean of a popu-
lation’s leg length would inevitably mean that the distance
to the pedals would be too great for many smaller, and too
small for many larger, individuals. Consequently, designers
tend to design to a range of percentile values for the popula-
tion with appropriate adjustment built into the design.
If the mean and standard deviation for a parameter are
known, then the percentile values for the variable can be cal-
culated. The percentile values allow us to define a range and
consider limits for proportions of the population. The actual
range must be specified by the acquirer of a new aircraft
and stated in the contract documentation. The consequence
of too narrow an acceptable anthropometric range might
be that there are insufficient people with the right body
dimensions to operate the aircraft. Broadening the specified
K17577_C014.indd 230
percentile range beyond the central mass of the population
will increase the number of individuals included in the group
but, per additional percentile, the increase in total number
eligible will reduce and it will become increasingly difficult
and expensive to achieve an accommodating design.
Ideally, designers would design for a range from the 3rd
to 97th centile, excluding only six per cent of the population,
but it is more practical to design for the 5th to 95th centile,
meaning 10 per cent of the population would be either too
large or small for the design.
While specifying a range would be relatively straightfor-
ward when only one body dimension is relevant, it is more
complex when multiple body dimensions are important, as
is normally the case. Although one often hears the term ‘the
nth centile man (or woman)’ there is no overall body size
that can be used in terms of centiles because body segments
will differ and anthropometric dimensions are not perfectly
correlated with one another. So, by designing for the 5th to
95th percentiles on more than one dimension, the design
will exclude significantly more individuals than the implied
10 percent. In fact, applying 5th and 95th limits on each of
13 dimensions could exclude 52 percent of the potential user
population! Therefore, the chosen percentile ranges must be
considered in relation to individual body dimensions, not
applied globally to all body dimensions.
Anthropometric surveys
Due to the variability in human shape and size, aircraft
are normally designed for ranges of size based on knowl-
edge of the population from which those individuals are
drawn. That information is generally gathered by surveys
of the population.
Anthropometric surveys will form the basis of design
but they are costly, labour-intensive exercises that tend to be
undertaken at infrequent intervals. When commissioning
an anthropometric survey, or interpreting preceding sur-
veys, it is important to understand the limitations.
●● Target population: The target population may be the
general population or a sub-set from which you wish to
select to fly your aircraft.
●● Survey data: The survey data must be representative of
your target population but could be flawed for a number
of reasons:
●● National differences: The maximum, minimum,
means and centile ranges for one population may
not adequately describe a similar group of a differ-
ent nationality, even with the same gender and age
range. Similarly, the data for a Caucasian popula-
tion may not be representative of an Asian popula-
tion or vice versa, even if other factors are equal.
●● Time: Over time, the population ‘normal’ may
change, for example, individuals have tended to
become larger over time, consequently, a survey
from 40–50 years ago may not be representative of
the same age and gender group today.
17/11/2015 15:51

●● Gender: Several decades ago there were few, if any,
female military aircrew in the UK or many other
nations. Now female aircrew serve in numerous air-
crew roles, but legacy aircraft types were designed
for a male population. Although there is an overlap
in the anthropometric ranges for females and males,
if a female population is selected against male
anthropometric standards then a larger proportion
will be too small and too low in weight. Although
females are more likely than males to be accommo-
dated and less likely to make contact with aircraft
structures, they will have greater problems with
reach and external view. However, since both male
and female populations seem to be increasing in size
compared to decades ago, if this trend continues,
more females will begin to fall within existing limits
and more males will be found too large, so the
gender difference may be mitigated to some degree.
The problem for designers will be to accommodate
a larger range of size from the 5th centile female to
the 95th centile male in future aircraft.
●● Existing populations and confounding: It might
seem obvious that if one wished to check the
anthropometry required for aircrew in the future,
then a good starting point would be existing
aircrew; indeed, they have been the basis of many
previous surveys. However, assuming the correct
principles have been used in design and selection,
the current aircrew population will have been
selected to fit aircraft designed many years ago.
Therefore, using existing aircrew as the model for
future aircraft design will ensure that new aircraft
are designed to the same anthropometric param-
eters as in the past, the acceptable size for aircrew
will change little, but it may drift further from the
general population. Ideally, the basis of any new
anthropometry survey and aircraft design should
be the general population from which one wishes
to recruit.
●● Relevance of chosen parameters: The parameters
chosen for design or crew selection should be rel-
evant to the functional tasks required of the aircrew
in the aircraft, based on the workspace, workstation
design and tasks to be performed.
●● Accuracy: In the same way that any scientific measure-
ments are taken, one must have confidence that the
conduct of any survey was sufficiently accurate and that
the measurements were reliable. In so far as is reason-
ably practicable, errors and biases must be excluded.
Anthropometric measurement techniques are discussed
in the following section.
Anthropometric measurement methodology
Detailed discussion of anthropometric measurements and
techniques is beyond the scope of this chapter but, with any
anthropometric survey, it is essential to develop a detailed
K17577_C014.indd 231
Anthropometry 231
methodology and to conduct extensive training in order to
minimize variance between and within different observers.
Anthropometric measures may be:
●● Static: Static (or structural) dimensions are taken with
the subject in a rigid standardized position.
●● Dynamic: Dynamic (or functional) dimensions are
measured in working positions and take account of
certain degrees of body movement and flexibility.
Although static dimensions are useful for many design pur-
poses, they do not take into full account the flexibility and
movement of joints, although they are easier to assess and
measure. Dynamic anthropometry deals with the dimen-
sions of the workspace envelope needed by persons as
they perform their work. In the authors’ experience, static
anthropometrics are the only measurements commonly
used in aviation medicine, although dynamic movements
are frequently used in individual checks. (See below.) The
remainder of this section will consider static measurements.
Whichever parameters are chosen, it is vital they are per-
formed in a standardized way. This must include the posi-
tioning of the subject because correct posture of the subject
is essential to exclude potentially large errors. For example,
if a subject is allowed to rotate their shoulder forward when
functional reach is being measured, the distance may be
artificially increased by several centimetres. For the same
measurement, the result may be either reduced or increased
by incorrect positioning of the wrist and fingers. The pre-
cise points that are measured are also critical, with many
measures relying on bony landmarks for consistent mea-
surement; consequently, many measurements need to be
taken with the subject unclothed. Most surveys will detail
how measurements have been taken and if used in design,
they must be applied in precisely the same way for selection.
Anthropometric measurement techniques
MANUAL MEASUREMENTS
The standard method for recording body size parameters
was by simple measurement using tape measures, anthro-
pometric rods, callipers or a measuring rig to define the
distance between two anatomical points or around a body
segment. In all cases, accurate positioning of the subject,
careful assessment of the measurement points and correct
use of the measuring device are essential. Purpose-built
anthropometry rigs are useful in removing some (though
not all) observer errors to achieve consistency. More mod-
ern rigs incorporate electronic measurement recording,
that can be linked to a computer database and that can
ensure some aspects of positioning. For example, in func-
tional reach measurement, to prevent forward rotation of
the shoulder, pressure must be exerted on a pressure pad
behind the scapula for the system to record a measurement.
However, anthropometric rigs will only be useful to mea-
sure the parameters for which they are designed and they
are usually large and fairly immobile (Figure 14.1).
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 232  Anthropometry and aircrew equipment integration
Figure 14.1  A typical anthropometry rig.
Aircrew Equipment Integration Group, RAF Centre of
Aviation Medicine.
PHOTOGRAMMETRY
Photogrammetry, in which the body is photographed and
the dimensions are measured from the photograph, is well
established. It has a number of advantages, including the
fact that it reduces the time required of both the subject and
the measurer, it produces a permanent record of the raw
data, from which additional measurements can be taken
in the future without recourse to seeing the subject again,
and movement is frozen so that all measurements relate to
one posture. Unfortunately, numerous measurements do
not fall within the capabilities of photogrammetry, particu-
larly those that involve circumferences and measurements
along curves at a certain axis. Furthermore, these tech-
niques are not very satisfactory in providing information
on the shape or changes of the surface curvature between
anatomical landmarks.
3-D SCANNING
Three-dimensional surface scanning can provide accurate
contour data in addition to traditional landmark data. It can
be achieved either using white light or lasers. In the white
light method, the light is projected through an interfer-
ence grating onto the surface being scanned. This produces
Moiré fringe interference patterns that can be photo-
graphed for later analysis. Twin Moiré measuring units can
be computer processed to provide an accurate 3-D image
of the surface being scanned. More recently, laser scanners
have been used to produce very accurate 3-D images that
can be manipulated to extract the required anthropometric
K17577_C014.indd 232
information. While scanning can provide a large amount of
accurate data and can model both the human form and the
workspace into which it must fit, considerable caution must
be used in combining the two to try to predict, for example,
the ability of a given body size to reach or operate specific
controls. At the current time, the main practical use of laser
scanning in UK military aviation is to measure heads for
the fitting of the most recent helmet types.
CHOICE OF METHODOLOGY
Researchers based at a single site may choose a very tech-
nical and accurate method to record multiple parameters.
However, if the technique is to be cost effective and used
at numerous sites, then simpler methods would prove more
useful. In addition, there would be little point in using a
sophisticated method that can produce large amounts of
data for numerous parameters if the relevance to the cock-
pit and to human function has not been defined. Ultimately,
the choice of anthropometry methodology will depend on
its intended use, with more expensive and complex meth-
ods better suited to research and development rather than
to medical, aircrew selection or equipment uses.
AIRCRAFT DESIGN
Background
Correct design of the workspace and working environ-
ment is essential to meet the functional needs of the system,
while minimizing stresses on the operators and providing
adequate comfort, in order to maintain efficient and effec-
tive aircraft operation. At the outset of aircraft design, the
target population needs to be known as it is essential to
provide sufficient space to allow for movement, changes in
posture and adequate safety for the different sized aircrew
that will use the aircraft. As in most other human activities,
humans are adaptable and can squeeze into a space which is
not satisfactory for the task. Although this incompatibility
may not be immediately obvious, the crew member’s effi-
ciency will be severely impaired, particularly with the pas-
sage of time and when compounded by other stressors such
as fatigue, ride motion, environmental extremes and men-
tal demands.
Cockpit design
Designers have conflicting requirements because cock-
pit design entails a series of compromises. They must try
to optimize the performance of the crew and the aircraft;
accommodate the overwhelming majority of the aircrew
and potential aircrew populations; minimize the size,
weight and aerodynamic drag provided by the cockpit; as
well as ensure that the multitude of controls and switches
can be reached and operated. To compound these chal-
lenges there will be a limited range of seat adjustment, crew
will be restrained by a harness and they will need to accom-
modate the clothing and equipment that must be worn.
17/11/2015 15:51

Essential aspects of design
There are some critical aspects of cockpit design that relate
to the size and dimensions of the crew.
DESIGN EYE POSITION
A cockpit will generally be designed around a defined eye
datum point, often referred to as the design eye position
(DEP), the optimum eye position for crew to see all impor-
tant displays and achieve an adequate view of the outside
world with minimum head movement. Potential crew
must be able to achieve this position using the range of
seat motion provided in the design, so sitting height will be
critical in ensuring that it can be achieved. Once the DEP
and the range of seat adjustment are known the range of
anthropometry and adjustment to achieve adequate control
will follow.
CLEARANCE
Adequate clearance must be provided to ensure sufficient
room for movement and to ensure safe clearance from
structures in the event of an accident. All occupants must
have adequate ranges of limb movement to ensure that they
have full control authority. For example, their shins must
not contact the lower console edge, preventing full pedal
movement, and their elbows must not be restricted by the
seat structure or cockpit sides. They must also have suffi-
cient room to permit full head movement for lookout, visual
scans and an unobstructed view of the instruments, while
wearing any head-mounted equipment. These consider-
ations generally apply to the tallest, broadest and longest
limbed at the upper percentile limit of the population from
which the aircrew are being selected, so it is the dimensions
of the largest predicted operators that should be used for
this purpose.
REACH
In general, it will be the dimensions of the smallest pre-
dicted operators that will be used to determine the max-
imum reach requirements, to ensure that all controls
(pedals, switches, handles, levers, displays and other avi-
onics) that need to be reached can be reached and operated
to their full extent. Functional reach is the key parameter
because front seat aircrew are not necessarily free to lean
and bend to achieve reach because military aircrew will
wear multi-point harnesses for safe restraint and often
these will be locked. Consequently, all essential controls
must be reached with the individual held back into the seat
by the harness. It will be up to aircraft operating authori-
ties to decide whether any leeway can be given for non-
essential controls that may not be needed when the harness
is locked.
ESCAPE
The considerations above are essential in normal flight
but there are additional considerations in the event of an
aircraft emergency.
K17577_C014.indd 233
Aircraft design  233
Ejection seats
Occupants of ejection seats must be clear of cockpit struc-
tures when departing the aircraft in the seat. If the knees
strike the instrument console, the individual could be
severely injured, then fail to survive, or escape and evade,
once on the ground. In some aircraft, a secondary escape
path clearance mechanism exists on the top of the ejec-
tion seat head box, in the form of spikes that will break
the canopy if the primary mechanism fails. If the hel-
meted head of the seat occupant extends above the head
box, then the occupant may take the force of the head
striking an intact canopy, resulting in injury. Finally,
weight is critical so that escape can be achieved with-
out excessive acceleration forces. Hence, leg lengths, sit-
ting height, stature and weight are important measures
for ejection seat aircrew. This is covered more fully in
Chapter 10.
Stroking seats
Aircrew, particularly rotary wing crew, have stroking seats
that protect them in the event of an impact. These have safe
working weight limits to ensure that the design parameters
are not exceeded. Individuals below the minimum weight
may experience higher forces than considered in the design
because the seat may fail to stroke. Occupants above the
weight limit may cause the seat to stroke too far, resulting
in it ‘bottoming out’ and causing dynamic overshoot. The
stroking of a seat will move the occupant to a position dif-
ferent from that in which they normally fly, with the con-
sequence that they may be unable to reach critical switches
such as the canopy jettison lever, fire extinguisher and
emergency fuel shut off controls. Functional reach limits
must include these considerations.
Escape hatches
In rotary and fixed wing aircraft following a crash landing,
crew members may need to escape via escape hatches if the
normal exits cannot be used due to damage or obstruc-
tion. Escape hatches are often small in size, so exces-
sively large individuals may be unable to escape. In this
situation, the clothing and equipment worn will have a
considerable bearing.
AIRCREW EQUIPMENT ASSEMBLY
In discussing anthropometry, we have considered the case
of nude measurements because these are easier to take and
more consistent. However, in flight, aircrew will be wearing
their clothing and essential equipment, the aircrew equip-
ment assembly (AEA) and allowance must be made for this
equipment during design. The AEA worn will vary between
situations such as training, operations, different climates
and over water, or chemical, biological, radiological and
nuclear (CBRN) flights. All will impose different space
requirements. Over time, the AEA will be updated and,
in recent decades, the tendency has been for the bulk and
weight of equipment to increase.
17/11/2015 15:51
 234  Anthropometry and aircrew equipment integration

AIRCRAFT DESIGN SUMMARY obstructions, protection during accidents and ability to

Anthropometric constraints that are critical are not always
easy to identify from anthropometric tables until the
designer understands the whole situation. Consideration at
the drawing board stage does not always ensure an ergo-
nomically sound design, so tests should include computer-
based systems, full-scale mock ups and representative
samples of users. Beyond the design stages, most military
aircraft are in service for such long periods that, for most
practitioners, anthropometry is used primarily to select air-
crew for existing aircraft or to assess new AEA.
AIRCREW SELECTION
Introduction
Aircraft designed for an anthropometric range should
allow individuals within the anthropometric range to
carry out all required functions in flight. Individuals out-
side the range will have compromised lookout, mobility,
control authority, reach to essential switches, clearance of
escape. Individuals must be correctly assessed during air-
crew selection. The required selection parameters should be
based on the functional requirements of the cockpit and are
likely to have been those used during the aircraft design.
CURRENT UK MEASURES
Currently in the UK, selection is based on up to six static
anthropometric parameters (Table 14.1). These are:
HOW, WHEN AND WHERE SHOULD
ANTHROPOMETRY BE TESTED?
It is likely that measurements will be taken at the aircrew
selection medical examination, particularly since many
nations use ‘nude’ measurements, most easily achieved when
candidates are unclothed at the medical board. However, a
different approach could be taken, provided the process is
dependable. The personnel taking measurements must be
trained to take consistent, accurate measurements both for
fairness to candidates and in cases where failed applicants
might appeal.

Table 14.1  Anthropometric selection measures and their relevance

Ser Measure Size Issues Comment

(a) (b) (c) (d) (e)
1 Stature Small Overall reach A crude measure: may not be
Overall lookout required if buttock-heel and
Large Likely clearances sitting height are used
Likely mobility
2 Sitting height Small Design eye position Limits should take into
Lookout and view of instruments consideration:
Large Structural clearance – canopy and panels Seat adjustment
Head mobility Control adjustments
View of instruments Restraint harness
Ejection safety AEA bulk and restriction
3 Buttock–heel Small Control authority – rudder/yaw pedals range Worst case AEA (minimum AEA
Large Clearance of lower leg from console for small, maximum AEA for
Control authority – uninhibited range of large)
movement
Visibility of lower instruments
4 Buttock–knee Small Control authority – rudder/yaw pedals range
Large Ejection clearance
Clearance of lower leg from console
Control authority – uninhibited range of
movement
Visibility of lower instruments
5 Functional Small Reach to essential switches and levers
reach Main flying control authority
Large Mobility and control authority through
uninhibited range of movement, especially
when constrained by e.g. armoured seats
6 Weight Small Health Nude limits must accommodate
Suitability for ejection or stroking seats. AEA weight to give correct
Large Health walkout weights
Suitability for ejection or stroking seats.

K17577_C014.indd 234 17/11/2015 15:51


HOW MANY MEASUREMENTS?
Both scientifically and for presentational reasons, repeated
measures should be taken, with the candidate being repo-
sitioned between each measurement. If three readings are
taken and all are outside the limits, most authorities would
then reject the candidate but many will first use a second
observer to confirm the finding before a final decision. If the
initial readings are split across the limit, a second observer
should be used and, if uncertainty remains, a functional
cockpit check will be needed.
WHICH AIRCRAFT LIMITS SHOULD BE USED?
Aircrew must be suitable for their operational aircraft types,
so these limits must be used at some point during selection.
However, to get to an operational type, a student pilot is
likely to have to fly at least one training aircraft, perhaps fol-
lowed by one or more advanced trainers. A policy will need
to be determined by a number of factors, such as the num-
ber of available operational types and the number of appli-
cants, because both will determine the flexibility of options
after training. Large forces with multiple operational types
may have sufficient flexibility to allocate aircrew to aircraft
types following training based, to some extent, on their
anthropometric suitability. This does necessitate that all ab
initio students will fit at least one operational type and that
all are suitable for the training aircraft. Smaller forces may
have to ensure suitability at the very start for all aircraft.
One approach would be to take the most restrictive limit
in each parameter for each aircraft type and apply the most
restrictive limits at selection. For example, a sitting height
range from the largest minimum to the smallest maximum
for the range of aircraft could be adopted. One could then be
confident that all students would fall within limits for that
variable for all of those aircraft.
COCKPIT CHECK
Candidates that fail but are borderline may require a more
detailed functional assessment in an actual aircraft cockpit
or a simulator. These are known as ‘cockpit checks’ and they
are sound in principle but fraught with potential pitfalls.
A few of the considerations include:
Objectivity
The subject should wear the appropriate AEA; minimum
summer training equipment for small individuals and max-
imum (e.g. winter, over water) for large subjects to ensure
the ‘worst case’ situation. The subject must be shown how
to reach the DEP and their seat adjusted to achieve it. They
should then be instructed how to conduct each of a series of
test movements through a schedule particular to that air-
craft, testing look out, control movements, switch operation,
etc. Cockpit checks can be very subjective, so the format
should have been agreed with the instructors and each test
graded as ‘essential’ or ‘desirable’ prior to the assessment.
They should be marked by an aviation medicine specialist
and instructor independently with the results discussed and
agreed prior to briefing the subject and the executive.
K17577_C014.indd 235
Aircrew equipment assemblies  235
Who should be eligible?
The eligibility of selection candidates for a cockpit assess-
ment will vary with the policy of the nation and service.
One example of a potential approach would be to check
any candidate that falls outside any of the selection limits
but accept anyone that is inside limits on all parameters.
Another would be to reject outright any applicant that is
outside any parameter but to check any that are close to, but
inside, the limits, to make allowance for errors in the mea-
surements. These methods, or any other approaches, will
have to be considered in relation to the resources needed,
as well as the over-arching selection policy. All implications
should have been considered prior to their adoption and
must have been agreed with the executive.
Aircraft and equipment arrangements
An aircraft must be used but, to be able to assess control
movements adequately, a hydraulic rig and possibly external
power will be needed if it is to be completed in relative quiet.
Arrangements need to be made with the squadron and
engineers, as well as the clothing store or survival equip-
ment section for the AEA.
Weight limits
While anthropometric measurements will be based on
cockpit design, when absolute weight limits are needed,
they are likely to have to be interpreted. This is because the
weight limit specified by an ejection or stroking seat manu-
facturer will be the seat limit in operation, i.e. the weight
range for the clothed seat occupant. Consequently, the nude
weight limits at selection must have the weight of the AEA
applied for a ‘walk out weight’ to be considered. The weight
of the AEA will differ between scenarios, such as between
summer, non-operational training and full, operational,
winter equipment for over water flight. For selection, the
worst case should be used; the lightest equipment weights
for light individuals and heaviest weights for large individu-
als. The equipment weight might vary from perhaps 6  kg
for summer training equipment in small sizes to perhaps
24 kg for operational, winter, overwater assemblies, includ-
ing body armour, in large sizes. Consequently, if the seat
limits were 68–120 kg, then the selection limits would have
to be 62–96 kg nude weight. We could then be confident that
whichever AEA is worn, selected individuals will be within
the aircraft seat limits. AEA weight figures will need revi-
sion as equipment changes.
AIRCREW EQUIPMENT ASSEMBLIES
Background
An observer with little or no experience of military flying
might wonder why military flying clothing is different; the
reasons are evident if we consider why military aircrew do
not wear standard military combat clothing. First, combat
clothing tends to be baggy to allow for movement and to
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 236  Anthropometry and aircrew equipment integration

accommodate warm mid-layers. Consequently, in a cockpit, Requirements

there would be lack of space due to bulk; snagging of cloth-
ing folds or pockets; and difficulty in emergency egress.
Second, there would be a potential for foreign object debris
from loose articles, such as mud and stones from boot soles
or inadequately retained pocket contents. Third, much com-
bat clothing is not flame retardant so there would be little
protection in the event of a fire. Finally, the clothing would
not provide for specific aviation functions, such as pockets
designed and configured to fit items needed in flight and to
be accessible when strapped into an aircraft. This is not an
exhaustive list nor, indeed, are these requirements unique to
the military environment. Commercial offshore helicopter
operations, air ambulance and law enforcement helicopters
face similar challenges and wear clothing optimized for
their environment.
Introduction to AEA
Aircrew clothing and equipment comprises those items
worn or carried by aircrew in the normal performance of
their duties in flight and in case of the need for emergency
escape and survival on the ground. As noted above, these
are often referred to as the AEA. Other items that are part
of the aircraft inventory, such as restraint systems, dinghies,
etc., are not covered further in this chapter. The AEA worn
in flight is intended to ensure operational effectiveness by
protecting against the physiological hazards of flight while
meeting the demands of comfort and performance. In addi-
tion, AEA includes items worn in flight but needed for
escape and survival. In general, AEA consists of a multi-
layered ensemble of garments that can be adjusted to suit
the prevailing conditions and the demands of the mission.
Divisions of AEA
AEA may be subdivided into four groups by function.
These are:
Head breadth (mm)
While performing the functions mentioned above, the
AEA must not prevent integration between the aircrew,
their equipment and the workspace. There are three
main considerations.
Sizing
The sizing process aims to determine the appropriate dimen-
sions for the clothing and the number of sizes required in
the size roll. The appropriate dimensions will be based on
the anthropometric range of the target population and the
size roll represents the number of sizes needed to cover that
range. The normal approach is to take two control mea-
surements, typically stature and chest circumference for a
one-piece garment and to plot a scatter gram. Sizing grids
can then be superimposed to include the majority of indi-
viduals. In order to keep costs low and to reduce logistic and
supply problems, the number of sizes should be kept to a
minimum (Figure 14.2).
Fitting
Fitting is the process of bringing together the garment
with the wearer to evaluate suitability for the purpose
intended. This will initially be predicted from the individ-
ual’s anthropometric measurements and knowledge of the
sizes available. Following this, a trial fit with all other items
of AEA should be undertaken. Simulation of movements
5 Role size chart
180
Med Large
Med/ Large
Broad
170
Large

Med
1. Life Support. This includes oxygen equipment; protection 160
against G; CBRN protection; and personal conditioning. Med/
Med Long
2. Operational. Items such as communications systems;
vision enhancement; displays and equipment to attach 150
or stow personal weapons fall into this category. Med/Long
3. Escape and survival. This includes restraint and
parachute harnesses; head protection; flotation and Small
immersion protection. 140
4. Personal. Clothing items, including socks, mid-layers,
outer clothing, gloves and boots are in this group.
130
The first three groups are described in detail in other 160 170 180 190 200 210 220 230 240
chapters but the final category, together with integration Head length (mm)
will be considered further here. It is essential that all four
groups work together so that physical function of the air- Figure 14.2  An example of a grid for sizing: Mk X Helmet
crew (ranges of movement, strength, fine control) together or QQ for FACS.
with relative comfort are maintained in all conditions and Digital Air Publication 108F-0214-1, Ministry of
all combinations of the AEA. Defence.

K17577_C014.indd 236 17/11/2015 15:51


required during flight or aircraft escape can be undertaken
as a first step but, for more complex aircraft and AEA, a
workplace integration exercise should be undertaken. This
is proving increasingly important with modern escape,
restraint and load carriage systems where poor selection
and integration of AEA can impair performance, increase
the likelihood of accidents and potentially reduce surviv-
ability. Since no individual will be at the same percentile
value for all of their parameters, there will often be prob-
lems with limb lengths compared to individual trunk sizes.
In many cases, such problems can be catered for by indi-
vidual adjustment on station; adjustments in the clothing
item (e.g. lacing in the sides of anti-G trousers); or by a
special measure programme to provide individual fit gar-
ments. To ensure correct fit between different layers, sys-
tems should be designed such that the stated size takes
into account where the items are worn in relation to other
items. This will mean that an individual will take the same
size in all garments and the sizing will allow them all to
fit comfortably over the layers beneath. For garments that
are less dependent on stature than other body dimensions
alternative control measurements may be used. For exam-
ple, the successful operation of the active arm restraint sys-
tem in the Tornado aircraft necessitates correct fitting of
the life-preserver sleeves, so arm length replaces stature as
the control measurement.
Functional fit
Functional fitting is used to ensure that the wearer and
clothing, when combined, can each fulfil their intended
function. This process is integral to the design of items and
testing the generic integration, but it can also be conducted
on an individual level. Integration is considered further
later in this chapter.
Clothing items and considerations
The aircrew clothing ensemble comprises undergarments,
mid-layers and outer garments plus gloves, socks and boots.
The ensemble must allow adequate mobility, physical com-
fort, thermal comfort in a wide variety of conditions and
provide adequate protection in the event of fire. It must fit
adequately into the cockpit without causing restriction and
accommodate protective equipment worn over the top, such
as anti-G garments. It must also wear in an acceptable way
and be able to be laundered easily. Although the basic func-
tions should be universal, additional features may differ
between nation, service, command or aircraft. These may
include features such as pockets or escape tool positions that
suit the aircrew role and that are accessible when strapped
into an aircraft seat.
Functional layers
This section will cover the functions of each clothing layer
but more detailed information on the fabrics will be left for
the section on flame protection.
K17577_C014.indd 237
Aircrew equipment assemblies  237
Underwear
Aircrew underwear provides thermal insulation in cold con-
ditions, insulation to protect from fire and it protects from
potential chaffing of the skin from the outer layers. Since it
fits next to the skin, comfort is essential. Comfort will be
achieved by a close fit that is not too tight but not so loose
that ridges develop causing pressure. Wicking of sweat and
rapid drying when wet are also important qualities. Since
underwear is essential to provide insulation against thermal
load in a fire, it should be worn for all flights. Consequently,
it must not provide an excessive thermal burden in normal
flight in warm conditions. Potential choices include cot-
ton, wool or synthetic flame retardant (FR) fabrics such as
Kermel viscose. Merino wool functions very well and it is
currently popular in outdoor recreation, but for military
aircrew it is questionable whether it would stand the bulk
laundry arrangements on operations.
MID LAYERS
Mid layers are needed to provide adequate thermal insula-
tion in cold conditions, e.g. for rear crew in an open helicop-
ter doorway in Arctic conditions, but they will not be worn
in warm conditions. Concern has been expressed in the past
regarding the effect of non-flame retardant mid-layers on
fire protection of the ensemble but recent research has been
reassuring. Provided non-FR mid-layers are covered by a FR
outer layer, tests have shown that the UK Defence Standard
level of protection can be achieved.
OUTER LAYERS
In general, aircrew have traditionally used one-piece cov-
eralls as an outer layer for flying training, due to the ease
of fit, integration with other items and integration into the
cockpit. On operations, rotary wing and multi-engine crews
have tended to move to two-piece clothing so that they can
live comfortably in the field and appear similar to ground
troops, while fast jet crews have tended to remain in one-
piece clothing due to the limitations of their aircraft cockpit.
Outer layers for flight must be of an acceptable appearance
on station, if needed to be worn outside the flight area. For
operations, they need an acceptable appearance and should
be of the standard pattern camouflage for the force, have an
acceptable IR signature and look similar to ground forces.
BOOTS
Aircrew have very specific requirements for boots. A com-
fortable boot is required that allows sufficient ankle flexibil-
ity to operate controls and provide feel through the sole to
operate the brakes, rudder or yaw controls in helicopters.
At the same time, it may need to survive ejection, the efflux
from seat-mounted rocket motors, wind blast and provide
adequate support for a parachute landing. In addition,
there is a requirement for soles that do not collect objects
(soil, stones, vegetation) that could become foreign objects
in the cockpit and potentially block controls. Anti-static
and non-slip properties are also required of the sole and
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 238  Anthropometry and aircrew equipment integration
protection from fire is a further requirement. These require-
ments have tended to result in a boot that is specially made
for aircrew, expensive and far from ideal for living in the
field. In recent years, due to the lack of availability of such
a boot and increasing performance requirements for escape
and evasion, ground pattern boots have had to be cleared.
Unfortunately, these have resulted in complaints about lack
of sensitivity and there have been incidents where they have
jammed in the foot tunnels in some fast jets due to the larger
size of the boot and sole. Meeting the conflicting demands is
a challenge that will remain in the future.
GLOVES
Gloves have a variety of functions but, generally, protect
the hands from minor trauma, fuels, oils, cold and flame,
though all to a limited extent. They also give the ability to
touch hot surfaces during escape and, in the UK, are manu-
factured from a pearl white kid leather to enhance the vis-
ibility of hand signals. There are broadly two types of flying
glove for aircrew, either an all leather glove (as in the UK) or
a combined FR fabric and leather glove (as in the US). There
will also be a range of other gloves in addition to the stan-
dard flying glove, such as those for winch-men. However,
the balance between dexterity and insulation is difficult
to reconcile so cold weather gloves are likely to remain
a challenge.
REAR-CREW ROLES
Multi-engine aircraft and helicopter rear crew have slightly
differing needs to flight deck crew. They regularly have to
kneel, crawl and lie on the aircraft floor when managing
loads, so will benefit from knee pads and trousers made
from more robust fabrics. They may also benefit from
outer layers that can be donned or doffed during a sortie to
change their insulation, rather than using mid-layers. This
is because, in some environments, they may be working on
the ground and taking off in warm or hot conditions, then
flying into mountains where it can be very cold.
FUTURE DEVELOPMENTS
Improvements in fabric technology mean that it is now
possible to provide insulated garments in a camouflage
fabric that is also FR, as well as waterproof, breathable fab-
rics that are FR and in the relevant camouflage pattern.
Consequently, the layer principle has potential to move
away from mid-layers that must be worn under the normal
FR outer garments to additional garments that provide the
same FR protection that can be donned over the normal
coverall or two-piece outer layers.
Flame retardant clothing
BACKGROUND
The combination of the risk of impacts during mishaps, plus
large volumes of volatile, flammable fuel, hot engines and
electrical cables, makes the risk of fire in aircraft ever pres-
ent. Although the risk of accidents has generally declined in
K17577_C014.indd 238
recent decades, there remains a significant risk of post-crash
fires. For example, between 1997 and 2012 there were fires
in 16  per cent of UK helicopter accidents, resulting in six
fatalities and 10 aircrew admitted to hospital with burns. To
save life and to prevent morbidity, it is essential that aircrew
have some flame protection to ensure that, during the time-
window in which survival is possible, they survive with the
minimum of injury.
PERFORMANCE PRINCIPLE
It is possible to provide significant amounts of flame pro-
tection but high levels of protection will bring physiological
thermal burdens which would have to be tolerated through-
out flight. Hence, it is important to achieve a balance. The
current model used in the UK uses the temperature and
energy of a typical aviation fuel fire (1200°C at 84 kW/m2)
for the time period which an individual could hold their
breath (four seconds), with the assumption that a deep
breath of hot, toxic gases would prevent survival. Protecting
against this model allows an ensemble that is acceptable in
day-to-day flight without excessive physiological thermal
burden and that provides significant protection from flame
within the stated parameters.
LAYER PRINCIPLE
To provide an ensemble that is FR but sufficiently light and
cool, a layered principle is utilized with FR fabric outer gar-
ment and base layers. The FR layer may not burn but it will
transmit thermal energy, so the base layer is essential to
ensure an air gap for adequate thermal insulation between
the FR layer and the skin. Hence, long underwear is essen-
tial. Mid-layers can be added to give better thermal insu-
lation in cold conditions and these will increase the burn
protection. Additional outer layers, such as body armour,
load carrying jerkins, G-pants, etc., will also increase pro-
tection and will do so even if they are not FR because they
are heavier fabrics that will not ignite during a survivable
flame exposure.
FR FABRICS
The choice of FR fabrics is now reasonably broad with vari-
ous types of natural fibre, Nomex®, Defender M™, Aramid/
Rayon or Kermel/Viscose suitable for different layers. All
have different wear characteristics and most come in a vari-
ety of weights and weaves. There are a number of issues to
be considered, including the appearance, weight and the
colour pattern. Some fabrics will be better suited to being
base or mid-layers while others will be more acceptable
as an outer layer due to their appearance. Some are better
able to take the multiple dyes needed to develop a cam-
ouflage pattern, while others will only really take a single
dye. Increasing the weight of the fabric will increase pro-
tection but at the price of an increased thermal load to the
wearer under normal conditions. It will be tempting to use
lighter fabrics but it is important that they do not become
breached in flame. Finally, since many of these fabrics will
shrink in flame, designs should be optimized to control this
17/11/2015 15:51

as shrinkage reduces the air gap and, hence, the insulation
and protection. Large single layers of fabric tend to shrink
more but this can be mitigated by careful manipulation of
panel size and shape, in association with increased pocket
numbers and careful positioning. It is noteworthy that burn
injuries seen in survivors tend to occur over the shoulder
and deltoid regions and tops of the thighs and buttocks.
This corresponds to the regions where fabric is pulled tight
during movement and hence the insulation and protection
is reduced.
TESTING
It is important that clothing is adequately tested by a stan-
dardized regimen. Currently, in the UK, a thermal manne-
quin surrounded by an array of 12 gas burners that provide
a thermal flux representative of an aviation fuel fire is used.
The 135 sensors on the mannequin give an indication of the
extent and thickness of any burns, so different garments
and fabrics can be compared. However, it is important to
note that this data is representative and clearly cannot pro-
duce every likely scenario, or represent movement simulat-
ing escape. It is important to bear these limitations in mind
and not to develop items simply to pass the test on a man-
nequin (Figure 14.3).
AEA assessment and integration
INTRODUCTION
Integration of AEA aims to ensure that the equipment is
comfortable to wear, does not compromise the function
of any items worn and does not impair the wearer’s abil-
ity to see or operate any controls. It must not degrade the
operational capability of the crew, aircraft or escape system.
Figure 14.3  An example of a prediction of burn injury
using an instrumented mannequin.
BTTG Fire Technical Services, BTTG Ltd Group.
K17577_C014.indd 239
Aircrew equipment assemblies  239
The adequacy of the integration should be determined
by a series of tests including potential effects on aircrew
procedures including escape and survival. The schedule
of tests adopted in the UK and the precise pass/fail crite-
ria demanded are detailed in Defence Standard (Def Stan
05-134) However, likely integration success commences
with design and development.
INTEGRATION ASSESSMENT
Before any aircrew or survival equipment can be used in
flight, a formal flight clearance from the regulatory author-
ity must be achieved. The precise requirements and the
process of approval for flight will vary between nations and
services, but all will require assurance that the equipment
functions correctly and imposes no potential hazards. In
general terms, the evaluation process can be subdivided
into a number of stages.
LABORATORY TEST AND EVALUATION
The laboratory phase requires comprehensive assessment
in an appropriate integration laboratory. If possible, repre-
sentative cockpit mock-ups should be used, together with
subjects across the range of anthropometric sizes, generally
small, medium and large (around the 5th, 50th and 95th per-
centile for the target population). Of course, these percentile
values will tend to be stature only, with other parameters at
a range of percentile levels for each subject. This is generally
acceptable but, where there is a critical parameter such as
buttock–knee length, sitting height or functional reach, one
should endeavour to find subjects at the right level for the
critical value.
The primary objectives of an integration laboratory are to:
●● Integrate various developmental items with all existing
or other new items of AEA.
●● Validate fit and function of the AEA at an early stage
to prevent unnecessary flight trials or the need for
expensive equipment or aircraft modification during or
after production.
●● Detect any deficiencies that might be corrected prior to
wider user or flight trials.
●● Focus efforts on increasing the probability of mission
success, increasing combat effectiveness and surviv-
ability, ensuring cost-effectiveness and reducing
logistic requirements.
To achieve this, the items must be evaluated for any
effects on both aircrew procedures and escape and survival
but also cover appropriate dynamic and environmental tests
(Figure 14.4).
Effect on aircrew procedures
DRESSING AND UNDRESSING
The purpose of this test is to assess any interaction between
the items of AEA that could cause snagging of any part
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 240  Anthropometry and aircrew equipment integration
Figure 14.4  Cockpit integration in a fast jet cockpit
mock-up.
Aircrew Equipment Integration Group, RAF Centre of
Aviation Medicine.
of the assembly. Dressing should be conducted in a simu-
lated crew facility and should follow accepted procedures,
including assistance, if available. The test must be deemed
a failure if one or more items of the AEA consistently and
adversely interacts with the remaining items of the assem-
bly to impair function or cause wear in an unreasonably
short time.
WALK-OUT AND COCKPIT ENTRY
This test is intended to confirm that the AEA does not inter-
fere with normal access to the aircraft or impair any pre-
flight inspection. If any interaction between AEA and the
aircraft structure inhibit the completion of checks or entry
into the aircraft then the test is deemed a failure.
STRAPPING-IN PROCEDURES
Any adverse interaction between the AEA, seat-restraint
system or aircraft controls that impairs access to the person/
seat connection preventing the agreed strapping-in proce-
dures from being completed is considered a failure.
WORKSTATION MANOEUVRES
This test demonstrates that none of the items of AEA inter-
feres with the ability of the aircrew to carry out normal and
emergency procedures during take-off, landing and flight.
Qualified aircrew participate or advise, to ensure that the
full range of movements and activities required in a typical
sortie is covered.
K17577_C014.indd 240
COCKPIT EGRESS
For completeness, normal egress from the cockpit needs to
be assessed to ensure that it is physically possible without
snagging or other issues.
Effect on escape and survival
A series of tests is required to demonstrate that the AEA
under development does not inhibit the aircrew from
escaping from the aircraft either on the ground or in
the air.
EMERGENCY EGRESS ON THE GROUND
This must be simulated with the subjects having donned any
appropriate survival aids and commenced from the appro-
priate position. If any component consistently and across
the size range causes a hindrance to exit from the aircraft,
then the test should be considered a failure.
ESCAPE FROM EJECTION-SEAT AIRCRAFT
Comprehensive tests are required to confirm that aircrew
can operate the escape facilities available in the ejection
seat and use the post-escape survival equipment. These
tests include assessment of the ability of the aircrew to
operate the seat emergency controls with an aircraft out
of control and inverted. These assessments include con-
firmation that an aircrew member of maximum critical
dimensions and dressed in the bulkiest AEA will have
sufficient clearance from the cockpit for a clean ejected
exit; simulated automatic and manual separation from
the seat following ejection; assessment of the security of
items of AEA; and any interactions between the AEA and
the parachute harness that could potentially be hazardous
during and after parachute deployment. The first requires
a drop test, with the subject representatively settled into
his or her harness and then allowed to drop in the har-
ness, thus simulating the opening loads of the particular
parachute being used. This drop can be followed by the
second assessment, suspension in the harness, used to
check that the AEA does not interfere with actions that
may be required under the canopy. The ability of a sub-
ject, dressed in AEA under test, to release and divest the
harness while being dragged by the parachute on land is
also required.
ESCAPE AND SURVIVAL AT SEA
The effect of the AEA on escape and survival at sea com-
pletes the assessments in this phase of the schedule of tests.
These tests are conducted at sea or in a suitable wave tank
and will vary slightly between aircraft types. In all types,
it will require water entry but ejection seat aircraft will
require parachute dragging at sea, and rotary aircraft will
require an underwater escape trainer. All types will require
harness release, flotation, life-raft operation and boarding,
followed by the final action in the crew member’s survival
sequence, i.e. winching into a helicopter.
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Dynamic tests
EJECTION TEST
The most comprehensive way of assessing the behaviour of
fast-jet AEA under airborne escape conditions is for it to
be incorporated as part of an ejection seat test programme.
Generally, when new aircraft are introduced, the AEA can
be included in the test schedule, which has the additional
advantage that the number of tests and dummy sizes is
defined by that programme. The AEA must complete the
defined ejection test without damage to those items that are
required to function either during or following ejection.
Other non-essential items of the AEA should not become
detached under the influence of the ejection forces. The cost
and complexity of ejection tests may not be justified when
a new item of AEA is introduced retrospectively. In these
circumstances alternative dynamic tests such as the effect
of entry into the air stream can be studied by the use of an
air-blast test facility. Such equipment should be capable of
simulating the airspeed and decay profiles experienced by a
seat and crew member emerging from the aircraft during an
Figure 14.5  An inversion rig.
Aircrew Equipment Integration Group, RAF Centre of
Aviation Medicine.
K17577_C014.indd 241
Aircrew equipment assemblies  241
ejection. However, this cannot recreate all of the dynamic
forces of an ejection, and the results must be interpreted
with caution. Testing items of the AEA that are required to
function just before or at the initiation of ejection, e.g. sepa-
ration of night-vision enhancement devices, arm restraint,
etc., can be tested on an ejection-seat ramp. The ramp must
be able to project a seat and the occupant at similar accel-
erations to those of a genuine ejection. Additional dynamic
tests to simulate person–seat separation and the activation
of facilities that are required to function, e.g. a locator bea-
con, etc., may be checked on a rig that is capable of extract-
ing a manikin from the seat by the parachute-deployment
system at a velocity similar to that which occurs during an
ejection. In the absence of such a device, simple roll-out
tests using human subjects may suffice. Pass/fail criteria for
these alternatives are similar to those mandated for the ejec-
tion test, so all components of the AEA required to func-
tion during and after the ejection sequence is complete must
operate successfully after each test.
INVERSION RIG TESTING
For fixed wing aircraft able to invert then a 1 G inversion rig
is useful to check the effects of being inverted on the AEA
in flight. Such a rig can determine whether items will work
loose or move position when inverted (Figure 14.5).
DROP RIG TESTING
For rotary or other aircraft where significant vertical impacts
can occur during an accident or incident, it is important to
assess the motion of items when exposed to decelerations.
Loose items that are inadequately controlled during impact,
e.g. body armour plates, can cause significant injury, render-
ing a crew member unconscious or making them physically
incapacitated, preventing escape from a potentially surviv-
able accident. Hence, all items added to AEA should be tested
under impact conditions (in the UK a 15 Gz deceleration over
400 milliseconds is used) with a slow motion camera used to
allow a view of the stability of the AEA (Figure 14.6).
Figure 14.6  A drop test rig.
Aircrew Equipment Integration Group, RAF Centre of
Aviation Medicine.
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 242  Anthropometry and aircrew equipment integration
Environmental tests
Tests to demonstrate the effects of the operational envi-
ronment on the various items that comprise an AEA must
also be carried out. These normally require the participa-
tion of human subjects and can be included with appraisal
of other items that constitute the life-support system,
e.g. oxygen delivery equipment, acceleration protection
facilities, etc.
Flight acceleration profiles similar to those experienced
operationally can be produced on a human subject-carry-
ing centrifuge or appropriate flight trials. Exposure to the
vibration spectrum simulating aircraft flight should be
conducted with a subject dressed in the AEA under test
and strapped into an appropriate seat. A frequency sweep
is also conducted in order to identify any critical frequen-
cies that cause interaction between the components of the
AEA. The full altitude profile of the aircraft can be simu-
lated in a decompression chamber and, where appropriate,
must include rapid decompression profiles appropriate to
the operational use of the aircraft.
The acceptability of the AEA must be assessed in a
range of operationally representative thermal conditions.
These tests would normally be conducted in appropri-
ate environmental chambers in which air temperature,
humidity, radiant heat load and air movements corre-
sponding to the operational environmental conditions can
be produced. This will test whether heat or cold affect the
function or the construction of items. For example, cold
may make materials brittle and heat could cause adhe-
sives to soften, with either condition leading to failure of
the equipment.
User trials
Wear and comfort of the AEA are best assessed by expe-
rienced subjects, to ascertain whether interaction between
various components of the AEA, both before and dur-
ing flight, is sufficient to cause unacceptable discomfort.
Longer-term assessments of comfort following repeated
donning and doffing of the AEA, together with evaluation
of wear and tear can be achieved, ideally before authoriz-
ing full production. If the AEA is required urgently, then
careful and detailed monitoring following introduction
into service is essential. In addition, if the item is to be
worn on a daily basis for non-flying duties then that suit-
ability must also be assessed and is best conducted by a
group of the intended users during their daily activities,
provided that they do not fly with it prior to the formal
flight trial clearance.
Flight trials
In-flight assessment is the final phase of AEA evaluation.
The integration of all items under test is evaluated in real-
istic operational environments using experienced aircrew
members. These may be conducted by a small number
K17577_C014.indd 242
of experienced pilots in trials and evaluation units, or
by larger numbers of the intended users in regular units.
Each method has advantages and utilization of both
is ideal.
Flight trials ensure that all items under test are evaluated
in realistic operational environments using experienced
aircrew members. They confirm the characteristics dem-
onstrated in earlier assessments, validate the compatibility
of items and their integration with the aircraft systems and
confirm that the AEA enhances and does not inhibit per-
formance in flight. Finally they provide information from
both aircrew and equipment maintenance personnel on the
effectiveness, safety, comfort, ease of operation and main-
tainability of the AEA under test.
SUMMARY
●● Anthropometry is the study of the human body
size, both overall and in segments. In aviation,
it is vital in allowing aircrew to operate their
aircraft safely. Thus, it becomes important in the
selection of aircrew and their suitability for vari-
ous air platforms.
●● Many measurements of the human body can
be taken but few individuals fall into the same
centile range for all of them. Some measurements
such as sitting height and functional reach are at
least as important as overall height and weight,
especially in military aircraft and particularly in
those equipped with ejection seats.
●● Measurements must be repeated for accuracy and
consistency. Both static and dynamic measure-
ments may be required. A variety of measure-
ment techniques from manual to automatic are
available. Cockpit checks of fit and function may
be required.
●● Aircraft design should include consideration
of the workspace and include consideration of
design eye position, clearance, reach and escape.
The space required should address the aircrew
equipment assemblies that may be worn in differ-
ent environments or for flight over water.
●● AEA support one of four functions: life support,
operational items, escape/survival and personal.
●● Clothing design is often built up in layers with
differing functions, from underwear to outer pro-
tective garments and includes boots, gloves and
helmets (see Chapter 9 for helmet considerations).
Flame retardant properties should be considered.
●● AEA testing involves laboratory, field and inflight
assessments including integration with the air-
craft and other equipment as well as robust use in
service. Parachute drop tests, harness suspension,
inversion ejection, sea-survival and environment
tests may be required.
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REFERENCES
Bolton CB, Kenward M, Simpson RE, et al. An
Anthropometric Survey of 2000 Royal Air Force
Aircrew, 1970/71. Neuilly-sur-Seine, France: NATO
AGARD-AG-181, 1974.
Churchill E, McConville JT. Sampling and Data Gathering
Strategies for Future USAF Anthropometry. Technical
report AMRL-TR-74-102. Wright-Patterson Air Force
Base, OH: Aerospace Medical Research Laboratory,
Feb 1976.
Green RG, Muir H, James M, et al. Human Factors for
Aircrew. Aldershot: Avebury Aviation, Ashgate
Publishing, 1996.
International Organization for Standardization. Protective
Clothing Against Heat and Flame – Test Method for
Complete Garments Prediction of Burn Injury Using an
Instrumented Manikin (ISO 13506:2008). Geneva: ISO,
2008.
K17577_C014.indd 243
References 243
MacMillan AJF. Anthropometry and Aircrew Equipment
Integration. In: Rainford DJ, Gradwell DP. Ernsting’s
Aviation Medicine, 4th edn. London: Hodder Arnold,
2006.
Ministry of Defence. Defence Standard 00-25. Human
Factors for Designers Part 14. 25 August 2000.
Ministry of Defence. Defence standard 05-134.
Rench ME, Johnson S. Cost Benefit Analysis for Human
Effectiveness Research: Air Combat Capability
Enhancement Suite. Wright-Patterson Air Force
Base, OH: Air Force Research Laboratory, Human
Effectiveness Directorate, Crew System Interface
Division, Oct 2001.
Trudgill MJA. Enhancing Fire Protection for Helicopter
Crews by Selecting the Appropriate Fabric for Flying
Clothing. CAM/LR/AEIG/30/12 dated 25 Sep 12.
17/11/2015 15:51
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Physiology of sleep and wakefulness, sleep
disorders and the effects on aircrew
J. LYNN CALDWELL
Introduction 245
History of sleep research 245
Recording and classifying sleep stages 246
What affects sleep architecture? 250
INTRODUCTION
Several reports have indicated that pilots and crews fre-
quently experience shortened sleep, reduced sleep efficiency
and/or changes in sleep architecture that prevent full recov-
ery from preceding periods of wakefulness (Bisson et  al.
1993; Boll et  al. 1992; Caldwell et  al. 2009; Dement et  al.
1986; Neville et  al. 1994; Nicholson et  al. 1986; Rosekind
et al. 1994; Sasaki et al. 1986). Needless to say, these off-duty
sleep troubles often lead to serious problems with on-the-job
sleepiness (Akerstedt and Folkard 1995). Anything that dis-
rupts the quality and quantity of restful sleep subsequently
creates a potential safety hazard on the flight deck because
of the fatigue that stems from heightened sleep pressure.
Fatigued pilots suffer from increased lethargy and distract-
ibility, decreased willingness to work cooperatively with
other crew members, degraded ability to integrate incoming
information and impaired capacity to make the higher-level
cognitive decisions that are often crucial for flight safety
(Drury, Ferguson and Thomas 2012; Petrie and Dawson
1997; Powell, Spencer and Petrie 2010; Ritter 1993). To make
matters worse, recovery from the inadequate sleep that
often leads to such problems on the flight deck is unfortu-
nately not as rapid or straightforward as once was thought.
In fact, it may take multiple days, even as long as a week to
recover full alertness and performance levels after several
prior days of restricted sleep lengths (Axelsson et al. 2008;
Balkin et al. 2008; Banks et al. 2010; Belenky et al. 2003; Van
Dongen et al. 2003). And during this time, pilots are more
K17577_C015.indd 245
15
Insomnia 252
Sleep disorders 255
References 258
susceptible to the involuntary micro-sleeps (short involun-
tary sleep episodes) that traditionally have been associated
with acute fatigue – even during critical periods such as the
time span from top-of-descent to landing (Rosekind et al.
1994).
Since optimum sleep is necessary to maintain alertness
in the flight environment, every effort should be made to
ensure that sleep is of the best quality and of sufficient dura-
tion. This chapter will address the physiology of sleep and
the variables that disturb sleep quality, including medically
recognized sleep disorders.
HISTORY OF SLEEP RESEARCH
When German psychiatrist Hans Berger recorded electri-
cal activity in the human brain in 1928, the door opened
to the measurement of brain patterns during sleep and the
science of sleep began. Even after the discovery of rapid-
eye-movement (REM) sleep by Eugene Aserinsky and
Nathanial Kleitman in the early 1950s, the other non-rapid-
eye-movement (NREM) sleep stages were not described
fully until much later. Most of the research focused on REM
sleep and its cyclical pattern. The idea that REM sleep and
non-REM sleep were qualitatively different first developed
after many years of research, but the duality of sleep was
not established until 1960. Sleep research blossomed in the
1960s and was the precursor of sleep medicine and clinical
polysomnography. In 1957, William Dement and Nathanial
Kleitman categorized sleep stages solely on the basis of
245
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 246  Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew
the electroencephalogram (EEG) and electro-oculogram
(EOG) but, in 1968, criteria were modified to include muscle
activity based on research by Michel Jouvet, which showed
the importance of muscle atonia in classifying REM sleep.
This now-standard sleep-staging system (Rechtschaffen
and Kales 1968) officially defined the sleep stages. The
formalization of the practice of sleep medicine evolved in
the 1970s with the 1979  publication of the Association of
Sleep Disorders Centers’ (ASDC) Diagnostic Classification
of Sleep and Arousal Disorders (DCSAD). It is from these
decades of work that the knowledge of sleep and sleep dis-
orders has grown.
RECORDING AND CLASSIFYING SLEEP
STAGES
To monitor sleep stages, it is necessary to first attach a series
of electrodes to the scalp according to the international
10–20 system (Jasper 1958). Most researchers and sleep cli-
nicians use one or two central recording sites – C3 and/or
C4 – and one or two occipital recording sites – O1 and/or O2.
These sites are referenced to the contralateral mastoid or ear
lobe to record the EEG. Additionally, the EOG is recorded
from two eye-monitoring sites – one at the outer canthus
and slightly above the horizontal plane of one eye and one
at the outer canthus and slightly below the horizontal plane
of the other eye. Both of the EOG electrodes are referenced
to either the right or the left mastoid or ear lobe (both eyes
are referenced to the same point). Electromyography (EMG)
is recorded in a bipolar fashion from two electrodes placed
beneath the submentalis muscle underneath the chin. A
third electrode can be placed on the chin as a backup in
the event that one of the other EMG signals is lost during
recording. Figure  15.1  shows the placement sites for the
EEG, EOG, and EMG sensors discussed above. Of course,
more electrodes or transducers are necessary to record res-
piration, limb muscle activity, etc. for clinical diagnosis of
some sleep disorders, but these are not necessary for staging
normal human sleep.
The American Association of Sleep Medicine revised
the guide to conducting sleep recording and scoring in
2007 with the final manual published in 2012. The new stan-
dards include two additional EEG recording sites (F3  and
F4), the classification of sleep stages into one slow wave sleep
stage rather than two, and other modifications to address
the digital technology used in modern sleep laboratories
(Berry et  al. 2012). However, the majority of published
sleep-research papers available at present reflect the older
scoring standards that have been in place for decades.
The use of a standardized recording and classification
system for sleep enables information collected from many
different laboratories to be compared and quantified, and
sleep recordings from the same individual, collected at dif-
ferent points in time, also can be compared. Through the
use of such recordings, it is possible to determine exactly
when an individual falls asleep and wakes up, to calculate
total sleep time and to determine changes in sleep quality by
K17577_C015.indd 246
Ground
F4 F3
F3
C3
Ground O1
EOG EMG
EMG
F4
C3 C4
C4
O2 Ground
O1 O2
EMG
Figure 15.1  Electrode placements for standard
sleep-stage recordings.
examining the different sleep stages as well as the frequency
of disruptions throughout the sleep period. This informa-
tion can, in turn, be used to identify impediments to optimal
sleep and to evaluate the effectiveness of sleep-promoting
strategies that may be useful in operational contexts.
Stages of sleep
NREM AND REM SLEEP
Sleep is separated into two distinct states: NREM and REM.
NREM sleep is divided further into four stages that prog-
ress from the lightest (stage 1) to the deepest (stage 4). The
new AASM scoring manual combines the deepest stages of
sleep (stages 3  and 4) into one stage. Each of these stages
is discussed below with the new stage classifications shown
in parentheses.
AWAKE
When a person is awake and active, the EEG activity is fast
and desynchronized. These activated EEG waveforms, char-
acterized by oscillations of 12 or more cycles per second, are
called beta activity. When a person closes his or her eyes
and relaxes, the EEG activity changes to a pattern of activ-
ity ranging between 8 and 12 cycles per second called alpha
activity. Alpha activity is more uniform and synchronous
than beta activity. Usually, when a person relaxes with the
eyes closed, the eyes become relatively still and overall mus-
cle tension is reduced. However, a relaxed person is not nec-
essarily asleep, and the patterns observed in the EEG, EOG
and EMG reflect this. Figure 15.2 shows the EEG, EOG and
EMG patterns that normally occur when a person is relaxed
but awake with the eyes closed. This recording is more than
50  per cent EEG alpha activity; EMG is high and EOG is
relatively inactive.
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 Recording and classifying sleep stages  247

STAGE 1 SLEEP (STAGE N1)
When sleep onset begins to occur, the brain activity slows
even more than it did under conditions of relaxation. This
slower EEG pattern, called theta activity, is characterized
by waveforms that oscillate at about four to eight cycles per
second. When the EEG recording contains a combination
of alpha and theta activity, with the majority of the activity
in the theta range, the epoch being scored is labelled stage
1  sleep. The EOG pattern shows slow movements as the
eyes roll from side to side in a pendulum fashion. However,
muscle activity remains similar in magnitude to that under
conditions of relaxation (indicating the continued presence
of muscle tone), even as the EEG and EOG features suggest
sleep onset. Figure 15.3 shows the EEG, EOG and EMG pat-
terns typical for stage 1 sleep.
Stage 1 sleep is the transition between wakefulness and
sleep. During this stage, the sleeper may still be aware of
activity in the surrounding environment. Conversations
might still be heard, even though the eyes are closed and the
brain is transitioning into sleep. A person who is awakened
from this very light stage of sleep might not even remember
being asleep, which is part of the reason why sleepiness can
be hazardous in the operational environment. People who
‘nod off’ during a meeting, while watching TV or even while
driving or flying are usually in stage 1 sleep. When evidence
of stage 1 sleep is observed in a person who is supposed to

Figure 15.2  Electroencephalogram (EEG), electro-oculogram (EOG) and electromyogram (EMG) activity during wakeful-
ness. The figure represents a 30-second epoch of data, which equates to one page of a written polysomnograph record.
A 20-second epoch is also used in some sleep laboratories. When scoring an entire episode of sleep, each epoch of the
record is staged to evaluate sleep quantity and quality. Diagram is C3/A2, C4/A1, O1/A2, O2/A1, EOG-L, EOG-R and EMG.
The figure represents a 30-second epoch of data.

Figure 15.3  Electroencephalogram (EEG), electro-oculogram (EOG) and electromyogram (EMG) activity during stage 1 sleep.
Diagram is C3/A2, C4/A1, O1/A2, O2/A1, EOG-L, EOG-R and EMG. The figure represents a 30-second epoch of data.

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 248  Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew
be awake, it is often referred to as a micro-sleep or a micro-
lapse (Dinges et al. 1987; Harrison and Horne 1996; Porcu
et al. 1998). While relaxing at home, these short lapses are of
little or no concern, but on-the-job micro-sleeps can be very
dangerous. Obviously, falling asleep while flying an aircraft,
even for a few seconds, can cause a pilot to miss navigational
checkpoints, warning indications or hazards to safe flight.
Disturbingly, micro-sleeps often occur involuntarily, even
in people who are trying to stay awake; and upon awakening
from a micro-sleep, there often is no recognition that a sleep
episode has occurred.
STAGE 2 SLEEP (STAGE N2)
During a normal night-time sleep period, stage 1 sleep lasts
about five minutes before sleep progresses to the deeper
stage 2. From an electrophysiological standpoint, this stage
of sleep is characterized by unique EEG waveforms called
k-complexes and sleep spindles. Most researchers and clini-
cians believe that the occurrence of stage 2 (rather than stage
1) sleep is actually the true onset of sleep (Carskadon and
Dement 2011). During stage 2 sleep, generally the eyes are
still, but they may show some movement. The muscles are
somewhat relaxed but still taut. The major change between
stage 1  and stage 2  sleep is found in the EEG tracing. An
example of stage 2 sleep is shown in Figure 15.4; notice the
sleep spindle and k-complex in the middle of the recording.
STAGES 3 AND 4 SLEEP (STAGE N3)
In normal night-time sleep, the first cycle of stage 2  lasts
about 10–20 minutes as sleep becomes deeper and the brain
activity slows even more. As time progresses, these deeper
stages of sleep are signalled by the appearance of slow high-
amplitude delta-waves, which have a frequency of between
0.5 and two cycles per second and an amplitude of at least
75μV. Together, stages 3  and 4  constitute slow-wave sleep
Figure 15.4  Electroencephalogram (EEG), electro-oculogram (EOG) and electromyogram (EMG) activity during stage 2 sleep.
Diagram is C3/A2, C4/A1, O1/A2, O2/A1, EOG-L, EOG-R and EMG. The figure represents a 30-second epoch of data.
K17577_C015.indd 248
(SWS), also called delta-sleep, because the brain’s patterns
consist mostly of delta activity, as can be seen in Figure 15.5.
Stage 3 sleep is separated from stage 4 sleep by the amount
of delta activity in the sleep epoch. When more than 50 per
cent of the epoch is composed of delta activity, the epoch is
considered to be stage 4 sleep. When the epoch consists of
only 30–49 per cent delta activity, it is considered to be stage
3 sleep. From a behavioural standpoint, it is much more dif-
ficult to awaken someone from SWS than from either stage
1 or stage 2 sleep. Furthermore, once someone is awakened
from SWS, they tend to be very groggy, and it may take sev-
eral minutes for them to overcome this sleep inertia. Note
that in Figure 15.5, the eyes are still relatively inactive and
the muscles are still taut but a little more relaxed than they
were in the lighter sleep stages.
Sleep inertia is always a consideration when using stra-
tegic naps to sustain performance in operational contexts.
Although the degree of sleep inertia appears to depend
partially on the previous amount of sleep deprivation and
the time of day at which sleep occurs, the primary factor is
the depth of sleep obtained immediately before waking up.
This is why some experts recommend only short naps, since
this often minimizes the transition from light sleep to SWS.
However, a better approach is to let the crew sleep for as
long as possible and to provide a 30-minute ‘wakeup buffer’
before engaging them in tasks requiring mental effort.
REM SLEEP (STAGE R)
After spending about 30  minutes in SWS, brain activity
begins to become more active as a transition is made back
into stage 2 sleep for several minutes. The next progression
of sleep is into REM sleep. During REM sleep, the eyes move
rapidly from side to side, usually in bursts, as shown in the
EOG tracing in Figure  15.6. In addition to the quick eye
movements, the EEG is characterized by higher-frequency
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(a)
(b)
Figure 15.5  Electroencephalogram (EEG), electro-oculogram (EOG) and electromyogram (EMG) activity during stage 3
(a) and stage 4 (b) sleep. Diagram is C3/A2, C4/A1, O1/A2, O2/A1, EOG-L, EOG-R and EMG. The figure represents a
30-second epoch of data.
low-voltage desynchronous activity. Another factor that
classifies this period of sleep as REM is the relative lack of
muscle tone. A novice looking at a polysomnographic repre-
sentation of REM sleep (particularly if the focus is placed on
only the EEG channels) could mistake it as being indicative
of wakefulness, which is why some authors refer to REM
sleep as ‘paradoxical sleep’.
There are four to six episodes of REM sleep during each
eight-hour sleep period. The first REM period is very short,
but the length of each REM period increases as the sleep
episode progresses. REM sleep is when most dreaming
occurs, as evidenced by the fact that dreams are reported
about 80 per cent of the time when subjects are awakened
from REM sleep but only eight per cent of the time after
subjects are awakened from non-REM stages of sleep (Pace–
Schott 2011). Since REM periods tend to occupy more of
K17577_C015.indd 249
Recording and classifying sleep stages  249
the sleep architecture just before awakening, many people
awake from the night out of REM sleep and, as a result, can
remember the dream that was occurring just before waking.
DISTRIBUTION OF STAGES THROUGHOUT A PERIOD
OF SLEEP
The progression of sleep through the stages identified above
occurs predictably during the night. Sleep begins in stage
1 and then progresses to stages 2, 3 and 4, before returning
back to stage 2  and then to REM. This pattern of activity
recurs in approximately 90-minute cycles. SWS dominates
the first half of the night, while REM sleep dominates the
second half. Throughout the night, brief transitions to stage
1 sleep and/or brief awakenings are often observed as well.
The progression of sleep stages over an eight-hour sleep
period is shown in Figure 15.7.
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 250  Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew

Figure 15.6  Electroencephalogram (EEG), electro-oculogram (EOG) and electromyogram (EMG) activity during rapid-
eye-movement (REM) sleep. Diagram is C3/A2, C4/A1, O1/A2, O2/A1, EOG-L, EOG-R and EMG. The figure represents a
30-second epoch of data.

Awake

Stage 1

Stage REM

Stage 2

Stage 3

Stage 4
0 1 2 3 4 5 6 7 8
Hours of sleep

Figure 15.7  Hypnogram of an eight-hour sleep period in a normal young adult.

WHAT AFFECTS SLEEP ARCHITECTURE? Age

The average amount of sleep needed by most adults is about
eight hours (Drake et  al. 2001; Van Dongen et  al. 2003).
However, a small percentage of people need less sleep than
this and are able to function normally with only five or
six hours of sleep a night. There are also some people who
require more than the average person, requiring as much as
nine or ten hours of sleep to feel fully rested and alert during
the day. While the need to sleep for more than eight hours
a day may be inconvenient, it is not a pathology and should
not be considered as such.
Regardless of the length of the individual’s sleep
requirements, sleep structure can be affected by a number
of factors, including age, time awake, time of day, environ-
mental characteristics, medications and sleep disorders.
These factors can influence the overall structure of sleep,
and many exert a noticeable subjective effect on the quality
of sleep.
Age affects the sleep cycle (Bliwise 1993; Ohayon et al. 2004;
Van Cauter et al. 2000). Infants sleep much longer than adults;
children and adolescents require less sleep than infants but
more sleep than adults. Most of an infant’s sleep time is spent
in REM sleep. The amount of SWS increases with age until
adulthood. Around the third decade of life, the amount of
SWS begins to decline until around age 60–70, when almost
all SWS is gone. Frequent night-time awakenings are more
common in older people. Since the sleep of older individu-
als is no longer deep, noises occurring during the night and
other disruptive factors such as light and caffeine are more
likely to disturb sleep than when the person was younger.
Sleep deprivation
When job requirements entail sleep loss because of
extended duty periods, the sleep that occurs in the first rest

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opportunity often contains significantly more slow-wave
activity throughout the night, while REM sleep is pushed
either much later in the sleep episode or sometimes even
into the next night of sleep (Borbely 1982; Carskadon and
Dement 2011). The brain shows a preference for recovering
SWS first and REM sleep afterwards, which has led some sci-
entists to believe that SWS probably conveys a greater sur-
vival advantage than REM sleep (Sejnowski and Destexhe
2000). However, the exact roles of the different stages of sleep
have not been determined precisely (Brown 2012; Dang–Vu
et al. 2010; Hanlon et al. 2011; Nicolau et al. 2000).
The extent of changes in sleep characteristics will depend
in part on how long the person has been awake before recov-
ery sleep occurs. Typically, a person enters SWS much faster
than normal after periods of prolonged wakefulness. This
type of change in sleep architecture is important to note
in situations in which a sleep episode occurs immediately
before the onset of work, such as when strategic napping
is used as a countermeasure against workplace fatigue. As
noted earlier, sleep inertia will be greater when a person is
awakened from SWS than when a person is awakened from
a lighter stage of sleep (Balkin and Badia 1988; Borbely
1982; Naitoh et  al. 1992). If a previously sleep-deprived
pilot is taking a nap before resuming duties at the controls,
then it is important to remember that the nap probably
contains a higher than normal amount of SWS, and extra
time should be allotted in order for sleep inertia to dissipate
before resuming flight duties.
Timing and duration of sleep
The time at which a person sleeps can affect the structure
of the sleep cycle. With night-time sleep, the preponder-
ance of REM sleep generally occurs later in the sleep period
and most of the SWS occurs at the beginning of the night.
When sleep onset is delayed until the early morning, when
the body-temperature rhythm is at its nadir, most of the
REM activity usually occurs in the first part of the sleep
period, while SWS shifts to the second half of the sleep cycle
(Czeisler et  al. 1980a,b). Shift workers who change from
night sleep to day sleep may show this reversed sleep pat-
tern on the first few days before their circadian cycle adjusts
to the new schedule. Such a change can noticeably affect the
restorative quality of sleep during the transitional period,
particularly if the sleep period is truncated.
In situations in which the majority of sleep occurs in the
form of napping, there are characteristic effects on sleep
architecture that should be borne in mind. Naps that are
placed early in a period of sustained wakefulness (pro-
phylactic naps) will differ markedly from those occurring
after lengthy periods of sleep deprivation (recovery naps).
Earlier-placed naps tend to contain more of the lighter
stages of sleep, whereas later-placed naps will likely contain
significantly more SWS, largely because of differences in the
levels of the homeostatic sleep drive. Both types of nap are
helpful for improving subsequent performance, but recov-
ery naps should be longer than prophylactic naps in order
K17577_C015.indd 251
What affects sleep architecture?  251
to derive the same performance benefit (Gillberg 1984;
Haslam 1985; Nicholson et  al. 1985). The quality of a nap
also will be affected by the time of day at which the napping
occurs. Sleep tendency is highest when core body tempera-
ture is in its trough (early morning hours) and lowest when
core body temperature is at its peak (early evening hours).
Thus, there may be significant problems initiating and/or
maintaining a nap during times when core temperature is
high, which is why this period of time (2–3 hours prior to
the habitual bedtime) has been termed the ‘forbidden zone’
for sleep (Lavie 1986). Naps are easier to maintain if taken
at times when body temperature is low, and they will likely
bestow a greater benefit on later performance. However,
sleep inertia is highest following these naps, because the
sleep is deeper. Naps taken at any time of day (during circa-
dian peaks or troughs) will improve performance measured
later in the day in comparison with having no sleep at all,
but naps taken in the temperature trough will produce the
most benefit (Carskadon and Dement 1982; Dinges et  al.
1985; Dinges 1986; Lavie 1986) and will likely contain more
restorative sleep than naps taken at other times.
Environment
Environmental factors are a common cause of sleep difficul-
ties. An unfamiliar environment, noise, light, heat and cold
will interfere with sleep, as will a bed that is either too hard
or too soft, a pillow that does not support the head and neck
properly, or a sleep partner, bunk mate or roommate who is
restless, snores or otherwise disturbs the tranquillity of the
sleep setting. Deployed military pilots are especially sus-
ceptible to the adverse effects of a poor sleep environment.
Sharing a tent with several other people, and trying to sleep
in a cot, in the desert, in the middle of the day, while listen-
ing to the sounds of aircraft departing and landing, trucks
driving through the area, and people talking as they walk
from one place to another, can thwart even the best efforts
to sleep before the next duty cycle.
In some situations, aircrew are given space and oppor-
tunity to nap on board the aircraft during certain portions
of the flight. While this strategy to combat fatigue is very
helpful, one must remember that the sleep that occurs in
the aircraft is not the same quality as the sleep that occurs
at home in a comfortable bed. With regard to the on-board
bunk sleep of long-haul pilots, Rosekind et  al. (2000)
reported that 71 per cent of pilots who identified themselves
as ‘good home sleepers’ reported difficulty with sleeping in
the aircraft bunk ‘often’ or ‘the majority of the time’. Five
areas were identified that interfered with sleep: environ-
mental disturbance (e.g. background noise, turbulence),
luminosity (e.g. lighting), personal disturbances (e.g. bath-
room trips, random thoughts), environmental discomfort
(e.g. low humidity, cold) and interpersonal disturbances
(e.g. bunk partner). Pilots attempting to sleep on board
an aircraft in a regular reclining passenger seat cannot
obtain the same level of sleep quality that is possible when
lying flat. Nicholson and Stone (1987) found that subjects
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 252  Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew
experienced reductions in total sleep time, decreased sleep
efficiency and increased awakenings when they attempted
to sleep in a more upright sitting position (17.5 degrees from
the vertical angle) compared with either lying flat or reclin-
ing at 49.5 or 37 degrees. Similar results were reported by
Aeschbach et al. (1994), who discovered that subjects who
slept in reclining chairs rather than lying flat in bed experi-
enced reduced sleep efficiency, less REM sleep and increased
stage 1 sleep. The section below on insomnia discusses the
impact of environmental effects on sleep along with some
potential solutions.
Medications and herbal remedies
Medications or herbal substances can change the sleep cycle.
Although pilots generally do not use many prescription
drugs, it is worthwhile for the flight surgeon/physician/avi-
ation medical examiner (AME) to note which medications
affect sleep. Some medications inhibit the amount of SWS
or REM sleep, some interfere with the ability to go to sleep
or to stay asleep, and others lead to excessive sleepiness. It
is necessary not only to consider the effects of prescription
medications but also to warn aircrew of the effects of over-
the-counter (OTC) medications, since many of these can
affect sleep and alertness. Several OTC pain/headache rem-
edies contain caffeine, some as much as 65 mg per tablet; a
person taking a recommended dose of two tablets will thus
consume sufficient caffeine to interfere with sleep onset and
sleep maintenance (Boutrel and Koob 2004). Many OTC
cold medications contain pseudoephedrine, another central
nervous system stimulant that can lead to sleep difficulties.
Alcohol also affects sleep quality in several respects, one
of which is by causing a reduced latency to sleep onset. This
often makes alcohol appear to be an attractive substance for
those having difficulties going to sleep. However, under the
influence of alcohol, sleep is disrupted in the second half of
the sleep period, affecting both REM and SWS (Ebrahim
et  al. 2013). These sleep architecture changes result in a
less restorative effect despite the increased sleep duration.
In addition, the use of moderate alcohol consumption as a
sleep promoter, while possibly a ‘legal’ option from a reg-
ulatory standpoint, has been shown to affect subsequent
performance even after the blood alcohol content (BAC)
returns to 0.0 (Ling et al. 2010; Yesavage and Leirer 1986.)
Owing to the popularity of herbal supplements, it is
worth knowing which of these alter sleep and alertness. The
major alerting herbal agents that may affect sleep adversely
include ephedra, ma huang, Indian sida, bitter orange,
yohimbe and ginseng. In addition to these herbs, many tea
and green tea beverages contain caffeine, which may dis-
rupt sleep in some individuals. Herbs that have been shown
to possess sleep-inducing properties include valerian, kava
and lavender. Comprehensive reviews of the efficacy and
safety of these and a variety of other herbal stimulants and
sedatives are beyond the scope of this chapter, but are avail-
able elsewhere (Cooper and Relton 2010; Gyllenhaal et  al.
2000; Yeung et al. 2012).
K17577_C015.indd 252
INSOMNIA
Clearly, there are a number of factors that can impact the
content or characteristics of sleep episodes. However, pilots
(and others) also may suffer from some type of insomnia,
which will severely limit sleep duration. There is no specific
objective definition of insomnia such as the criteria that
define other sleep disorders (Sateia 2002). However, insom-
nia is generally defined as the inability to initiate sleep and/
or to maintain sleep throughout the night. The diagnosis of
insomnia is made by acquiring a medical history and dis-
cussing life events and sleep patterns. It is important that
the flight surgeon/physician/sleep specialist rules out respi-
ratory disorders, including sleep apnoea and neurological
disorders, some of which are discussed later in this chapter.
Some of the reasons for insomnia may be identified quickly
and thereby rectified once the specific circumstances under
which the sleep problems occur are discovered. However,
if physiological causes are ruled out, then the underly-
ing cause of the insomnia sometimes is not easy to iden-
tify and treat. As detailed below, there are many common
possibilities that must be considered. Especially within the
aviation arena, stress, environmental factors and circa-
dian factors should be explored when insomnia occurs in
an otherwise normal, healthy individual. Aircrew mem-
bers, who are, by definition, in positions of responsibility
and who find themselves often taken away from home and/
or away from standard work schedules, can easily relate
to difficulties in all three of these areas. Once the source
of the problem is clear, a specific treatment option can be
identified and implemented.
Transient insomnia
Insomnia occurs in most people at some time or another.
If the problem occurs regularly, i.e. for more than three
weeks, then it falls into the category of chronic insomnia;
if the problem is short-term, then it is classified as transient
insomnia. Both types of insomnia often are symptomatic
of another problem, such as stress, anxiety, apprehension,
pain or new surroundings (Hauri 1993). In addition, short-
term insomnia can be caused by environmental factors
and circadian disruptions (Gander et al. 1998; Gander and
Graeber 1987). People with insomnia usually seek treat-
ment either because of their frustration over the inability
to take advantage of sleep opportunities or because their
sleep problems are impairing alertness during waking
hours. In the aviation context, numerous factors can cause
frequent short-term bouts of insomnia, especially since fre-
quent work/sleep-scheduling changes, long duty hours and
rapid time zone transitions are commonplace (Rosekind
et  al. 1994, 2000; Gander et  al. 1998; Nicholson 1987).
Flight surgeons and other physicians should work with
pilots and crew members to help resolve mild to moder-
ate cases of insomnia or other sleep difficulties before these
disturbances threaten operational readiness (Morgenthaler
et al. 2006).
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Insomnia due to stress
Everyone lives with stress to some extent on a daily basis, but
pilots seem to be facing an escalation in job-related stress due
to, for example, work pressures and downsizing. Although
the sources of stress can be either negative (tight deadlines,
long work hours, expanded responsibilities) or positive
(increased pay or rank, desirable transitions into larger or
faster aircraft), stressful events can temporarily disrupt sleep
until either the source of the stress is removed or the individ-
ual has learned to deal adaptively with the stressful situation.
If sleep suddenly becomes difficult for no apparent reason,
then a psychological stressor may be the underlying source.
TREATING INSOMNIA DUE TO STRESS
To prevent this temporary problem from becoming chronic,
the individual should try to alleviate the source of the stress,
or their negative reaction to the stress, as early as possible. The
crew member should be advised to take stock of the current
situation and implement one of many strategies designed to
cope with psychological stress. A plethora of advice is avail-
able on how to overcome worry and transient anxiety, and
some techniques are immediately effective for minimiz-
ing the impact of stress on sleep. For instance, progressive
relaxation exercises (systematically tensing and relaxing the
body’s muscle groups) have been proven to be very effective
for dealing with temporary anxiety or psychological pres-
sure, because these quick and easy self-help strategies bring
the body’s natural relaxation response under more voluntary
control (Lushington and Lack 2002; Smith and Neubauer
2003). In addition, the act of focusing on producing a relax-
ation response may be all that is necessary to divert attention
away from an anxiety-provoking situation towards a sleep-
conducive state long enough to fall asleep. This may sound
overly simplistic, but it is true that people can consciously
identify and cope with a previously unrecognized problem
once they focus energy in this direction. In the meantime,
and at a minimum, it would be worthwhile to engage in some
type of aerobic exercise three to four hours before bedtime,
because this has been shown to improve the onset and quality
of sleep later on (Youngstedt 2003). If psychological stress is
producing transient sleeping problems, then self-help tech-
niques, relaxation exercises, aerobic exercise or some other
stress-management strategy may offer a solution.
Insomnia due to environmental change
Environmental factors are a common cause of transient
insomnia. As discussed earlier, a pilot may have particular
difficulty in sleeping in constantly changing environments.
This is in part why Comperatore et al. (1996) have recom-
mended a systematic approach to planning crew rest that
includes daylight management, environmental manage-
ment and living-quarters planning, as well as coordina-
tion of scheduled events such as meetings, meals and flight
schedules, in such a way as to minimize the impact on avail-
able sleep opportunities.
K17577_C015.indd 253
Insomnia 253
TREATING INSOMNIA DUE TO ENVIRONMENTAL
FACTORS
Treatment of insomnia due to environmental factors usu-
ally involves alleviation of the noise, light, etc., that is
interfering with sleep. If the environmental problems are
temporary, such as is often the case in aviation with a short
layover, then a hypnotic may be prescribed to induce sleep
despite conflicting factors. However, when this strategy
is used for pilots, it should be kept in mind that there are
post-drug grounding times designed to avoid subsequent
impairments in on-the-job alertness. For example, current
US Air Force (USAF) policy specifies a post-drug ground-
ing time of 12 hours for temazepam, six hours for zolpidem
and four hours for zaleplon (Department of the Air Force
2011). Also, it should be considered that reliance on hypnot-
ics is typically discouraged for aviation personnel by regula-
tory authorities. For civilian pilots, the US Federal Aviation
Administration does not permit any use of temazepam or
zaleplon; however, it does specify that zolpidem may be used
(maximum twice a week) as long as the pilot waits 24 hours
before resuming flight duties and does not use the medica-
tion for circadian disturbances (Silberman 2003). However,
despite this allowance for zolpidem, the use of this medi-
cation is typically discouraged, and although as noted in
Chapter 36, this and other sleep promoting medications can
be a very beneficial short-term method for enhancing sleep
quality and, as a result, enhancing subsequent alertness and
performance, airmen should discuss this option carefully
with their aeromedical examiner or flight surgeon prior to
implementing such a strategy.
As well as the use of a pharmacological approach,
sleep difficulties associated with new environments also
can be overcome with behavioural types of intervention.
Sometimes, adjustment to a new environment can be facili-
tated simply by making the new setting more familiar.
Bringing along a comfortable pillow, a family picture or
minor convenience items that might not be available in a
typical hotel room or temporary military quarters can make
the situation more comfortable and, therefore, more sleep-
conducive. Improving the environment itself (lighting, tem-
perature, etc.) is also an option. Although this is difficult in
military field settings and in-flight environments, the use
of sleep masks can block light, foam ear plugs can attenuate
noise, and cooperative agreements with tent/bunk/room-
mates can minimize the disruptive effects of conversation
and other disturbing activities in the sleeping quarters. In
hotel rooms, and often in on-board, in-flight bunks, envi-
ronmental control is somewhat easier than it is in the field,
but it is still up to the crew member to evaluate and optimize
the environment prior to attempting sleep.
Insomnia due to circadian disruptions
Another source of short-term insomnia is related to the
sleep schedule. Shift workers often have a very difficult
time maintaining sleep due to the timing of their sleep
opportunities. Work/rest cycles that vary frequently often
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 254  Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew
are associated with sleep difficulties because the body can-
not establish a consistent routine (Akerstedt 1988, 2003;
Costa 1997). In addition, travelling across multiple time
zones can produce sleep difficulties similar to those experi-
enced by shift workers (Stone and Turner 1997; Waterhouse
et  al. 1997; Waterhouse 1999). Long-haul pilots are con-
stantly confronted with disagreements between their cir-
cadian rhythms and the environmental cues present at
their destination. Military pilots, likewise, must face these
problems when they are deployed across multiple time
zones, especially when travelling in an easterly direction.
A pilot working a normal daytime schedule in London
may be in the habit of waking up early in the morning and
going to sleep at 22:00  or 23:00  each night; such a sched-
ule means that the time span from approximately 17:00 to
21:00  will be associated with a high degree of alertness.
This is fine in the UK. However, when pilots travel from
London to Tokyo, they cross eight time zones in less than
a day, and when they attempt to stick to the 23:00  local
bedtime in Tokyo, they are actually trying to initiate sleep
at 15:00  according to the body’s internal clock. In addi-
tion to the problem of getting to sleep, there is also the
problem of waking up at a time that is eight hours before
the usual body-clock wakeup time. In this example, the
Tokyo wakeup time of 07:00 is only 01:00 according to the
body’s clock.
TREATING INSOMNIA DUE TO CIRCADIAN
DISRUPTIONS
Insomnia due to circadian disruption is difficult to man-
age, particularly in aviation settings. The body cannot
adjust quickly to changes in schedules, and sleep is gen-
erally one of the casualties of a new schedule. In some
situations, hypnotics may be prescribed in the short term.
However, implementation of behavioural countermea-
sures also represents a successful alternative. The applica-
tion of countermeasures depends in part on the length of
time that the person will be in the new time zone or on
the new work schedule. Generally, it will be necessary to
combine several strategies to promote optimal adjustment.
For instance, a traveller might be advised to use a hypnotic
during the early part of a departure flight to promote sleep
(only useful for non-pilots), caffeine during the later part
of the flight and/or after arrival at the destination to sus-
tain wakefulness (pilots and non-pilots), varying degrees of
sunlight exposure to help shift the body’s rhythms (pilots
and non-pilots), and rapid adjustment to new meal/activ-
ity times to facilitate more effective time-zone adaptations
(pilots and non-pilots). For the first few days in the new
time zone, it may be necessary to continue the use of either
a short-acting or a long-acting sleep medication (depend-
ing on the direction of the travel and the number of time
zones crossed) to promote night-time sleep, but as noted
earlier, airmen should check regulations and discuss medi-
cation options with a flight surgeon or AME prior to utiliz-
ing sleep medications. Many of these strategies are covered
in Chapter 36.
K17577_C015.indd 254
Flight status and insomnia
There are no specific criteria under which insomnia will
impact the ability to secure and maintain flight status. Many
cases are relatively mild and, therefore, have an inconse-
quential effect on routine alertness levels. Also, even when
transient insomnia is more severe, the short duration of the
sleep difficulty is unlikely to result in any chronic impair-
ment. However, it should be remembered that any degree
of sleep loss translates into some decrement in subsequent
alertness. Because of this, countermeasures for sleep diffi-
culties, shift lag and jet lag should be implemented.
Chronic insomnia
Chronic insomnia is a sleep disturbance that lasts for more
than three weeks. It is much more difficult to treat than
transient insomnia due to the various reasons for its occur-
rence. Sometimes, the sufferer has developed habits that are
not conducive to sleep or is taking a medication that inter-
feres with sleep. If the problem is as simple as this, then the
insomnia can be treated fairly successfully. However, if the
insomnia results from a less identifiable cause, then a more
complex solution may be needed. Regardless of the source,
chronic insomnia is a serious condition due to its adverse
effects on health and safety.
TREATMENT OF CHRONIC INSOMNIA
Pilots who experience chronic insomnia may be treated
successfully with behavioural interventions (Manber and
Kuo 2002; Mitchell et al. 2012). Relaxation techniques may
be helpful in some situations; stimulus control therapy is
helpful for those people in whom poor habits interfere with
sleep. In some cases, sleep-restriction therapy is successful
in breaking the insomnia cycle. Sleep restriction works by
increasing the homeostatic sleep pressure by limiting time
spent in bed until the effects of sleep deprivation accumu-
late to the point that sleep efficiency improves. Cognitive-
behavioural therapy is used widely to treat insomnia
successfully, combining behavioural treatments with cogni-
tive therapy to educate the patient and resolve dysfunctional
thought processes that lead to insomnia. Generally, cogni-
tive and behavioural therapies require several treatment
sessions to overcome the problem behaviours or thoughts.
In addition, chronic insomnia due to environmental factors
often can be rectified by modifying the characteristics of the
sleep setting. Chronic insomnia due to circadian factors can
be corrected without medication, although it is difficult to
eliminate the adverse effects of constant schedule changes
in transcontinental pilots or frequently deployed military
aviators. Chronic sleep disturbances often can be corrected
without affecting fitness for full flying duty. Once the phy-
sician or sleep specialist has ruled out the possibility of a
sleep disorder, then persistence and time on the part of the
physician and the patient are required to work through the
behavioural interventions that will break bad sleep hygiene
habits and alleviate the insomnia.
17/11/2015 15:51

FLIGHT STATUS AND CHRONIC INSOMNIA
As with transient insomnia, there are no specific criteria
under which chronic insomnia will impact the ability to
secure and maintain flight status. Although chronic sleep
loss will seriously impair on-the-job alertness/performance,
it is true that many individuals seem to continue functioning
at some marginal level despite the problem. Nevertheless, it
is desirable to treat such sleep difficulties because the day-
time sleepiness associated with night-time sleep restriction
represents a serious threat to flight safety. The strategies
outlined above should be effective in most cases.
SLEEP DISORDERS
It is important to recognize that some alertness difficulties
are a function of medically recognized sleep disorders
rather than more controllable factors such as the envi-
ronmental conditions and medications mentioned above.
Sleep disorders can impair alertness because of their
interference with the sleep cycle, either by causing fre-
quent awakenings or by disrupting the phases of sleep
(Bonnet and Arand 2003; Vaughn and D’Cruz 2011). The
International Classification of Sleep Disorders (ICSD), first
published in 1990 by the joint efforts of the European Sleep
Research Society, the Japanese Society of Sleep Research
and the Latin American Sleep Society, was developed for
diagnostic and epidemiological purposes (Thorpy 2011).
There are 84  sleep disorders described in the text; these
disorders are classified into four major categories:
●● Dysomnias: disorders of initiating or maintaining sleep
and disorders of excessive daytime sleepiness.
●● Parasomnias: disorders that are characterized by prob-
lems that occur during sleep, but do not lead to insom-
nia or excessive sleepiness.
●● Other sleep-disrupting disorders associated with medi-
cal or psychiatric problems.
●● Proposed sleep disorders: sleep-related disorders that
are understood too poorly to be classified.
Of these sleep disorders, only dysomnias will be dis-
cussed here.
As with any disorder, the first step in treating it is to
diagnose it correctly. Proper diagnosis of a sleep disor-
der occurs after the sleep specialist/physician interviews
the patient for medical and family history review, con-
ducts a thorough physical examination and usually stud-
ies an overnight sleep record from the sleep laboratory.
The overnight stay in a sleep laboratory involves poly-
somnography, in which the EEG, ECG, EMG, respiration,
limb and muscle movements and oxygen saturation are
monitored while the patient sleeps. Following documenta-
tion of the magnitude of the problem, treatment options
can be investigated. In many cases, an interview with the
patient’s partner may be highly informative, since he or
she may be aware of the behaviours that occur while the
patient is sleeping.
K17577_C015.indd 255
Sleep disorders  255
Once the sleep specialist determines that a sleep dis-
order is present, and once the exact nature of the disor-
der is known, proper treatment can begin. Although the
prevalence of sleep disorders is likely to be small in young,
healthy and physically fit aviators, they can be a problem for
a small percentage of the pilot population. When working
with pilots, it is important to note that some of these disor-
ders can be treated successfully in a way that does not affect
flying status. A few of the most common sleep disorders,
along with their treatments, are discussed here.
Sleep apnoea
The diagnosis of obstructive sleep apnoea syndrome (OSAS)
is made when there is evidence of repetitive apnoeas (cessa-
tion of breathing) during sleep, each of which lasts at least
ten seconds (Butkov 2002). The sleep of a normal person
contains as many as five short sleep apnoeas per hour (an
apnoea index of 5), generally without any residual effects on
health or daytime alertness. However, if the apnoea index
increases to as many as 20 or more per hour, if an individ-
ual apnoea event lasts for many seconds, or if the oxygen
desaturation falls significantly, then both health and day-
time alertness will subsequently suffer. Apnoea events cause
sleep disruptions because the oxygen-deprived sleeper usu-
ally reacts to the lack of oxygen with a jerk, which precipi-
tates an awakening or a shift into a lighter sleep stage. As
these events occur throughout the night, sleep becomes
fragmented and non-restorative. The severity of the symp-
toms is linked to the severity of the apnoea. A person with
severe sleep apnoea can stop breathing more than 100 times
an hour, with episodes lasting 60 seconds or more. A person
with minor sleep apnoea may stop breathing ten times an
hour, with each episode lasting only a few seconds.
People with sleep apnoea often do not awaken fully
every time they experience an apnoea event, so they may
not complain of a ‘sleep problem’. However, they sometimes
will complain of restless sleep, and usually they complain
of excessive daytime sleepiness, headaches in the morning,
depressed mood or personality change, possibly impotence,
inability to control the bladder and/or a decline in mental
performance. Their partners may complain of loud snor-
ing, which often ends in a snort and awakening (or par-
tial awakening) from sleep. Many people with apnoea are
overweight, and the incidence of apnoea increases with age.
Sleep apnoea is more common in men than women. A ran-
dom sample of 1520 people in Wisconsin, USA, studied by
overnight polysomnography indicated a prevalence of sleep
disordered breathing in 10  per cent of women and men
(Peppard et  al. 2013). A telephone study conducted in the
UK (with no examinations or sleep recordings) indicated a
similar prevalence of up to 4.6 per cent in males and 2.2 per
cent in females (Ohayon et al. 1997). Untreated apnoea that
worsens progressively over time can lead to serious health
problems, such as high blood pressure, stroke and increased
risk of accidents due to increased sleepiness. Treatment of
apnoea can significantly mitigate these associated problems.
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 256  Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew
Identification/diagnosis of sleep apnoea usually begins
with complaints from the person’s partner about loud snor-
ing, which prompts the sufferer to seek treatment. Following
the person’s visit to a sleep laboratory, the physician or sleep
specialist determines from the polysomnographic record
the magnitude of the problem and investigates various
treatment options.
TREATMENT OF SLEEP APNOEA
Sleep apnoea can be treated in a number of ways, depend-
ing on the severity of the problem, the physical construc-
tion of the nose and throat and the weight of the patient.
The most successful treatment is through continuous posi-
tive airway pressure (CPAP). This consists of a small mask
that fits over the patient’s nose and mouth and is linked to
a small air pump. The pump sends air through the mask
and acts as a splint to the airways, holding the airway open
during inspiration. Prevention of airway collapse alleviates
snoring as well as the apnoeas, which leads to less disrupted
sleep during the night. As sleep becomes less fragmented,
daytime sleepiness diminishes, the heart and brain have a
continuous flow of oxygen, and the patient’s mood and per-
sonality return to normal. Compliance is usually the big-
gest problem with CPAP success. A proper-fitting mask and
appropriate air pressure are essential to the comfort of the
device, both of which will encourage compliance.
Another mechanical treatment option for sleep apnoea is
a dental appliance that can be fitted by a qualified dentist.
The appliance modifies the position of the mandible, which
allows better airflow in some cases.
Other treatments for sleep apnoea include surgery on the
upper airway, which can be as minor as removal of the ton-
sils and adenoids, straightening of the nasal areas or uvulo-
palatopharyngoplasty (UPPP) or as major as reconstruction
of the jaw and tongue. Usually, any surgical treatments
involve a series of operations, each of which is followed
by a re-evaluation designed to determine the extent of the
improvement after each treatment. The success of any of the
procedures varies depending on the type, size and location
of the obstruction.
Another treatment for some apnoea patients is weight
loss. Overweight people have additional fatty tissue sur-
rounding the airways, which can obstruct proper breath-
ing. In some situations, weight loss can resolve the problem
entirely. Often, when overweight sufferers of sleep apnoea
are placed on CPAP, they reap a secondary gain in terms of
weight loss once their improved energy leads to increased
physical activity. Many people can lose enough weight so
that CPAP is no longer needed or the pressure required to
keep the airways open can be decreased, making the CPAP
more comfortable.
There are three different types of sleep apnoea. The
most common is the obstructive sleep apnoea described
above. This derives its name from the fact that the breath-
ing difficulties result from a physical airway obstruction.
The person exerts the effort to breathe but inadequate air
gets through. Another type of sleep apnoea is central sleep
K17577_C015.indd 256
apnoea. This occurs when the signals from the respira-
tory control centres of the brain fail to evoke stimulation
of the peripheral respiratory system, and the patient does
not breathe for several seconds. In contrast to obstructive
sleep apnoea, patients with central apnoea fail to exert any
effort to breathe. The problems associated with this type
apnoea are the same as for obstructive apnoea – including
poor sleep and excessive daytime sleepiness. The treatment
is usually either CPAP or medication. Sometimes, central
sleep apnoea is associated with other medical disorders,
such as congestive heart failure, cerebrovascular disease
and some endocrine disorders; when these disorders are
treated, the central apnoea often improves. The third type
of sleep apnoea is mixed, i.e. a combination of obstructive
and central apnoea. Treatment for this type of apnoea usu-
ally focuses on the obstructive part of the apnoea, which,
when treated, also may lessen the central apnoeas. In some
cases, a patient suspected of sleep apnoea but who does not
show apnoeas on the polysomnogram is diagnosed with
upper-airway resistance syndrome. The symptom of day-
time sleepiness is due to the increased breathing effort dur-
ing the night, which creates brief arousals from sleep. When
this diagnosis is made, CPAP is a good treatment choice.
FLIGHT STATUS AND SLEEP APNOEA
In military aviation, a pilot diagnosed with sleep apnoea
often cannot continue their flying career if the apnoea is
treated with CPAP. However, successful treatment via sur-
gery or weight loss may be acceptable. If CPAP is required,
the pilot may not be deployable if their health and alert-
ness depend on the use of an electrically powered CPAP
machine, because electricity may be unavailable in a field
environment. Successful treatment with surgery or weight
loss resolves the issue without complications.
In the civilian aviation community, a pilot may still fly if
diagnosed with sleep apnoea as long as treatment is success-
ful and compliance with treatment can be demonstrated.
Usually, after diagnosis is made and treatment has begun,
the pilot is brought into a sleep laboratory for the mainte-
nance of wakefulness test (MWT), which provides an objec-
tive measure of how well a person can stay awake. If the pilot
is able to pass this test, then they are considered fit for flight
duty. However, the regulatory agency, the physician and/
or the airline will probably require a record of compliance
with CPAP treatment and/or proof that the apnoea has been
treated successfully through surgery. Most CPAP machines
now have the ability to track the hours of use, so compliance
is easy to verify. A second overnight sleep test following sur-
gery often proves that the surgery was successful.
Periodic limb movements in sleep
Periodic limb movements in sleep (PLMS) is another sleep
disorder that disrupts and fragments sleep. The disorder
can disturb sleep to the point that its restorative value is
degraded significantly, leading to problems with daytime
sleepiness (Tabbal 2002).
17/11/2015 15:51

PLMS involves periodic contraction of the tibialis ante-
rior, with muscle dorsiflexion of the ankle and toes, which
results in a leg jerk or twitch, usually lasting between 0.5 and
5 seconds and with a frequency of one every 20–40 seconds.
Usually, these movements are associated with short EEG
arousals. The severity can range from a mild toe movement
to a full kick of the leg. The most common type of PLMS
involves the legs, but there are cases in which the arms are
affected. Often the person is not aware of the limb move-
ments during sleep, so frequently the problem is reported by
a partner. The rhythmic jerks of PLMS should not be con-
fused with hypnic jerks (also called hypnic myoclonus and
sleep starts), which are brief contractions of the muscles of
the arms and legs that occur at sleep onset and are a normal
feature of falling asleep.
In order to diagnose PLMS, the patient should stay over-
night in a sleep laboratory while EEG, EMG, ECG and respi-
ration are monitored. Bilateral EMG electrodes attached to
the anterior tibialis muscles are used to identify and count
the muscle movements associated with PLMS. A PLMS
index (average number of limb movements per hour of
sleep) of greater than 5 is considered pathological; however,
the number of leg movements varies from night to night.
Restless legs syndrome
A similar disorder that may occur with PLMS is restless
legs syndrome (RLS), characterized by limb discomfort that
occurs while the person is awake and is of sufficient inten-
sity to prevent or delay the onset of sleep. The symptoms of
RLS vary from mild tingling in the legs to severe discomfort
and pain that becomes pronounced when sitting or lying
down. To eliminate or reduce the unpleasant sensations,
the sufferer usually needs to move the legs, which adversely
affects sleep. Some patients fall asleep rapidly but wake up
frequently with paraesthesias that are relieved only by walk-
ing. Many people with RLS also have PLMS. The treatments
for both disorders are the same.
TREATMENT OF PERIODIC LIMB MOVEMENTS IN
SLEEP AND RESTLESS LEGS SYNDROME
Sometimes sleep is not disrupted by these movements,
and in such cases no treatment is necessary. However, if
there are disruptions in sleep architecture, the physician
or sleep specialist may prescribe appropriate medication
in an effort to reduce or eliminate the limb movements. In
a small percentage of people, large doses of vitamin E are
effective at alleviating the symptoms. Prescription medi-
cations used include a levodopa/carbidopa combination
and other medications that are prescribed for other types
of movement disorder, such as Parkinson’s disease. (Even
though the treatments are the same for these two problems,
there is no indication that people with PLMS are suscep-
tible to Parkinson’s disease.) Some physicians prescribe a
benzodiazepine to treat PLMS; this may not stop the limb
movements, but it can increase the depth of sleep enough to
protect it from movement-related disturbances.
K17577_C015.indd 257
Sleep disorders  257
FLIGHT STATUS AND PERIODIC LIMB MOVEMENTS
IN SLEEP OR RESTLESS LEGS SYNDROME
Unless pilots with these disorders are fortunate enough to
respond to vitamin E therapy, some type of prescription
medication may be necessary. Since these medications are
not likely to be acceptable, there may be problems maintain-
ing flight status. The administration of benzodiazepines or
levodopa/carbidopa usually requires a grounding period
after dosing due to the sedative characteristics of the drugs.
Some other antiparkinsonian medications do not have the
sedative qualities of the more common medications, but
they may have some other side effects that are not compat-
ible with flying and thus are not allowable under civil avia-
tion or military regulations.
Narcolepsy
Narcolepsy is a sleep disorder characterized primarily
by excessive daytime sleepiness. The prevalence of nar-
colepsy in the general population varies among the dif-
ferent countries, with a very low estimate in the Israeli
population of about 0.002  per cent, to a relatively high
estimate in the Japanese population of about 0.18  per
cent. The incidence in the US population is estimated at
about 0.05 per cent. Overall, more males are affected than
females (Brooks and Mignot 2002). This is a fairly seri-
ous disorder that is often resistant to complete allevia-
tion. Patients with narcolepsy usually begin to experience
symptoms during adolescence or young adulthood, but
symptoms can start as late as the fifth decade. The clas-
sic tetrad for narcolepsy is excessive daytime sleepiness,
muscle weakness (cataplexy), which is usually brought on
by emotions, sleep paralysis (unable to move for several
seconds when falling asleep or upon awakening) and hyp-
nogogic hallucinations. In addition, automatic behaviours
and disturbed night-time sleep have also been noted in
patients with narcolepsy. Some or all of these symptoms
may be present, from mild to severe levels.
The diagnosis of narcolepsy requires an overnight stay
at a sleep laboratory, during which EEG, EMG, EOG, ECG
and respiration are monitored. Since sufferers often seek
treatment because their excessive daytime sleepiness is
impairing their ability to function in day-to-day activities,
other possible sources for their impaired alertness are ruled
out first. Once an overnight stay indicates that other dis-
orders such as sleep apnoea and PLMS are not present, the
patient is required to stay an additional day for a multiple
sleep latency test (MSLT). The MSLT requires the patient
to lie down for 20  minutes every two hours and attempt
to fall asleep while the standard physiological parameters
are measured. The time it takes to fall asleep on each occa-
sion is recorded, and the type of sleep is assessed. Typically,
four or five nap periods are used in the evaluation. If sleep
occurs within 20  minutes across most of the naps, and if
REM sleep occurs during at least two of these 20-minute
naps, then a diagnosis of narcolepsy is made and treatment
options are discussed.
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 258  Physiology of sleep and wakefulness, sleep disorders and the effects on aircrew
TREATMENT OF NARCOLEPSY
Depending on the severity of the disorder, naps can some-
times be used to alleviate the excessive daytime sleepiness, but
usually stimulant medication is required. If cataplexy occurs,
medication is prescribed for this as well. Usually all symp-
toms can be alleviated or reduced with proper medication.
FLIGHT STATUS AND NARCOLEPSY
A diagnosis of narcolepsy will end the flying career of a pilot,
whether civilian or military. Even with medication, neither
the civil aviation authorities nor the military will allow a
person with narcolepsy to pilot an aircraft, because the pos-
sibility of falling asleep or experiencing cataplexy during
flight is too dangerous. The prevalence of narcolepsy within
the pilot population is no doubt virtually insignificant.
However, it can occur, and the diagnosis and treatment of
this disorder in anyone who is responsible for operating
complex machinery (especially in the transportation indus-
try and the military) is important to the safety of both the
patient and others who are dependent on their actions.
SUMMARY
●● Although sleep is a poorly understood process,
it nonetheless has clear implications for the
performance, alertness and wellbeing of pilots,
aircrew and others associated with military and
commercial aviation.
●● Unfortunately, many factors can disturb the
sleep process, ranging from job related schedul-
ing problems and environmental issues, to an
individual’s poor sleep habits, to the presence of a
severe sleep disorder.
●● Fortunately, the impact of many sleep-disrupting
factors can be mitigated once the issue is properly
identified. If a pilot or crew member indicates
that he or she is experiencing sleeping difficulties,
then various reasons for the problem must be
considered by the flight surgeon or physician.
●● Recognizing the complexities of the normal
sleep process provides a basis for understanding
disruptive influence of a variety of factors on the
recuperative nature of sleep.
●● Inappropriate sleep environments, poor sleep
habits, changes in schedules and sleep disorders
all interfere with the ability to obtain a restful
period of sleep.
●● Offering behavioural and/or pharmacological
treatment for the individual experiencing sleep
difficulties will improve mood, performance,
safety and overall health, as well as the welfare of
the entire unit.
●● Improved sleep quality and duration will
maximize the safe and successful completion of
the mission.
K17577_C015.indd 258
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 16
Optics and vision

PAUL WRIGHT AND ROBERT A. H. SCOTT

Science of light 263 Performance of the eye 272

Measurement of light 265
Science of colour 265
The focusing system 266
Inherent errors in eye focusing 268
Defects and correction of focus 268
Image processing 271
Differentiation of motion 272
Visual acuity 273
Aviation hazards to vision 275
Canopies and windscreens 278
Night-vision goggles 279
Helmet-mounted displays 280
Further reading 280

SCIENCE OF LIGHT The energy contained within a given wavelength is

defined by
The energy from a light source can be considered as a stream
of discrete particles – photons – or as a continuous stream E = ρf = ρ/λ
of energy along a ray or wave. Both theories are equally
valid, and together they form the ‘duality of light’ hypoth- where E is energy, ρ is Planck’s constant and f is the fre-
esis. The concept of the photon is useful when considering quency of the wave.
light in terms of quantum physics, as used in the investiga- Therefore, the higher-energy wavelengths are located in
tion of the origin of light and how light interacts with mat- the ultraviolet (UV) to blue end of the spectrum.
ter. Generally, the concept of the propagation of waves of
light gives useful insight into classical optical phenomena PHASE
and underpins the majority of visual optics. Light waves travel in a straight optical path, but particles
in the wave oscillate in a sinusoidal pattern perpendicular
Characteristics of light to this line. At a given point along the optical path, light
waves are said to be in phase if the position of oscillation is
A wave of light can be described by various characteristics, the same, i.e. if the particle is found at the peak, in a trough
including wavelength, frequency, phase, polarization and
coherence. The wavelength and frequency of a wave are
Table 16.1  Electromagnetic spectrum
related to the speed of light in a vacuum as
Light Wavelength (nm)
c = fλ UV(A) 315–380
UV(B) 295–315
where c is the speed of light, f is the frequency of the wave
UV(C) 200–295
and λ is the wavelength.
Visible light is a small part of the electromagnetic Visible 380–780
spectrum found between 380  and 780  nm (Table  16.1). Near-IR 780–1400
Wavelengths outside of this band are not seen, but their Far-IR 1400+
energy can have significant effects on visual function. IR, infrared; UV, ultraviolet.

263

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 264  Optics and vision
or at a point in between. Two waves are said to be in anti-
phase when the positions of the particles are diametrically
opposite each other, e.g. one wave is at a peak and the other
is in a trough. The points between in-phase and anti-phase
are normally described by the angle of phase. The angle of
phase when the waves are in phase is zero (or 360 degrees)
and when the waves are in anti-phase 180 degrees.
POLARIZATION
A wave follows a sinusoidal motion in one plane. That plane
can be in any one of 360  degrees and so a wave can also
be described by its angle of polarization. Conventional light
sources emit unpolarized light, and so the waves of light
are emitted through all 360 degrees. It is possible to control
polarization by using a filter that allows passage of only a
single plane. If two polarizing filters are placed perpendicu-
lar to each other, they halt transmission of light completely.
Polarized light occurs when light in a given wave has only
one orientation. Polarized light arises from filtering unpo-
larized light or can be created from coherent light sources
such as lasers.
COHERENCE
When two waves of light of the same frequency arrive at
a given point along their optical paths, there is a constant
phase relationship between the waves, and the energy
intensity of the combined wave is equal to the sum of the
individual amplitudes. A source of light does not emit
a continuous wave train but emits a succession of wave
trains of finite and varying lengths and with no fixed phase
relationship between the successive wave trains, i.e. the
source emits light with random variations in phase. The
combination of light of the same wavelength from two
independent sources will vary in intensity due to the end-
less phase changing effect. These variations are both too
small and too fast for the eye to perceive. Light with a con-
stant phase relationship between two or more wave trains
of light is said to be coherent; if this condition is not met,
then the light is described as being incoherent. Coherent
light can occur only with monochromatic (single-wave-
length) light. With current technology, the LASER is the
nearest we have come to achieving a fully coherent light
source. Conventional light sources, such as the tungsten
light bulb, emit many different wavelengths, including
infrared (IR) (heat), and therefore are described as inco-
herent light sources.
Attributes of a medium
The speed of light in a medium is different from that in a
vacuum. If the velocities are v and c, then the ratio c/v is
called the refractive index, usually denoted by n. When light
enters a medium of greater refractive index, light is ‘bent’
towards the perpendicular of the surface. Refraction of light
is greater with larger differences in refractive index at the
boundary between two media. For example, most refrac-
tion in the eye occurs at the air–cornea surface, because the
K17577_C016.indd 264
relative refractive index between these two media is greater
than that at the lens, which, surrounded by the humours,
has a smaller relative refractive index. Most media used
in optics are chosen for their refractive-index-dependent
properties. Frequently, there can be problems with bire-
fringence, wherein the refractive index of the media varies
in two directions of orientation. Combinations of different
media can be used to reduce this property.
Refraction is used to bend light to a focus and is the basis
for lens design. The ability of a lens to bend light is known
as the refractive power and is described as the inverse of the
focal length of the lens, i.e. the larger the power of refrac-
tion, the shorter the focal length. The unit of refractive
power is the dioptre (D), e.g. a 1-D lens has a focal length of
1 m and a 2-D lens has a focal length of 0.5 m.
EFFECTS OF A MEDIUM ON LIGHT
When light is incident upon a material medium, the
medium exerts a number of effects on light. These are
related to the refractive index properties of the material.
In particular, light is reflected at the medium boundary,
changing its optical path combined with potential changes
in polarization and phase. Most material boundaries have
reflective properties, with light being reflected in a given
direction or diffusely in all directions as a function of the
surface. If one considers light in terms of energy, then the
total incident light energy on contact with the material
medium boundary is split into two components. Some
light energy is reflected at the surface, while the rest is
refracted through the material medium. The energy being
refracted continues to lose energy in the material due to
the material both absorbing and scattering energy away
from the optical path.
Light scatter is the dispersion of light through a medium
as a result of light interaction with particles that make up
the material. For example, light entering the eye usually
passes through the pupil; however, additional light can
transilluminate the iris and sclera. The photo-pigments
melanin and haemoglobin absorb some of this light, but
the majority of light can pass through into the humours. In
addition, some light is also scattered by the humours, result-
ing in ‘stray light’ reaching the retina. Stray light reaching
the fovea decreases the contrast of foveal images, result-
ing in disabling glare. Rayleigh scattering of light is due to
interaction with small particles (cf. wavelength of light) that
make up the medium. Light affected by Rayleigh scattering
is scattered in all directions; it tends to affect shorter wave-
lengths. This is observed when solar light travels through
the Earth’s atmosphere and accounts for the blue appear-
ance of the sky, except in the direction of the sun, and the
red sky around the sun at its rising or at sunset. Mie scatter
of light is due to interaction with large particles within the
medium and results in a forward scatter, i.e. it can produce a
blurring effect in an optical device. Mie scatter is not wave-
length-dependent, as Rayleigh scattering is, and is typically
found in foggy conditions, where image focus and contrast
are reduced.
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MEASUREMENT OF LIGHT
When dealing with any form of radiant energy, it is usual
to define its measurement in terms of radiometry. When
dealing with visible light, the principles of radiometry are
used, but the energies measured are weighted according to
the visual response that the energy can produce in the eye.
The measurement of visible light energy is called photom-
etry. For illustration, we can consider a basic optical sys-
tem such as a slide projector illuminating a display screen
that is observed by a viewer. The luminous flux describes
the rate of flow of photon energy from the source, again
weighted according to its efficiency in producing a visual
response. The unit of luminous flux is the lumen. The
luminous intensity of the source is defined as the amount
of luminous flux emitted per unit solid angle (a three-
dimensional angle, giving rise to a conical shaped beam).
The unit of luminous intensity is the candela, approxi-
mately equivalent to the intensity emitted by a domes-
tic candle. These two terms describe the source. Moving
through our optical system, the next term we come across
is that of illuminance. This is the amount of luminous flux
received over a unit area on any point on the surface of the
screen. In other words, it describes the concentration of
light energy on a given area of the screen: the greater the
illuminance level, the brighter the image will appear on
the screen. The unit of illuminance is the lux. In the same
manner as for all radiant energy, the energy level in the
beam drops with distance from the source, in accordance
with the inverse square law. In addition, the energy level
drops with deviation from the centre of the beam, in line
with the cosine law of illumination. The illuminant energy
is incident upon the screen; some energy will be absorbed
into the screen, but the remainder will be reflected back
towards the viewer. The term ‘reflectance’ (or albedo)
describes the amount of light energy reflected as a fraction
or percentage of the illuminating energy. The greater the
level of reflectance, the brighter the image will appear to
the viewer. Finally, the light energy received by the viewer
is called the luminance and is the concentration of light
energy over a unit surface area in a stated direction. Not all
surfaces reflect equally in all directions or all in one direc-
tion, which can give rise to variations in luminance. The
unit is candelas per square metre. For a stated direction,
it can also be considered as the product of the illuminance
and the screen reflectance in a given system. Again, lumi-
nance is considered as a concentration of light energy. To
perceive an object to be bright, the viewer needs to receive
a high luminance level from the object together with a
retina sensitive to that light level. For example, if two indi-
viduals, one having been in a dark room for an hour and
the other having been outside in the sunshine for the same
time, view a dimly lit cathode-ray tube (CRT) display, then
the dark-adapted individual would perceive the display
to be brighter than would the light-adapted individual.
Therefore, brightness of an object is a factor of both the
luminance and the light sensitivity of the retina.
K17577_C016.indd 265
Science of colour  265
SCIENCE OF COLOUR
Different wavelengths of light produce different sensations
of colour (hue). A stimulus that does not contain a marked
excess of any one group of wavelengths produces the sen-
sation of white light. If one wavelength is slightly domi-
nant, then the sensation is of a pale or desaturated colour.
An alternative term is ‘chroma’, which defines the amount
of white light in the mixture. As the proportion of domi-
nant wavelength is increased, the colour is said to become
more saturated. Monochromatic light is said to have
complete saturation.
An additive mixture of red, green and blue light can pro-
duce a wide range of coloured lights. From these colours,
it is possible to match an additive mixture against many
colours that are not highly saturated. This is true only for
coloured light sources and not for paint or dye pigments.
A mixture of red and green light can create additive mix-
tures of fairly saturated orange, yellow and yellow-green
light, depending on the relative amounts of each additive.
Additive mixtures cannot match very saturated colours,
especially in the blue-green region. When an additive mix-
ture of two colours produces white light, then these colours
are said to be complementary. If red, green and blue light are
mixed to give white light, and then the blue is removed, the
resultant colour is yellow. When yellow light is mixed with
blue light, the resultant light colour is white, and so blue and
yellow are complementary.
Opponent system of colour vision
The human retina contains photoreceptors. These consist
of light-sensitive pigments (photo-pigments), which absorb
photons of light, and neural elements, which help to chan-
nel nerve impulses to the brain. There are two main classes
of photoreceptors: rods and cones. Rods function in sco-
topic (low light) conditions and cones operate in photopic
(normal daylight) conditions, with an overlap between the
groups in mesopic (intermediate) conditions. Rods are not
colour-sensitive or sensitive to fine detail, but cones are sen-
sitive to colour and fine detail.
There are three types of cone photo-pigment, each type
having a maximum absorbance in a different part of the
visible spectrum, although there is a considerable spec-
tral overlap. The different cone types traditionally have
been referred to as ‘red’, ‘green’ and ‘blue’, but the maxi-
mum absorbance values, or peak wavelength sensitivities,
of the photo-pigments lie in the yellow-green (approxi-
mately 570  nm), green (approximately 542  nm) and blue
(approximately 442 nm) parts of the spectrum. It is, there-
fore, more appropriate to label them long-wave (L-cones),
medium-wave (M-cones) and short-wave (S-cones) sensi-
tive photo-pigments.
The molecules of the photo-pigments in the retina are
excited when light is absorbed, causing a signal to be gen-
erated and transmitted along nerve fibres to the brain.
The process of this signal transmission is not understood
17/11/2015 15:52
 266  Optics and vision
completely. It is, however, known that there are not four dif-
ferent types of signal, one for each type of receptor (rods
and three types of cones), but that different combinations
of these signals are transmitted along nerve fibres. It is most
likely that photoreceptor signals are combined to form three
channels – the achromatic channel and two colour differ-
ence channels. The achromatic signal is composed of inputs
from the rods and all three cone types. The two colour dif-
ference signals are composed of the three possible basic
difference signals:
L − M = C1
M − S = C2
S − L = C3
When these are added up, they equal zero, and so they
do not need to be transmitted separately. It has been sug-
gested that the signals transmitted resemble C1 = L − M and
C2 − C3 = M – S − (S − L) = L + M − 2S. These two colour
difference signals are referred to broadly as the opponent
system of ‘red minus green’ and ‘yellow minus blue’, where
L + M is labelled as yellow. From this system, the ratio of
the signal C1 to that of C2 − C3 can be used to indicate hue
and the strength of these two signals to indicate colourful-
ness. For achromatic ‘colours’ (white, grey, black) the signals
from each cone type are equal, and so the colour differ-
ence signals C1, C2 and C3 would be zero (as would be the
colourfulness).
Trichromatic theory
The trichromatic theory is based on two well-established
experimental outcomes: (i) that the proper mixture of
three-coloured stimuli can match any given colour and (ii)
that colour matching is predictable provided the relative
amount of coloured stimuli is known. The unit trichromatic
equation defines this principle as follows:
(C) ≡ r(R) + g(G) + b(B)
where C is the desired colour, and r, g and b are the rela-
tive amounts of red, green and blue light, respectively.
The units are chosen so that equal amounts of red, blue
and green stimuli are required to produce white light.
Many different chromaticity charts are available, allow-
ing any colour to be defined by its degree of saturation and
red, blue and green content. Examples of these include the
International Commission on Illumination (CIE) (x,  y)
chromaticity diagram, the Munsell system and the CIE
L*a*b* system.
If a light source emits a spectrum containing equal
amounts of energy for each constituent wavelength and
it illuminates an object that reflects all wavelengths, then
the object will appear white. If the object absorbs some
K17577_C016.indd 266
wavelengths and reflects others, then it will appear coloured.
The colour that an object appears to have is determined by
the wavelengths it reflects to the eye.
The additive mixture laws relate to the mixing of
coloured light. However, the laws for colour mixing of paint
pigments are different. A paint pigment of a specified colour
absorbs some wavelengths and reflects the rest. By vary-
ing pigments in a mixture, one can vary the intensity of
the wavelengths it absorbs but not necessarily those that it
reflects, as these remain at maximum intensity. One obtains
control of the red, blue and green light entering the eye by
varying the proportions of those pigments that absorb the
spectral region corresponding to these three colours, i.e.
by subtracting the complementary colour from the white
mixture. The primary pigment colours may be referred to
as minus red, minus green and minus blue. With the naked
eye, these pigments appear to be blue-green, magenta and
yellow, respectively.
In summary, with additive mixing of light, one starts
with no light and adds the chosen amounts of red, blue and
green light in order to produce the desired colour. However,
with subtractive mixing of pigments, one starts with light of
all wavelengths (white) and subtracts chosen amounts of red,
blue and green in order to produce the desired colour. The
subtraction is the loss of a colour absorbed into the pigment.
THE FOCUSING SYSTEM
Basic anatomy
Each eye is roughly spherical, measuring approximately
25 mm in diameter and lying within the bony orbit of the
skull. The bony orbit protects the eye in all directions apart
from the front, where protection is limited to the eyelids. The
eye is hollow and maintains its own shape by means of con-
trolling its internal pressure. The outer wall consists of three
layers, modified at the front to admit light. The outermost
layer, the sclera, is a tough fibrous outer coating modified at
the front to become the cornea. The middle layer is mainly
vascular, as it consists of the posterior choroid layer and the
anterior ciliary body and iris. The inner layer is the retina
and is associated closely with the coverage of the choroid.
The globe is divided into two main compartments separated
by the lens–iris diaphragm: the smaller anterior chamber
filled with a clear liquid called the aqueous humour and
a large posterior compartment filled with a jelly-like sub-
stance called the vitreous humour. Figure  16.1  shows the
anatomy of the eye.
EYE MOVEMENT
The globe rotates in the orbit about its own centre in
response to the pull of three pairs of extra-ocular muscles.
The two eyeballs are yoked together, and their axes remain
parallel in all conjugate movements. Their axes are, by
necessity, not parallel in the disjunctive movements of con-
vergence and divergence.
17/11/2015 15:52

Retina
Ciliary body
Suspensory ligaments
Iris
Pupil
Anatomical scotoma
Cornea Lens
Vitreous
Figure 16.1  Anatomy of the eye.
Refractive surfaces
Most refraction occurs at the air–cornea junction (38–48 D)
due to the large difference in refractive index between the
air and the corneal media. In addition, as the amount of
refraction occurring at a curved surface increases with an
increase in the degree of curvature, so the cornea is capable
of even larger refractive power than if it was a flat surface.
The cornea can be considered as having three layers – endo-
thelium, internal stroma and epithelium. The endothelium
faces the aqueous humour, while the epithelium faces the
tear film. The corneal stroma has a high colloidal pres-
sure, and the resultant water ingress increases the overall
refractive index. This influx of water is countered by a water
pump, which maintains a state of equilibrium. The cornea is
1 mm thick at its edge (limbus), thinning to approximately
0.7 mm in the centre. The cornea is avascular and achieves
oxygenation by a number of means. The outer epithelium is
oxygenated by gas diffusion from the atmosphere, while the
inner endothelium is oxygenated by the aqueous humour.
This accounts for sea-level oxygen tensions of 150 mmHg at
the epithelium, 100 mmHg in the mid-layer and 55 mmHg
at the endothelium. Use of contact lenses that result in a
reduction in corneal oxygen tension might, therefore, have
profound effects on vision at altitude.
The physiology of the lens is very similar to that of the
cornea. However, the lens does not have the same degree of
refractive power, due to the smaller differences in refractive
index either side of it. The lens is capable of changing its
refractive power by changing the degree of curvature of the
anterior surface and so controls the amount of refraction
(19–34 D). The eye uses this lens system to focus an image
on a light-sensitive screen, the retina (Figure 16.2).
Accommodation is the process that enables the eye to
change focal length from the furthest point of vision to the
nearest point. To focus on objects at the far point of vision
K17577_C016.indd 267
The focusing system  267
Sclera
Choroid
Fovea
Optic nerve
(infinity) the ciliary muscles relax, which in turn pull taut
the zonular fibres connected to the lens. This places the lens
under tension and reduces the lenticular degree of curva-
ture. To achieve vision at the near point, the opposite occurs,
i.e. the ciliary muscles contract and the zonular fibres relax,
resulting in a less tense lens and enabling the lens to take
up a more natural rounded shape. The range of accom-
modation is about 15 D at best, but this tends to degener-
ate with age, up to a maximum rate of 1-D loss per year in
middle age. For most people over the age of 60  years, the
eye is effectively a fixed-focus device. It takes time to change
the shape of the lens; in aviation in particular, this transit
time to the next focal point results in unfocused vision over
this period. To accommodate the lens fully, i.e. to move the
focus of vision from the far point to the near point, takes
Helmholtz equation h´ = –x´θ´ = –x´(n/n´)θ
(n) (n´)
Retina
h θ
h´
Object θ´
P P´
x x´
Figure 16.2  Helmholtz optical diagram. An object of
height h is at a distance x from the eye and subtends an
angle Θ at the eye. Points P and P′ are the principal points
of the eye optical system. The image in the retina has
height hΘ at a distance xΘ from the eye optics and sub-
tends a visual angle of Θ′. The apparent size of an object
is determined by the relative size of its retinal image.
Mathematically, it can be shown that the apparent size
of an object is directly proportional to the angle that the
object subtends at the eye.
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 268  Optics and vision
0.8 seconds; to change focus from the near point to the far
point takes 0.5 seconds. The combination of time taken to
achieve focus with typical aircraft speeds means that sig-
nificant distances are travelled in the air without the pilot
having any focused sight.
Role of the pupil
The pupil plays an important role in image formation. First,
the pupil restricts the total amount of light reaching the
retina, protecting it from dazzle and bright daylight condi-
tions. The time taken to constrict the pupil is much quicker
than the time taken to dilate it. Second, the pupil acts as
an aperture stop, restricting the number of rays reaching
the retina. This is beneficial as it improves the sharpness of
the image by reducing the degree of image aberration and
increases the depth of focus. Depth of focus is the maxi-
mum range of movement away from the focal plane with
which deterioration of image quality is not serious. It is
often confused with the depth of field, which is the permis-
sible movement of an object in the object plane resulting in
the image being moved to an out-of-focus location on the
retina. At night, when the pupil widens, there is a reduc-
tion in the depth of field of the eye, which can exaggerate
the visual decrement caused by refractive error. Third, the
pupil is associated with the Stiles–Crawford effect – light
entering the eye near the centre of the pupil is more effective
in producing a visual response than that entering near the
periphery. In daylight conditions, this effect occurs across
the full visible spectrum, but at night it appears to be limited
to wavelengths above 580 nm (green to red).
INHERENT ERRORS IN EYE FOCUSING
Chromatic aberration
With transparent materials, the refractive index of the
material usually decreases with increasing wavelengths of
light. Therefore, a shorter focal length occurs for shorter
wavelengths. For example, after refraction in a lens, incident
white light spreads out into its constituent wavelengths – the
prismatic effect. There is no focal point for the white light
source and, therefore, each wavelength will form a separate
image. This defect is called longitudinal chromatic aberra-
tion (Figure 16.3). As well as different focal lengths, differ-
ent levels of magnification will also occur, so each coloured
image will be a different size. This is known as chromatic
difference of magnification. Both focal length and magnifi-
cation effects of chromatic aberration severely degrade the
image quality.
Chromatic aberration is thought to play a large part in
rapid focusing. When one accommodates in white light,
if the image is too close, red fringes predominate; if the
image is too far away, then there is a predominance of blue
fringes. Therefore, using such a system of aberrations, it is
possible to determine whether accommodation needs to be
increased or relaxed.
K17577_C016.indd 268
Spherical aberration
With optical systems, including the eye, an aperture stop
(iris) produces an edge effect at the pupil, resulting in a
change in focal length. Rays of light in the centre of the
pupil will be focused on the retina, whereas rays affected
by the edge effect will come to a focus before reaching the
retina (Figure 16.4). An optical system with spherical aber-
ration has no point where all the rays intersect to produce a
classical focal point. The dispersion of focal lengths due to
spherical aberration is directly proportional to the square of
the aperture height, i.e. spherical aberration worsens as the
pupil gets larger. This, in part, reduces image quality in the
eye in night conditions.
DEFECTS AND CORRECTION OF FOCUS
There are four types of focusing defect: myopia, hyperme-
tropia, presbyopia and astigmatism.
Myopia
In myopia, parallel rays of light are brought to a focus in
front of the retina in the unaccommodated eye. This is usu-
ally due to an enlarged eyeball, from either congenital or
Blue Red
focus focus
White light Blue
Green
Red
White light
Figure 16.3  Chromatic aberration. A lens can be consid-
ered as two prisms placed base to base. White light is
split into its component wavelengths, resulting in a range
of focal lengths from the blue end to the red end of the
visible spectrum.
Range of spherical
aberration
Axial ray
Marginal ray
Marginal Axial ray
ray focus focus
Figure 16.4  Spherical aberration. When the pupil wid-
ens, spherical aberration increases, resulting in defocus-
ing of the image. The location of the aberrant images is
found anterior to the retina, in the same region as the
uncorrected myope.
17/11/2015 15:52

pathological aetiology. As a result, the range of accommo-
dation is very much reduced, with the far point becoming
nearer the observer. Very frequently, myopes may find that
they need corrective flight spectacles at night although their
vision is adequate by day. This is due to the effect of a wide
pupil at night and the concomitant loss of depth of field. For
some individuals, the near and far points can be collocated.
Correction of myopia is with a negative lens.
Hypermetropia
In hypermetropia, parallel rays of light entering the eye are
brought to a focus behind the retina in the unaccommo-
dated eye. Generally, this is due to a hereditary cause, with
the lens being closer than usual to the cornea. The range
of accommodation is reduced, with the near point moving
further away from the observer. Correction of this condi-
tion is with a positive lens (magnifying glass).
Presbyopia
Presbyopia is a physiological condition related to age. The
lens is said to have elastomeric properties, i.e. it has both
elastic and plastic properties but, with increasing age, elastic
tissue is lost gradually, resulting in loss of accommodation
power. This causes a progressive inability to focus on near
objects, similar to hypermetropia. In addition, another age-
ing effect is a yellow discolouration of the lens, which can
result in intraocular haze when viewing light sources with a
high yellow content.
Astigmatism
The refractive power of a surface is related directly to the
degree of curvature of the surface. Frequently, the cornea
has different degrees of curvature occurring in different
planes. Therefore, dissimilar refractive power exists and the
resultant image can be focused in one plane but will be out of
focus in the other. This is known as astigmatism. If the max-
imum and minimum powers are in orthogonal planes, then
the astigmatism is said to be regular. This type of refractive
error is corrected with a cylindrical lens. A cylindrical lens
focuses not to a point but to a line. Therefore, in order to
correct astigmatism, both the power of correction and the
angle to which the line is placed need to be determined.
Positioning of spectacles
The positioning of spectacles is not arbitrary. A lens placed
anywhere in front of the eye will have a magnifying effect,
except if the lens is placed at the front focal point of the eye,
at which point the magnification factor will be unity. This
means that widely different lens powers can be placed in
front of each eye without affecting the image size. Contact
lenses work by different means. They are worn on the surface
of the cornea and are used to correct myopia by flattening out
the curvature of the cornea, hence reducing refractive power.
K17577_C016.indd 269
Defects and correction of focus  269
The detection system
RETINA
The retina is divided into two layers, the retinal pigment
membrane and the neural retina. The retinal pigment epi-
thelium is the outermost layer of the retina. It lays on the
choroid and contains melanin for absorption of stray light.
The neural retina has five main types of photoreception
and retinal image processing. Rods and cones are the light
detectors, while horizontal cells, bipolar cells, amacrine
cells and retinal ganglionic cells have image-processing
functions. The photo-detector cells are found adjacent to
the retinal pigment layer, while the image-processing cells
form the innermost layer. This means that retinal imagery is
degraded as it passes through the neural layer before reach-
ing the rods and cones.
The rods are monochromatic receptors. They have no
central visual function, as they are found mainly in the
periphery of the retina. Rods are used in low light levels and
can be sensitive to individual photons. They may, in part,
be responsible for detecting object movement, but they
are incapable of good image resolution. The cones provide
the means of colour perception but require daylight levels
of light to function, the ability improving with increasing
ambient light levels. Cones are distributed universally in
the retina and are responsible for the high image resolution
associated with central visual function. The area of greatest
cone concentration in the retina is in the macula lutea; at its
centre, the fovea centralis, only cones are present. When fix-
ating on an object, the image is centred on the fovea. There
are approximately seven million cones in the retina; there
are 20 times as many rods.
The retina is a concave light-sensitive screen that contains
blind spots – scotomata – areas devoid of light detection. Two
non-pathological scotomata are found in the retina. The ana-
tomical scotoma (blind spot) occurs at the head of the optic
nerve and subtends a small proportion of the visual field – it
subtends a visual angle of five degrees and is found lateral to
the point of fixation by 15 degrees. The physiological (func-
tional) scotoma is located at the fovea and occurs when there
is not enough light for this pure cone region to function.
Light and dark adaptation
The visual system is a sensitive detector for the discrimina-
tion of small differences in luminance across the retinal
image (Figure  16.5). It is capable of operating over large
changes in ambient illumination with a dynamic range of
about 12 orders of magnitude. It has been said that this range
equates to the ability to sense light from quantum levels up
to tissue-damaging levels. The visual system compensates
automatically and involuntarily for changes in ambient illu-
mination level, and even a 100-fold change in luminance in
daylight would go largely unnoticed by the observer. The pur-
pose of adaptation is to keep the retinal response to visual
objects constant when ambient illumination levels are chang-
ing. This does, however, break down at high light intensities.
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 270  Optics and vision
100
75
Visual acuity (%)
50
25
10–2
Figure 16.5  Effect of ambient illuminance on visual acuity.
The visual threshold is approximately 10−6 cd/m2, corre-
sponding to faint starlight conditions; the maximum limit
is as high as 106  cd/m2, equivalent to bright sunlight over
fresh snow. Photopic, or cone, vision occurs above 1 cd/m2;
scotopic, or rod, vision occurs below 10−3  cd/m2. Mesopic
vision is the intermediate stage between scotopic and phot-
opic vision, when both rods and cones function. Night driv-
ing and night flying are considered to be mesopic tasks.
When the eye adapts from photopic to scotopic condi-
tions, dark adaptation is slow. Dark adaptation occurs in
two stages: the initial stage commensurate with lowering of
stimulus threshold in the cone cells and the second stage
affecting the rods (Figure  16.6). The time to dark adapt is
variable, as it depends on both the start and end-point lumi-
nance. The term ‘dark adaptation’ should be considered as
a laboratory condition, because its measurement is per-
formed in initial light levels that are bright enough to bleach
a significant amount of photo pigments while the end-point
illumination level is the equivalent of the photographer’s
dark room. For these conditions, cone adaptation takes
approximately seven minutes and full rod adaptation takes
30–40 minutes. In nature, these levels of illuminance do not
usually occur, and so the time to adapt is much shorter.
0 of saturation, which in turn are influenced by other factors.
Cone
–1
Log luminance (cd/m2)
adaptation
–2
–3
–4 Rod
adaptation
–5
0 5 10 15 20
Time (min)
Figure 16.6  Dark-adaptation curve.
K17577_C016.indd 270
Solar
Snow or
Indoor light Cloudy glare
from sand
source day
road brightness
surface
Night sky
light sources
10–1 1 10 102 103 104 105 106
Luminance (cd/m2)
Colour vision
Human colour perception is a complex topic. It can be dis-
cussed both in terms of colour stimulus based on the science
of colour and in terms of colour perception based on psy-
chophysical science. Colour sense is mediated by the cones
in photopic light conditions and spatially by the relative
positioning of cones in the retina. The three-receptor theory
is the essential basis of the Young–Helmholtz trichromatic
theory of colour vision. There are three classes of cone – red,
green and blue – each with different sensitivity to a given
wavelength. The cones are found in the ratio of ten red cells
to ten green cells to one blue cell. The perception of colour is,
in part, the relative activation of the three cone types. Cone
output travels in three channels, one channel for summated
brightness information and two colour channels – red-green
(R-G) and blue-yellow (B-Y). The two chromatic channels
have complex interactions. Some colours, e.g. brown, do not
exist in the visible spectrum, and the perception of brown is
the effect of colour image processing in the brain. In order
to perceive all colour potential, one needs to have normally
functioning R-G and B-Y channel systems. The perception
of colour is complex, as it depends on a number of factors,
including the hue, colour brightness, contrast and degree
Purkinje shift phenomenon
A problem with mesopic vision is that the transition from
one light detector to another results in an overall change
in sensitivity to visible light. When blue and red objects
with the same light energy in daylight are viewed at dusk
or dawn, the colour brightness of the objects appears to
change. Viewing a blue object in daylight correlates to the
25 30 35 cone sensitivity for that wavelength on the Vë curve, and as
light levels continue to fall, rod function begins to increase
(Figure 16.7). Consequently, blue objects stimulate rods to
a greater degree than cones, and so blue objects appear to
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Relative sensitivity (%)
Rods Cones
400
Wavelength (nm)
Figure 16.7  Spectral sensitivity of the eye. Different
wavelengths produce different intensities of colour. The
sensitivity for the cones (a composite curve for the three
classes of cone) is called the Vλ curve, with its maximum
sensitivity occurring at 555 nm (yellow-green). The rods
are also wavelength-sensitive but do not contribute to
colour perception. The sensitivity curve for the rods is
called as the Vλ′ curve; its maximum sensitivity is 510 nm
(blue-green). The difference in wavelength sensitiv-
ity between the rods and cones is the basis for the
Purkinje phenomenon.
glow. The reverse is true with the appearance of red objects
in diminishing light levels. A red object in lighter condi-
tions stimulates the cones more than the rods in darker con-
ditions and so red objects will appear darker. At dawn and
dusk, this phenomenon can be troublesome for aviators,
as changing colour brightness can lead to misperceptions
when judging depth.
Ambient red lighting
In theory, red-light illumination reduces the problem of rod
desensitization before night operations and so negates the
need for dark adaptation. The advantage of preserving rod
vision is, in fact, illusory, as the night-flying task is in meso-
pic conditions. In aviation, the disadvantages of red cockpit
lighting negate its use in the aviation setting. The eye loses
its ability to rapidly change focus by means of chromatic
aberration adjustment when the spectrum is limited from
the full visible spectrum to only the red end of the spec-
trum. In addition, poor colour discrimination makes it dif-
ficult to interpret conventional maps. Other disadvantages
include decreased accommodation cues and distortion of
relative brightness of objects, which can result in errors of
depth judgement and lead to visual illusions.
Defects in colour vision
In general, a colour-defective subject is one whose powers
of colour discrimination between lights of different wave-
lengths are more limited than normal. The complete failure
of colour discrimination is known as monochromatism;
dichromatism is the loss of one class of cone cell. Colour-
anomalous people have all three classes of cone but one
class is relatively insensitive and requires more stimulation
K17577_C016.indd 271
Image processing  271
to achieve equivalent perception in the colour-normal indi-
vidual. The most common defect in colour vision is red-
green deficiency. People who cannot perceive either red or
green merge both colours into yellows, and any differences
that are perceived are due to brightness, which is not a reli-
able indicator for colour discrimination. Impaired or atypi-
cal colour perception can be categorized into three groups,
as follows.
MONOCHROMATISM
700 Monochromatism is complete loss of colour sensation. There
are two varieties of monochromatism – rod monochroma-
tism and cone monochromatism. Rod monochromats have
no functioning cones; the prevalence of this condition is
one in 30 000. Cone monochromats possess both rods and
cones, but central image processing is lost; this very rare
condition has a prevalence of one in 100 000 000.
DICHROMATISM
Dichromatism is loss of function of a single colour cone.
Protanopes do not have red cones; clinically, they are
found to have a red-green colour defect and a perceived
loss in image brightness. The prevalence is one in 100.
Deuteranopes have a conjoined red-green cone with a red-
green colour defect but do not suffer a loss of image bright-
ness. The prevalence is one in 100. Tritanopes do not possess
blue cones; the condition has a prevalence of one in 65 000.
Only three per cent of cones in the fovea are blue, and so
it can be considered that fovea-only vision is very close to
being tritanopic.
TRICHROMATISM
In trichromatism, all three cone types are present in the
retina, but one type of cone cell requires a greater stimu-
lus than normal to function. Protanomalous individuals
have relatively insensitive red cones and require greater
red stimulus than normal; the prevalence is one in 100.
Deuteranomalous trichromats have insensitive green cones
and require greater green stimulus. This is the most preva-
lent colour deficiency in the population, occurring in one in
20 individuals. Tritanomalous trichromats have insensitive
blue cones and require greater blue stimulus; it is thought to
have a prevalence of about one in 4000.
As well as congenital causes of colour defects, colour
sense can be lost as a result of ocular disease, drug reac-
tions and light hazards. In addition, coloured filters placed
in front of the eye can induce loss of colour sense, which
is a particular concern for designers of aircraft coloured
multifunction displays.
IMAGE PROCESSING
The retina contains other cell types in addition to the
photo-detector cells. In human embryology, the retina
develops from tissue that also forms elements of the brain,
so the retina itself can be considered as specialized brain
tissue. Retinal output can be considered as image-processed
17/11/2015 15:52
 272  Optics and vision
visual information, which in turn is passed via the optic
nerve to the brain for higher-level processing, modelling
and interpretation.
Recognition of targets is influenced by the inductive state
of the retina. One part of the retina modifies the function of
another part, and this is known as spatial induction. When
a signal from a cone cell passes through a bipolar cell to a
ganglion, an excitatory nerve from the ganglion is also acti-
vated. This increases the likelihood of an action potential
in a nearby ganglion occurring. Therefore, if light falls on
a specific area of the retina, specific ganglia will be stim-
ulated. This has given rise to the mapping of the retina in
terms of the receptive field of a ganglion. This lateral activa-
tion of ganglia is known as lateral summation. In the fovea,
there are very small receptive fields, indicating a one-to-one
cone/ganglion association. In the distal reaches of the ret-
ina, the receptive fields are much larger, signifying a larger
cone/ganglion ratio. This may also account for reduced
visual acuity in the retinal periphery, as a specific ganglion
is managing a much larger spatial area of the retina.
When a signal from a cone passes through a bipolar cell
to a ganglion, an inhibitory nerve from the ganglion can
also be activated. This decreases the likelihood of an action
potential occurring in a nearby ganglion. This lateral inhi-
bition has been associated with enhanced border-contrast
image processing. This would make the identification of a
dark aircraft against a uniformly bright sky easier to recog-
nise (Figure 16.8).
DIFFERENTIATION OF MOTION
The eye makes never-ending unconscious movements, even
if it is fixated on an object. This creates the problem of how
to keep this moving image placed on the fovea. Objects that
are constantly moving further complicate the situation. It
has been postulated that the amacrine cells are involved in
the process of motion detection and differentiation. Major
advances in the understanding of amacrine cell function
have occurred in the past few years. Most research in this
area has been animal-based, but there is strong scientific
opinion that it is also valid for humans. The amacrine cell is
a polyaxonal cell with many axons spread across the whole
retina. It receives visual information from the rods and cones
and compares signals across the whole retina. If  a  fixated
Optic nerve
+ve
Ganglionic
layer –ve
+ve – excitatory effect
–ve – inhibitory effect
Bipolar
neuron
layer
+ve
Cone cell
Figure 16.8  Retinal micro-circuitry.
K17577_C016.indd 272
object and its background move together, then the apparent
movement of both the object and its background must be
due to eye movement. This could, potentially, confuse the
individual with artefact object motion information, and so
a terminating signal from the amacrine cell aborts the firing
of the retinal ganglion cells, thus, preventing retinal out-
put of this signal. If an object moves independently of its
background, then the amacrine cells perceive differentiated
image movement, thereby allowing an output signal to be
generated from the retina.
PERFORMANCE OF THE EYE
Contrast sensitivity
The Snellen visual acuity specifies the smallest spatial detail
that can be resolved for high-contrast stimuli. It does not
provide information about the ability to detect and dis-
criminate between objects of different sizes and contrast.
Sinusoidal grid patterns of different contrast against an
even background are used to measure the contrast sensitiv-
ity. The human visual system varies in the amount of con-
trast needed to detect a grating pattern for different spatial
frequencies or sizes of light and dark bars. Intermediate
spatial frequencies are visible at lower contrast levels than
low spatial frequencies or high spatial frequencies, and this
gives an inverted U-shaped appearance to the contrast sen-
sitivity curve. Contrast sensitivity is affected particularly by
media opacities such as cataracts, corneal disease, includ-
ing refractive surgery, and macular disease. Certain charts
may also be used to assess contrast sensitivity. These include
the Vistec contrast sensitivity chart, the Bailey–Lovie visual
acuity chart and the Pelli–Robson contrast sensitivity
letter chart.
Contrast-sensitivity measurement of retinal image deg-
radation is not easy to carry out, and its effect on visual
performance is difficult to quantify. A new test based on
contrast acuity assessment (CAA) has been developed to
identify subjects who fall out of the normal range of visual
function. This test is based on a study of modern aircraft
cockpit design and has allowed a normal range of contrast
acuity for aviators to perform their roles safely (Figure 16.9).
Weber’s law (Figure 16.10) describes the liminal contrast
as being a constant in photopic light levels. In other words,
the brighter the background, the brighter the light stimulus
(ΔΒε) increment has to be for the disc to be seen. This law is
true for all photopic conditions, apart from very high light
levels, when the law breaks down due to excessive photo-
receptor pigment bleaching. The implication of Weber’s
law in retinal light adaptation is to maintain the retinal
response to visual objects when ambient illumination levels
are changing. De Vries’ law (Figure  16.10) describes lim-
inal contrast in scotopic conditions and shows that ε varies
with the background brightness B in an inverse square-root
relationship. This means that in darker conditions, greater
differences in brightness between disc and background are
needed to maintain a 50 per cent detection rate.
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Light
Brightness
Dark
Distance from left edge
Figure 16.9  Edge enhancement. Consider an image
consisting of a bright area with a sharp border to a darker
area. When the image is formed on the retina, the ganglia
near the boundary and ‘in the dark’ will have their ganglia
inhibited from the ganglia in the bright region. This has
the net effect of increasing the perceived contrast of the
border above that of the actual pattern.
De Vries’ law
2
Log luminal contrast (ε)
1
(minutes
of arc)
0 including the central nervous system. The resolving power
–1
Scotopic
–2
–5 –4 –3 –2
Log brightness (B)
Figure 16.10  Weber’s and De Vries’ Laws.
Other experiments have looked at the relationships
between disc size and liminal contrast. In general, the
larger the disc, the less contrast is required to maintain
the 50  per cent detection rate (Figure  16.11). The disc
experiments have important implications in aviation,
as contrast is an important flight safety factor, e.g. mid-
air collision avoidance (much worse at night), identify-
ing the edge of the runway in a desert strip, and design of
aircraft instrumentation.
The second type of experimentation relates to the use of
spatial gratings. In this case, a computer monitor is used to
show a sinusoidal light- and dark-striped (grating) display.
In a similar manner to the testing of hearing, the funda-
mental frequency of a given wave can be used to test the
eye. Using different frequencies, the contrast sensitivity of
the eye can be determined; this is probably the most sen-
sitive measure of acuity. Under photopic conditions, the
liminal contrast is directly proportional to the frequency
of the spatial grating. In other words, the larger the spatial
frequency (and, consequently, the smaller the wavelength),
the greater contrast is needed to maintain a 50  per cent
detection rate.
K17577_C016.indd 273
Visual acuity  273
Large field of
luminance B
Angle subtended
at eye θ
Disc of luminance
B + ΔB
Figure 16.11  Disc experiments. A target disc is placed
against a uniform background. The size of the disc is
controlled and usually defined in terms of the angle sub-
tended at the eye. The brightness of the background, B,
can be varied as can the brightness of the target disc, B +
ΔB. The contrast is defined as C = ΔB/B. Liminal contrast,
ε, is defined as the contrast corresponding to a 50 per
cent detection rate, i.e. ε = ΔB ε/B, where ΔB ε is the incre-
ment of brightness above the background brightness level
seen 50 per cent of the time.
Weber’s law
VISUAL ACUITY
θ
Vision is a sensory outcome of integration between the
refracting system, the retina and the visual pathways,
5
20
of the eye is the smallest angle of separation between two
120 distinct points that allows the formation of two discernible
Photopic images, empirically 1 min of arc. The theoretical two-point
discrimination of the eye is directly proportional to the
–1 0 1 2 wavelength of light and inversely proportional to the pupil
radius (Rayleigh’s equation). As a result, the best theoretical
resolution of the eye is 0.5 min of arc (1/120 of 1°). This is
commensurate with a linear image separation of 4 μm on
the retina. Since photoreceptors are approximately 1.5 μm
in diameter, it supports the idea that two stimulated cones
are separated by an unstimulated receptor. With line-
detection acuity, the eye can resolve down to 0.5  s of arc
(1/7200 of 1°), as long as the line is longer than 1°of arc and
there is 100 per cent contrast. This equates to the detection
of a pencil-thick wire a mile away against a uniformly bright
sky. Vernier acuity measures the degree of misalignment
between two lines; the eye is capable of achieving a detec-
tion of misalignment at 4 s of arc (1/900 of 1°).
The Snellen test type is the most common chart used to
measure visual acuity. It bears letters constructed so that
each letter subtends a total visual angle of 5 min of arc when
viewed from the specified distance. Each component of the
letter is separated by 1 min of arc. The chart bears letters of
diminishing size, the largest having a viewing distance of
60  m and the smaller letters having viewing distances of,
respectively, 36 m, 24 m, 18 m, 12 m, 9 m, 6 m and 5 m. The
patient is positioned 6 m from a backlit chart. A normal eye
reads the 6-m letters from a distance of 6 m and is said to
have 6/6 vision. A weaker eye may be able to resolve only the
larger letters, e.g. an eye that resolves the 36-m letters is said
to have 6/36 vision. A normal eye would resolve the 36-m
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 274  Optics and vision
letters at 36 m. If the patient reads the chart from a differ-
ent distance, the numerator of the Snellen angle is amended
accordingly, e.g. 2/60 if the 60-m letter is read at 2 m.
A number of factors affect visual acuity, including ambi-
ent luminance level, spectral composition of illumina-
tion, pupil size, retinal location of the stimulus, refractive
errors and pathological changes. Visual acuity improves
with increasing luminance up to 103  cd/m2, where acuity
remains optimal, until 105 cd/m2, at which point glare will
start to reduce it. The relationship between Snellen acuity
and contrast sensitivity is not tenuous and relates to the
association between a pure frequency and a complex mix
of frequencies, in the same manner as pure tone frequency
relates to a complex sound. A complex sound, such as from a
musical instrument, is made up of a fundamental frequency
note together with a series of harmonics that are related
mathematically to the fundamental. The same principle
is true with vision, as a visual image can be considered as
consisting of fundamental frequencies and their harmonics.
Contrast-sensitivity measurement using sinusoidal gratings
determines the ability to sense fundamental frequencies,
while Snellen acuity is founded on a square-wave pattern,
i.e. the border between a black letter and the white back-
ground is a sharp distinct border in the same manner as
a light/dark square wave. The Snellen chart is, in essence,
the visual equivalent of the measurement of hearing with
a musical instrument, i.e. the sum of the fundamental
frequency and its harmonics. Despite this, Snellen acuity
remains an excellent visual measure, as it is easy to perform,
the results are easy to replicate and the results relate well to
overall visual function.
Visual acuity reduces with increasing eccentricity due to
a number of reasons (Figure 16.12):
●● The number of cones reduces with distance from
the fovea.
●● The number of photoreceptors per bipolar cell and reti-
nal ganglion increases with distance from the fovea.
●● Effects of spherical aberration.
●● Stiles–Crawford effect.
Depth perception
Depth or distance judgement consists of two stages: the
receipt of perceptual cues (information) to depth followed
by the interpretation of the cues to form a judgement of dis-
tance. The loss of any cue leads to riskier decision making,
as the decision will be made with less information. There are
two types of cue, monocular (psychological) and binocular
(physiological). Monocular cues consist of the following:
●● Relative size: the apparent size of an object appears to
get smaller with greater distance from the observer, as
the visual angle gets smaller.
●● Perspective: the convergence of parallel lines to a point
on the horizon. Classically used by artists to create the
impression of depth in two-dimensional images.
K17577_C016.indd 274
6/6
Nasal Temporal
Visual acuity
6/12
6/36
Anatomical Fovea
scotoma
6/60
40 30 20 10 0 10 20 30 40
Degrees eccentric from the fovea
Figure 16.12  Peripheral visual acuity. Visual acuity dimin-
ishes rapidly away from the foveal image, so the observer
has to continually scan the surroundings in order to keep
the image of a moving object on the fovea. The acuity
found 5° eccentric from the fovea is approximately one-
quarter that found at the fovea and one-twentieth that
found at 20° eccentricity.
●● Overlapping of objects: suggests that the distant object
is being partly hidden by a nearer object.
●● Position in visual field: as an object moves into the dis-
tance, it appears to be closing in on the horizon.
●● Aerial perspective: a depth cue arising from Rayleigh
scattering of light in the atmosphere. As a result,
similarly-coloured objects in the foreground appear to
be intensely coloured whereas those in the distance take
on a desaturated appearance.
●● Parallax: on viewing two objects, head movement in one
direction results in the nearer object appearing to move
in the opposite direction while the distant object moves
with the head.
●● Motion parallax: when an observer moves, objects near
the viewer appear to move faster than more distant
objects. In aviation, this explains the height cue – the
blur zone – with lower altitude, there appears to be
greater blurring of the approaching terrain.
The binocular cues comprise lens accommodation, eye-
ball convergence and stereopsis. The eyeballs should be in
the anatomical position when viewing distant objects. As
an object comes closer to the observer, the eyes rotate medi-
ally, converging on to the object. The angle between the two
optical axes is known as the convergence angle. As a general
rule, the larger the convergence angle, the nearer the object
is to the observer. Both lens accommodation and eyeball
convergence are under muscular control, so afferent signals
are relayed to the brain, detailing the degree of muscular
tone. This information gives indirect indication of depth.
The brain considers optical infinity to be anything more
than 6 m away from the observer, and so accommodation
and eyeball convergence are limited to within a 6-m range.
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In aviation, these cues are useful only inside the cockpit and
in the immediate surrounds of the individual.
As an individual’s eyes gaze on the world, they do so from
slightly different positions and so have slightly different views
of the world. Binocular vision relates to vision from two eyes
with overlapping fields of view. Stereopsis is the exploitation
of binocular vision for the purposes of three-dimensional
perception (Figure 16.13). The angle subtended at an object
between the two optic axes is known as the binocular paral-
lax. The closer the observer to the object, the larger the angle
of binocular parallax. When comparing the relative distances
between two objects, the brain is effectively judging the differ-
ence in angle at each object. We do not understand how this
is achieved. Fixating on an object places the image on both
foveae, and objects close to the fixated object will have their
images on non-corresponding parts of each retina. The brain
perceives the extent (disparity) to which different images fall
on non-corresponding parts of the retinas and can estimate
the relative object distance. We do not know how the brain
fuses these two images in order to perceive a three-dimen-
sional image. The role of retinal image disparity in stereopsis
is central to our current understanding of this process.
Q cent can result in a temporary amblyopia.
e
θ2
P fusing both images. In addition, chromatic aberration
θ ●●
d eye: if the brightness of an image in each eye differs by
d
Left Right
b
Figure 16.13  Stereopsis. Consider a pair of eyes looking
at point P. The distance between the pupils is b and the
object P is at a distance d from the observer. The angular
disparity between the left and right eye at P is tan Θ =
b/d. The object at point Q is at a distance (d + e) from the
observer, and so the angular disparity Θ2 between each
eye at point Q is tan Θ2 = b/(d + e). The angle of disparity
Θdis is the difference between these two angles, i.e. Θdis =
Θ − Θ2. So, Θdis = (b/d) − ( b/[d + e]). If the angle of dispar-
ity Θdis is zero, then e must also be zero, and so points P
and Q are equidistant from the observer. If the angle of
disparity Θdis is constant, then the larger d becomes, the
larger e has to become in order to maintain the disparity.
When d = b/Θdis then e must equal infinity, i.e. stereopsis
ceases to exist. In this case, d is the stereoptic range.
K17577_C016.indd 275
Aviation hazards to vision  275
Taking the theoretical limit for two-point discrimination
of the eye as being 0.5 min of arc and using this as the mini-
mum angular separation the eye can resolve, together with
an inter-pupillary distance of 75 mm, then from Rayleigh’s
equation, the range of stereoscopic vision is 450 m.
About 12 per cent of the population does not have stere-
opsis. In part, this is related to the childhood incidence of
strabismus (four per cent) and amblyopia (two to three per
cent). Stereopsis can also be compromised or lost with age.
At 65 years of age, approximately a third of individuals have
no stereopsis, a third have reduced stereopsis and a third
retain stereoptic ability.
There are other factors that affect stereopsis and, as
a result, reduce the range of stereopsis, including the
following:
●● Poor illumination: visual acuity reduces in
darker conditions.
●● Refractive errors, e.g. myopia.
●● Different magnification of an image presented to each
eye, e.g. with a poor optical device: magnifications less
than 0.5 per cent present no problems, up to two per
cent can result in eye strain, between two and five per
cent can seriously degrade stereopsis and above five per
●● Different colouration of an image presented to each
eye: if a red filter is placed in front of one eye and a blue
one in front of the other, then the brain has difficulty in
effects give rise to different states of lens accommoda-
tion in each eye, compounding the visual confusion.
Different brightness of an image presented to each
more than ten per cent, then significant degradation in
stereopsis occurs. In extremis, this can result in motion
illusions, i.e. the Pulfrich effect (Figure 16.14).
AVIATION HAZARDS TO VISION
Light hazards
Glare is defined simply as an intrusive light source, irre-
spective of whether it is viewed directly or indirectly. Glare
can reduce visual acuity and contrast sensitivity and can be
considerably uncomfortable. It is classified into two types,
discomfort glare and disability glare. Discomfort glare
does not impair visual performance but can cause blink-
ing, squinting and aversion and can impair individual
performance, as it is distracting and fatiguing. There are
three types of disability glare, each type having a signifi-
cant impact on visual performance. Veiling disability glare
occurs when a diffuse light source superimposes its image
over the retinal image, resulting in a reduction in image
contrast. A classic example of this is the reflected image
of a map placed on the instrument panel in the cockpit,
reducing the contrast of outside world images. Dazzle dis-
ability glare occurs when a bright glare source is imaged
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 276  Optics and vision
C
Apparent path
B A
Actual path
Neutral density
filter
Left eye Right eye
Figure 16.14  Pulfrich effect. Consider a pendulum swing-
ing in a straight horizontal line and viewed by an observer
with a neutral density filter over the left eye. The signal
from the left eye is delayed, because it has a dimmer
image and so takes longer to process. When the pendu-
lum is at A, moving from left to right, the right eye will see
it in real time, at A. The left eye, however, perceives the
pendulum at B, as the time taken to process the image
has been longer than for the right eye, even though the
pendulum has moved to A. The disparity in retinal posi-
tion creates the illusion that the pendulum is at C and
moving in an elliptical path.
on an extra-foveal location, e.g. flying when the sun is low
on the horizon. This glare scatters in the ocular media and
strays into the retinal image at the fovea, again reducing
image contrast at the point of fixation. Finally, scotomatic
disability glare occurs when a brilliant light source reduces
the retina’s sensitivity to light, as seen following flash pho-
tography. In this case, retinal sensitivity falls rapidly during
the period of light exposure and then regains its sensitivity
more slowly after the exposure. Photo-stress is another term
for scotomatic disability glare and results from retinal pig-
ment bleaching and regeneration. The time to recover from
photo-stress worsens with age.
OTHER RISKS FROM SOLAR LIGHT
Apart from light intensity, the main risk from solar light
is wavelength-dependent. The energy contained within
different wavelengths of light increases with shorter wave-
lengths; therefore, the blue end of the spectrum has the
potential to be more damaging than the red end. There is
more blue and UV content in the atmosphere with increas-
ing altitude, so aviators encounter specific risks to their
vision. Wavelengths in the blue end of the visible spectrum
– 400–500  nm – risk accelerated retinal ageing and have
been linked with macular degeneration. Outside of the vis-
ible spectrum, long-term exposure to UV(A) – 315–380 nm
– can cause cataract formation, while shorter-wavelength
UV(B) – 295–315  nm – can lead to episodes of acute
kerato-conjunctivitis.
K17577_C016.indd 276
PROTECTION FROM SOLAR LIGHT DAMAGE
It is recommended that either sunglasses or a helmet-
mounted tinted visor be used to protect the eyes from high
intensity solar light. In general, the filter (tint) needs to
reduce the overall energy being transmitted through the tint
to 10–15 per cent of the incident level. The overall aim is to
reduce light levels at the eye to a value at which the eye can
obtain maximum visual information. This system is lim-
ited, as the incident light level will always vary, so the avia-
tor may find that the level of tint is not dark enough in very
bright conditions and yet is too dark in dimmer conditions.
Technologies that can dynamically change the level of tint
as a function of the ambient light levels are also limited. The
time taken to darken the level of tint in bright conditions is
rapid, but lightening of tint when conditions darken, e.g. on
entering cloud, takes much longer, thus reducing the visual
performance of the aviator until the lag period has passed.
Wavelength-specific protection is also required, espe-
cially as the amount of blue light and UV radiation in solar
light increases with increasing altitude. Ideally, the tint
needs to reduce the transmittance of UV(A) and UV(B) to
below one per cent and the blue end of the spectrum to below
five per cent. Technically, this is difficult to achieve with-
out affecting the rest of the visible spectrum, but it remains
an objective in future filter development. A consequence of
filtering the visible spectrum from a tint would be to affect
the aviator’s ability to discriminate colour and so make
coloured displays potentially more difficult to read. The
physical and optical properties of aircrew optical devices
such as sunglasses or visors should be within International
Organisation of Standardisation (ISO) standards; it may be
advisable to consider the application of both quarter-wave-
length anti-reflection coatings and anti-abrasion coatings.
LASER
The term LASER is an acronym for Light Amplification
by the Stimulated Emission of Radiation. When energy is
applied to an atom, the electrons of the atom are raised to
a higher energy level. Higher-energy levels are inherently
unstable; consequently, the electrons fall back to a lower
energy level, with the release of surplus energy as light. The
emitted wavelength is dependent on the energy loss between
high- and low-energy states which, in turn, is dependent
on the type of atom. If the atoms are contained in a tube
lined with mirrors, then the emitted light can be reflected
back and forth through the atoms, exciting even more light
emission. The laser light is allowed out of the tube through
a small aperture in one of the mirrors. There are three char-
acteristics of laser light:
●● Monochromatic: Laser light is a single wavelength,
unlike conventional light sources, which are heated and
thus emit visible and IR wavelengths.
●● Collimation of beam: the light travels in the same direc-
tion as a beam that can be focused to a tiny spot, with
all the energy of the source transmitted to that area.
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●● Coherence: Laser light consists of light waves emitted
in phase with each other. When two waves of light are
in phase, the sum of the wave amplitudes (energy) is
at a maximum; if the two waves are in anti-phase with
each other, then the sum of the wave amplitudes is zero
and the beam has no energy. Conventional light sources
emit only very small amounts of coherent light and so
are less powerful.
A laser is normally described by the type of laser media
(type of atom), its energy output and the type of output.
The type of output can be continuous-beam (beam lasts
for more than one second), pulsed-beam (small packets of
beam energy released every second) or Q-switched (very
short, very high-energy pulse of laser light).
Lasers are being used increasingly frequently in the avia-
tion environment, especially in non-destructive testing of
aircraft components. There is also the risk to military avia-
tors, as lasers have the potential to be used as weapons. For
damage to occur in the eye, energy must be transferred from
the laser beam to the energy-absorbing tissue. The degree of
tissue damage depends on the energy output from the laser
and the wavelength of the laser radiation. Different tissues
within the eye absorb different wavelength bandwidths;
if enough energy is applied, tissue damage will result
(Figure 16.15). The magnitude of damage from a laser ranges
from transient photo-stress (low-energy continuous lasers),
to burning (continuous or low-energy pulsed lasers), to
photo-acoustic damage (high-energy pulsed or Q-switched
lasers). The cornea is vulnerable to wavelengths in the far-
UV(B) and UV(C) (200–315  nm) and far-IR(B) and IR(C)
(1400  nm–1  mm) spectrum and can result in either acute
keratitis or corneal opacity. The lens can develop cataracts
chiefly from wavelengths in the near UV(A) region (315–
380 nm). The retina is at risk from visible light (380–780 nm)
and near-IR radiation (780–1400  nm). An additional risk
with retina-damaging lasers is that the optical components
of the eye can concentrate the beam into a very small area of
the retina, exacerbating the damage.
Loss of vision for even a short period of time during flight
can be extremely hazardous. To protect people in the vicin-
ity of lasers, the nominal ocular hazard distance (NOHD)
has been determined for each type of laser. The NOHD is
100
80
% Transmission
60
40 Visible
range Invisible range
20
Ocular focus
0
200 400 600 800 1000
Wavelength (nm)
Figure 16.15  Wavelength transmission curve.
K17577_C016.indd 277
Aviation hazards to vision  277
the distance along the axis of the laser beam beyond which
eye exposure is acceptable, i.e. may result only in temporary
photo-stress effects. Generally, protection is best afforded by
distance, as energy falls in line with the inverse square law.
The calculation is based on the knowledge of the limit of
safe exposure, the maximum permissible exposure (MPE),
together with factors such as the maximum beam output
energy and the degree of beam divergence in the atmo-
sphere. NOHD does not take into account atmospheric con-
ditions that allow hot spots, i.e. areas of atmosphere having
lens-like effects.
Additional protection is possible with the use of appro-
priate filters placed in front of the eyes, such as laser-pro-
tective glasses or goggles. The filter needs to attenuate the
laser energy reaching the eye to a safe level, with an appro-
priate wavelength-matched filter corresponding to that
laser. The filter substrate also has to have the mechanical
characteristics to withstand the laser energy and not to be
damaged itself.
Eye hazards in flight
EMPTY FIELD MYOPIA
The empty field myopia phenomenon occurs when an avia-
tor has nothing to focus on outside of the aircraft. Flying
in a fixed-wing aircraft in featureless conditions such as
at high altitude, over flat desert or at night can give rise
to this phenomenon. It tends not to occur in rotary-wing
aircraft because of the continual visual interest created by
each pass of a rotor blade. The eye attempts to locate an
object in the distance to focus upon but is unable to locate
a target. In this situation, the ciliary muscles are unable to
stay in the relaxed state and will assume some degree of
contraction. As a result, the far point of the eye becomes
nearer to the aviator, producing a physiological myopia,
with a focal length down to 1.5 m from the aviator’s eyes.
This phenomenon can occur within seconds, especially if
the aviator is fatigued or if the only outside object of inter-
est is dirt on the windscreen or canopy. The pilot needs to
be able to focus to infinity to scan the skies for other air-
craft and other flight hazards. To correct empty field myo-
pia, the aviator needs to be aware of the risk in featureless
scenes and to be able to return his or her focus to the hori-
zon. To restore focus to infinity, the pilot needs to either
focus on the aircraft wingtips, if they are in view and more
than 6  m away from him or her, or focus on the head-up
display (HUD).
HIGH-SPEED FLIGHT
Large distances may be travelled during the time taken to
perceive and react to objects appearing in the visual field,
and this effectively increases the reaction time. Supersonic
flight creates the greatest potential visual problems. For
1200 1400
example, while travelling in an aircraft at 700 knots, if the
pilot observes a flight hazard, in order to react appropri-
ately, i.e. identify the problem, make a decision about the
correct course of action and then physically undertake that
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 278  Optics and vision
action, takes time and five to six seconds may have elapsed.
Over this time period, a distance of more than a nautical
mile has been travelled, which may not be distant enough to
avoid the hazard. In addition, the need for the pilot to scan
the skies for hazards is interrupted at irregular intervals as
they check the aircraft instruments. It takes time to change
the focal length of the eyes and also to read and register
the information from the flight instruments. At the previ-
ous example speed of 700 knots, this whole process, taking
five seconds, results in a fight distance of 1.05 nautical miles
being travelled with the pilot not focusing on anything out-
side the aircraft.
DYNAMIC VISUAL ACUITY
When a target moves across the visual field, the eye must
track it in order to maintain foveal fixation. The ocular pur-
suit mechanism is capable of maintaining steady fixation
where the angular velocity does not exceed a value greater
than 30°/s. At an angular velocity of 40°/s, visual acuity may
drop to half its static value, the decrement increasing further
with increasing angular velocity. This phenomenon gives
rise to the ‘blur zone’ around the aviator, in which objects
become less distinct due to their relative speed of movement.
CANOPIES AND WINDSCREENS
Most flying today is performed within a fully-enclosed
cockpit. As a result, windscreens and canopies need to be
designed to protect the aviators from meteorological condi-
tions while having the optical properties to minimize the
effects of magnification, distortion, prismatic effects and
multiple reflections. Many modern aircraft transparencies
incorporate various coatings in order to reduce these prob-
lems. Any transparency placed in front of a pilot’s eye has
the potential to create visual difficulty for that pilot. These
problems include multiple reflections between the canopy or
windscreen and other reflective surfaces within the cockpit,
e.g. HUD, mirrors, helmet visor and spectacles. In addition,
any light traversing a medium will result in light scatter, espe-
cially if the surface is dirty or oil-stained. This can give rise
to image distortion and glare. Precipitation, especially rain,
can be troublesome, as a rain-swept windscreen can act like a
lens. The image distortion through a rain-swept windscreen
occurs more readily at higher air speed. The lens effect results
in objects appearing closer than they are, giving the pilot the
tendency to undershoot on a visual landing approach.
Visual illusions
The most important visual illusions, such as the Coriolis
effect and oculogravic and oculogyric illusions, are dis-
cussed in Chapter 17. Autokinesis is an illusion that would
appear to be attributed solely to the eyes. When a single
light source is watched against a dark background, such as
the night sky, after a short period the light source will start
to wander spontaneously, even if it is a stationary source.
The movement observed can be linear, circular or elliptical,
K17577_C016.indd 278
but how it moves appears to be constant for a given individ-
ual. The cause of this phenomenon is unknown, but there
is conjecture that involuntary eye movements produce an
apparent motion of the image on the retina.
Flicker effects, such as those produced by helicopter
rotor blades and strobe lighting systems, can lead to sys-
temic problems in susceptible aviators. For most people,
flickering acts as a distraction but, occasionally, it can cause
headaches, dizziness or nausea. Most significantly, and
least commonly, flicker can induce epileptiform episodes.
Flicker photo-stimulation can induce seizures, especially if
the flicker occurs at a frequency between 5 and 20 Hz. The
maximal frequency for photo-induced epilepsy is 12  Hz.
The strobe lighting used in aircraft anti-collision light
strobes at the much slower rate of around 1 Hz is safe. The
incidence of photo-induced epilepsy is relatively small, as it
affects only approximately five per cent of epileptic people.
Normal medical screening procedures for epilepsy before
flying training normally preclude such individuals from
controlling an aircraft in the first place.
Mechanical hazards
BIRD-STRIKE
Bird-strikes are a demanding hazard in low-altitude avia-
tion. Approximately 95 per cent of bird-strikes occur below
750 feet above mean sea level and usually result in the bird
being ingested into an engine intake or colliding with the
airframe. Sixteen per cent of bird-strikes result in a collision
with the canopy or windscreen. The canopy or windscreen
transparency needs to be made of a substrate capable of
withstanding these considerable forces. However, to prevent
bird penetration absolutely would be very costly in terms of
weight, manufacture and optical degradation. The amount
of energy lost as a result of a bird penetrating a windscreen
is significant, and windscreen design does impart a consid-
erable amount of protection for the aviator. That said, not
all of the energy is lost, and so another protection layer is
required for the pilot, particularly those involved in low-
altitude, high-speed flight, such as military aircrew. The
most common solution is the use of a helmet-mounted visor
to protect the eyes from blunt trauma. Visors are generally
made from 3  mm polycarbonate material. Polycarbonates
have a very high tensile strength and can withstand very
high forces. Visors generally cover most of the area of the
face not protected by an oxygen mask. The combination of
visor and mask gives almost full-face protection from blunt
injury. The helmet must be fitted properly to the individual,
and the gap between the inferior edge of the visor and the
upper edge of the oxygen mask must be minimized in order
to reduce the risk of penetration through to the aviator.
Aerodynamic blast protection
With high-performance fast-jet aircraft, the risk of high-
speed ejection is always present. On ejection, the head may
be subject to very high aerodynamic forces, risking both
17/11/2015 15:52

acceleration injury and blunt trauma to the eyes. The hel-
met-mounted visor, as currently used by the Royal Air Force
(RAF), is designed to withstand blast winds up to 650 knots
indicated air speed (IAS). Again, it is vitally important that
the helmet, visor and oxygen mask are appropriately fitted,
so as to remain in place with ejection.
Canopy fragmentation devices
With the initial stages of ejection from a fast-jet aircraft, the
canopy needs to be removed and in some cases fragmented.
Miniature detonating cord (MDC) is an explosive material,
lined on its internal surface by a layer of lead that is designed
to fragment the canopy. On detonation, the lead directs the
explosion through the substrate of the canopy, shattering it
and ensuring that downward explosive forces towards the
aviator are limited. A consequence of this design is that the
explosion creates enough heat to melt the lead, which can
then fall on to the aviator. This results in lead splatter to
unprotected skin and eyes, risking penetrating eye injury
in particular. Linear cutting cord has a very similar mecha-
nism to MDC but is designed to cut the canopy (usually in
half), which then falls away. This system has the same risk
of lead splatter to the eyes. Canopy jettison rocket motors
use rockets to remove the intact canopy away from the
fuselage. This system risks rocket propellant splatter, which
may include a burns risk. A polycarbonate helmet-mounted
visor together with oxygen mask provides adequate protec-
tion, and it is recommended that the visor is down and the
eyes closed for ejection.
NIGHT-VISION GOGGLES
Given the poor-resolution qualities of the naked eye at night,
systems were designed to improve visual quality, primarily
to gain military advantage. Night-vision goggles (NVGs) are
helmet-mounted electro-optical image intensifiers increas-
ingly used in aviation. They operate by amplifying light and
near-IR radiation by means of an image-intensifier tube and
present the image on a phosphor display (Figure 16.16). The
perceived ambient brightness through the goggles is depen-
dent on the level of near-IR illumination in the night sky. IR
content varies according to the presence and height of the
moon and starlight and is reduced by the presence of clouds
and adverse weather conditions. There are also incandes-
cent light sources on the ground from cultural lighting (e.g.
roads, railways, housing), contributing to the overall ambi-
ent illumination level in addition to ground-reflected night-
sky illuminance. Different terrains will reflect different
amounts of illuminant energy back into the sky, e.g. flying
over soil will appear darker than flying over sand or snow.
The NVG phosphor output is a narrow band in the green
part of the spectrum (530–545  nm), and the illumination
level is commensurate with mesopic vision. Most goggles
are focused to optical infinity, but some can be focused
nearer. As a result, the aviator needs to view under the
goggles to view cockpit instrumentation. There must be
K17577_C016.indd 279
Night-vision goggles  279
Objective Micro-channel
lens plate Phosphor
Photocathode Fibre-optic Collimating
inverter eyepiece lens
Figure 16.16  Schematic diagram of night-vision goggles
tube. Night radiation is focused on a gallium-arsenide
photocathode with an objective lens. The radiant energy
is capable of ejecting an electron from the inner surface
of the photocathode. The photocathode is most sensitive
to wavelengths in the near-infrared (IR) region and the red
end of the visible spectrum. The electrons are then accel-
erated in an electric field towards the multiplying ele-
ment, the micro-channel plate (MCP). There are millions of
micron-sized channels at a small angle of inclination to the
electron beam. As an electron enters a channel, it hits a
channel wall and dislodges another electron. This multi-
plying effect occurs along the full length of the channel
and is capable of generating 100 000 electrons from the
incident electron.
adequate lighting in the cockpit for the aviator to see instru-
mentation, but this light must be compatible with the use
of NVGs. No amplification is desired from cockpit lighting
sources, since this would give rise to an intra-cockpit glare
source, thus negating any advantage gained by using NVGs.
NVG-compatible lighting systems (Figure 16.17) use a nar-
row band of green wavelengths, either by filtered white light
bulbs or electroluminescent panels. The NVG photocathode
is largely insensitive to green wavelengths, and the cones
have maximum sensitivity, thereby maximizing both direct
and NVG viewing.
With NVG, visual acuity is 6/9 at best, and the field of view
is limited to a circular 40  degrees, compromising normal
daytime visual assumptions. There are continuing develop-
ments in NVG technology, improving both visual acuity
and field of view. However, a significant risk to the aviator is
the loss of visual cues to depth perception, with a resultant
Photocathode
sensitivity
Vλ
Sensitivity (%)
Near-infrared
region
380 780
Wavelength (nm)
Figure 16.17  Night-vision goggles-compatible lighting.
Vλ represents the cone sensitivity curve.
17/11/2015 15:52
 280  Optics and vision
overestimation of clearance distances. Both reduced visual
acuity and depth perception are common factors in NVG-
related aircraft accidents. Stereopsis appears to be degraded
significantly, while some of the monocular cues are lost.
After prolonged use, some aviators have ‘magenta’-coloured
after-effects on returning to white-light conditions. This is
believed to be a result of desensitization of the green-sensi-
tive cones, resulting in the perception of the complementary
colour on viewing white objects. This effect is transient and
normal colour vision returns.
HELMET-MOUNTED DISPLAYS
Aircraft instrumentation is displayed primarily either on
the instrument panel or on an HUD, but the latest technolo-
gies have allowed for instrumentation to be displayed on a
helmet display visor. Both colour and monochromatic hel-
met-mounted displays (HMDs) are currently in use, coupled
with head-tracking systems to provide a head-stabilized dis-
play. As well as aircraft status displays, both near- and far-
(thermal) IR imagery from aircraft-mounted sensors can be
shown. Presently, monocular systems predominate, which
can create additional problems with depth information,
visual field loss and binocular rivalry. Binocular rivalry
occurs when there is competition between the two disparate
images to each eye, and the aviator may have to learn how
to switch focus of attention in order to view from one to the
other. Binocular systems are under development, but there
are technological difficulties in fusing the two images. As
a result, bi-ocular systems that present the same image to
each eye could be used. These systems do not address the
issue of loss of depth information, as a stereoptic image is
not produced.
K17577_C016.indd 280
SUMMARY
●● Eye hazards in flight include empty field myopia,
inattention in high-speed flight and blur zones
around moving objects seen from the cockpit.
●● The most common colour vision defect is red/
green deficiency.
●● Night vision goggles provide a slightly reduced
visual acuity, a constricted visual field and a loss
of stereopsis.
●● Laser effects to the eyes include corneal surface
burns, macular burns and temporary loss of
vision due to glare or dazzle effects.
FURTHER READING
Abrams D. Duke–Elder’s Practice of Refraction, 10th edn.
London: Churchill Livingstone, 1993.
Davson H. Physiology of the Eye, 5th edn. London:
Macmillan, 1990.
Falk DS, Brill DR, Stork DG. Seeing the Light: Optics in
Nature, Photography, Colour, Vision and Holography.
New York: John Wiley and Sons, 1986.
Gregory RL. Eye and Brain: The Physiology of Seeing, 5th
edn. Oxford: Oxford University Press, 1998.
Olveczky BP, Baccus SA, Meister M. Segregation of object
and background motion in the retina. Nature 2003;
423: 401–8.
Wilson J, Hawkes JFB. Optoelectronics: An Introduction,
2nd edn. London: Prentice Hall, 1988.
17/11/2015 15:52

Spatial orientation and disorientation in flight
J.R. ROLLIN STOTT AND ALAN J. BENSON
Introduction 281
Definition 281
Why do pilots become disorientated? 282
The relationship between spatial disorientation and
illusions of flight 283
INTRODUCTION
Orientation implies a sense of location in relation to our
surroundings. The capacity to orientate is an essential
requirement for all free living organisms and a range of
sophisticated physiological mechanisms have evolved to
bring it about. As with many important physiological func-
tions, orientation occurs with little conscious thought and
we remain unaware of its underlying complexity.
The capacity to orientate can be considered in geographi-
cal terms, for example, the ability to create a mental map
of a previously unfamiliar locality or the ability to recall a
once familiar location. However, a further aspect of orien-
tation relates to the disposition of the body relative to the
immediate surroundings and to the force of gravity. Am I
upright or tilted, sitting or lying down? This latter aspect of
orientation assumes particular importance in flight. What
is the disposition, or attitude, of the aircraft? Is the aircraft
flying wings level or banked, pitched up or nose down? It
is important for a pilot to understand why the answer to
these questions is not as intuitive in the dynamic environ-
ment of flight as it is in the static terrestrial environment.
As on the ground, flight also involves orientation in relation
to specific objects such as a runway, another aircraft or a
mountain-side and poses the reciprocal question: Where is
my aircraft in relation to it? Where is it in relation to me?
And equally importantly: Where will my aircraft be relative
to it, given the current flight trajectory?
Orientation can only occur in relation to something
external, a frame of reference. Human orientation is largely
K17577_C017.indd 281
17
Vision and spatial disorientation 284
Operational aspects of disorientation 310
Prevention of spatial disorientation 315
References 318
Further reading 319
dependent on two frames of reference. First, our surround-
ings give a predominantly earth-fixed visual frame of ref-
erence and secondly, the sensed constancy of the force of
gravity, both in terms of its intensity and its direction
provides a force frame of reference. On the ground there
are dependable relationships between these two frames
of reference. The visual world has mainly come about as a
consequence of the force world so that we have the visual
expectation that seas and lakes are horizontal and that
buildings and trees indicate the vertical. An important
potentially disorientating feature of flight arises from the
fact that the aerodynamics of the aircraft generates in the
pilot a sense of the vertical that is not necessarily aligned
with earth vertical. As a result, the expected relationship
with the external visual world no longer holds. In conse-
quence, it is sometimes the force world that determines how
we see the visual world. One familiar example of this occurs
in a banked turn when a level horizon appears to slope.
DEFINITION
Spatial disorientation is a term used to describe a variety of
incidents occurring in flight in which the pilot fails to sense
correctly the position, motion or attitude of the aircraft or
of themselves within the fixed coordinate system provided
by the surface of the Earth and the gravitational vertical.
In addition, errors in perception by pilots of their position,
motion or attitude with respect to their aircraft, or of their
own aircraft relative to other aircraft, may also be embraced
within a broader definition of spatial disorientation in flight.
281
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 282  Spatial orientation and disorientation in flight
This definition of spatial disorientation includes what
has been termed ‘geographic disorientation’, an error in
the position of the aircraft in respect of its intended loca-
tion on the map. Conventionally, this form of disorienta-
tion has been excluded from true spatial disorientation as it
involves a navigational error rather than one of aircraft atti-
tude. However, an error in location may bring the aircraft
into proximity to high ground or some other obstruction in
much the same way as an altitude error, which is regarded
as a form of spatial disorientation. Furthermore, there
are instances in which the distraction involved in resolv-
ing a navigational error has led to an unperceived error in
aircraft attitude.
The concept of situational awareness (SA) has gained
currency since the early 1980s, although there is still some
uncertainty about what should be included within the defi-
nition of the term. For some, it has become synonymous
with the aviator’s awareness of the aircraft’s spatial orien-
tation. However, more commonly, the term is used more
broadly to include not only awareness of spatial orientation
but also of other aspects of the current state of the aircraft
and of the external environment. It also incorporates an ele-
ment of anticipation of future events. A pilot who has an
erroneous perception of aircraft orientation also incurs a
loss of SA, but loss of SA can occur for many different rea-
sons in the absence of any spatial disorientation.
In some countries, particularly the USA, the term ‘ver-
tigo’ or ‘aviator’s vertigo’ is used synonymously with spatial
disorientation. Vertigo has the specific meaning of a false
sensation of turning and the use of the term should be con-
fined to this particular kind of sensory experience. A pilot
with vertigo may well be suffering from spatial disorienta-
tion, but there are many instances in which the pilot is spa-
tially disorientated but does not have vertigo.
WHY DO PILOTS BECOME DISORIENTATED?
In the air, the task of orientation can no longer be the uncon-
scious activity that it is on the ground. There are certain
crucial factors that increase the likelihood of disorientation
in the flight environment. These can be reduced to just three
essential principles.
1. The external visual world may be remote, degraded by
haze or darkness or totally obscured by cloud. When
lost, the external visual scene has to be replaced by the
far less convincing visual interpretation of the aircraft
attitude indicator.
2. The aerodynamics of the aircraft generates a sense of
gravity that for much of the time acts vertically through
the floor of the aircraft and gives the pilot no indication
of the true aircraft attitude with respect to earth verti-
cal, either in roll or in pitch.
3. Rotations that result in a change of aircraft attitude or
heading may not be correctly sensed if they are of low
intensity or prolonged, or if they do not generate any
consequent sense of having been tilted.
K17577_C017.indd 282
In order to fully understand the reasons for spatial dis-
orientation in flight, it is important to view the subject from
two perspectives: How is it that the flight environment and
the aerodynamics of the aircraft have the capacity to deceive
the pilot, and how, through misperceptions and sensory
shortcomings, has the pilot the capacity to be deceived?
Distraction
Distraction is a potent underlying cause of disorientation.
The aphorism ‘First, fly the aircraft’ emphasizes the prime
importance of the pilot remaining in control of the air-
craft. This involves awareness of aircraft attitude, heading,
airspeed and altitude, in other words, maintaining spatial
orientation. The amount of attention that a pilot needs to
devote to the task of flying the aircraft varies considerably
in different phases of flight. In level flight, given a clear
horizon and a ground separation of a few thousand feet,
the task of maintaining an appropriate aircraft attitude is
to a trained pilot an almost automatic activity that only
requires an occasional, though regular, cross-check against
the aircraft instruments. In these circumstances, the pilot
will have spare mental capacity to deal with other aspects of
the flight. At low level, however, particularly when manoeu-
vring, small errors in aircraft attitude can have fatal conse-
quences and the scope for attending to anything other than
flying the aircraft is severely limited.
There are, of course, other aspects of the flying task that
demand the attention of the pilot, and about which the pilot
must remain aware. However, there is a limit on the number
of pieces of information of which a pilot can simultaneously
be aware and it has to be recognized that, in dealing with
these other aspects of the flight, there may be a temporary
loss of awareness of aircraft orientation. In most circum-
stances, this is of no consequence to flight safety, but in
other circumstances it is crucial. It is often termed ‘distrac-
tion’ on the accident report rather than disorientation, but
it represents a failure, for whatever reason, to ‘first, fly the
aircraft’.
There are wide differences in the flight environment
experienced by the light aircraft pilot, the commercial pilot,
the helicopter pilot and the fast jet military pilot. Though
disorientation can occur to pilots involved in each type of
flying, the reasons for its occurrence are markedly different.
For the pilot of a light aircraft the most likely background
to a disorientation incident or accident is flight into weather
conditions for which the pilot has inadequate instrument
flying skills to maintain control of the aircraft. In commer-
cial flight, accidents are rare and in those few that involve
disorientation, a variety of factors can be identified. These
include failures in interaction between the flight crew
(cockpit resource management), deviation from standard
operating procedures, fatigue, overconfidence and flight
into severe weather conditions. The helicopter pilot, in
exploiting the versatility of the aircraft may be operating
over unfamiliar terrain, near the ground. The military fast
jet pilot is often called upon to push the aircraft to the limit
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 The relationship between spatial disorientation and illusions of flight  283
of its capabilities, often flying in difficult weather condi-
tions, in cloud or at night and in circumstances where small
errors in aircraft attitude can have disastrous consequences.
It is not surprising that the majority of incidents and acci-
dents attributable to disorientation occur in military flying
or that it is in this area that most surveys of disorientation
and research into its mechanisms have been carried out.
THE RELATIONSHIP BETWEEN SPATIAL
DISORIENTATION AND ILLUSIONS OF
FLIGHT
When a pilot makes an error in the attitude or spatial posi-
tion of the aircraft the pilot is said to be disorientated and
to have suffered an illusion. The term ‘illusion’ is wide-
spread throughout the literature on spatial disorientation
(SD) and the nature of the underlying illusion has tended
to form the basis of classification of disorientating in-flight
events. An incorrect interpretation of sensory information,
which is the definition of an illusion, can often be recog-
nized as an underlying feature of a disorientation episode.
However, it is important to realize that an illusion is not
synonymous with spatial disorientation. In fact, the term
‘illusion’ may serve to confuse the issue of spatial disori-
entation (Cheung 2013). A pilot in describing a disorienta-
tion incident does not use the term. This became evident
from a survey in which military pilots were asked to give
an account in their own words of events in flight during
which they had become confused about the attitude or spa-
tial position of the aircraft or had suddenly become aware
that the aircraft was not in the attitude they expected it to
be. It was considered that a survey of this type would give
a truer picture of the functional significance of the disori-
entating aspects of flying. A significant finding was that in
accounts of over 300 incidents the word ‘illusion’ was men-
tioned only once, and then only in that pilot’s retrospective
assessment of the incident. Though to an outside observer
a disorientated pilot has suffered an illusion, it must be
concluded that a pilot who experiences a disorientating
incident is only retrospectively aware of it having been an
illusion; at the time, the incident is a mistaken reality. This
finding has implications for the way in which pilots should
be taught about spatial disorientation.
To be aware of an illusion requires a simultaneous
appreciation of the deception and the reality. A pilot can
be aware of an illusion without necessarily being disorien-
tated. It could even be argued that once a disorientated pilot
becomes aware of the illusion, they are no longer disorien-
tated. The recognition of an illusion in flight may simply
indicate an awareness of the potential of that circumstance
to lead to disorientation. This is suggested by the conclu-
sion of an illusion-based disorientation survey which found
that ‘pilots who had received inflight SD training reported
more episodes of SD than those who had not participated
in this training’ (Holmes et al. 2003). It is hardly likely that
in-flight training had increased the incidence of disorienta-
tion. It is more likely that ‘episodes of SD’ in this context
K17577_C017.indd 283
refers to a pilot’s recognition of circumstances in flight that
might lead to disorientation.
A truly disorientated pilot often cannot say, even retro-
spectively, what illusion they suffered. This was highlighted
by an unpublished survey of 100 pilots who were asked to
report their most recent experience of disorientation and
its impact on flight safety. In four of the five reported inci-
dents in which flight safety was considered at risk, the pilots
were unable to say what illusion they had suffered. In many
instances of unrecognized disorientation the aircraft con-
tinues to feel level despite a potentially dangerous change in
roll or pitch attitude that has occurred at a rate that was too
low for the pilot to sense. The absence of any alerting sensa-
tion from an inadvertent deviation from the intended flight
path is rarely described as an illusion.
The presentation of disorientation
Spatial disorientation is concerned with the way in which
the flight environment can deceive a pilot, either because
the visual environment is degraded or obscured, or because
the force environment is altered by the dynamics of the air-
craft. To the pilot, disorientation presents itself in just one
of two ways. Either there is a sense of confusion about the
attitude of the aircraft on account of deteriorating visual
information or the presence of conflicting sensations which
have to be resolved by attention to a reliable source of ori-
entation information, usually from the aircraft attitude
indicator. This is termed recognized, or Type II, disorienta-
tion. Alternatively, there is an unperceived deviation of the
aircraft from the intended flight path which may only be
resolved by the pilot’s abrupt realization that the aircraft is
no longer in the attitude or position that it was expected
to be, termed unrecognized, or Type I, disorientation. It is
unsurprising that unrecognized disorientation poses the
greater risk to flight safety and that at some point the orien-
tation error has to become recognized if an accident is to be
avoided. Sadly, that does not always happen.
Some authors consider that those incidents in which pilots
experience disorientation of an overwhelming intensity
should be classified as Type III, or incapacitating, spatial dis-
orientation. However, the addition of incapacitating disori-
entation in this classification is questionable as it is based not
on the nature of the pilot’s perception but on the behavioural
consequences of the disordered perception. In those rare
instances in which pilots are incapacitated by spatial disori-
entation, they are aware of their difficulties and are therefore
suffering from recognized, or Type II, disorientation.
The classification of a disorientation
incident/accident
UNDERLYING ILLUSION
Though not necessarily experienced at the time or correctly
identified by the pilot, it is often possible, retrospectively, to
determine the illusion that formed the basis of the incident
or accident. However, this may not always be easy. Also, the
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 284  Spatial orientation and disorientation in flight

identification of an illusion often fails to reflect the underly- Table 17.1  Spatial disorientation – associated factors
ing complexity of many incidents.
Environment
Illusions in flight can be classified according to their
physiological origin. Some illusions are visual in origin, Cloud
others can be linked to the function of the vestibular system Night
in its capacity to sense angular motion through the semi- Haze – goldfish bowl conditions
circular canals or linear motion or tilt through the otolith Dazzle
organs. There is an important neurological link between Featureless terrain – snow, desert, sea
the vestibular and visual systems, as a result of which, False horizons
there are related visual illusions that have a vestibular basis. Unexpected scale
Consequently, vestibular-based illusions can be separated Manoeuvre
into those that are seen and those that are felt or sensed
non-visually. They can also be separated into those in which Turns – high G, low level
the non-visual element is based on the semicircular canal Low-level abort/go-around
sensation of rotation and those in which it is based on input Takeoff into cloud or at night
derived from the cutaneous, muscle stretch and otolithic Black hole approach to land
sensors of linear accelerations that give a sense of the gravi- Missile evasion
tational vertical. This leads to four categories: Use of night-vision goggles (NVGs), forward-looking
(1) Somatogravic effects relate to the forces that gener- infrared (FLIR) displays
ate the non-visual sense of the vertical. (2) Somatogyral Aerobatics/spinning
effects relate to the non-visual sensation of rotation. These Bunt manoeuvre – low/negative G
effects can result in a corresponding change in appearance Helicopter snow/desert landing-whiteout, brownout
of the visual scene termed (3) oculogravic, an apparent tilt Pilot
or slope, and (4) oculogyral, an apparent rotation. (The term
‘effect’ is used when considering the underlying physical Training – instrument flying
phenomenon; the term ‘illusion’ refers to the consequent Distraction – navigation, radiotelephone (R/T), weapons
misperception by the pilot.) systems, in-cockpit emergency
High arousal – coning of attention, instrument scan
CAUSAL FACTORS breakdown
A further way in which a disorientation incident or accident Low arousal – boredom, fatigue
can be analysed is to identify the contributory factors that Intercurrent illness – upper respiratory tract infection
may have predisposed the pilot to become disorientated. (URTI), gastrointestinal (GI) upset, etc.
These may be grouped in terms of the environmental factors, Intoxication – fumes, alcohol, drugs
those that relate to the manoeuvre, factors associated with Life stress – arguments, financial/family worries
the pilot and those that relate to the aircraft. Table 17.1 lists Aircraft
some of the factors to be considered within each of these
Equipment malfunction – loss of information, e.g.
groups. It is also of interest to know what alerted the pilot to
airspeed, attitude
his/her disorientation.
Instrument design – size, ambiguous symbology (HUD)
TYPE OF DISORIENTATION Cockpit ergonomics – instrument layout, position of
Was the incident to be classified as unrecognized (Type I) controls, switches, etc.
or recognized (Type II)? For how long had the orientation Alerting factors
error remained unrecognized? View of the ground
Instrument scan
CONSEQUENCE
Ground proximity warning
It may be useful to consider the nature of the error that Other crew member – expletives from the navigator
resulted from the disorientation. Was the error primarily in
the roll or the pitch attitude of the aircraft? Was there an
inadvertent height loss? Or was there no significant devia- VISION AND SPATIAL DISORIENTATION
tion from the intended flight path, suggesting that this was
a recognized disorientation in which any confusion had Flying an aircraft is an inherently visual activity. Good
rapidly been resolved? Attitude errors are, however, often foveal vision is required for object recognition; periph-
inter-related. For example, an inadvertent roll attitude error eral vision is important to maintain stability and orienta-
can cause the aircraft to adopt a nose-down attitude with a tion and for the detection of movement. To an earthbound
consequent loss of height. A further consequence to be con- individual, the visual scene is generally earth stable and
sidered is the degree to which the disorientation incident detailed. Within this detail are multiple visual cues to self-
was a threat to flight safety. orientation in the form of verticals and horizontals and

K17577_C017.indd 284 18/11/2015 14:11


objects of known size that give a sense of scale. Much of this
visual detail is retained in low level flight, together with the
added pleasure of gaining a new perspective on the world.
However, even when flying at 500 feet, the visual sense of
speed over the ground is much reduced and this perception
continues to diminish with increasing altitude. Pilots who
are used to flying at low level in fast jet aircraft, on transfer-
ring to a lower performance aircraft, may find themselves
flying too low in an attempt to achieve their accustomed
sense of speed over the ground.
As the height above the ground increases, ground fea-
tures lose visual detail and appear increasingly two dimen-
sional. The pilot’s decisions about aircraft orientation
are based on increasingly restricted visual information.
Eventually, the one remaining external visual cue to air-
craft attitude may be the line of the horizon or perhaps the
lights of an oil platform that a helicopter pilot is approach-
ing on a dark cloud-covered night. A pilot has to be par-
ticularly alert to the possibility of confusion when visual
conditions are deteriorating, either from increasing haze
or at dusk or, more abruptly, with inadvertent cloud pen-
etration. With abrupt loss of external vision there may be
a delay before an inexperienced pilot transfers attention to
attitude instruments during which time the aircraft may
have departed significantly from its intended flight path
and the attitude indicator may be difficult to interpret
or believe.
False horizons
Pilots are taught to use the position of the external hori-
zon on the windscreen as a means to maintain level flight.
Because of the lack of redundancy in visual information, an
excessive reliance on this one orientation cue can give rise
to error. The horizon may be rendered indistinct by haze. A
distant bank of cloud may suggest a horizon that is signifi-
cantly below the true horizon.
During a rapid descent to low level over the sea
I was aware that the cloud was not ‘coming up
to meet me’ as expected. The ‘cumulus’ cloud
was in fact a bank of sea fog sitting at around
200  feet. Thankfully, meticulous height checks
from both cockpits prevented an embarrassing/
fatal outcome.
Other false horizons are generated by sloping cloud tops,
by mountain ridges and, at night, by lines formed by cul-
tural lighting, for example, along a coastline or a motorway.
A sloping false horizon would not be so convincing were it
not for the fact that, if the pilot banks the aircraft to align
the wings with what appears to be the horizon, the aircraft
enters a gentle turn and continues to feel level.
Although low-level flight generally offers good visual ori-
entation cues, there is little margin for attitude errors that
may arise when a pilot is distracted either by something
within the cockpit or by searching the sky for the presence
K17577_C017.indd 285
Vision and spatial disorientation  285
of another aircraft. The problem is particularly acute when
executing turns at low level when the need for good look-
out conflicts with the requirement for accuracy in flying
the aircraft.
I was leading a pair of aircraft with a third aircraft
acting as a bounce. I was solo and the sortie was
flown at low level. Conditions were perfect with
little or no cloud and good visibility. I gained tally
on the bounce aircraft attempting to attack my
pair of aircraft and countered towards it. I was
sharing the lookout between the bounce over
my left shoulder and the terrain ahead of my air-
craft. Approximately 20 seconds into the coun-
ter, whilst looking over my shoulder, I became
aware of ground-rush in my peripheral vision.
Looking forward, I was about 10 to 15 degrees
nose-down in a hard left turn. I aggressively
recovered the aircraft to straight and level flight
at 250 feet (using approximately 7 to 8 G) and
then continued fighting. Only afterwards did
I realize how lucky I had been. Neither of the
other aircraft had noticed the proximity of my
aircraft to the undulating terrain. I suggest that I
had become target (bounce) fixated.
There are, however, circumstances in which the visual
cues at low level, though clearly visible, are impoverished or
deceiving. It may be difficult to judge height over the ground
when flying over featureless terrain such as snow or sand or
over open water where the apparent size of waves is a poor
indicator of separation. The pilot of a float-plane attempt-
ing to land on the glassy surface of a lake may be obliged
to set up a descent rate of no more than 150 feet per minute
and wait until the aircraft touches down on the water rather
than risk rounding out too soon or impacting the water at
too high a descent rate. A similar technique may be required
by a pilot when landing on featureless snow.
Other problems arise from the scale of ground features.
A pilot who mistakes conifer saplings or stunted trees for
fully grown trees may find the aircraft to be closer to the
ground than intended. A helicopter pilot described the
following incident.
We had been flying at low level down a lake in
Wales and then over a forest. Beyond the for-
est we crested a ridge and came upon what
appeared to be a very large sheep! Only then
did we realize how close we were to the ground.
On re-flying the route, we discovered the pine
trees, that we had assumed were 60 feet, were
only 8 to 10 feet high.
There can also be problems in certain sunlight condi-
tions when the distant terrain masks the contour of more
imminent high ground that is lying in the flight path of
the aircraft.
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 286  Spatial orientation and disorientation in flight
While flying a navigational turn during an evasion
sortie, the pilot and navigator failed to spot a hill
in the foreground that blended into a larger hill
beyond. The low height warning sounded and
the aircraft was levelled and climbed away. The
lowest radar altimeter height seen was 170 feet.
(Minimum Separation Distance 250  feet, radar
altimeter bug set at 225  feet). Causes of this
incident were insufficient contrast between fore-
ground and mid-distance objects due to sparse
tree cover and snow. Both aircrew were concen-
trating on lookout for the bounce aircraft.
Similarly, a snow-covered ridge may become invisible
against a background of uniform brightly-lit cloud. This
last scenario was a contributory factor in the accident in
1979  when a passenger aircraft crashed on the slopes of
Mount Erebus in Antarctica (New Zealand Air Line Pilots’
Association 2009).
In search and rescue operations, helicopter pilots may
be required to maintain hover over a visual background of
moving waves. In a similar fashion, the rotor downdraught
can create a moving wave-like appearance when hover-
ing over crops or grassland. Such conditions call for close
coordination between the pilot and the rear end crew to
maintain accurate aircraft position. There is an added risk
to helicopters when landing on snow or dusty terrain that
the pilot may become unsighted at a critical phase by snow
or dust blown into the air by the rotor downwash – so called
‘whiteout’ or ‘brownout’.
NIGHT FLYING
Aircraft flying at night operate under instrument flight
rules (IFR), which require pilots to hold a current instru-
ment rating. However, in clear weather the night flying pilot
is very likely to fly using vision of the external world with
frequent instrument cross-checks. At night, what remains
visible to the pilot outside the aircraft depends on many
factors such as the presence of moonlight or ground lights
from towns and cities and on the prevailing weather condi-
tions. However, even in apparently clear conditions, there
may be no distinct horizon and, in consequence, starlight
and points of light on the ground may become confused.
I was descending from medium level to low level
to conduct a detail at a bombing range. It was
twilight with good visibility and there was a thin
broken cloud layer at about 2000  feet. After a
safe level off at 500  feet and while entering a
positioning turn for the range I became imme-
diately disorientated, unable to determine visu-
ally which way was up. The aircraft descended
approximately 200  feet before I locked on to
head-down instruments and climbed away. On
the subsequent pass we determined that we
had over-flown a number of fishing vessels and
had almost certainly become confused between
K17577_C017.indd 286
stars and their lights. I believe the good weather
had caught me between VFR (visual flight rules)
and IFR (instrument flight rules) flying. Spatial
disorientation training was useful. It reinforced
the need to get on to instruments if in any doubt.
As mentioned earlier, lines of light, for example from
road lighting or along a coastline, may create false horizons.
A particular instance of this can be experienced by a pilot
approaching at an angle to an inhabited coastline. Because
of a reduced sense of perspective at night, the border
between unlit sea and the lights onshore forms an oblique
line across the cockpit canopy which can be misinterpreted
as being horizontal and lead to an error in the perception of
roll attitude.
In the absence of a visual context, stationary isolated
lights may appear to be in motion, which can lead to misin-
terpretation of their true nature. This phenomenon, known
as autokinesis, is particularly evident when there are iso-
lated flashing lights. The effect is probably the result of ocu-
lar drift occurring in the dark intervals between flashes, so
that the next flash falls on an adjacent portion of the retina,
which the brain interprets as movement of the light source.
In military operations, there are important tacti-
cal advantages to be gained from the use of night-vision
devices. However, the potential increase in safety that such
devices might afford is offset by the increased hazard asso-
ciated with the night-time operations that they enable.
Night-vision goggles amplify the residual light to create a
monochromatic image of the view ahead. However, they
restrict the field of view to about 40 degrees and so deprive
the pilot of important peripheral visual orientation cues.
The image presented to the pilot is of lower resolution and
its single green colour leads to problems with depth percep-
tion and the estimation of the rate of closure on a target or
another aircraft. In helicopter operations the spatial disori-
entation accidents associated with the use of night-vision
goggles have most frequently involved undetected drift or
descent from the hover or controlled flight into terrain or
water. Aircrew are sometimes tempted to use night-vision
goggles at light levels below the safe minima with conse-
quent degradation of the image they provide. Other night-
vision devices can operate in the absence of visible light by
generating a visible image using the thermal radiation from
ground features. Contrast within the image is determined
by the amount of infrared radiation from different objects
in the field of view. This does not remain constant over
time because it is dependent on the amount of previously
absorbed solar radiation and the rate at which it is re-radi-
ated during the night. More so than with daytime flying,
the pilot has to exercise particular care during flight over
featureless terrain when using these devices.
Approach and landing
A visual approach to land an aircraft demands a pilot’s
skill and judgement and, in certain circumstances, can be
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 Vision and spatial disorientation  287

highly demanding for even the most experienced pilots. It
is not surprising that many aircraft accidents occur during
this phase of flight. During the approach, the pilot needs
simultaneously to control the aircraft attitude, alignment
with the runway (which may not be straightforward in a
strong crosswind), the power setting for the desired air-
speed and descent rate. In the final stages immediately prior
to touchdown the pilot has to round out in order to reduce
the descent rate. At major airfields the pilot is assisted by
Precision Approach Path Indicators (PAPIs) adjacent to the
runway threshold, but, in their absence, pilots use a variety
of visual cues to judge their approach path: the distant hori-
zon, the scale and visual detail of objects on the ground,
the increasing streaming effect in peripheral vision as the
aircraft nears the ground. One important cue is the chang-
ing shape of the runway from the small, almost rectangular,
shape viewed at distance to a truncated conical shape whose
base gradually widens as the aircraft approaches the runway
threshold. Glideslopes are typically three to four degrees.
At these small angles, even a gently sloping runway can
give an appearance that might suggest to the pilot that the
approach was too high or too low (Figure  17.1). A similar
runway appearance suggesting a high approach is given by a
runway that is narrower or longer than runways with which
the pilot is more familiar and the opposite effect from one
that is wider or shorter.
Other visual cues arise from ground features below the
aircraft on the approach or the distant terrain beyond the
runway. If the runway is on higher ground than the terrain
on the approach, the pilot may think he is too high on the
approach only to find that the aircraft is too low as it nears
the runway threshold. A similar tendency towards too low
an approach can occur when there is an upward slope of the
ground beyond the runway. These effects on aerial perspec-
tive are more of a problem in degraded visual conditions
and particularly when flying at night when the perception
of depth provided by detailed objects on the ground may
be replaced by a pattern of lights whose relative distance is
much harder to estimate.
Atmospheric conditions that reduce visibility, such as
fog, rain, smoke, haze or snow, can lead to overestimation
of distance. In such conditions, the runway may appear to
be further away than its true distance, and the pilot may
also think that the height of the aircraft above the ground
is greater than, in fact, it is. Conversely, in, for example,
the clear bright conditions of a high-altitude airfield when
atmospheric attenuation is less than that which the pilot has
commonly experienced, distances may be underestimated
and lead to a premature descent. Other aspects of the local
topography may also lead to errors. In an approach over
featureless terrain, snow-covered ground or a smooth sea,
there is a lack of visual texture and other visual cues that
would allow a reliable perception of height.
Darkness degrades or eliminates many of the visual
cues employed during daytime approach and landings.
Most accidents during this phase of flight occur at night
and, characteristically, the pilot makes a low approach and
risks impacting the ground short of the runway. At night,
the pilot must rely on the limited visual cues provided by
runway and approach lights; the perceptual task is made

Is this approach...
...just right?

...too high?

...too low?
c

Or does the runway slope? Or is it wider or longer than usual?

Figure 17.1  Runway appearances. The changing shape of the image of the runway provides a pilot with visual confirmation
that the aircraft is on the correct approach path. Too high an approach elongates the appearance of the runway, too low
shortens it. However, not all runways are built on level ground so that a similar difference in appearance may be evident
from an aircraft on the correct glideslope depending on whether the runway slopes upwards or downwards. The appear-
ance of the runway on the approach is also affected by variations in its length and width.

K17577_C017.indd 287 18/11/2015 14:11

 288  Spatial orientation and disorientation in flight
even more difficult if the approach is over water or terrain
without lights, the so-called black-hole approach. In simu-
lations of a black-hole situation, in which only runway and
approach lights were visible, it was found that pilots over-
estimated their approach angle, on occasions by a factor of
two, and made a low approach.
The particular danger of disorientation during the
approach and landing phase of flight lies in the narrow tem-
poral and spatial limits within which the aircraft must be
controlled. There is little time and little altitude for errors
to be corrected, and a decision to abort the landing and go
around must be anticipated and correctly executed if an
accident is to be avoided. As summarized by Perrone (1984),
‘Humans are not very good at judging the slant of long, nar-
row, rectangular surfaces. Pilots must learn to believe their
instruments, not their eyes’.
Instrument flying
In daylight with clear external visual conditions, pilots
gain the information they need about the aircraft attitude
from looking outside the aircraft. In these circumstances,
they are said to be flying in visual meteorological condi-
tions (VMC). In cloud, at night or when visual conditions
deteriorate to the extent that they cease to give an unam-
biguous attitude reference, they are obliged to transfer to
the aircraft instruments and are said to be flying in instru-
ment meteorological conditions (IMC). The most impor-
tant of these instruments is the attitude indicator which
is generally placed centrally on the instrument panel in
front of the pilot, though may be less prominent in air-
craft in which the head-up display has become the pri-
mary attitude reference. In older aircraft, in which there is
a separate instrument for each function, the flight control
instruments are typically laid out in the form of a T with
the airspeed indicator to the left of the attitude indicator,
the barometric altitude to the right and the gyro com-
pass below. With this configuration, the pilot has to set
up a radial scan pattern centred on the attitude indicator
to check in turn the aircraft altitude, airspeed and head-
ing, returning to the attitude indicator between each radial
visual excursion. At other times, the vertical speed indica-
tor and the turn and slip indicator need to be incorporated
into the scan pattern. Good instrument flying takes many
hours to learn and constant practice to maintain. The use
of foveal vision to interpret the symbolic representation of
the horizon in the attitude indicator is an unnatural way of
assimilating orientation information, a function normally
performed by peripheral vision.
With the advent of electronic flight instrument displays,
it became possible to group multiple functions on to a single
screen. The primary flight display screen typically incor-
porates a central attitude display with airspeed shown on a
vertical scale to the left, pressure altitude and vertical speed
on a similar scale to the right and heading on a horizontal
scale below it (see Figure 48.10). While this arrangement
reduces the need to make such large changes in the direction
K17577_C017.indd 288
of gaze, it is still necessary to assimilate the multiple pieces
of information in a systematic manner.
The way in which aircraft attitude is displayed has long
been the subject of debate (Johnson and Roscoe 1972). There
are two principal alternatives known as the ‘inside-out’ and
the ‘outside-in’ displays. The inside-out display, also known
as a moving horizon display, is the standard attitude display
in all western-built aircraft. It shows an aircraft symbol that
remains fixed with respect to the aircraft. Behind it is a line,
blue above and brown below, which represents the horizon
and is free to move so that it remains aligned with the true
horizon when the aircraft rolls and pitches. This type of dis-
play behaves as if it were a forward-facing hole in the aircraft
through which the pilot could see the true horizon. While
this might seem a logically correct way in which to convey
attitude information to the pilot, to the untrained it tends
to be perceptually incorrect. Its very name, a moving hori-
zon display, betrays the dilemma. The pilot tends to perceive
the aircraft to be the stable environment against which the
representation of the outside world is seen to move. This is
probably because, when flying on instruments, the visually
stable cockpit environment occupies much of the orienta-
tion-sensing peripheral ambient vision while the horizon
is represented only in the central focal vision, and also
because, whatever its attitude, the aircraft continues to feel
level. A pilot who responds to an unexpected roll attitude
error by mentally attempting to rotate the representation of
the horizon in the attitude indicator back to its level posi-
tion will do the reverse of what is required. This so-called
roll reversal error has been held responsible for a number of
accidents (Roscoe 1997).
The alternative configuration for the attitude display, the
outside-in or moving aircraft display, has been widely fitted
to Russian commercial and military aircraft. Here, a repre-
sentation of the aircraft moves with respect to a horizon line
that remains transverse with respect to the aircraft cockpit.
So, for example, in an aircraft banked to the left, whereas a
moving horizon display would show a horizon that appears
tilted to the right, a moving aircraft display will show an
aircraft symbol tilted to the left. Experiments have indicated
that while pilots can be trained to use either type of display,
naïve individuals can assimilate and respond to aircraft atti-
tude information more rapidly and reliably from the mov-
ing aircraft display (Ponomarenko 2000). In consequence
of this research, a number of Soviet military aircraft were
fitted with moving aircraft displays.
A commercial aircraft crashed into the sea about
three minutes after takeoff in the dark. To attain
the desired outbound heading and avoid high
ground, the captain, who was the handling pilot,
was instructed to make a 270  degree climbing
turn to the left over the sea. He duly established
the aircraft in a 30 degree banked turn to the left.
However, he must have become distracted as,
over the next 30 seconds, the bank angle slowly
decreased and the aircraft continued to roll past
18/11/2015 14:11

wings-level until it was banked 30  degrees to
the right. At this point, the co-pilot alerted the
captain that the aircraft was now turning to the
right. The captain evidently had some difficulty
in understanding the situation as his next action
was to bank the aircraft a further 30 degrees to
the right, as a consequence of which it became
impossible to recover the aircraft in the available
height and it crashed into the sea. It is proba-
bly of significance that the captain was an ex-
military pilot who had accumulated many hours
flying Soviet-built aircraft fitted with a moving
aircraft attitude display.
The force environment of flight
All pilots should be made aware at an early stage in their
training, even before they take to the air, of the precept: ‘You
cannot fly an aircraft by the seat of the pants’. This means
that if external vision is lost, it is not possible to maintain
control of aircraft attitude simply by the feel of the aircraft.
Why this should be so involves an understanding of the
other major cue to orientation, the force environment, and
how in flight this is generated by the aerodynamics of the
aircraft. With the loss of a clear external visual environment
a pilot unconsciously may accord more perceptual weight
to the spatial reference frame provided by the force envi-
ronment. An appreciation of the force environment of flight
and the way in which it deceives the pilot is fundamental to
an understanding of the mechanism whereby many forms
of disorientation occur.
Newton’s third law states that for every force there is an
equal and opposite reaction. This means that all forces are
‘interactions’ between different bodies; there is no such thing
as a unidirectional force or a force that acts on only one body.
The downward force that we experience as the force of grav-
ity only exists as a consequence of the upward force exerted
by the floor. This upward force acting on the body gives the
perception of weight and defines what we sense as the verti-
cal. During running and jumping when both feet are off the
ground the body is transiently weightless. It was the realiza-
tion that without the support of the ground, objects would
be weightless that led Einstein to formulate his ideas on the
equivalence of gravitational and accelerative forces and ulti-
mately to his General Theory of Relativity.
In flight, the upward force of the ground is replaced by
the upward aerodynamic force acting on the wings. This
force, known as lift, is related to wing area and is propor-
tional to the square of the speed through the air and, up to
a certain limit, the angle of attack – the angle that the wing
makes relative to the airflow. Both airspeed and angle of
attack are under the control of the pilot through the throttle
and the fore and aft position of the control column. As a
consequence, it is the pilot that determines the weight of the
aircraft and the sense of gravity experienced by the occu-
pants, not only in terms of its intensity but also, by changes
in aircraft attitude, its direction. As well as generating
K17577_C017.indd 289
Vision and spatial disorientation  289
weight, the effect of aerodynamic lift is to impose on the air-
craft its own force vertical which is not necessarily aligned
with earth vertical. The mistaken assumption by a pilot that
what is felt as gravity is truly vertical underlies a significant
number of disorientation incidents and accidents.
The effect of the gravitational attraction of the Earth
imposes the same physical constraint on the pilot of an
aircraft as on earthbound individuals; the component of
force acting in the Earth vertical direction must average
over time to the static weight of the body, whether running,
jumping, free-fall parachuting or flying an aircraft. Any
period for which this component of force is decreased must
be compensated by a corresponding period of increased ver-
tical force. The only difference in this respect between air-
borne and earthbound man is in the longer time period for
which this constraint can either be deferred or advanced.
Given sufficient height above ground, an aerobatic pilot can
enjoy a degree of gravitational freedom that is denied mere
earthbound mortals.
An example of the extent to which the requirement to
generate a force of 1 G in the Earth vertical direction can be
either anticipated or deferred is provided by the parabolic
flight manoeuvre carried out in modified commercial air-
craft in order to give individuals the experience of weight-
lessness. From level flight at an airspeed of 350 kt the aircraft
is pulled up into a 45 degree climb. In order to do this the
pilot has to increase the lift force to 1.8 G. Once the climb
angle is established, the pilot pushes forward on the control
column until the aircraft G meter reads zero. At this point,
there is no longer any aerodynamic lift on the wings and the
aircraft and its occupants become weightless. This period of
weightlessness can be maintained for about 25 s by which
time the aircraft has assumed an attitude of 45 degrees nose
down. The pilot then pulls out into level flight and, to do so,
has again to generate a lift force of 1.8 G. It is as if the pilot
had a gravitational credit card (Figure 17.2). The 25 s period
of zero G is, in effect, paid for by the preceding and subse-
quent periods of increased G so that, averaged over the 60 s
period of the whole manoeuvre, the lift force is exactly 1 G.
A further force on a fixed wing aircraft that acts in the
long axis of the aircraft approximately at right angles to the
lift force comes from the thrust of the engines or the retard-
ing effect of the airbrakes. Though this force contributes to
problems with spatial orientation during changes in air-
speed, its intensity in most aircraft is substantially less than
that of the lift force required to oppose the effect of gravity
(Figure 17.3a). In a helicopter, there is no similar longitudi-
nal force. The force that both lifts the aircraft off the ground
and drives it forwards (or backwards or sideways) is gener-
ated by the main rotor and this force to a close approxima-
tion always acts vertically upwards relative to the fuselage
of the helicopter, whatever the aircraft attitude with respect
to the surface of the Earth (Figure  17.3b). In a fixed wing
aircraft, if there is no change in longitudinal thrust from the
engines, the lift force will continue to act vertically relative
to the aircraft even if it adopts a nose-down or nose-up atti-
tude (Figure 17.3c). This is considered in more detail below.
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 290  Spatial orientation and disorientation in flight

34000 The somatogravic effect

32000 The foregoing examples form part of a group of disorien-
45° Nose high 45° Nose low tating problems known as somatogravic effects or illusions.
30000 Specifically, the term ‘somatogravic’ refers to a sensation of
Altitude, feet

weight that is acting in a direction that is no longer vertical

28000
with respect to the Earth. Standing on two feet is inherently
350 Kias 350 Kias unstable and humans have to be particularly sensitive to the
26000
need to align the body with the sensed vertical in order to
24000
remain upright. It is perhaps not surprising, therefore, that
1.8g Zero-g 1.8g the direction of weight redefines the perceived vertical and
leads to this illusion.
0 20 45 65 The somatogravic effect is important for two reasons.
Manoeuvre time, seconds First, it is involved in almost every aircraft manoeuvre and
provides an explanation of why, in the absence of external
Figure 17.2  The ‘gravitational credit card’ of flight. This vision, a pilot can readily be deceived by what he feels the
parabolic flight manoeuvre is used to give the aircraft attitude of his aircraft to be. Second, it is an underlying fac-
occupants 25 seconds of weightlessness. This is achieved tor in many aircraft accidents. This effect is responsible for
by gaining gravitational credit of 1.8 G during the initial situations in which the aircraft continues to feel level despite
20-second period, overspending during the 25 seconds of being either in a banked attitude or pitched up or pitched
weightlessness, and repaying the debt during the 1.8 G of
down, and also situations in which the aircraft is felt to
the final 20 seconds. Over the course of the manoeuvre,
the aircraft will have exerted an average downward force be pitched up or pitched down to a greater extent than it
of 1 G in the Earth vertical direction. actually is.

Figure 17.3  The somatogravic effect – the non-visual sensations of aircraft attitude. In these diagrams the arrows represent the
magnitude and direction of the resultant force generated by powered fixed-wing aircraft and rotary wing aircraft during accel-
eration, constant velocity flight and deceleration. They indicate the direction that a pilot might feel to be the true vertical.
In the fixed wing aircraft (a), the resultant force is generated by the addition of two forces, the upward lift on the wings
and the inertial force resulting from a change in thrust to produce acceleration or deceleration in the line of flight. To the
aircraft occupants, the resultant force feels indistinguishable from the effect of gravity and therefore indicative of the
true vertical. In consequence, a powered aircraft when accelerating tends to feel more pitched up and when decelerating,
more nose-down than it actually is.
In the helicopter (b), the lift of the main rotor is the only source of force for both lift and forward acceleration or decel-
eration. Forward acceleration can only be achieved by putting the helicopter into a nose-down attitude. However, the
force from the rotor remains predominantly vertical with respect to the aircraft. In consequence, a helicopter feels to be in
a level attitude whether it is accelerating, at constant velocity or decelerating.
A fixed wing aircraft (c) can also feel to be in a level attitude if, without any change in engine thrust, the aircraft adopts a nose-
down or nose-up attitude (the inadvertent somatogravic effect). The change of attitude alone results in acceleration or decelera-
tion in the line of flight. This absence of sensation of any change in pitch attitude is similarly experienced by the pilot of a glider.

K17577_C017.indd 290 18/11/2015 14:11


In flight, by far the most frequent example of the somato-
gravic effect is provided by the level turn (Figure 17.4). To
change direction in flight the pilot puts the aircraft into
a banked attitude. The lift force continues to act at right
angles to the main wing and continues to generate a sense
of gravity that is vertical with respect to the aircraft, but this
force now serves two purposes. As with any force, the lift
force can be resolved into two components at right angles
to each other, one vertical and one horizontal with respect
to the Earth. If the aircraft is to maintain height, the Earth
vertical component must continue to be sufficient to oppose
the effect of gravity. At the same time, the horizontal com-
ponent will bring about the desired change in aircraft head-
ing. The overall aerodynamic force must, therefore, be
increased. However, for small angles of bank, this increase is
small and hardly perceptible. At a bank angle of 20 degrees,
typical of the maximum normally encountered in a com-
mercial aircraft in a level turn, this force is only 1.06 G, but
what the passengers perceive as gravity is now at an angle of
20 degrees to the true vertical.
R reference imposed by the aircraft. The horizon reference in
Turn
F
R Because any sensation of gravity in an aircraft is determined
G
Figure 17.4  The level turn. The aerodynamic lift on
the wings generates the weight force (R) acting down-
wards with respect to the aircraft. When the aircraft is
in a banked attitude, this force serves two purposes. It
maintains the aircraft at the same altitude and it causes
the aircraft to change heading. Force R can be resolved
into its two component forces, an Earth vertical force G,
which to maintain altitude has to equal the static weight
of the aircraft, and a horizontal force F to change head-
ing. The force R has to be somewhat larger than it would
be in level flight, but for small angles of bank, say up to
20 degrees, this increase is small. Whatever the angle of
bank, the force R tends to act vertically down through
the floor of the aircraft and gives the aircraft occupants a
continuing sensation of level flight.
K17577_C017.indd 291
Vision and spatial disorientation  291
In a more agile aircraft, a more rapid rate of turn is
achieved by banking the aircraft more steeply and increas-
ing the lift force on the wings (Figure 17.5). At 45 degrees
of bank, the lift force must be 1.4  G in order to create a
1  G component in the vertical direction to maintain alti-
tude. There is a corresponding horizontal force of 1  G to
change heading. At 60 degrees of bank, a level turn requires
2 G of lift force. At greater angles of bank, the requirement
for increased lift goes up more steeply. At a bank angle of
75  degrees, 4  G of lift is required to maintain height, at
80 degrees, nearly 6 G. With high G turns in agile aircraft,
the angle of bank becomes increasingly critical for the main-
tenance of height above the ground. Were the bank angle to
increase to 90 degrees, there would be no component of the
lift force, however great, to act in the vertical direction and
the aircraft would inevitably lose height.
If a pilot deliberately puts the aircraft into a banked atti-
tude from level flight they are likely to be aware of a sense
of rotation of the aircraft in roll. There may also be a sense
of lateral motion if the head is some distance from the axis
of roll rotation of the aircraft. These sensations act as con-
firmation of the pilot’s intentional control action. However,
the sensation of roll rotation is unusual as it is unaccom-
panied by any sensation of increasing tilt as would occur
in the static earthbound environment. Once in a banked
attitude, the aircraft will still feel level. Instead, the external
horizon will appear tilted relative to the vertical frame of
the attitude indicator will also appear to be tilted. However,
if a pilot, perhaps distracted by some task within the cock-
pit, inadvertently allows the aircraft to roll, a gentle rate of
roll rotation may remain undetected and the absence of any
sensation of being tilted confirms the erroneous percep-
tion that the aircraft is still in a level attitude. With good
external visual conditions, an unintended roll attitude error
is rapidly detected and corrected. However, if the aircraft
is flying in cloud, the unexpected evidence from the atti-
tude indicator might not be so immediately interpreted or
readily believed.
THE GRAVEYARD SPIRAL
by the position of the control column, the pilot could main-
tain a reassuring sensation of 1 G downwards through the
floor of the aircraft while inadvertently allowing the bank
angle of the aircraft to increase. At 60 degrees of bank, the
component of the lift force is only half what is required to
maintain level flight so the aircraft will begin to lose height.
At 90 degrees of bank, all of the 1 G of lift is acting to change
the aircraft heading and none of it to maintain height. The
aircraft will now, at least initially, be in free-fall, though it
may still feel wings level. Any increase in the bank angle
beyond this point will cause the lift force to augment the
effect of gravity in accelerating the aircraft towards the
ground and lead to a rapid descent. The loss of life from
this inadvertent manoeuvre has earned it the name of ‘the
graveyard spiral’.
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 292  Spatial orientation and disorientation in flight

AoB 0° 1G

AoB 45° 1.4G

AoB 60° 2G

AoB 70° 3G

AoB 75° 4G

Figure 17.5  The level turn at high turn rates. To achieve a high rate of turn the pilot banks the aircraft and increases the
lift on the wings (pulling G). If the aircraft is to maintain altitude during the manoeuvre, the lift force on the wings must be
sufficient to generate the required Earth vertical component. Consequently, the angle of bank and the necessary G force
are related. At high angles of bank, the bank angle becomes increasingly critical. Overbanking the aircraft without a cor-
responding increase in G force will allow the aircraft to descend.

I was undertaking a solo night navigation exer-
cise in training for my commercial pilot license.
After takeoff, I found the cloud base to be lower
than my safety altitude but hoped to be able to
climb through the cloud into clear skies. After
about 10 minutes, I was still in cloud so I decided
that I would abandon the exercise and turn back.
I put the aircraft into a 20 degree banked turn
and set about establishing a reciprocal heading
on my navigation equipment. Fortunately for
me, the aircraft had windows in the cockpit roof,
as, on glancing up, I suddenly became aware of
what I realized was a row of street lights - the air-
craft had now descended below the cloud base.
A glance at the altimeter and airspeed indicator
showed that I was in a spiral dive. I recovered
the aircraft as best I could using the visual hori-
zon, but with very little height to spare. I remem-
ber going into mild shock when two years later
I first told a colleague of what had happened. A
few seconds later and I might have been too low
to recover.
The somatogravic effect also occurs in the pitch axis
of the aircraft if there is acceleration in the line of flight
(Figure  17.6). The thrust required to generate acceleration
combines with the lift force on the wings to give a resultant
force that acts upwards and forwards. In consequence, the
equal and opposite force of weight is now directed down-
wards and backwards. As with the level turn, the direction
of the weight force gives a sense of the vertical which, if
directed downwards and backwards with respect to the air-
craft, would erroneously imply that it is in a nose-up attitude.
Correspondingly, if the aircraft is decelerating, the combined
effect of the retarding and lift forces generates weight that is
directed downwards and forwards implying a nose-down
attitude. In good visual conditions, a pilot has little difficulty
in interpreting the true situation as an acceleration or decel-
eration in the line of flight. However, in the absence of exter-
nal vision and a neglect of the attitude indicator, the induced
sensations of pitch-up or pitch-down can be very compelling.
Furthermore, in situations in which the external visual scene
is degraded to the extent that an object in the field of view
lacks any visual context, the pilot may erroneously inter-
pret the spatial position of the object in relation to the force

K17577_C017.indd 292 18/11/2015 14:11


Aircraft motion
and attitude
Constant
linear
speed
No acceleration
in line of flight
Acceleration
Increase
in speed
Inertial force
due to
R gravity (g)
acceleration
Resultant
Deceleration
Decrease
in speed
I Pitch
Force of
gravity (g)
Figure 17.6  The somatogravic effect in level flight. Forward acceleration is associated with a false sensation that the
aircraft is pitched up and deceleration with a false sensation of pitch down. These sensations can lead to errors of pitch
attitude in conditions where there are limited or absent external visual cues such as in cloud or at night.
frame of reference created by the aircraft. This visual effect is
known as the oculogravic effect or illusion (see below) and is
the visual counterpart to the somatogravic effect.
A type of aircraft accident that was recognized during
World War II became known as the dark night takeoff acci-
dent (Collar 1949) in which, after takeoff on a night with few
external visual cues, the aircraft was flown into the ground
at a shallow angle some distance beyond the end of the run-
way. The forward acceleration of a fixed-wing aircraft dur-
ing and after takeoff combines with the lift on the wings to
generate a net force that is no longer aligned with the verti-
cal and leaves the pilot with a sensation of a steeper climb
angle than is actually the case (Figure 17.7). The response of
the pilot may be to push forward on the control column in
an attempt to lower the nose of the aircraft. However, there
is unlikely to be any sensation of a reduction in pitch atti-
tude in response to this control action; there may even be a
sensation of an increase in nose-up attitude. This is because
a reduction in climb angle allows the aircraft acceleration
to increase and thus to intensify the illusory pitch-up sen-
sation at the expense of actual pitch attitude. As a conse-
quence, the pilot may continue to push forward on the
control column until the aircraft is in a nose-down attitude
accelerating towards the ground. Since its recognition, there
have been many examples of this type of accident, either at
night or following takeoff into cloud. It can also be a prob-
lem when, after a missed approach to land, often in bad
weather, the pilot is obliged to go around. This manoeuvre
involves an immediate increase in thrust from the engines
K17577_C017.indd 293
Vision and spatial disorientation  293
Perception of attitude, relative to true
vertical, by pilot
Of himself Of his aircraft
Up
Force of
gravity (g) G g
Down
Up
Pitch
up
I
I I
Force of g
G
R
R Down
Up
Inertial force
due to I I
down
R deceleration G g
Resultant R R
Down
which may leave the pilot with the reassuring sensation that
the aircraft is climbing when it is not. A similar situation
arises when low level flight in a military aircraft has to be
aborted on account of deteriorating visual conditions, low
cloud or failing light. This manoeuvre involves a rapid climb
to a safe altitude with full thrust applied to the engines. The
desire to correct what feels like an excessive pitch angle has
to be resisted in favour of what the aircraft instruments are
saying. A further disconcerting sensation for the pilot can
arise from the curved flight path (bunt) as the aircraft, pos-
sibly still at full thrust, levels off at a safe altitude. With the
aircraft assuming a more nose-level attitude, its forward
acceleration will increase and if the pilot pushes forward too
vigorously on the control column, the lift force on the wings
may become negative, i.e. acting downward, so that the
resulting sensation of weight will now be directed upwards
relative to the aircraft, and may give the pilot a false percep-
tion that the aircraft has become inverted.
A catapult launch from an aircraft carrier involves a for-
ward acceleration of up to 4 G and exerts a powerful sensa-
tion of pitch-up. For this reason, the pilot is required not
to touch the control column until the aircraft is clear of
the deck in order to avoid an inappropriate control action
(Cohen et al. 1973).
The corresponding somatogravic effect from decelera-
tion of the aircraft leads to an illusory sensation of pitch-
down. An inappropriate nose-up response by the pilot is
possibly less dangerous but the consequent loss of airspeed
will reduce aerodynamic lift and may lead to a stall.
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 294  Spatial orientation and disorientation in flight

(c) (b) (a)

Figure 17.7  The somatogravic effect in the climb. An aircraft accelerating in the climb feels to the pilot to be climbing
more steeply than intended (a). If the pilot pushes forward on the control column, it will not feel to have had the desired
effect. As a result of this inappropriate control action, the aircraft may no longer be climbing (b), and then may begin to
descend (c). In the lower aircraft pictures the inertial forces generated by the engine thrust and the decreasing lift from
the wings are shown with the resultant force vector in bold. In the absence of visual evidence of aircraft attitude, the pilot
may perceive this resultant force as indicating the true vertical. The consequent sensation of unchanging or even increas-
ing aircraft pitch attitude would be as shown in the upper three aircraft pictures.

Low level climb-out at night, scattered cloud
at 2000  to 4000  feet, limited moonlight, night
vision goggles worn. Whilst climbing out VMC
approximately 15  degrees nose up, I was dis-
tracted by a cockpit minor emergency. When I
looked back at the head-up display the attitude
was 40 degrees nose-up. I felt I was still in a shal-
low climb. However, instruments were trusted
and having bunted back to 20 degrees nose-up,
the body readjusted to this attitude.
An almost identical situation led to the opposite outcome
in the following incident.
Low level abort, reducing cloud base. Low-
level abort carried out, however flew incor-
rect technique (flew head-up not head-down).
Experienced severe pitch-up resulting in a bunt
to 20 degrees nose-down. Second more severe
abort then carried out head-down. Navigator
was totally unaware of risk at any time.
Experiments carried out in the laboratory and in flight
(Graybiel et  al. 1979) suggest that the perceived tilt pro-
duced by linear acceleration is generally an underestimate
of what would be predicted by a trigonometric analysis of
the forces involved. The sensation of pitch-up tilt produced
by forward acceleration in level flight does not involve
any actual pitch rotation. The absence of a confirmatory
neural signal from the semicircular canals of the inner
ear to indicate rotation may provide an explanation for
the underestimate.
The somatogravic effect in the aircraft pitch axis thus
described often occurs in association with deliberate
manoeuvres initiated by the pilot and is therefore amenable
to training programmes that emphasize the circumstances
in which this effect may lead to inappropriate control
actions. There is, however, what may be termed an inadver-
tent somatogravic effect in which a pilot, distracted while
flying straight and level, inadvertently allows the nose of
the aircraft to drop (Figure 17.3c). In this attitude, the air-
craft will accelerate and the consequent sensation of upward
pitch will negate the actual pitch-down of the aircraft and
leave the pilot with the sensation that the aircraft remains
straight and level.
The inadvertent somatogravic effect can occur in all air-
craft types, even gliders. An increased nose-down attitude
in a glider causes it to accelerate and its low aerodynamic
drag may allow the aircraft to build-up excessive airspeed
without the pilot becoming aware from the feel of the air-
craft of any change in pitch attitude.
The inadvertent somatogravic effect is a particular prob-
lem in helicopters. A helicopter has no source of force in
the longitudinal direction of the fuselage. For this reason,
a helicopter pilot cannot experience the sense of pitch-up
on forward acceleration that occurs in a fixed wing aircraft.
In order to accelerate in the line of flight, a helicopter has
to pitch down so that a component of the lift force gener-
ated by the rotor acts in a forward direction. The illusory
sense of pitch-up that accompanies a forward acceleration

K17577_C017.indd 294 18/11/2015 14:11


almost exactly compensates the actual pitch-down required
to achieve that acceleration and in consequence the aircraft
continues to feel level. Likewise, in order to reduce airspeed
the helicopter pilot has to put the aircraft into a nose-up
attitude so that a component of lift acts in a backward direc-
tion. The pitch-down sensation associated with deceleration
negates the actual pitch-up. An alternative way to explain
this effect is to recognize that, neglecting the tail rotor, the
only source of aerodynamic force is the force exerted by the
main rotor. Its predominantly upward pull creates a sense
of gravity within the aircraft that remains vertically down-
ward with respect to the aircraft whatever its attitude rela-
tive to the true vertical. It is true that to initiate a change of
attitude in pitch or roll the pilot has aerodynamically to tilt
the rotor with respect to the fuselage, but this is only tran-
sient. The fuselage soon follows the alignment of the rotor
disc. As a general principle therefore, a helicopter will tend
to feel level whatever its actual attitude and whether or not
it is accelerating or decelerating.
It is important to recognize that the somatogravic
effect is not evidence of shortcomings in the gravity sen-
sors within the inner ear. They are responding correctly to
the force environment. Linear accelerometers would, with
greater accuracy, give the same indication.
THE LEANS
A pilot manoeuvring an aircraft when flying in cloud may
return the aircraft to straight and level flight according to
the attitude instruments only to be left with the sensation
that the aircraft is flying with one wing low. This sensation
may be so compelling that the pilot feels the need to lean in
the seat to bring the head and trunk more in line with what
is felt to be the vertical – hence the name of this illusion.
Surveys of military pilots indicate that over 90 per cent have
experienced the leans. However, the assertion that this is the
V V
V
R
R g
(a) (b)
Aircraft in co-ordinated Pilot rolls out of turn,
turn to right. Pilot feels feels that aircraft
that wings are level. is banking to left.
Figure 17.8  The leans. A possible sequence of events that, in the absence of an external visual scene, may lead to the false
perception that the aircraft is flying one wing low, despite level flight indicated by the attitude indicator.
K17577_C017.indd 295
Vision and spatial disorientation  295
most common illusion of flight is incorrect. The illusion that
an aircraft is in level flight when it is in a banked turn is far
more common – so common that pilots do not consider it to
be an illusion but rather an everyday part of flying. Despite
this, a false sensation of level flight is the precursor to many
disorientation incidents, and may also be the precursor to
the leans.
A sequence of events that may lead to the leans is illus-
trated in Figure  17.8. A pilot, flying without any external
visual reference has inadvertently allowed the aircraft to
develop a banked attitude to the right. The pilot then recog-
nizes this unintended aircraft attitude and makes a deliber-
ate roll to the left to restore level flight. Because the aircraft
felt to the pilot to be straight and level when, in fact, it was
banked to the right, the roll to wings level may be perceived
as a roll from wings level to a banked attitude to the left.
An instructor may fly this sequence of manoeuvres in an
attempt to demonstrate the leans to a student, but may not
always be successful. Correspondingly, the leans can some-
times be corrected if the pilot allows the aircraft slowly to
roll in the direction of the perceived leans and then makes a
more deliberate roll in the opposite direction to return the
aircraft to wings level. However, when pilots develop the
leans they are often unable to say what sequence of manoeu-
vres brought it about.
For many pilots, the leans constitute a minor distraction,
readily overcome by attention to correct instrument flying.
The false sensation of bank may persist for many minutes,
often for as long as the aircraft remains in cloud. Control
is maintained by instrument reference, but the continued
sensory conflict can drain the nervous energy of even the
most experienced pilot. However confident a pilot may be in
the accuracy of the attitude indicator, the leans are often not
dispelled until there is an unambiguous view of the external
visual scene, such as a well-defined horizon or a clear sight
V
g
(c) (d)
Aircraft in straight and Pilot aligns head and
level flight. Pilot feels trunk to perceived
left wing low. vertical and leans to
right.
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 296  Spatial orientation and disorientation in flight
of the ground, when their disappearance is then almost
instantaneous. Here is a demonstration of the greater
strength of ambient visual cues over focal cues derived from
instruments in determining aircraft attitude.
In some circumstances, the leans can be a much more
disconcerting experience. This is particularly so if the leans
develops during air-to-air refuelling or when flying in close
formation on the wing of another aircraft. When in forma-
tion, attitude reference is with respect to the lead aircraft,
and the task of maintaining correct separation is demand-
ing enough without the intrusion of false sensations of
aircraft attitude.
The physiology of the otolithic component of the vestibu-
lar system has little to contribute to an understanding of the
leans. In continuous straight and level flight, there is no rea-
son why there should be spurious otolithic signals to indicate
a tilt from the vertical. The problem must arise at the level of
perception. The aircraft manoeuvres that provoke the leans
are likely to have involved the sensation of rotation in roll
unaccompanied by any corresponding otolith-derived sen-
sation of tilt. Without the benefit of external vision, and lack-
ing any useful indication of roll attitude from the otoliths
or other kinaesthetic sensors, a pilot in these circumstances
may be deriving a perception of the current roll attitude from
the recent history of roll attitude changes that have occurred
while the aircraft has been manoeuvring in cloud. If roll atti-
tude changes have been more gradual in one direction and
more vigorous in the other, roll signals from the semicircular
canals will be biased in favour of the more vigorous direc-
tion and lead to a cumulative sensation of increasing roll
attitude change in this direction. There may also be a visual
component to the illusion. When in cloud, the only stimulus
to the ambient visual system is provided by the interior of the
cockpit. The oculogyral effect will produce a confirmatory
visual sense of roll rotation of the aircraft when the manoeu-
vre is deliberate which is likely to be absent if there is only a
slow drift in roll attitude.
The term ‘leans’ is sometimes applied to the misinterpre-
tation of visual cues. A false horizon reference from the tops
of clouds may be described as ‘cloud leans’. When flying
in thin cloud, sunlight may brighten a region of the cloud
which may be erroneously interpreted as being vertically
above the aircraft, an effect known as ‘lean-on-the-sun’.
The oculogravic effect
The visual and the force environment of flight have been
described separately but there are important interactions
between the two. For this reason, spatial disorientation in
flight cannot be entirely separated into visual disorientation
and what is often termed vestibular disorientation but might
more properly be called force disorientation. One impor-
tant example of the interaction between the visual and force
environments is provided by the oculogravic effect.
In everyday life, the ability to locate an object in the field
of view can generally be derived from its visual context. Such
cues as size and position relative to other objects, the effect
K17577_C017.indd 296
of parallax resulting from head movement and, for nearer
objects, the effect of stereopsis produce multiple pieces of
evidence on which to derive an accurate perception. This
perception is confirmed by the sense of the vertical gener-
ated by the effect of gravity on the body. The frame of refer-
ence may appear to be predominantly visual but there is an
associated concordant gravitational frame of reference. In
an aircraft, particularly when flying on a moonless night,
circumstances can arise in which the object of interest, such
as a distant runway or the lights of an oil platform, lacks any
useful visual frame of reference. In these circumstances,
a pilot may unconsciously fall back on the force frame of
reference provided by the aircraft. It has already been dis-
cussed how a force frame of reference is generated by the
aerodynamics of the aircraft and how a pilot can mistakenly
assume that it represents a true vertical. If the force frame of
reference is deceptive, so too may be the apparent location
of the object or of the aircraft relative to it.
This situation is exemplified by an accident to a heli-
copter on the approach at night to a North Sea oil platform
(AAIB 2011). Conditions were calm, but the approach was
complicated by fog in the vicinity of the platform. The moon
was below the horizon and stars were obscured by cloud.
There would have been no visible horizon. When
about 400 m from the platform the aircraft was
at a height of 420  feet and began to descend
and turn towards the platform. On the final
approach, both pilots were looking out in an
attempt to identify the green perimeter lights
of the helideck at an elevation of 166 feet above
the sea when the aircraft unexpectedly impacted
the sea with a nose-up attitude of 22  degrees
some 300 m short of the platform. The accident
involved no loss of life, in large measure due
to the fact that an increasing, but unperceived,
nose-up attitude had reduced the forward air-
speed to about 20 kt at the moment of impact.
In the few seconds before impact, the pilots reported that,
far from thinking themselves to be below the level of the
helideck, they had a visual impression that they were high
above the platform and about to overshoot it. This marked
discrepancy between the perception and the true situa-
tion had come about from the sense of level flight derived
from the force environment of the aircraft having become
the frame of reference against which the pilots judged the
visual environment.
The data shown in Figure 17.9 are derived from the flight
data record of the pitch attitude of the aircraft and from the
combined accelerometer recordings in the fore-aft and air-
craft vertical directions. They illustrate how the change in
pitch attitude had no effect on the linear force environment
of the aircraft and thus lead to the pilots’ increasing misper-
ception of the true gravitational vertical (Figure 17.9), and
the visual impression that they were above and looking
down on the platform (Figure 17.10).
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 Vision and spatial disorientation  297

25

20
Pitch angle

15

(Degrees)
10

Angle of resultant force vector

0
60 50 40 30 20 10 0
Time to impact (s)

Figure 17.9  The dissociation between tilt and pitch attitude change in a helicopter. While the aircraft developed an
increasing pitch-up attitude during the final 10 seconds of flight, there was no corresponding change in the angle of the
combined Gx and Gz force vectors as measured by on-board accelerometers. The aircrew would have had no sensation of
backward tilt to alert them to the increasing pitch-up attitude of the aircraft.

(perceived)
α

α (actual)

Figure 17.10  The oculogravic effect. In the absence of any visible horizon, and probably of any depth perception associ-
ated with the lights of the oil platform, the pilots were unaware of the increasing pitch-up attitude of the aircraft, which
had reached 22 degrees at the point of impact with the sea (angle α). They had unconsciously used the sensation of level
flight generated by the helicopter dynamics as the frame of reference against which to judge their position relative to the
platform. In consequence, they had perceived the platform to be below them.

Another helicopter accident had occurred a few years pre-
viously in similar night time conditions when approaching
to land on a gas platform in Morecambe Bay (AAIB 2008).
During the approach, the handling pilot inadvertently flew
the aircraft into an attitude of 38 degrees of rightward roll
and 38 degrees nose down. Using the flight data records it
could be shown that despite this slowly developing unusual
attitude, the lights of the platform on which they were to land
would have appeared in the same place on the windscreen –
a seemingly appropriate approach strategy. Expert opinion
from experienced helicopter pilots asserted that the unusual
attitude would have felt very alarming. In truth, it would
only have appeared very alarming, and then only if there had
been anything else to see outside the aircraft other than the
two dimensional pattern of lights of the platform against a
uniformly black background. Again, it could be shown from
the flight data records that the dynamics of the aircraft would
have ensured that the aircraft continued to feel level and that
the rotations in pitch and roll that led to the unusual attitude
would have been too gradual to be sensed.
In both these accidents, there was a failure to monitor
aircraft instruments together with a lack of appreciation
that in the prevailing visual conditions the isolated target
that the pilots could see might not be where it appeared
to be. In the disorientation literature this visual counter-
part of the somatogravic effect is not always well described
and its particular relevance to helicopter operations not
fully appreciated.
A further manifestation of an oculogravic effect is
described by helicopter pilots attempting a night landing at
a remote site, guided by an illuminated T laid out on the
ground. As the aircraft manoeuvres in its approach, if there
are no other visual cues in the immediate vicinity, the T is
seen to wander in the pilot’s gaze. The pilot’s perception is of
a moving visual target with reference to a fixed force envi-
ronment rather than the reverse.
The apparent slope of a true horizon during a banked
turn is another example of an oculogravic effect. The sense
of gravity that remains vertical with respect to the air-
craft acts as the frame of reference that perceptually tilts
the horizon.
Airline passengers who find themselves seated in an aisle
seat at the rear of the aircraft might be interested to make
the observation that, while the aircraft is accelerating along

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 298  Spatial orientation and disorientation in flight
the runway during takeoff, and well before the pilot raises
the nose of the aircraft to take to the air, the horizontal floor
of the aircraft cabin appears to slope upwards – an oculo-
gravic effect. In addition, if anybody were permitted to walk
forward along the aisle during the takeoff run, they would
have to lean forward and would feel as though they were
walking uphill – the corresponding somatogravic effect.
The somatogravic effect and its associated oculogravic
effect are the result of a misinterpretation of the force ver-
tical in an aircraft. They do not depend on a malfunction
of the sensory mechanisms that detect the direction of the
force vertical. Instead, they result from the fact that, for
the practical reason of maintaining an upright posture, the
direction of any steady force acting on the body establishes
a perception of the vertical. Unfortunately, in flight this may
not always indicate the vertical with respect to the Earth.
To a passenger walking in the aisle of a commercial aircraft
that is in a banked turn, the only vertical that matters is that
generated by the aircraft. To the passenger, at least, there is
little value in knowing the vertical with respect to the Earth’s
surface. Even the pilot may not be too concerned about the
discrepancy, particularly if the aircraft is flying on autopilot.
The elevator effect
An increase in the upward force on the body in excess of the
normal 1 G is perceived as the onset of upward movement,
as is experienced by passengers in a lift (elevator) when it
begins to ascend. An increase in G force in an aircraft may
similarly be interpreted as a climb, but this may not neces-
sarily be so. For example, to an individual unaware of the
manoeuvre, an aircraft in a 45 degree banked turn may be
felt to be in a climb on account of the increase in lift to the
1.4 G required to maintain a constant height in the turn at
this angle of bank.
Likewise, a reduction of the upward force to less than
1  G, as occurs at the onset of descent in a lift, is felt as a
downward movement. A similar reduction of G level in an
aircraft can generate a sensation that the aircraft is falling
away beneath the individual. This sensation was responsible
for a pattern of glider accidents when, on levelling off and
releasing the cable at the top of a winch launch, the aircraft
was perceived to have lost lift and, in the hands of inexpe-
rienced glider pilots, tended to provoke an inappropriate
response of forward movement of the control column and a
consequent steep descent.
There is a corresponding visual effect in response to
an increase or decrease in the upward force on the body.
During upward acceleration in an enclosed lift, the opposite
wall is seen to move upwards despite there being no rela-
tive movement between the observer and the wall of the lift.
Downward acceleration of the lift produces the opposite
effect. These visual effects are more evident in the longer
period of acceleration and deceleration involved in the high
speed lifts of tall buildings. The equivalent effect in flight is
an apparent movement of the interior of the aircraft which
is seldom noticed as it is to some degree confirmatory of
K17577_C017.indd 298
the non-visual sensation. More significantly, the effect may
lead to apparent movement of isolated fixed lights at night
with the possibility of their misinterpretation, for example,
as being the lights of another aircraft.
The vestibular system
In contrast to the somatogravic and oculogravic effects,
those associated with rotation, the somatogyral and oculo-
gyral effects, come about as a result of shortcomings in the
sensors of rotation, the semicircular canals, when exposed
to long duration rotational stimuli. They are, therefore, best
considered in the light of the function of the vestibular sys-
tem and its shortcomings.
The vestibular labyrinth of the inner ear is an important
sensor of the force environment. It is about the size of a
pea, and yet within this small volume are sensory receptors
that are stimulated by angular accelerations as low as 0.5°/
s2 and linear accelerations of less than 0.1 m/s2. The sensory
information generated by the vestibular system is used in
the maintenance of postural stability and balance and, more
exclusively, in the stabilization of the retinal image through
the vestibulo-ocular reflex.
Although popularly known as the balance organ, it
shares this function with the visual system and with kin-
aesthetic sensors within muscle, tendon and skin. On
account of its detrimental effect on vision, a pilot with a
total vestibular paresis would be grounded. However, in
other respects compensatory mechanisms would minimize
the effect on balance, both on the ground and in the air. A
pilot who developed total vestibular paresis following treat-
ment with an aminoglycoside antibiotic successfully flew
RAF transport aircraft for ten years before the diagnosis
was made. Similarly, a laboratory study of the sensation of
tilt produced by the somatogravic effect showed no differ-
ence between normal and labyrinthine defective individu-
als (Clark and Graybiel 1968).
Studies carried out in the 1870s established that the stim-
ulus to the semicircular canals was the movement of fluid
within them and that the neural transduction process arose
from the detection of movement by hair cells, both in the
vestibular labyrinth and the cochlea. Hair cells have a direc-
tional sensitivity. Deflection of the hairs along a defined axis
determines the rate of depolarisation of the cell which is
dependent on mechanically gated ion channels at the tips of
each hair (Hudspeth 1989).
The vestibular labyrinth consists of two anatomically
and functionally separate components. The otolith organs
sense linear forces, predominantly the force of gravity,
while the semicircular canals are sensitive to rotational
forces. Figure 17.11 shows the arrangement of the membra-
nous structure that forms the vestibular apparatus. There
are three ducts – the semicircular canals – which open into
the sac of the utricle. Below and in connection with the
utricle lies the saccule. The membranous labyrinth is filled
with endolymph which has a chemical composition high in
potassium similar to intracellular fluid. The membranous
18/11/2015 14:11

Su
p.
Sac. end.
st.
Po
t.
La
Ut
Can. reuniens
R. cochl. – sacc.
Gangl. spir. cochl.
Figure 17.11  The human inner ear. The vestibular component of the inner ear comprises the three semicircular canals whose
neural output indicates the angular velocity of the head in any plane, and the utricle and saccule whose combined output
indicates the direction and magnitude of linear acceleration, whether from gravity or from the effect of locomotion.
From Brödel, Max. Three unpublished drawings of the anatomy of the human ear. Philadelphia: W B Saunders
Co., 1946.
labyrinth is attached securely within the similarly shaped
labyrinthine cavity of the petrous temporal bone. The space
between the membranous labyrinth and bone is filled by
perilymph with an ionic composition high in sodium simi-
lar to that of extracellular fluid.
The semicircular canals
The three membranous canals are about 0.4 mm in diam-
eter, roughly one quarter of the diameter of the bony canals
in which they lie. They are positioned at right angles to
each other and this arrangement ensures that rotation of
the head in any plane is detected by activation of one or
more of the canals. Canals in the right and left inner ears
that are co-planar operate in opposing pairs. Thus, the two
horizontal canals act as a pair. The orientation of the ante-
rior and posterior vertical canals at roughly 45 degrees to
the sagittal plane means that the anterior vertical canal
of one side is in the same plane as, and forms a pair with,
the posterior vertical canal of the opposite side and vice
versa. With the head in the upright position, the vestibu-
lar labyrinth is tilted backwards such that the plane of the
horizontal canals is deviated by about 20 degrees from the
earth-referenced horizontal.
The neural signal from the semicircular canals rep-
resents the angular velocity of the head in the plane of
each canal. At rest a rate of firing of about 80  spikes per
second can be measured in single fibre recordings of ves-
tibular afferent nerves. A rotation in one direction results
in an increase in the rate of firing proportional to the
K17577_C017.indd 299
Vision and spatial disorientation  299
w
vie
of
on
re cti
Di R. sac. sup. (Voit)
N. sac. maj.
R. vest. –cochl. (Oort)
Sup. Gangl. scarpae
Inf.
N. vest. N. fac.
r.
N. cochl.
lus
ccu
Sa
instantaneous angular velocity and in the opposite direc-
tion, a decrease. Comparison of the signals from cor-
responding canals in each inner ear shows that, in the
presence of a rotational stimulus, when one canal gener-
ates an increase in the rate of firing, the opposite canal will
register a decrease. This so-called push-pull arrangement is
familiar to electronic engineers and is used, for example, in
the output of an amplifier to improve the linearity of the
response and thereby reduce distortion. It appears that
physiology is doing the same.
The semicircular canal does not sense rotational veloc-
ity directly but can only respond to the forces involved in
changing rotational velocity, typically the angular head
accelerations that initiate and then retard head rota-
tion (Figure  17.12). In deriving angular velocity from an
angular acceleration stimulus, the canal is behaving as a
mechanical integrator; it senses the accumulation of angu-
lar acceleration over time which is, by definition, angular
velocity. The way this is achieved depends on three char-
acteristics of the system. First, the cupula, the gelatinous
membrane that separates the ampulla into two halves is
an elastic structure that, at rest, maintains a central posi-
tion within the ampulla. However, it is very compliant
and readily displaced by movement of the endolymph.
Second, the semicircular canal is narrow in cross sec-
tion and exerts a significant drag on any movement of
endolymph within it. By contrast, it communicates with
a relatively capacious ampulla. Third, the endolymph, by
virtue of its mass, exhibits inertia so that, when the whole
structure is rotated, the fluid within the canal tends to
18/11/2015 14:11
 300  Spatial orientation and disorientation in flight
Sensory hair Nerve transmitting
cells of crista signals from sensory
cells to brain
Cupula
(deflected) Ampulla
Cupula (rest
Utricle position)
Angular
acceleration
of skull
Relative motion
of endolymph
to skull
Membranous
duct
Figure 17.12  Diagram to illustrate the function of a semi-
circular canal. The endolymph contained in the semi-
circular canal and the utricular cavity forms a complete
fluid ring interrupted only by the compliant cupula within
the ampulla. When the head is accelerated in rotation,
the inertia of the fluid causes it to lag behind the head
movement so that relative to the canal, there is a fluid
movement in the opposite direction. However, the canal
is very narrow and exerts a drag force on the fluid. In
consequence, while angular acceleration continues, fluid
will continue to accumulate in one half of the ampulla and
produce increasing deflection of the cupula. On account
of this property of the system, cupular deflection, and
hence the neural signal derived from the hair cells embed-
ded in it, is proportional to the accumulated acceleration
and hence to the angular velocity of the head. The cupula,
shown in this diagram as a swing door, is now considered
to be an intact diaphragm separating the two halves of
the ampulla. Its displacement under angular acceleration
is microscopically small, but its embedded hair cells are
exquisitely sensitive to movement.
remain stationary. However, the drag exerted by the walls
of the canal on the movement of endolymph ensures that,
although the rate of endolymph flow is proportional to
the applied acceleration, the actual amount of fluid move-
ment is very small and only a relatively small amount
enters one half of the ampulla and drains out of the other
half. Furthermore, because of the dilated space within the
ampulla compared with the canal, the displacement of the
cupula is even less. However, the hair cells within it are
exquisitely sensitive to any displacement. Ninety per cent
of the response range of a hair cell is generated by a 100 nm
(0.1 μm) displacement of the hair cell bundle and it is esti-
mated that the normal range of cupular displacement does
not exceed 3  μm [Fettiplace and Ricci 2008]. The compli-
ant cupula initially offers little resistance to the movement
of endolymph and for small deflections acts as an almost
passive indicator of fluid accumulation or drainage in and
out of the ampulla. The result is that, for short duration
K17577_C017.indd 300
angular acceleration, cupular deflection is proportional
to the accumulation over time of the accelerative force on
the endolymph and, hence, an indication of instantaneous
angular velocity of the head.
This system operates very successfully for natural head
movements in which an accelerative force is immedi-
ately followed by a decelerative force, as the head adopts
a new angular position. In this situation, the cupula is
constrained by inertial fluid movement, first in one direc-
tion, then immediately in the opposite direction, to return
to its central position at the end of the head movement.
However, the semicircular canal is not a perfect integrator
(Figure 17.13). If an initial angular acceleration is followed
by a period of constant angular velocity there will no lon-
ger be an inertial force from the endolymph to maintain
the cupula in its deflected position and the inherent elas-
ticity of the cupula will gradually return it to its central
position, pushing fluid back around the canal against the
retarding force of viscous drag from the walls. Because
the restoring force of the cupula becomes less the closer
it comes to its central position, the pattern of the neural
firing rate as it returns to its resting level will have the
form of a decaying exponential which can be character-
ized by its time constant – a measure of the rate of return
to the resting level. The consequence of a return to the
resting level of neural discharge under conditions of sus-
tained angular velocity is that the sense of rotation gradu-
ally decays to zero and, with it, any vestibular signal to
maintain visual stability. When a period of sustained rota-
tion is eventually stopped, the decelerative force involved
results in a cupular deflection which, if the cupula has
already returned to its central position, now deviates it
in the opposite direction and signals to the brain an illu-
sory rotation in this opposite direction and with it, inap-
propriate and destabilizing eye movements. This sequence
of events is familiar to children who, after turning on the
spot for a while, when they stop, enjoy seeing the world
spinning round and have difficulty in keeping their bal-
ance. However, the notion expressed in some texts that,
under these conditions, fluid is continuing to swirl around
the canals or that the hair cells are deflected like reeds in
a river is entirely wrong.
When measured using electrodes inserted into the ves-
tibular nerve to record the firing rate in the afferent neurons,
the time constant of decay following a stopping stimulus
from a period of constant velocity rotation is of the order
of 5 seconds [Fernandez and Goldberg 1971]. An alternative
indication of semicircular canal activity is provided by the
recording of eye movements induced by a vestibular stimu-
lus – a technique that is used as the basis of clinical tests
of vestibular function. However, the time constant derived
from the measurement of eye movements following a stop-
ping stimulus is found to be in the region of 15  seconds.
This prolongation of the time constant beyond that of the
vestibular end organ is brought about within the vestibu-
lar nuclei and other midbrain structures and is known as
velocity storage.
18/11/2015 14:11

Right
Angular velocity
100
(degree/s)
0
100
Cupula
Arbitrary units
deflection
0 Sensation: roll right
–100
0 5
Figure 17.13  The response of the semicircular canal to sustained angular velocity. The onset of rotation is correctly sensed.
Once a constant velocity is attained, because there is no further angular acceleration stimulus, the cupula by virtue of its
elasticity gradually returns to its rest position and thus no longer indicates any rotation. Once this state has been reached,
the deceleration as rotation ceases is sensed as the onset of a rotation in the opposite direction.
The apparent shortcoming of semicircular canal func-
tion in failing to sense prolonged rotation at constant veloc-
ity can be viewed in a different light. As already discussed,
the semicircular canal behaves as an integrator. An integra-
tor generates its output by a process of accumulation over
time of a given input. However, any spurious offset in the
input signal, however small, will accumulate over time
and lead to a progressive drift of the output. This prob-
lem is overcome by the tendency of the canal gradually to
return towards its resting state when no further accelerative
stimulus is present. This means that any errors that would
otherwise accumulate and lead to persistent dizziness are
rapidly eliminated, but, as a consequence, the semicircu-
lar canal system is only accurate as a transducer of angular
velocity for time periods of a few seconds. A more abrupt
resetting can be achieved by central mechanisms. The veloc-
ity storage mechanism can be ‘dumped’, for example, by a
change of head position that takes the head out of the plane
of sensed rotation. Also, visual fixation can largely suppress
vestibular-induced eye movements. It appears that evolu-
tion has optimized the response of the vestibular system
to provide an accurate measure of angular velocity at the
frequencies encountered in normal head movements during
pedestrian life.
In the laboratory, using a high fidelity turntable, it is
possible to measure a threshold for the perception of rota-
tion. For angular acceleration lasting less than 10 seconds,
rotation will not be perceived until the product of accelera-
tion (degrees/seconds2) and the time for which it is applied
exceeds 2.5  degrees/second. Known as Mulder’s law, this
defines a perception threshold in terms of rotational velocity,
K17577_C017.indd 301
Vision and spatial disorientation  301
Sensation: roll left
10 15 20 25 30
Time (s)
and reflects the function of the canal as an integrating accel-
erometer. In the flight environment, the threshold of detec-
tion of rotation is likely to be much greater, particularly if a
pilot is distracted. Also, a rotation in pitch or roll is less likely
to be detected for lack of any sensation of increasing tilt.
The otolith organs
The otolith organs, the utricle and saccule lying in two
chambers below the semicircular canals, are sensitive to lin-
ear accelerations. On two feet, such accelerations are gener-
ated by locomotor activities, as well as by the force of gravity.
The forces of locomotion and that of gravity are physically
equivalent and when both are present they act as a single
force. However, it is unlikely that the brain would have dif-
ficulty in distinguishing between the transient or oscilla-
tory nature of locomotor forces and the invariant nature of
gravity. Travel in moving vehicles complicates this simple
distinction since accelerations and decelerations may be of
comparatively long duration and, consequently, may alter
the intensity and direction of what the brain perceives as
gravity. This effect, the somatogravic effect, is particularly
evident in aircraft and is an important cause of orientation
errors and accidents.
Each otolith organ contains a sensory epithelium, the
macula, consisting of a carpet of hair cells, the hairs of which
project into the base of the overlying statoconial membrane
(Figure  17.14a). This membrane is rendered denser than
the surrounding endolymphatic fluid by the incorporation
within it of crystals of calcium carbonate, giving the mem-
brane a stony appearance, from which the name otolith
18/11/2015 14:11
 302  Spatial orientation and disorientation in flight

(a) Statoconial membrane

Statoconia Striola

Gelatinous
substance

Sensory cells Supporting Myelinated nerve fibres

Kinocilium Stereocilium cells leading to utricular
nerve

Posterior (b) Lateral Anterior

Medial Posterior
Medial

Superior
Anterior

Posterior
Anterior

Inferior

Figure 17.14  The structure of the otolith organ. The macula of the utricle or saccule consists of a carpet of hair cells, the
hairs of which project upwards into gelatinous material beneath the statoconial membrane. This membrane is rendered
more dense than the surrounding endolymph as a result of crystals of calcium carbonate (otoconia) contained within it.
The effect of gravity on this structure causes the statoconial membrane to move in response to tilt and in so doing bend
the underlying hairs and change the rate of depolarization of the hair cell. Similarly, the otolith organs will be stimulated
by the changing linear accelerations associated with locomotion. Hair cells have a directional sensitivity (a). Figure 17.14b
shows the direction of maximum responsiveness of the hair cells of the maculae of the utricle and saccule. This anatomi-
cal arrangement ensures that whatever the direction of the applied force there will always be a group of hair cells that are
maximally stimulated.

is derived. The hair cells of the sensory epithelium have a
directional sensitivity and will change their rate of firing
if there is relative movement in the appropriate direction
between the sensory epithelium and the statoconial mem-
brane. Such movement comes about if, as a result of tilt,
there is a change in the component of gravity acting on the
statoconial membrane in the plane of the macula, or if, as a
result of a dynamic acceleration, it is subject to an inertial
force. The direction of maximum sensitivity of the hair cells
changes progressively across the surface of the macula in
such a way that, whatever the direction of acceleration act-
ing in the plane of the macula, there will always be a group
of hair cells that are maximally stimulated (Figure 17.14b).
Since the macula of the utricle lies approximately in the hor-
izontal plane and that of the saccule in the sagittal plane,
the anatomical arrangement of these two structures allows
sensation of the direction and intensity of any acceleration
acting on the head. The only force in terrestrial life that acts
continuously on the inner ear is that associated with gravity.
As a result, though sensitive to the transient accelerations
associated with locomotion, the predominant function of
the otolith organs is to act as sensors of tilt of the head with
respect to the direction of gravity.
Just as there is a rule of engagement that links angu-
lar head motion and its effect on vision of the static visual
world, so there is a link between angular motion of the head
and its effect on the otolith organs. Specifically, because
the force of gravity is invariant in direction, angular head
movements in pitch or roll are expected to be accompanied
by a corresponding angular change in tilt as sensed by the
otoliths. While this rule is transiently broken in everyday
life, for example, when changing direction while running,

K17577_C017.indd 302 18/11/2015 14:11


infringements become far more evident when manoeuvring
in an aircraft. Changes in roll attitude of an aircraft are sel-
dom associated with any change in the direction of what is
perceived as gravity. As a result, it is likely that the ability of
a pilot to detect an inadvertent roll of the aircraft is much
reduced for lack of any confirmatory tilt sensation.
The otolithic system is sensing accelerations as they affect
the head. This sensory information would have little rele-
vance to the balance of the body as a whole without proprio-
ceptive information derived from the neck and trunk. The
detection of the gravitational vertical and the maintenance
of a standing posture is a shared function between cutane-
ous pressure sensors, muscle stretch receptors, vision and
the vestibular system. An individual who lacked vestibular
function could still remain standing with feet together and
eyes closed (Romberg’s test) using proprioceptive informa-
tion from the feet, legs and trunk. By contrast, an individual
who had a sensory deficit from the lower part of the body,
affecting joint position sense, would be unable to remain
standing with eyes closed despite a normally functioning
vestibular system.
Vestibulo-ocular reflexes
An individual with a total lack of vestibular function may
experience some difficulty with maintaining balance when
walking in the dark, but gait is little affected in daylight.
However, there will be a persistent effect on vision which
consists of apparent motion of the stable visual scene during
any physical activity, a symptom known as oscillopsia. An
individual who lacked vestibular function described this
symptom as follows:
Imagine the results of a sequence taken by point-
ing the camera straight ahead, holding it against
the chest and walking at a normal pace down a
city street. In a sequence thus taken and viewed
on the screen, the street seems to careen crazily
in all directions, faces of approaching persons
become blurred and unrecognizable...(JC 1952).
This problem is the consequence of the loss of the vestib-
ulo-ocular reflex which serves to stabilize the retinal image
against the effects of head movement, either voluntary or
induced by activities such as walking, running and jumping.
The angular velocity signal generated by the semicircular
canals in response to angular head movement in any plane is
relayed through a three neurone reflex arc to the appropriate
eye muscles to produce a contrary rotation of the eyeball in
that plane. If the amplitude of head movement is large, greater
than about 10 degrees, the compensatory eye movement is
interrupted by saccades, high-velocity eye movements that
occur in the same direction as the head rotation and return
the eye to a more central position from where the compensa-
tory eye movement is resumed. Rather than undergoing the
same movement as the head, the direction of gaze is aligned
with a succession of visual targets with saccades moving the
K17577_C017.indd 303
Vision and spatial disorientation  303
eye from one to the next. During a saccade, a blurred image
of the visual scene must sweep across the retina but central
saccadic visual suppression ensures that this is not perceived.
The activity of the vestibulo-ocular reflex can be
explored in the laboratory by the measurement of eye
movements in a subject undergoing angular motion on a
turntable. The system can be characterized by its frequency
response, which gives a measure of the gain and phase of
the eye movement in response to sinusoidal oscillation
over a range of frequencies (Figure 17.15). For perfect com-
pensatory function, it would be expected that the gain of
the response would be unity at all frequencies, that is, the
angular amplitude of eye movement would be the same as
the angular amplitude of the turntable stimulus, and that
the phase would be 180  degrees, indicating accurate tim-
ing of the response, but in the opposite direction. This is
indeed what is found if the experiment is carried out in the
light. However, in darkness, although the phase is compen-
satory over a wide range of frequencies from 0.1 to 10.0 Hz,
the gain is below unity at the lower frequencies (typically
0.6  at 0.1Hz) and increases with increasing frequency of
oscillation to approach unity gain at a frequency of 2–3 Hz.
It is evident that, in the light, the gain at low frequency is
being enhanced by visual mechanisms.
It is also possible to detect an eye movement response
to linear motion mediated through the otolithic component
of the vestibular system, the so-called otolith-ocular reflex.
However, attempts to measure this reflex have yielded
variable results. Unlike the expected one to one relation-
ship between stimulus and response for angular motion,
the ideal angular eye movement response to linear motion
depends on the distance from the eye to the visual target. If
the visual target is at infinity, no eye movement is required.
The nearer the target, the greater is the angular eye move-
ment required to stabilize the retinal image.
In summary, the vestibulo-ocular reflex is responsible for
the capacity to perceive a stable visual world. This reflex can
also be viewed as an essential neurological link that main-
tains concordance between the visual frame of reference
represented by the stable external world and the inertial
frame of reference that relates to forces and accelerations.
The cross-coupled (Coriolis) effect
A subject who undergoes a sustained period rotation at
constant velocity, for example, about a vertical axis on a
turntable, will experience a diminishing sensation of rota-
tion. If, at this stage, the subject makes a head movement
out of the plane of rotation, for example in roll (left ear to
left shoulder), there will be an illusory sensation of rotation
forwards or backwards in pitch. Likewise if the head move-
ment were made in pitch, an illusory sensation would be
felt in roll. This is known as the cross-coupled or Coriolis
effect. As originally defined, a Coriolis force arises when a
mass mounted on a radial arm rotating at constant angular
velocity moves inward or outward along the arm. The ini-
tial motion of the mass on the arm describes a circle. If the
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 304  Spatial orientation and disorientation in flight

2 Gain
dB
– ± 30°/sec
ωsmax ^
0

Gain –2
ωe
ωs
120 –4

130 –6

140 –8
Phase angle

150
Expt I N = 9
Expt II N = 6
160

170
Lead
180
Log

0.01 0.02 0.05 0.1 0.2 0.5 1.0 2 3 4 5 Hz

Frequency of angular oscillation (ωs)

Figure 17.15  The frequency response of the eyes to angular oscillation. A subject’s eye movements are measured in
response to whole body angular oscillation about a vertical axis in the dark. Gain, the ratio of angular eye movement to
that of the head, is shown in dB (20 log10(ωe/ωs)). Full gain compensation (0 dB) is only achieved at 2 Hz; ideal phase
compensation (phase angle 180 degrees) is achieved over a wide range of frequencies from about 0.2 Hz upwards. When
measured in the light the apparent deficiency of the vestibulo-ocular response at the lower frequencies is augmented by
visual pursuit mechanisms to achieve ideal gain compensation over the full range of frequencies.

mass were to move outwards along the radial arm it would
have to travel around the circumference of a bigger circle
and would therefore have to move at an increased circum-
ferential velocity. The tangential force required to accel-
erate the mass to this increased velocity is known as the
Coriolis force. It might be thought from this physical def-
inition that the origin of the Coriolis effect was based on
physical principles with no regard to the behaviour of the
semicircular canal under conditions of prolonged rotation.
This, however, is not so. The illusory sensation is more evi-
dent the longer has been the preceding period of constant
velocity rotation.
For simplicity, assume that the canals are anatomi-
cally orientated within the head in the transverse, sagit-
tal and coronal planes and are correspondingly named.
Assume also that a head movement in roll can be made
through 90 degrees (Figure 17.16). If this idealized subject
is rotated around a vertical axis on a turntable, the accel-
eration associated with the onset of rotation will stimulate
the transverse canal. However, once a constant velocity of
rotation is established, the cupula of this canal will gradu-
ally revert to its rest position and cease to signal any rota-
tion to the brain. A head movement at this point through
90  degrees in roll will carry the transverse canal into the
sagittal plane, and will bring the canal that was previously
in the sagittal plane into the transverse plane. The canal
newly arrived in the plane of rotation will experience the
onset of rotation and will correctly signal to the brain the
ongoing yaw rotation. Correspondingly, the canal that has
been taken out of the plane of rotation will register a stop-
ping stimulus. However, because this canal was previously
signalling no rotation, the stopping stimulus will be reg-
istered as a rotation in the opposite direction. The percep-
tual process within the brain takes account of the altered
position of the head on the trunk and refers any sense of
rotation to the orientation of the body so that this post-
rotational sensation will be perceived as a rotation of the
body in the sagittal plane, that is, in pitch. The illusory
sense of pitch is explained by the response of the one canal
taken out of the plane of rotation. The canal brought into
the plane of rotation by the head movement is responsible
for a renewed sense of yaw axis rotation. The overall sensa-
tion provoked by a head movement is, therefore, somewhat
more complex than originally described – a combination
of the underlying rotation and of rotation in the plane at
right angles to that of the head movement.
The cross-coupled sensation is easily provoked in
the laboratory or even in a rotating office chair and it is

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 Vision and spatial disorientation  305

ωz movement. Roll manoeuvres in aircraft can involve high

ωz
rates of rotation but are not usually sustained for many
ωs
ωx seconds. Spinning manoeuvres involve high rotation
rates for more prolonged periods, but, though regularly
r
p practiced, are otherwise manoeuvres that are avoided.
p Nonetheless, there have been sufficient reports from pilots
y r
flying in poor visual conditions who have experienced
y ωs powerful, but illusory, sensations following an abrupt head
Head moved movement to advise aircrew that they should not make
in roll unnecessary head movements when manoeuvring in cloud
or at night. It is likely that even low intensity spurious rota-
tional sensations can be difficult to ignore in conditions
Angular velocity in where they cannot be countermanded by a clear view of the
plane of canal
ωz
Sensation of turning
stable external world.
Yaw canal in plane of canal
The weather at our destination was amber with
0
a 200  feet cloudbase. We were positioned for
Angular velocity

–ωz
a radar approach but, having arrived at the
ωz bottom of the descent a little late and fast in
Pitch canal instrument meteorological conditions we were
–ωz instructed to carry out a 270 degree turn to the
ωx right. I elected to complete the checks while
Roll canal in the turn, but had to move my head down
and to the left in order to check the hydraulic
0
Time and brake pressures. On returning to a normal
head position and recommencing my instru-
Cross-coupled stimulation
Head movement in roll (ωx) during sustained
ment scan, I experienced an incredibly strong
rotation in yaw (ωz). Idealised three-canal system. case of disorientation. I have experienced the
leans many times and handled it without diffi-
Figure 17.16  The cross-coupled (Coriolis) stimulus. The culty, but this was something else. The feeling
left hand diagram shows an idealized semicircular canal of being in a descending right-hand turn was
system with the canals orientated in pitch roll and yaw. incredibly strong. I was staring at the attitude
The subject is rotating at constant velocity about a indicator which showed straight and level flight,
vertical axis (ωz). After, say, 30 seconds any sensation of but was absolutely convinced it was wrong. By
turning will have decayed to zero. The subject then makes instinct, I cross-checked with the stand-by atti-
a head movement through 90 degrees in roll (ωx) which tude indicator, which also showed straight and
is correctly sensed. This head movement brings the pitch
level flight. However, so strong was the disori-
canal into the plane of rotation which gives a renewed
sensation of the vertical axis rotation. It also takes the yaw entation that I began to doubt the accuracy of
axis canal out of the plane of rotation which, therefore, both attitude indicators; all my instincts told me
experiences a stopping stimulus and generates a post- I was continuing a descending turn and would
rotational sensation. Because this canal is now in the pitch shortly impact the sea. Luckily, I managed to
axis of the body, the sensation it generates is of a rotation maintain a straight and level picture on the
in pitch (ωy). The cross coupled sensation induced by the attitude indicator, but was having to stare at it
head movement is one of both an actual yaw rotation and intently to do so. This was followed by a call of
an illusory pitch rotation both of which gradually decay ‘Airspeed!’ from the front cockpit. In concen-
over the next 10–20 seconds.
trating on the aircraft attitude I had allowed the
airspeed to drop below the 150 knots required
regularly demonstrated to aircrew in rotating spatial dis- at this stage of the approach. I applied power
orientation trainer devices. However, the circumstances and handed control to the front cockpit. After
in which it is provoked in flight are probably not very fre- about a minute I took control again, asking
quent. An introspective passenger may detect a change the front seat pilot to keep an eye on me. We
of heading in a commercial aircraft by being aware of a broke cloud at decision height and made a
slightly odd sensation on moving the head. The standard successful landing. However, I had to fight the
rate-one turn in an aircraft involves a yaw rate of 3 degrees feeling of disorientation all the way down the
per second, significantly less than the 40–60  degrees per approach and only when visual with the run-
second of yaw rotation that might be used in a disorienta- way did I begin to feel a little (but not a lot)
tion simulator to impress aircrew with the effects of head more comfortable.

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 306  Spatial orientation and disorientation in flight
The somatogyral effect
As discussed in the previous section, the semicircular
canal receptors are stimulated only by angular accelera-
tions. During a sustained period of rotation at a constant
angular speed in an aircraft, resulting from a change of
heading or a sustained roll or a spin, these receptors give
correct information only during the first few seconds of the
manoeuvre (Figure 17.13). Once a steady speed of rotation
has been achieved, the signals from the semicircular canals,
stimulated by the initial angular acceleration, die away pro-
gressively and fall below the threshold value after about
10–20 seconds. The time taken for the sensation of turning
to die away depends on a number of factors: the speed of
rotation, the axis of rotation, the nature of cues from other
sensory receptors and the extent to which the pilot is famil-
iar with the motion stimuli (level of habituation). But for
a typical spin, in which the aircraft may reach a rotational
speed of 120–150°/s (2–3  rad) in two to three seconds, it
can be reckoned that most pilots will be unable to perceive
rotation accurately by purely vestibular mechanisms after
15–30 seconds. They can, however, detect the continuation
of the spin by the erratic pitching rolling and yawing move-
ments that occur in most spinning aircraft and can deter-
mine the direction of the spin from the blurred image of
the outside world as it swirls past the pilot’s gaze. The task
of maintaining an awareness of aircraft orientation is even
more difficult during an inverted spin, partly because roll-
ing and yawing movements do not appear to occur in the
same sense as they do in an erect spin and partly because
of the pilot’s unfamiliarity with this configuration of flight.
In an erect or inverted spin, external visual cues and,
more reliably, the turn indicator display allow the pilot to
determine the direction of the spin and to initiate appro-
priate recovery action but, as soon as the aircraft begins
to come out of the spin, there is an angular acceleration
in the opposite direction to that which occurred on enter-
ing the spin. The semicircular canals are stimulated again
and evoke a sensation of turning in the opposite direction.
This somatogyral illusion occurs at a time when the pilot
has to decide when the rotational component of the spin has
ceased in order to complete the recovery manoeuvre. The
only reliable means of detecting the cessation of the spin is
by reference either to instruments or to the appearance of
the external visual scene. At this critical point, vision may
be degraded by nystagmus that is inappropriate for viewing
a stable visual world and it may take several seconds for the
eye movement to be suppressed sufficiently so that instru-
ments can be read.
The presence of false sensations and impaired vision can
have serious consequences during spin recovery. On the one
hand, the pilot may feel that the spin has been neutralized
before this has actually happened and subsequently get into
difficulties on attempting to pull out. Alternatively, having
recovered correctly, the pilot may feel that the aircraft is
spinning in the opposite direction and may make inappro-
priate control movements to counteract this illusory spin.
K17577_C017.indd 306
If this happens, then the aircraft can enter a spin in the orig-
inal direction or even an inverted spin. This can give rise to
an even more complex and confusing impression of motion,
so that, finally, it might be impossible for the pilot to regain
control of the aircraft.
Spinning provides an extreme example of rotational
and post-rotational effects. More recently, an inflight study
has explored the post-rotational effect in relation to roll
manoeuvres. The study required the pilot to roll the aircraft
at a steady rate from a bank attitude of 45 degrees one wing
low until it was banked by 45 degrees in the opposite direc-
tion. At this point the pilot was required to close the eyes and
attempt to maintain this banked attitude. It was found that
pilots tended to increase the angle of bank to compensate
for a post-rotational sensation in roll that suggested that the
aircraft was rolling back towards a wings-level attitude. This
effect was found to be greater at slower rates of roll when the
initial roll acceleration to initiate the manoeuvre had longer
to decay away and so increase the illusory post rotational
sensation when the roll was stopped (Ercoline et al. 2000).
The oculogyral effect
The oculogyral effect is the visual counterpart to the
somatogyral effect. The normal expectation is that a rota-
tional movement of the head occurs against a background
of a static visual scene. An important consequence of the
vestibulo-ocular reflex is that, in these circumstances,
there is a correct perception that the visual world remains
stationary and good visual acuity is retained. However, if
rotation at a constant velocity is prolonged, the return of
the cupula of the semicircular canals towards its cen-
tral rest position means that there is a gradual reduction
in the drive to the vestibulo-ocular reflex. This not only
leads to a reduction in the non-visual sense of rotation but
also results in a blurred image of the static visual world
streaming across the subject’s gaze in the opposite direc-
tion. When rotation is stopped after a period of constant
velocity rotation, the post-rotational sensation of rotation
in the opposite direction is accompanied by an illusory
visual perception of rotation of a static visual scene in the
same direction as the preceding rotation. In these circum-
stances, given a detailed visual scene, there is a neurologi-
cal mechanism that can suppress, though not completely,
such vestibular-induced eye movements in the interest of
maintaining visual acuity.
If the field of view is not earth-fixed but surrounds and
rotates with the subject, there is a perception that the visual
scene appears, also, to turn. This is one manifestation of the
oculogyral effect which is not an illusion since it is a visual
confirmation of what is actually occurring.
Aisle-seated airline passengers can observe a manifesta-
tion of this illusion, most convincingly seen at night when
any peripheral visual cues through the aircraft windows
can be ignored. When, after landing, the aircraft is taxiing,
each turn that the aircraft makes between the runway and
the terminal can be detected by the apparent left or right
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movement of the forward view when looking along the
length of the aircraft, even though the view is entirely con-
fined to the interior of the aircraft.
A laboratory-based study of this effect required a subject
seated in the dark on a turntable to view a solitary light,
itself attached to the turntable a metre or so in front of the
subject. The onset of rotation of the turntable was associated
with an apparent movement of the light in the direction of
rotation, even though there had been no relative movement
between the subject and the light. Studies that have com-
pared the detection threshold of rotation with and without
the light have shown that the presence of the light reduces
the threshold of detection by a factor of 2.5  (Benson and
Brown 1989). The most likely explanation for this phenom-
enon is that the vestibular stimulus that accompanies the
rotation elicits an eye movement that tends to keep the eye
directed to a point fixed in space. This results in a displace-
ment of the retinal image of the light that the brain inter-
prets as a movement of the light.
Also in the category of oculogyral effects is the visual
counterpart to the cross-coupled illusion. A subject rotating
in the dark at constant velocity on a turntable while viewing
a fixed point of light mounted on the turntable will be aware
of apparent upward and downward movement of the light as
a result of making small angular head movements from side
to side in roll. The direction of the apparent up and down
movement of the light is in the same direction as the illu-
sory sensation of pitch motion that would accompany more
generous roll axis head movements. As with the other mani-
festations of the oculogyral illusion, vestibular-induced eye
movements are the most likely basis of the perceived motion
of the visual target.
The visual consequences of sustained rotation as it occurs
in spinning manoeuvres have already been described in
connection with the somatogyral effect.
Alternobaric (pressure) vertigo
The change in atmospheric pressure with altitude can, in
certain circumstances, lead to a disturbance of vestibular
function. This takes the form of an abrupt onset of vertigo
typically during rapid ascent in an aircraft. The vertigo is
often initially intense, with blurring of vision and apparent
movement of the visual scene, but this is usually short-lived
and the vertigo dies away in 10–15 seconds, in much the same
way as the vertigo produced by a sudden change in angular
velocity on a laboratory turntable. However, the symptoms
are not always transient; some aircrew have reported a less
intense vertigo that has persisted for many minutes. There
is also considerable variability in the plane of the illusory
sensation, although it is usually of a consistent and repeat-
able pattern in any one individual. This problem may occur
at a critical time in the flight and it may be very difficult
to dispel the perception that the sensed rotation is affect-
ing the whole aircraft. The phenomenon of alternobaric, or
pressure, vertigo is more familiar to divers on ascent from
depth on account of the much greater changes in pressure
K17577_C017.indd 307
Vision and spatial disorientation  307
associated with diving. Here too, it is associated with the
hazard of disorientation. The affected individual usually
reports that the onset of vertigo is triggered by clearing of
the ears when, on ascent, air is vented from the middle ear
via the Eustachian tube, and particularly when there is an
asymmetry between the two ears in the ease with which
pressure can be equilibrated. The problem can also occur on
descent if an over-energetic Valsalva manoeuvre leads to a
sudden increase in pressure in the middle ear.
Overpressure of the middle ear will result in outward
bulging of the tympanic membrane which, in turn, pulls
the stapes outward from the oval window. An abrupt relief
of excess pressure in the middle ear will result in a sudden
inward movement of the stapes and a corresponding move-
ment of perilymph. For this to result in vertigo implies that
this pressure change has been transmitted to the endo-
lymph and has resulted in the displacement of one or more
of the cupulae of the semicircular canals, though the precise
mechanism is not well understood.
Surveys have shown that some 10–17  per cent of pilots
have experienced pressure vertigo at some time or other
during their flying careers (Lundgren and Malm 1966),
though not all cases come to medical attention. Symptoms
are most likely to occur when there is some difficulty in
equilibrating middle ear pressure on account of congestion
around the nasopharyngeal openings of the Eustachian
tubes as a result of an upper respiratory tract infection. This
is a further reason, in addition to the risk of barotrauma,
why aircrew should not fly with sticky ears. There are, how-
ever, a few individuals who suffer from pressure vertigo
even in the absence of infection. Experiments have shown
that these individuals require a higher middle ear pressure
(> 5.9 kPa above ambient) than the normal 4.3 kPa in order
to open the Eustachian tube and vent gas to ambient. On
the other hand, not all individuals with high opening pres-
sure suffer from pressure vertigo, and nor does the lack of
Eustachian patency, as indicated by the Valsalva test, cor-
relate well with susceptibility.
It was an early morning takeoff. I had not eaten
before departure as I expected a good break-
fast on arrival. I had had a cold two weeks before
and appeared to have fully recovered. As the air-
craft was levelling at 3000  feet with the sea in
sight below but the only horizon being the top
of the haze layer at about 2000  feet, my ears
cleared and I suddenly had the most powerful
impression that the aircraft was yawing very fast
to the left. Fortunately, the autopilot was flying
the aircraft and all the instruments were show-
ing normal straight and level flight. I realized
very quickly that I was disorientated but found
myself fighting the autopilot on the controls.
The only way I stopped myself from doing this
was by placing my feet on the floor and sitting
on my hands. I am sure that the only reason I
had the impression of yaw alone was because of
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 308  Spatial orientation and disorientation in flight
the definite but featureless horizon. I felt airsick
while all this was going on and was only able
to relieve the sensation when I stared for some
time at a small cloud that I found above the hori-
zon at about 4 o’clock.
Influence of alcohol
The loss of inhibitions and the impairment of cognitive
function are well-recognized central effects of alcohol.
Giddiness and unsteadiness of gait are also typical of exces-
sive alcohol consumption. While this disturbance of bal-
ance may have a central component, there is an effect on the
vestibular labyrinth that is thought to arise as a consequence
of a density disparity within the semicircular canal system.
To function correctly as a rotation sensor it is essential that
the cupula within the ampulla of each semicircular canal
remains insensitive to gravity. This is achieved by the cupula
having exactly the same density as the endolymphatic fluid
that surrounds it. Provided this is so, whatever the position
of the head, the cupula neither tends to float or to sink. Were
it to do either, it would send a spurious signal to the brain to
indicate rotation. It appears that alcohol in the circulation
diffuses into the cupula before it reaches the endolymphatic
fluid, and because alcohol is less dense than water sets up a
density difference between the cupula and the endolymph.
As a result, when a head movement brings the cupula into
a more horizontal position, the subject becomes aware of a
sense of vertigo.
This effect can be demonstrated clinically by the posi-
tional test in which the subject from a sitting position adopts
a lying posture with the head turned to one side and tilted
below the horizontal. A sustained horizontal nystagmus
can be seen either by recording eye movements with the
eyes closed by means of the electro-oculogram, or else by
direct inspection of the eyes through Frenzel lenses, strong
magnifying lenses worn by the subject which prevent visual
fixation by defocusing any image of the surroundings.
This explanation of the origin of alcohol-induced vertigo
receives support from experiments using deuterium oxide
(heavy water) in place of alcohol (Money and Myles 1974).
This substance, which has a density that is greater than that
of water, also induces vertigo and a positive positional test,
but the induced nystagmus is in the opposite direction to
that produced by alcohol. If alcohol intake is continued over
several hours, it penetrates into the endolymphatic fluid, the
density disparity becomes less and the positional nystagmus
is reduced or abolished. However, once alcohol ingestion is
stopped, it clears from the circulation and from the cupu-
lae more rapidly than from the endolymph and a density
disparity is re-established that can remain for 48  hours
or more.
The implication for flying is that a period of prolonged
generous alcohol ingestion may require longer than the
rule that specifies the 12 hour alcohol-free ‘bottle-to-throt-
tle’ interval before flying. Though alcohol may be cleared
from the blood and cognition unimpaired after this time,
K17577_C017.indd 308
it is sequestered in the endolymph for a longer period and
may cause positional vertigo after a much longer inter-
val. If flying involves high G manoeuvres the increased G
amplifies the effect of any density disparity and thus any
related vertigo.
Drugs
There are many prescribed drugs that are incompatible with
flying, either because of the underlying condition for which
they are prescribed or on account of unacceptable side
effects. Most significant of these in relation to disorientation
are the central side effects of light-headedness or drowsi-
ness. There are a number of over-the-counter drugs with
such side effects. They include all currently available anti-
motion sickness medications, the sedating antihistamines
and compound analgesics containing codeine or dihydro-
codeine. Recreational drugs have only achieved this status
on account of the profound central effects they produce and
are, of course, totally prohibited.
Flicker vertigo
Aircrew have described a number of sensory disturbances
that can be attributed to a flickering visual stimulus. Such
problems are more common in rotary-wing aircraft, par-
ticularly when the aircraft is heading towards a sun that
is low in the sky and visible to the pilot through the rotor
disc. The resulting flicker is at the blade pass frequency,
typically 20–25  Hz. The principal complaint is irritation
and distraction rather than true vertigo. Nausea and a sense
of disorientation are also occasionally reported. More sig-
nificant is the remote possibility of total incapacitation as
a consequence of flicker-induced epilepsy. The frequency
of flicker that can induce an epileptic attack varies between
susceptible individuals but is possibly most common in the
8–13 Hz range of the alpha rhythm of the electroencepha-
logram (EEG). Fortunately, the incidence of flicker-induced
epilepsy in the general population is very low. The incidence
in aircrew could in theory be further reduced by the record-
ing of a screening EEG together with photic stimulation in
an attempt to provoke an epileptiform spike and wave pat-
tern. However, the incidence of such EEG abnormalities in
fit healthy individuals is about 0.5 per cent and the risk of
subsequent epilepsy in those showing such abnormalities is
very low, of the order of 2.5 per cent (Gregory et al. 1993).
Difficulties have in the past been described while flying
in cloud, when the light from a rotating anti-collision bea-
con is reflected from the cloud and produces a perception of
yaw rotation of the aircraft in the opposite direction. This is
similar to the sense of self rotation, known as circular vec-
tion, produced in the laboratory by the movement of a dark
and light striped pattern projected on to a circular screen
surrounding a subject. However, most anti-collision bea-
cons are now fixed omnidirectional lights emitting a brief
flash at a rate of about once per second, so this effect does
not occur.
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The G excess effect
It has been customary to attribute erroneous sensations
of angular motion when head movements are made in a
turning aircraft to cross-coupled stimulation of the semi-
circular canals. However, experiments carried out in high-
performance aircraft where a large-radius coordinated turn
was flown with a resultant acceleration of 2 Gz but with a
low rate of turn (4 °/s), have shown that head movements in
pitch, roll or yaw could induce false sensations of aircraft
attitude. Commonly, subjects reported an illusory sensa-
tion of climb or dive on moving the head in pitch, although
neither the direction nor the magnitude of the sensation
was entirely consistent between individuals. These false
sensations were not caused by cross-coupled stimulation of
the semicircular canals because the plane of the apparent
motion did not accord with such a mechanism and the rate
of turn was so low. Rather, it is suggested that the sensations
are the consequence of atypical stimulation of otolithic
receptors, as the orientation of the head to the increased G
force vector changes when the head is moved. Despite the
lack of a clear-cut relationship between head movement and
sensation, the illusory sensation experienced by some sub-
jects can be powerful, particularly when the head is moved
quickly; others find the sensations confusing and disorien-
tating but difficult to describe precisely in terms of aircraft
attitude and motion. Other experiments have shown that
a forward head movement in pitch, made during a pull-up
from a dive, consistently evoked a sensation of tumbling
forward in pitch. The illusion is not just an apparent change
in attitude but contains an element of rotation in the plane
of the head movement, despite the absence of any cross-cou-
pled stimulus to the semicircular canals.
A more specific description of the effect of the G excess
illusion involves a tendency by the pilot when in a high G
turn to overbank the aircraft if a head movement is made
looking up and into the turn, for example, to check on a
wingman. An inflight experiment to explore this possibil-
ity required a study group of eight highly trained pilots to
establish a 2 or 4 G turn for 10 seconds, then to close their
eyes and immediately to make the specific head movement.
The changes in roll attitude of the aircraft were recorded for
the next 10 seconds. The results showed a slight increased
likelihood of overbanking the aircraft following a head
movement but the predominant effect was the consequence
of visual inattention which led to random and increasing
errors in angle of bank (Stott 1999).
Coning of attention and target fascination
Student pilots, under the stress of attempting to perform a
demanding and unfamiliar task, may allow their attention
to be confined to one aspect of the task. With experience and
the acquisition of skill, a pilot learns to maintain a regular
scan, so that all aspects of the aircraft’s flight trajectory and
systems are monitored adequately. However, even an experi-
enced pilot, when presented with a high workload, or when
K17577_C017.indd 309
Vision and spatial disorientation  309
anxious or unduly aroused, can lose efficiency. One aspect
of this impairment of performance is a restriction of the field
of attention. Thus, when flying by instruments, the pilot may
fix attention on one instrument and fail to notice a poten-
tially dangerous change in attitude or height. The absence of
information from non-visual receptors at such a time may
contribute to the disorientation that occurs with coning of
attention. This type of perceptual limitation occurs most
commonly during instrument flight, but it is not unknown
for a pilot in good visual conditions to become ‘fascinated’
during an attack manoeuvre on a ground target and to fail
to perceive their height above the ground until dangerously
late in the manoeuvre. Coning of attention should not be
mistaken for coning of vision as might occur under high G.
Information outside the area of attention remains visible but
is not perceived. The problem is not overcome by present-
ing more information within a smaller area, as in a head-up
display, or electronic flight instrument system.
Arousal level
Coning of attention is one manifestation of the changes
in brain function and behaviour that can arise from a
level of arousal beyond a certain optimum level. The term
‘arousal’ in this context is used in a somewhat specialized
way to identify a continuum which ranges from drowsi-
ness at one extreme to acute awareness, or even panic, at the
other. Although the concept has its limitations, it is useful
in attempting to integrate the varied effects of physical and
mental stress on behaviour and brain function.
One important effect of high arousal is that it causes
‘regression’, a term first used to describe the reversion to
a more firmly established pattern of behaviour that was
observed in flying personnel under stress during the First
World War. In flight, this regression may be manifest as a
breakdown of the more complex and more recently acquired
skills, of which instrument flying is the prime example.
When learning to fly by instruments, the pilot is trained to
ignore vestibular and kinaesthetic sensations; indeed, the
experienced pilot is mostly unaware of such potentially dis-
orientating sensations. However, when aroused, the pilot is
more likely to base control of the aircraft on such inappro-
priate cues, despite training to disregard them.
In addition to the loss of recently acquired skills in high
arousal states, there may be a diminution of higher mental
function affecting perceptual integration, decision-making
ability, cognitive function and supervisory activity. A few
pilots who have become highly aroused, for example by a
sudden awareness from aircraft instruments of a severe atti-
tude error, have reported that they were unable to interpret
the cockpit instruments, even though they could be seen
with clarity. In contrast, there is seldom any difficulty in the
interpretation of clear external visual cues.
While on a training Casevac sortie at night on
night vision goggles (NVGs), we decided to
abort the sortie and return to base as we found
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 310  Spatial orientation and disorientation in flight
the cloud base was too low. The commander
took control and initiated a left hand turn. I was
looking out at the time and realized I was los-
ing visual cues. I informed the commander who
replied that he had gone on to instruments and
that the aircraft had 20–30  degrees of bank
and 10  degrees nose-up attitude. Looking at
the instruments, my attention was grabbed by
the airspeed indicator that indicated 200 knots.
For what seemed like hours, I could not work
out why we were going so fast with a nose-up
attitude. It suddenly dawned on me that we
were going backwards – not a good situation at
200 feet AGL in IMC on NVGs over woods with
100 feet trees. I took control as the aircraft com-
mander was also disorientated and attempted
to regain airspeed. After again what seemed like
hours, I sensed I was getting the leans severely.
Fortunately, the commander again took con-
trol and initiated a rate of climb to start a cir-
cuit for an emergency GPS let-down. Once in a
safe flight configuration we contacted our field
operations and informed them of our situation.
With the verbal assistance of a very experienced
aircraft commander over the radio, we eventu-
ally landed back at base. Throughout the period
of emergency both the commander and I did
not have the capacity to spell our names, never
mind intercept headings and heights. I believe
the only reason we survived is that the severe
disorientation we both experienced lasted for a
short amount of time, and fortunately at differ-
ent times. Fatigue was also definitely a factor.
Although disorientation is more likely in high arousal
states, arousal below the optimum also causes a diminu-
tion of cerebral competence and with it a greater probabil-
ity of perceptual errors that may lead to an ill-considered
response to misinterpreted sensory information.
The level of arousal is far from being the only factor that
modifies the process of perception. In flight, many other
factors may interfere with brain function including the
classic environmental stresses of flight, such as hypoxia,
hypocapnia, high G, the effect of alcohol and other toxic
agents, and occasionally clinical disorders that can impair
cerebral function.
Dissociative sensations, the ‘break-off’
phenomenon
High altitude flight can also produce a disordered percep-
tion described by the aviator as a feeling of detachment,
isolation or remoteness from their immediate environment
and the aircraft they are controlling. Less commonly, the
sensory disturbance is more severe and takes the form of
an ‘out-of-body’ experience, in which the pilot feels that
they are outside the aircraft and are watching themselves
K17577_C017.indd 310
fly the aircraft. Other descriptions of the phenomenon are
an increased awareness of changes in aircraft attitude and
motion, an exaggerated sense of bank or a false sensation
of turn or roll when flying straight and level. Alternatively,
there may be a feeling of instability, likened to the aircraft
being balanced on a knife edge or as if on top of a pin and a
fear that the aircraft will fall out of the sky. The term ‘break-
off’ was coined by Clark and Graybiel (1957) to identify
this type of disordered perception, because one of the early
descriptions came from a pilot who felt as if he had ‘broken
off from reality’.
The break-off phenomenon is primarily a sensory dis-
turbance experienced by pilots of single-seat aircraft when
flying at high altitudes during monotonous phases of flight,
such as level cruise on a constant heading. Similar sensa-
tions have been described by helicopter pilots flying at lower
altitudes, even at 500 feet (150 m) when flying over a feature-
less sea in hazy conditions. The dissociative sensations are
usually short-lived and often disappear spontaneously when
the pilot directs attention to some other aspect of the flying
task, such as cockpit checks, a change of heading or making
a radiotelephone (R/T) call. On other occasions, break-off
may persist until the pilot has a clear view of the ground
or is close to clouds that give unambiguous relative motion
cues and a reliable external visual reference. The symptoms
of break-off could be considered as the result of a mismatch
between the output demands of flying the aircraft and the
relative lack of the sensory input required for the task.
The results of several surveys have shown that between
14 and 35 per cent of aircrew involved in solo high altitude
flight have experienced some form of dissociative sensa-
tions. For most pilots, such sensations, if mild, are no cause
for concern and may even be described as pleasurable and a
contribution to the joy of flying. However, some pilots find
the altered perceptions to be disturbing and anxiety-pro-
voking, a concern that may worsen with repeated exposure
and lead to a loss of confidence and even a fear of flying.
Pilots may come to medical attention because of increas-
ing anxiety. In the early stages, they may respond to the
reassurance that their experiences are not unusual, that
there is no measurable abnormality of vestibular function
or other physical illness. It must, however, be recognized
that dissociative sensations may occasionally be the first
symptom of a neurosis that develops because of other fac-
tors in the individual’s work, social life or background and
may necessitate a psychiatric referral.
OPERATIONAL ASPECTS OF
DISORIENTATION
Disorientation in helicopter operations
Spatial disorientation is no less of a problem in helicopter
operations than it is in fixed-wing aircraft. There are cer-
tain features of the way helicopters fly and the way in which
they are operated that lead to specific types of disorienta-
tion. Helicopter operations generally are carried out at low
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level, and although this does not, of itself, increase the like-
lihood of disorientation, it may leave little time to recover
from an unexpected aircraft attitude. Unlike a fixed-wing
aircraft, a helicopter has no motive power in the longitu-
dinal axis of the fuselage. In order to transition from the
hover to forward flight, the nose of the helicopter is pitched
down, so that a component of the lift provided by the main
rotor now accelerates the aircraft in the forward direction.
As ever, forward acceleration of an aircraft causes it to feel
more pitched up than it really is. Initially, before significant
aerodynamic drag builds up, the pitch-up sensation of for-
ward acceleration exactly balances the actual pitch-down of
the aircraft, so that it continues to feel level, just as it did
in the hover. Likewise, in order to transition from forward
flight into the hover, the pilot brings the nose of the aircraft
up so that a component of the rotor lift now acts in the rear-
ward direction and decelerates the aircraft. A decelerating
aircraft feels more nose-down than it actually is, and this
sensation exactly balances the effect of the actual nose-up
tilt and again causes the aircraft to feel level. The situation is
not significantly different in the roll axis. A helicopter tilted
in roll will tend to side-slip with increasing lateral veloc-
ity and as a result will continue to feel level. In summary, a
helicopter will tend to feel level whatever its true attitude.
In search-and-rescue operations, the helicopter pilot is
often required to maintain an exact height and location
when in the hover. This is not made any easier by the motion
of waves when hovering over the sea or the wave effects on
grass produced by the rotor downdraft. In these circum-
stances, close coordination between the pilot and the rear
crew is often crucial. Landing on snow also poses problems.
Lack of features on the surface of snow makes it difficult to
detect a drift in position. In addition, if the snow is loose,
the rotor down-draft may whip up the snow and unsight the
pilot at a critical phase in the landing (whiteout). The same
may occur when landing on dry, dusty terrain (brownout).
Landing on sloping terrain, particularly if it is featureless or
at night, also creates difficulties on account of the sideways
drift that occurs if the slope causes the pilot to misalign the
roll attitude of the aircraft.
Night operations are often carried out with the assis-
tance of night-vision goggles or using images from a for-
ward-looking infrared (FLIR) camera mounted on a swivel
turret on the nose of the aircraft. By enhancing the visual
environment, such devices should, potentially, reduce the
likelihood of disorientation. However, they enable hazard-
ous operations that would be impossible without their use
but have limitations in the quality of the visual image they
present to the pilot.
Formation flying
When flying in close formation, the pilot of the number two
aircraft in the formation takes his or her orientation cues
from the leader. The primary task is to maintain a fixed spa-
tial relationship to the leader to the neglect of the spatial
orientation of the aircraft with respect to the outside world.
K17577_C017.indd 311
Operational aspects of disorientation  311
The pilot of the lead aircraft has the major responsibility of
maintaining spatial orientation on behalf of the formation
and to ensure that his or her manoeuvres are sufficiently
gentle to allow the number-two pilot to respond to them.
Formation flying often continues despite cloud penetration,
and the only difference may be that the aircraft fly closer
to each other in order to maintain visual contact. In these
circumstances, even greater concentration is required in
order to maintain separation from the lead aircraft. If visual
contact is lost and the number-two pilot is obliged to break
away, the pilot may have great difficulty re-orientating rela-
tive to the real world through the aircraft instruments.
Aircrew reports indicate that formation flying in cloud
is particularly conducive to producing the leans in the
number-two aircraft. The sensation can be very disconcert-
ing, and the task of staying with the lead aircraft becomes
increasingly demanding. The alternative of breaking away
from the formation means losing the orientation cue pro-
vided by the leader and having to use instruments, without
necessarily alleviating the leans.
Some disorientating military manoeuvres
MISSILE EVASION
A fast jet flying at altitude is able to detect when enemy radar
has locked on to its position. This will be the precursor to
the launch of an enemy rocket-propelled surface-to-air mis-
sile against which the pilot has to take evasive action. This
involves a series of actions to bring the aircraft to the rela-
tive safety of the low level environment as quickly as pos-
sible while attempting to confuse any incoming missile as to
the position of the aircraft. The pilot’s first action is to apply
full thrust using reheat and to initiate a maximum G turn
to align the aircraft lift vector with the target – in effect,
initially to fly the aircraft in a transverse direction to an
incoming missile. The pilot may then deploy decoy material
behind the aircraft in an attempt to deflect the missile away
from its target. The aircraft is then rolled to 130 degrees of
bank and in this partially inverted attitude maximum G is
used to pull the aircraft into a 45 degree descent. Once in
this pitch attitude, the aircraft, now travelling at supersonic
speed towards the ground, is rolled upright and the pilot
has to judge the height above ground at which to begin a
high G pull out from the dive to arrive at low level. There
is much scope for orientation error, particularly when the
manoeuvre has to be flown at night or in cloud and, there-
fore, entirely on instruments. The head-up display is the
primary flight instrument for this manoeuvre but, in situ-
ations of a rapidly changing pitch attitude, it may be dif-
ficult to interpret on account of the rapid movement of the
pitch ladder in the display and require the pilot to transfer
to head-down instruments.
THE TOSS MANOEUVRE
This manoeuvre is used to drop a bomb on a target without
incurring the risk of having to overfly it. The approach to
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 312  Spatial orientation and disorientation in flight
the target is flown at high speed and at low level. At some
point short of the target the aircraft is put into a 30 degree
climb. An on-board computer determines the moment of
release of the bomb and once released, the pilot’s priority
is to turn away from the target and to descend back to low
level and away from detection by enemy radar. To achieve
this, the aircraft is put into a 4 G turn with 135 degrees of
bank so that there is a simultaneous change of heading and
loss of height. The roll attitude of the aircraft is steadily
reduced so that, by the time the nose of the aircraft meets
the horizon, the aircraft has been brought back to a wings
level attitude and then descends more gradually to flight at
low level. This manoeuvre is generally flown in good visual
conditions but problems with orientation arise should the
aircraft inadvertently be flown into cloud at the apex of
the manoeuvre.
HELICOPTER DECK LANDING ON A SHIP AT NIGHT
On a dark night, there may be an indistinct horizon and the
lights of a minimally lit ship may be the only object in the
external visual scene. In these circumstances, it may be dif-
ficult for the pilot to arrive at a correct mental picture of the
location of the ship and the position of the aircraft relative
to it. This is the result of the oculogravic effect in which the
external scene is interpreted in relation to the force frame of
reference generated by the aircraft aerodynamics. The ship
steams into wind and the approach is from astern, usually
on the port quarter. There are visual aids on the ship in the
form of lights that display different colours to assist the pilot
in maintaining the correct horizontal angle of approach.
When the aircraft is at some distance from the ship, the
manoeuvre is flown predominantly on instruments but also
with the aid of night-vision goggles. As the aircraft closes on
the ship, an increasing proportion of the pilot’s visual atten-
tion is directed to the external view. The pattern of lights
on the ship gives little sense of perspective until late in the
approach, and the aircraft may be no more than 300 m from
the ship before it is perceived as a three dimensional object.
The pilot then manoeuvres the aircraft into the hover along-
side the ship using unaided vision before making a sideways
transit on to the flight deck.
Incidence of spatial disorientation
Nearly all aircrew experience illusory sensations of aircraft
attitude and motion or fail to detect changes in aircraft
orientation at some time during their flying career. Such
incidents are due to the deceptive features of the airborne
environment and the limitations of sensory mechanisms
already described. The reported incidence of spatial dis-
orientation differs widely between aircrew. It is likely to
depend on the type of flying in which they are engaged but
also on what a pilot considers to be disorientation. Some
will say that they have never suffered from disorientation
because they always knew the aircraft’s correct orientation,
if only by reference to aircraft instruments; others will say
that they have some form of disorientation on almost every
K17577_C017.indd 312
flight, although they, too, successfully maintain correct
control of the aircraft.
Quantitative information on the incidence of spatial
disorientation comes from questionnaire surveys of mili-
tary pilots, although these have tended to concentrate on
the illusions of spatial orientation rather than identifying
those situations in which the pilot had lost awareness of
aircraft orientation.
For example, in the Royal Netherlands Air Force, of
the 209  pilots of F5  and F16  aircraft, all reported hav-
ing been disoriented at some time or other in their fly-
ing careers and 26  per cent had severe incidents with
narrow escape from disaster. Data from a survey of
413  Indian Air Force pilots yielded lower figures: 75  per
cent of fighter pilots, 64  per cent of transport pilots and
only 55  per cent of helicopter pilots acknowledged that
they had been disoriented. In contrast, surveys of heli-
copter pilots of the US Navy, the UK Royal Navy and
the UK Army yielded incidences of spatial disorientation
of 91  per cent, 95  per cent and 90  per cent, respectively.
Of the Royal Navy pilots, 61  per cent had been disori-
ented severely on one or more occasions, and situations in
which both pilot and co-pilot were disoriented at the same
time were reported in 21  per cent of the questionnaires.
In a more recent UK Army survey, 24  per cent of pilots
had suffered severe disorientation, and both crew mem-
bers were disoriented in 24  per cent of incidents, a figure
that rose to 44  per cent for incidents occurring during
flight with night-vision goggles (NVGs). A survey of US
Army helicopter accidents over the 10  year period 2002–
11  found that disorientation was involved in 11  per cent
of accidents and that disorientation-related accidents were
responsible for 22 per cent of all fatalities.
Spatial disorientation is also a significant problem in civil
transport and general aviation (private) pilots, although the
frequency of disorientation in these groups is not known.
Over the period 1982–96, only 1.1  per cent of the returns
made by UK civil pilots to a confidential human factors
incident reporting programme (CHIRP) described disori-
entation incidents. This figure is certainly an appreciable
underestimate of the frequency with which disorientation
is experienced by this pilot population, for they are unlikely
to report incidents in which control of the aircraft was not
compromised. Private pilots also suffer from disorientation,
typically from inadvertent cloud entry if they have little or
no instrument flying skills.
Information on the incidence of the many different types
of perceptual disturbances, embraced by the definition of
spatial disorientation, has been obtained from question-
naire studies of military pilots. Table 17.2 summarizes the
findings of two such surveys [Holmes et al. 2003; Matthews
et  al. 2002). The table shows the percentage of pilots who
reported having experienced particular illusions or percep-
tual problems ‘sufficient to affect performance, situational
awareness or workload – however slight that effect may be’.
As in many earlier studies, the most widely experienced
illusion was the ‘the leans’, a false perception of roll attitude
18/11/2015 14:11
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Table 17.2  Surveys of spatial disorientation incidence Disorientation incident survey

Per cent A different perspective on spatial disorientation is obtained
reporting at least by asking pilots, not about disorientating illusions, but
one incident about disorientating incidents that they have experienced.
USAF RAF An extended tri-service survey of this type, covering the
‘Leans’ 76 92 six-year period 2004–09, asked pilots to describe, in their
Loss of horizon due to atmospheric 69 82 own words, incidents in which they experienced confusion
conditions about the attitude or spatial position of their aircraft or in
Undetected drift (helicopter pilots 90 55
which they suddenly became aware that the aircraft was not
only)
in the attitude or position they had expected. Pilots rated the
incident in relation to flight safety as either minor – ‘trivial’,
Sloping horizon 66 75
significant – ‘could have been nasty’ or severe – ‘lucky to
Misleading altitude cues 50 79
get away with it’. The analysis of each incident by subject
Distraction 61 66
matter experts avoided the identification of the underlying
Tumbling sensation (Coriolis) 61 66 illusion and instead concentrated on the environmental,
Night (black hole) approach 58 60 manoeuvre, pilot and aircraft factors that contributed to
Loss of horizon due to sand/snow 33 56 the incident and on the nature of the orientation error that
Poor crew coordination 41 50 had occurred. An assessment was also made as to whether
Graveyard spiral/spin 38 50 the incident involved recognized or unrecognized disori-
Autokinesis 37 43 entation. Descriptions of more than 300  incidents were
False sensation of pitching up 44 34 obtained from about 1140 completed questionnaires (26 per
Misjudgement of position – night 38 37 cent), of which 55 were rated as severe and 135 significant.
Elevator illusion 37 35 One hundred and twenty-seven incidents were from fixed
G-excess illusion 36 33 wing and 177  from rotary wing aircraft. Of the incidents
False sensation of pitching down 37 28 assessed by the pilots as being significant or severe, over
When using night-vision goggles 12 48
two thirds involved unrecognized disorientation. Examples
(NVGs)
of the orientation errors that were reported included over-
bank errors, two of them to more than 130 degrees; errors in
Roll-reversal error 23 31
pitch attitude, both unintended pitch-up and pitch-down;
Inability to read instruments clearly 22 29
and inadvertent height loss in which 19 out of the 21 reports
on recovery
were rated as severe. Problems were described in the safe
False sensation of yaw 32 20
execution of missile evasion manoeuvres and also with the
When using head-down displays 20 30 leans when flying in formation or during air-to-air refu-
False sensation of inversion 23 18 elling. A diverse range of visual misperceptions were also
Inappropriate use of the sun or 24 17 reported including, when flying at low level, the masking
ground lights as vertical cue of imminent high ground against a background of more
Instrument malfunction 13 24 distant mountains. Those from helicopter pilots included
Feeling of detachment (break-off) 11 17 drift when in the hover, problems with landing on sloping
Flicker vertigo 20  8 ground and dust recirculation (brownout).
Problem interpreting head-up 10 13
display Pilot reaction to disorientation
When using FLIR/targeting aids  9 11
When using aerial flare 10 10 During flight, a pilot must have a mental model of the atti-
FLIR, forward-looking infrared; RAF, Royal Air Force; USAF, United tude and spatial position of the aircraft derived from the
States Air Force. non-visual sensations generated by their control actions
Data from 2582 USAF aviators (Matthews et al. 2003) and 752 RAF and confirmed by visual information from the outside
aircrew (Holmes et  al. 2003). (Both papers in RTO Symposium world or from attitude instruments. An unrecognized dis-
HFM-085, TP/42.)
orientation, once evident, will require the pilot to abandon
the current erroneous mental model and establish a new
when flying straight and level. However, the importance one. This may take valuable seconds to achieve, particu-
of these statistics is not in the precise percentage of pilots larly if it has to be based on the less visually powerful atti-
who reported a specific illusion but in the demonstration tude instruments rather than a clear external view. In these
of the variety of illusions and conditions of flight in which circumstances, the pilot calls upon skills learned in instru-
spatial disorientation can occur. Unfortunately, it tells us ment flight training to recover from unusual attitudes.
little about which conditions carry the greatest hazard to However, such a situation can provoke a sudden high
flight safety. level of stress and possibly lead to an ill-judged recovery

K17577_C017.indd 313 18/11/2015 14:11

 314  Spatial orientation and disorientation in flight
manoeuvre or a failure to initiate a timely ejection from
the aircraft.
One consequence that has been described in a high stress
situation is known as the ‘giant hand’ phenomenon (Lyons
and Simpson 1989). The term derives from a description by
a pilot who had made a difficult landing in snowy condi-
tions at night. After a brief turnaround, he took off again
and was in the climb-out when he was assailed with sud-
den dizziness (possibly pressure vertigo) which resulted in
a temporary loss of control. The recovery from the unusual
attitude in which he found himself required him to fly an
outside loop, i.e. with negative G, in order to fly the aircraft
clear of the ground. Following this manoeuvre he saw that
the aircraft had a residual angle of bank but his attempts
to restore the aircraft to wings level were prevented by an
apparent restriction in the movement of the control col-
umn. He found, however, that if he gripped the control col-
umn lightly using only finger and thumb, it moved freely,
but when he again gripped it with his full hand the apparent
restriction returned. As he reported, it was as if a giant hand
had gripped the control column and prevented him from
moving it.
A similar account was given by a commercial pilot who,
on a night flight, encountered the most severe high level
turbulence that he had ever experienced. The aircraft had
been flying on autopilot but this dropped out, leaving him
in control. With much difficulty, he retained control but
found it impossible to make the necessary control action
finally to return the aircraft to straight and level flight and
had to be assisted in doing so by the intervention of the
non-handling pilot.
In one more recent survey of illusions, the giant hand is
now described as pressing down on one wing. This no lon-
ger conforms to its original description and arguably could
be taken to refer to the sensation known as the leans.
A further problem is that the giant hand phenomenon has
incorrectly become linked with the phenomenon known as
break-off. It is true that both involve an altered perception
whose origin is within the brain, but the circumstances in
which they occur are entirely different. A pilot who expe-
riences the giant hand phenomenon is likely to be highly
stressed by some unexpected event, whereas a pilot experi-
encing break-off is typically involved in a monotonous flight
at high altitude and may well have a low level of arousal.
The response of a pilot to a disorientation incident is gen-
erally one of ‘I learned about flying from that’. The aware-
ness of having made a mistake may make aircrew initially
unwilling to talk about the incident or to report it through
official channels if not obliged to do so. With the passage of
time, the incident falls into place in the pilot’s memory and
becomes a good story to be shared with colleagues.
There was a time when a pilot who had experienced a
significant disorientation incident was referred for medi-
cal assessment and measurement of vestibular function.
However, it has become increasingly clear that disorientation
affects fit pilots with normal vestibular function and rarely
is there any underlying medical problem. A disorientation
K17577_C017.indd 314
incident may, however, come to medical attention on the
rare occasions that it provokes an anxiety reaction or leads
to a flying phobia. There are also medical conditions, par-
ticularly those involving vestibular function such as posi-
tional vertigo, vestibular neuronitis or Ménière’s disease, for
which a pilot may be grounded on account of the risk of
disorientation should a further episode occur in flight.
Spatial disorientation accidents
It is unsurprising that a pilot’s loss of awareness of aircraft
attitude at a critical phase of flight can lead to an accident.
In an aircraft accident, there are often multiple causal fac-
tors and a sequence of errors leading up to the final event.
An assessment of the role played by disorientation in any
accident is always open to debate and, particularly when
the accident involves fatalities, may have to rely on cir-
cumstantial evidence, such as knowledge of weather condi-
tions at the time and of the manoeuvre being attempted. If
information is available from flight data and cockpit voice
recorders on the aircraft’s flight trajectory and the pilot’s
control actions and communications, the part played by
disorientation is usually clearer. However, accident sur-
veys, almost all of them dealing with military accidents,
vary quite widely in the reported percentage of acci-
dents attributable to spatial disorientation. Figures range
from 2.5  per cent in the Indian Air Force to 39  per cent
of F16  accidents in the Netherlands Air Force. A study of
406 accidents in the Royal Air Force (RAF) over the period
1973–91  found that disorientation accounted for 12  per
cent of accidents and 21 per cent of fatalities. In the US Air
Force (USAF), spatial disorientation was considered to be a
causal or major contributory factor in 20.2 per cent of class
A mishaps in the decade 1991–2000, with a fatality rate
three times greater than in accidents in which spatial dis-
orientation was not implicated.
A more recent survey of military aircraft accidents
(Bushby 2005) covering the two ten-year periods 1983–
92  and 1993–2002  showed a reduction in the rate of all
Table 17.3  Accident rates per 100 000 flying hours in
military aircraft
1983–1992 1993–2002
Fast jet aircraft
All accidents 7.0 5.8
Disorientation- related 1.7 (24%) 1.6 (28%)
accidents
Rotary wing aircraft
All accidents 4.1 2.4
Disorientation-related 1.0 (24%) 1.0 (42%)
accidents
Accident rates per 100 000 flying hours for the two 10-year peri-
ods 1983–1992 and 1993–2002. The figures show a decrease in
the overall accident rate, particularly for rotary wing aircraft, but
no corresponding decrease in the rate of accidents attributable
to disorientation.
18/11/2015 14:11

accidents, particularly in rotary wing aircraft, between the
two time periods but there was little change in the rate of
spatial disorientation-related accidents. The accident rates
per 100 000 flying hours are given in Table 17.3. To put these
figures in some context, in commercial aircraft belonging
to major airlines worldwide, the accident rate in 2011 was
3.6  per million departures. The military accident survey
identified several factors that increased the relative risk of a
disorientation-related accident. Risk was increased by a fac-
tor of two when night flying and by a factor of about three
when flying in cloud or in conditions described as having
a poor visual backdrop. Inadequate communication within
the cockpit led to an almost fourfold increase in risk. Of
particular significance in this survey were the findings that
50 per cent of disorientation-related accidents involved dis-
traction and that, at the point at which the accident became
inevitable, disorientation remained unrecognized in 85 per
cent of accidents.
The statistics relating to accidents involving commer-
cial aircraft are published annually by the International
Civil Aviation Organization (ICAO 2013) but their report
does not list causal factors. A further annual Statistical
Summary of Commercial Jet Airplane Accidents is pub-
lished by Aviation Safety, Boeing Commercial Airplanes
(2013). This publication excludes from analysis commer-
cial airplanes operated in military service and also, for
lack of operational data, airplanes manufactured in the
Commonwealth of Independent States (CIS) or the Union of
Soviet Socialist Republics (USSR). In addition to accidents
that have occurred in the current year, the report also sum-
marizes the accumulated accident figures from 1959  and
also those from the previous 10 years. As a cause of fatali-
ties over the past 10 years, the largest group is labelled ‘loss
of control in flight’ and the second largest ‘controlled flight
into terrain’ (CFIT). Spatial disorientation is not included
as a category, but it could be argued that in the category of
CFIT, when a fully serviceable aircraft is accidentally flown
into the ground, a large proportion of the pilots involved,
if not all, are likely at some point to have been unaware of
the attitude or spatial position of the aircraft, and therefore
disorientated. It is also likely that there will be instances of
disorientation included in the category of loss of control
in flight.
There are insufficient data on the incidence of disorienta-
tion accidents to private pilots. A far from recent survey of
US general aviation statistics for the period 1968–75 involv-
ing over 35 000 accidents identified spatial disorientation as
a prime cause or contributory factor in 2.5  per cent of all
accidents (Kirkham et al. 1978). The survey found that 90 per
cent of orientation error accidents were fatal, representing
16 per cent of all fatalities. In those pilots flying under visual
flight rules (VFR) who flew into adverse weather, orientation
error was found to be a factor in 35.6 per cent of fatal acci-
dents. However, this figure, and by implication the figure of
2.5 per cent of all accidents, are likely to be underestimates.
Any pilot who suffers a fatal accident from flight into bad
weather is almost certain to have been disorientated. It is
K17577_C017.indd 315
Prevention of spatial disorientation  315
more likely that these figures are evidence of the reluctance
of accident investigators to use the term spatial disorienta-
tion, perhaps because it is not sufficiently specific to explain
the sequence of causal events that led to the accident.
PREVENTION OF SPATIAL DISORIENTATION
Any attempt to reduce the number of incidents and acci-
dents attributable to spatial disorientation should focus
attention on aircrew training and the development of new
aircraft systems to keep a pilot informed of aircraft attitude
and position in the presence of other competing demands.
Aircrew training in the prevention of spatial
disorientation
The finding from the UK tri-service accident survey that
there has been no reduction in the rate of accidents attrib-
utable to disorientation suggests either that an irreducible
minimum has been reached or that there is a need for new
ideas in the training of aircrew.
It is of obvious importance to warn aircrew at an early
stage in training of the potential dangers of disorientation
and that the aircraft attitude has to be monitored consciously
rather than taken for granted. Training for disorientation
has traditionally been part of an aeromedical training pro-
gramme. While this is appropriate for the physiological
limitations that are involved, the aerodynamic behaviour of
the aircraft is also a major contributor to potential spatial
disorientation. Furthermore, the successful resolution of a
disorientating incident rests with the pilot and his train-
ing in learning to fly the aircraft so as to minimize the risk
of disorientation. Medical advice, listed at the end of the
chapter, on the avoidance of disorientation is inevitably
somewhat general in nature. The more specific aspects of
disorientation training in relation to specific manoeuvres
are the responsibility of the flight instructors.
In addition to lectures and video presentations, aircrew
are given the opportunity to experience spatial disorienta-
tion in a dedicated simulator. These devices have evolved
from relatively simple rotating chairs to increasingly sophis-
ticated motion devices with visual presentations of an air-
craft instrument panel and an external visual scene. The
aim of the earlier devices was to demonstrate the fallibility
of vestibular sensors of motion, particularly to rotational
stimuli. Rotation about a vertical (yaw) axis has remained a
feature of later disorientation training devices and subjects
are able to experience the confusing sensations associated
with a range of illusions and the disturbing effect of making
head movements in this environment. However, it is impor-
tant not to give pilots the impression that disorientation will
always present with such sensations. One solution to a pos-
sible negative transfer of ground based training to the flight
environment has been the adoption by some air forces of
dedicated flights designed to demonstrate manoeuvres that
leave a student pilot with eyes closed, unaware of the true
attitude or motion of the aircraft (Braithwaite 1997).
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 316  Spatial orientation and disorientation in flight
The problem of unrecognized disorientation, the situation
in which everything feels normal despite a worsening devia-
tion from the intended flight path, is not well addressed by
ground-based disorientation simulators. The confusing sen-
sations that they demonstrate, if experienced in flight, act as
the trigger for the trained pilot to rely on the aircraft instru-
ments to determine the true situation. However, the great
majority of disorientation-related accidents occur without
the alerting benefit of confusing sensations. For these, it is
necessary to train pilots in the circumstances, such as go-
around, takeoff into cloud, low level abort manoeuvres, in
which the risk of unrecognized disorientation is high. An
equally important aspect of disorientation training is prior-
itization of tasks and the apportionment of time devoted to
them in relation to the demands of maintaining an accurate
flight path. These considerations are well suited to the use of
modern training simulators in which the motion environ-
ment is far less important than the ability to create a large
range of scenarios that tax the pilot’s airmanship with an
increasing workload and create the potential for unrecog-
nized disorientation. This use of conventional simulators is
being introduced for disorientation training in both fixed
and rotary-wing aircraft at multiple stages throughout a
pilot’s career. Whether this development will have a ben-
eficial impact on the accident statistics only time will tell.
Much of the basic physiological science of relevance to
disorientation in aircraft has been elucidated many decades
ago, some even before the advent of powered flight. The
practical problem remains as to how the subject should be
taught and demonstrated to each successive generation of
pilots to forewarn them and maintain their awareness of the
potential dangers of disorientation in flight.
Cockpit aids to the prevention of spatial
disorientation
TACTORS
There has been an interest in the use of cutaneous sensation
to provide pilots with information about aircraft orienta-
tion or as a landing aid for helicopter pilots in conditions of
whiteout or brownout. In contemporary systems, a number
of small electromechanical vibrators (tactors) are arranged
in a grid pattern incorporated into a vest so as to surround
the torso. Information about aircraft orientation is given by
the spatial configuration of the tactors activated within the
grid, while rate of change of orientation can be coded by
the frequency of tactor vibration or by the sequential activa-
tion of tactors to give a sensation of movement. Simulator
experiments have shown that when a pilot was loaded by a
secondary audio task, the use of this type of tactile stimulus
improved performance without increasing ratings of men-
tal effort. These findings give substance to the claim that a
tactile system provides intuitive cues for spatial orientation
and can reduce the demands on other sensory modalities
and on high-level processing within the central nervous sys-
tem (Rupert 2000).
K17577_C017.indd 316
HEAD-UP DISPLAYS
The head-up display (HUD) was originally designed as a
weapons aiming system for use in fighter aircraft to aid air
combat. It later came to be used to display the basic infor-
mation from head-down aircraft instruments, airspeed,
attitude, altitude, heading, vertical speed, turn and slip
together with flight path indicators. In many aircraft, the
HUD has become the primary flight instrument system
with the head-down instruments as back-up. HUDs are now
in widespread use in commercial aircraft, business jets and
even in cars. They allow the pilot a simultaneous view of
flight instrument information and the external visual scene
and, by collimating the image in the HUD to optical infin-
ity, obviate the need for the visual accommodative change
that would be required for conventional head-down instru-
ments. Neither of these two benefits is entirely clear cut.
Unlike the visual processing of the visual scene, attention to
the symbolic information within the HUD display involves
different mental processes which can divert the pilot’s
attention from important details of the external visual
scene, such as conflicting traffic or runway incursions, that
should, in theory, be simultaneously visible. However, there
are many benefits from having flight information avail-
able without changing the direction of gaze. For example,
increased accuracy has been demonstrated in the approach
and landing phase of flight.
The scope of what is available using HUD technology has
widened. Flight path displays superimposed on the HUD
allow the pilot to see a 3D representation of the future flight
path of the aircraft, a ‘highway in the sky’ display. More
sophisticated are synthetic vision systems which superim-
pose on the HUD a computer-generated image of the view
ahead derived from detailed digital maps and data from the
inertial navigation and global positioning systems on the
aircraft attitude and spatial position. These developments
have the capacity to eliminate the disorientation associ-
ated with the approach and landing accidents that occur in
degraded visual conditions and are likely to become a stan-
dard feature of HUD displays in commercial aircraft.
GROUND COLLISION AVOIDANCE SYSTEMS
Though not affecting the incidence of pilot disorientation,
there are technological solutions available to reduce the
worst consequences of disorientation in accidents in which
a serviceable aircraft is flown into the ground. Ground prox-
imity warning systems have long been a standard feature
of commercial and military aircraft. Incident reports have
confirmed their value in alerting the pilot to a dangerous
situation but they require the pilot to respond appropriately
and cannot anticipate an unrecoverable aircraft attitude or
menacing terrain features. The Eurofighter Typhoon aircraft
is fitted with an automatic recovery system. The publicity
material states: ‘In the unlikely event of pilot disorientation,
Eurofighter Typhoon’s Flight Control System (FCS) allows
for rapid and automatic recovery by the simple press of a
button.’ However, such a system requires a pilot to recog-
nize that they are disorientated before pressing the button.
18/11/2015 14:11

It is, therefore, unlikely to be of much value in the 85 per
cent of disorientation accidents attributable to unrecog-
nized disorientation. The ultimate solution may be provided
by automated ground collision avoidance systems (GCAS),
their widespread use made possible by the availability of
software incorporating detailed terrain maps and accurate
information derived from global positioning systems.
Advice to aircrew
GENERAL
No pilot has ever been able to fly an aeroplane by the seat
of their pants: you are no exception.
Remain aware that you cannot determine the aircraft
attitude, either in roll or in pitch, simply from the feel of
the aircraft.
You don’t have to be flying in cloud or at night to become
disoriented, but it makes disorientation more likely.
When disoriented, your instruments are your lifeline.
Never be tempted to think your instruments are not telling
you the truth without an exceptionally good reason.
Cross-check instruments in clear visual conditions to give
you confidence in their reliability when you need them.
Aim to make an early transition to instruments in poor
visibility; once on instruments, stay on instruments
until external cues are unambiguous.
Do not unnecessarily mix flying by instruments with fly-
ing by external visual cues.
Remain aware of the circumstances in which the feel of
the aircraft can deceive you, e.g. takeoff into cloud or at
night, a go-around, a low-level abort. Check the VSI for
a positive rate of climb.
Be alert to manoeuvres in which small errors in aircraft
attitude can have significant consequences, e.g. the
angle of bank in high G turns at low level.
Distraction is a potent cause of disorientation. When
manoeuvring, the time you can allow yourself to be
distracted is much shorter than when in straight and
level flight.
First, fly the aircraft. Many instances of disorientation
arise from an excessive preoccupation with one aspect
of the mission to the temporary exclusion of controlling
the aircraft.
Beware of situations in which there is an unanticipated
change of pilot in control. If on account of disorien-
tation you have had to give control to your co-pilot,
switch immediately to monitoring the flight. Your
colleague may also have been disorientated or have dif-
ficulty in picking up where you left off.
The most dangerous forms of disorientation arise when
you think nothing has changed when, in fact, it has.
Ensure that you are fit to fly. Do not fly if you feel ill or
cannot clear your ears.
Take care with alcohol. Excessive alcohol may require
longer than the 12-hour ‘bottle-to-throttle’ rule to clear
from the system.
K17577_C017.indd 317
Prevention of spatial disorientation  317
Maintain a high proficiency and be in practice at flight
in IMC.
Avoid unnecessary head movements when manoeuvring
in IMC.
Make your first flight after a period off flying a simple day
VMC sortie.
Leave your worries behind when you go flying; the aircraft
needs your full attention.
Experience may help but does not make you immune
from disorientation.
Share your experience of disorientation with others.
Learn from the mistakes of others; you will not live long
enough to make them all yourself.
WHAT TO DO IN THE EVENT OF DISORIENTATING
SENSATIONS IN FLIGHT
You can dispel persistent minor disorientation, e.g. ‘the
leans’, by making a positive effort to redirect attention
to other aspects of the flying task. A quick shake of the
head, provided the aircraft is straight and level, is effec-
tive for some pilots.
When you are confronted suddenly by strong illusory
sensations or have difficulties in establishing orientation
and control of the aircraft:
Get on to instruments: check and cross-check and
ensure good instrument illumination.
Maintain instrument reference and correct scan pat-
tern; watch your height at all times.
Control the aircraft in such a way as to make the instru-
ments display the desired flight configuration.
Do not attempt to mix flight by external visual reference
with instrument flight until external visual cues
are unambiguous.
Seek help if severe disorientation persists. Hand over
to co-pilot (if present), call ground controller and
other aircraft; check altimeter.
If control cannot be regained, abandon aircraft with
safe ground clearance. Do not leave it too late.
Nearly all disorientation is a normal response to the envi-
ronment of flight. If you have been alarmed by a flight
incident, discuss it with colleagues. Your experience
probably will not be as unusual as you think.
SUMMARY
●● A pilot is disorientated if they are unaware of the
true attitude or spatial position of the aircraft.
●● Disorientation is as much a consequence of the
deceptiveness of the airborne environment as it is
of the sensory inadequacies of the pilot.
●● With increasing altitude, the external view
becomes less detailed. False horizons may be
generated by cloud banks or at night by lines of
cultural lighting. Flight over snow, sand or water
may lead to altitude errors.
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 318  Spatial orientation and disorientation in flight
●● The external view may become degraded or lost
and require the more demanding task of flight
by instruments. Not all pilots possess this skill.
Some that do, fail to use it at critical moments.
●● The feel of the aircraft cannot substitute for vision
and will inevitably lead to increasing errors both
in roll and pitch attitude as well as heading. You
cannot fly an aircraft by the seat of the pants, i.e.
by non-visual sensations.
●● The experience of an illusion and spatial disori-
entation are not the same. A pilot’s recognition of
an inflight illusion usually implies their recogni-
tion of the potential to be deceived by it. Whether
or not they are recognized, illusions of flight are
universal, the most common being the sensation
that an aircraft is in level flight when it is not. By
contrast, disorientation incidents and accidents
are relatively rare. A pilot describing a disorienta-
tion incident does not use the term ‘illusion’. To
them, the error of aircraft orientation was based
on a mistaken reality.
●● False sensations of pitch attitude during acceler-
ated flight, a manifestation of the somatogravic
effect, can often be identified as the precipitating
factor in accidents associated with takeoff into
cloud or with the need to abort low-level flight or
to go around following a missed approach.
●● Many of the visual misperceptions of aircraft
orientation such as false or sloping horizons are
made more convincing by the absence of non-
visual sensations to indicate an error in aircraft
attitude. Equally, the force environment of flight
can generate non-visual sensations that lead to an
incorrect perception of the location or orientation
of objects in the external visual scene if they are
isolated and lack any visual context.
●● In 85 per cent of accidents involving disori-
entation, the pilot was considered to have
been unaware of being disorientated up to
the point when the accident became inevi-
table. Unrecognized disorientation remains a
serious problem.
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Central Production Facility Platform in the North Sea
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Commercial Jet Airplane Accidents. Aviation Safety,
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Braithwaite MG. The British Army Air Corps in-flight
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Bushby A. An Assessment of the Influence of Spatial
Disorientation upon Military Aircraft Accidents from
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Cheung B. Spatial disorientation: more than just illusion.
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Clark B, Graybiel A. The break-off phenomenon – a feel-
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121–6.
Clark B, Graybiel A. Influence of contact cues on the
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Cohen MM, Crosbie RJ, Blackburn LH. Disorienting
effects of aircraft catapult launchings. Aerospace
Medicine 1973; 47: 39–41.
Collar AR. On an Aspect of the Accident History of
Aircraft Taking Off at Night. Aeronautical Research
Council, Reports and Memoranda No. 2277. London:
His Majesty’s Stationery Office, 1949.
Ercoline WR, Devilbis CA, Yauch DW, Brown DL. Post-roll
effects on attitude perception: the Gillingham illusion.
Aviation, Space, and Environmental Medicine 2000; 71:
489–95.
Fernandez C, Goldberg JM: Physiology of peripheral
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Neurophysiology 1971; 34: 661–84.
Fettiplace R, Ricci AJ. Adaptation in auditory hair cells.
Current Opinion in Neurobiology 2008; 13: 446–51.
Graybiel AW, Johnson H, Money KE, Malcolm RE, Jennings
GL. Oculogravic illusion in response to straight-ahead
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Environmental Medicine 1979; 50(4): 382–6.
Gregory RP, Oates T, Merry RT. Electroencephalogram
epileptiform abnormalities in candidates for air-
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Holmes SR, Bunting A, Brown DL et al. Survey of spatial
disorientation in military pilots and navigators. Aviation,
Space, and Environmental Medicine 2003; 74: 957–65.
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Hudspeth AJ. How the ear’s works work. Nature 1989;
341: 397–404.
International Civil Aviation Organization (ICAO) 2013
Safety Report. Available from www.icao.int/safety/
Documents/ICAO_2013-Safety-Report_FINAL.pdf.
Johnson SL, Roscoe SN. What moves, the airplane or the
world? Human Factors 1972; 14(2): 107–29.
Kirkham WR, Collins WE, Grape PM, Simpson JM,
Wallace TF. Spatial disorientation in general avia-
tion accidents. Aviation, Space, and Environmental
Medicine 1978; 49: 1080–6.
Living without a balancing mechanism. New England
Journal of Medicine 1952; 246: 458–60.
Lundgren CEG, Malm LU. Alternobaric vertigo among
pilots. Aerospace Medicine 1966; 37: 178–80.
Lyons TJ, Simpson CG. The giant hand phenomenon.
Aviation, Space, and Environmental Medicine 1989; 60:
64–6.
Matthews RSJ, Previc F, Bunting A. USAF Spatial
Disorientation Survey. Paper presented at the RTO
Human Factors and Medicine Panel (HFM) Symposium.
Spatial Disorientation in Military Vehicles: Causes,
Consequences and Cures. La Coruña, Spain, 15–17
April 2002. RTO-MP-086. Neuilly-sur-Seine, France:
NATO Research and Technology Organization, 2002.
Money KE, Myles WS. Heavy water nystagmus and effects
of alcohol. Nature 1974; 247: 404–5.
New Zealand Air Line Pilots’ Association. The Erebus
Story. The Loss of TE 901, 2009. Available from www.
erebus.co.nz/Background/TheFlightPathControversy.
aspx.
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Further reading  319
Perrone, JA. Visual slant misperception and the
‘black-hole’ landing situation. Aviation, Space, and
Environmental Medicine 1984; 55(11): 1020–5.
Ponomarenko VA. Kingdom in the Sky – Earthly Fetters
and Heavenly Freedoms. The Pilot’s Approach to the
Military Flight Environment. RTO AGARDograph 338.
Neuilly-sur-Seine, France: Research and Technology
Organization, 2000.
Roscoe SN. Horizon control reversals and the graveyard
spiral. CSERIAC Gateway 1997; 7(3): 1–4.
Rupert AH. An instrumentation solution for reducing
spatial disorientation mishaps. IEEE Engineering in
Medicine and Biology Society 2000; 19: 71–80.
Stott JRR. The Effect on Aircraft Control of Pilot Head
Movement During Increased G. DERA Report DERA/
CHS/PPD/CR990314/1.0, 1999.
FURTHER READING
Previc FH, Ercoline WR. Spatial Orientation in Aviation.
Reston, VA: American Institute of Astronautics and
Aeronautics, 2004.
Research and Technology Organization (RTO) Symposium.
Spatial Disorientation in Military Vehicles, Causes,
Consequences and Cures. Report No. HFM-085,
TP/42. Neuilly-sur-Seine, France: NATO Research
Technology Agency, 2003.
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Part    

Space Physiology and Medicine

18 Space Physiology and Medicine 323

Michael Barratt

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Space physiology and medicine
MICHAEL BARRATT
Vehicles/programmes 323
Physical factors of spaceflight 325
Physiological adaptation to weightlessness 335
Clinical problems during spaceflight 345
The field of space medicine practically began before the
launch of Russian cosmonaut Yuri Gagarin into orbit in April
of 1961. Aviation was progressing rapidly in the few decades
prior to this, and space physiology and medicine represent a
natural evolution from this world. Higher altitudes and the
increasing acceleration loads of high-performance aircraft
required a concerted effort to understand the effects on the
human occupant and provide protection to optimize per-
formance. High-altitude balloon flights had already demon-
strated the efficacy of completely enclosed cabins in rarefied
atmospheres, and most of the acceleration forces and toler-
ances that might be encountered during launch and landing
were understood from ground studies and aviation. What
had to await this first launch was the understanding of the
profound effects of weightlessness on the human body.
Since Gagarin’s first two-orbit flight, over 500 people have
flown into Earth orbit and a few beyond, and the ability of
humans to fly long durations and perform productive work
on these missions is now a working assumption. Missions of
six months’ duration have been routinely flown for decades
in the Russian Salyut, Mir, and now International Space
Station (ISS) programmes. Along with this we have devel-
oped an incomplete but functional understanding of the
predictable changes that occur as the human adapts to the
spaceflight environment. Similar to the aviation, undersea
and high-altitude arenas, we explore and operate in the space
environment because of the benefits it offers. Like these
others, spaceflight carries special hazards and risks, and a
deliberate and systematic effort has been made to under-
stand these and develop countermeasures and protections
to the deleterious effects to optimize human performance.
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18
Earth return and readaptation 348
References 352
Further reading 354
The fundamental elements influencing space medicine may
be distilled into altered acceleration loads – from the large
loads associated with launch and landing to their complete
absence in weightlessness – and altered atmospheres, with
variable pressures and oxygen mixes that meet the opera-
tional requirements of a mission scenario. Add to this the
unique occupational exposures associated with human
spaceflight, such as ionizing radiation and characteristics
associated with the vehicles that take us there, and the dis-
cipline of space medicine is defined.
At this point in time, the ISS as a permanently staffed
laboratory has been manned for a decade and a half with
long-duration crews, planning is underway for explora-
tion missions beyond Earth’s orbit, and a commercial space
effort is emerging to serve the research and tourist sec-
tors in low Earth orbit (LEO). In addition, the commercial
world is poised to provide suborbital spaceflight experi-
ences on a scale unprecedented from previous programmes.
Increasingly, space medical expertise will be called upon
to support these efforts. This chapter overviews the physi-
cal factors associated with spaceflight, the physiological
changes that the human undergoes during dynamic flight
phases and prolonged weightlessness, and common medical
problems encountered.
VEHICLES/PROGRAMMES
Because many of the physiological implications of spaceflight
are directly related to vehicle performance and characteris-
tics, a brief review of these is in order. Sufficient experience
has now been accrued to categorize these by vehicle type.
323
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 324  Space physiology and medicine

Capsules
The first vehicles that carried humans (and animals for
that matter) to sustainable orbits were the classic capsules,
simple vehicles that could easily attach to the top of a ver-
tical rocket booster stack beneath an aerodynamic fairing
and undergo atmospheric entry and parachute landing on
return to Earth. These were a natural evolution from bal-
listic missiles where the payload also rides atop a booster
stack beneath a fairing. Arguably these remain the domi-
nant design in human-rated spacecraft. They are compact
and efficient, orienting crewmembers on their backs with
respect to the spacecraft vertical axis for both launch and
landing. The implications for dynamic loads are that the
major forces associated with launch and landing are in the
+Gx (chest to back) direction, the most favourable from
the standpoint of physiological challenge. Capsules may
land on water or land. By offsetting the centre of mass
from the aerodynamic centre, a capsule may be steered
during entry, affording a limited cross-range capability
to fly towards a targeted landing site. Thus far all have
landed with the aid of parachutes. In spite of some degree
of cross-range steerage, capsules are fairly imprecise in
their landing site. Once atmospheric entry is complete
and orbital velocity has been shed, they are subject to
winds and weather. As such they require a large unpop-
ulated territory for landing and recovery, either water or
land. Table 18.1 summarizes the attributes of human-rated
space capsules used thus far.
Another advantage of a capsule involves abort modes
during hazardous launch and ascent events. Being situated
atop a vertical stack, a capsule has a clear path away from a
mishap by means of an escape rocket system. The efficacy
of this concept was demonstrated with the Russian Soyuz
T-10A mission in 1983, when the occupants were safely cata-
pulted clear of an explosion which engulfed the launch pad.
Gemini capsules were unique in that they employed ejection
seats for the two occupants, which would have catapulted
them laterally from atop the rocket stack in event of mishap
on the pad or during early ascent.
Winged spacecraft
From a strict definition of the term ‘space’, being 50 miles
for the US Air Force and 62 miles for the international com-
munity, winged vehicles carried humans into space very
early. The X-15 rocket plane performed the third suborbital
flight after the first two Mercury flights. The X-15 and early
lifting bodies represent a natural evolution of high-perfor-
mance aircraft, and may be considered ancestral to the US
Space Shuttle, Russian Buran and Spaceship 1. They offer
the advantage of full aerodynamic control upon entry to
the atmosphere, wide cross-range capability, and landing
on a conventional (albeit long) runway. This does necessi-
tate wings and landing gear, which are only useful during
atmospheric flight and landing and otherwise represent a
weight penalty during launch, ascent, orbital flight and
initial atmospheric entry. Like the X-15, Spaceship 1 uses
wings for orientation and lift as the rocket ascent is initi-
ated. Until final atmospheric flight and landing, however,
wings may also constitute a liability and safety risk. The US
Space Shuttle Columbia was lost owing to fatal damage of
the left wing during launch that went undetected until the
catastrophic breakup during entry.
From the standpoint of the human occupant, the impli-
cations are return to a horizontal reference frame and
an upright seated posture similar to a standard aviation
environment during the landing phase. This positions the
human such that the aerodynamic loads of entry are taken
in the body +Gz axis, which is less favourable for both sus-
tained and impact acceleration tolerance. Entry acceleration
levels for winged vehicles are of lesser magnitude but expo-
sure is prolonged compared with capsules. In addition, the
control inputs are basically akin to those of aircraft, and are
more complex and demanding than for a capsule. As will be
discussed, the transition from the weightless adapted state

Table 18.1  Space capsules – vehicles and attributes

Vehicle Years of operation Crew Pressurized Cabin atmosphere Maximum flight
volume (m3) duration
Vostok (R) 1961–1963 1 1.6 SL 4 day 23 hr
Mercury (US) 1961–1963 1 1.7 5 psi/100% O2 1 day 10 hr
Voskhod (R) 1964–1965 2 1.6 SL 1 day 2 hr
Gemini (US) 1965–1966 2 2.6 5 psi/100% O2 13 day 18 hr
Apollo (US) 1968–1975 3 6.2 5 psi/100% O2 12 day 13 hr
Soyuz (R) 1967–present 3 4.0 SL 5 day endurance*
Shenzhou (PRC) 2003–present 3 6 SL 15 day†
Shuttle (US) 1981–2011 7 65.8 SL 17 day 15 hr
The Soyuz, Apollo and Shenzhou spacecraft flew coupled to orbital modules with additional habitable volume. Crewmembers were con-
strained to the capsules for launch and landing. The US Space Shuttle is added for comparison. PRC, People’s Republic of China; R, Russia;
SL, sea level, 14.7 psi with roughly 20% O2/80% N2; US, United States.
* Soyuz mission to transport crew to and return from orbiting space station for up to 210-day mission, remain docked during mission;
5 day maximum free flight endurance.
† Included docked phase with Tiangong-1 station.

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to a standard aviation environment demanding of critical
control inputs offers some unique challenges.
Orbital stations
Orbiting platforms that afford long stays in space were an
early goal of both US and Russian programs. A large plat-
form can support extended stays and research into the
mechanistic understanding of spaceflight phenomena. As
will be described, complete human adaptation to weight-
lessness requires several weeks, which is beyond the inde-
pendent duration limits of the vehicles noted above. Long
stays on such platforms imply power, complex life support
systems, physical countermeasures equipment and a supply
chain to replenish food, water and other consumables. These
platforms allow the study of effects of microgravity on basic
physical and biological processes, as well as critical testing
and development of advanced life support systems. In addi-
tion, the study of basic physiological processes in this novel
environment allows a complete understanding of many of
these phenomena when away from the dominating influence
of gravity. The general evolution of stations has been in the
direction of increasing size and complexity. Table 18.2 lists
attributes of the manned orbital stations thus far.
Deep space vehicles and landers
Here ‘deep space’ is defined as away from the Earth’s vicinity,
beyond the practical influences of atmosphere and geomag-
netic fields. Thus far only the US Apollo lunar programme
has carried human explorers beyond these limits, flying a
total of nine missions to lunar vicinity, six of which involved
landings of two individuals on the lunar surface. The trip
from the Earth to the Moon required about three days and
involved achieving a stable lunar orbit from which a lander
could descend from a parent vehicle. Total mission dura-
tions were typically eight to twelve days. Although a lim-
ited programme, Apollo demonstrated that humans could
perform precision piloting duties of the manually controlled
landers and operate in a fractional gravity field of 1/6 G.
Table 18.2  Orbiting stations
Station Years of Crew Mass
operation (metric tons)
Salyut series (R) 1971–1991 2–3 18.2–19.9
Skylab (US) 1973–1974 3 77.1 kg
Almaz series (R) 1973–1977 2 19
Mir (R) 1986–2001 3 129.7
ISS* 2000–present 6 450
Tiangon-1 (PRC) 2011–present 3 8.5
PRC, Peoples Republic of China; R, Russia; US, United States.
* International Space Station partner agencies: Canadian Space Agency, European Space Agency, Japanese Space Development
Agency, National Aeronautics and Space Administration (US), Roscosmos (Russia).
K17577_C018.indd 325
Physical factors of spaceflight  325
For destinations beyond the Moon, such as to Mars or
near Earth asteroids, greater time periods in transit are
expected. As such, the transit vehicle will be larger and
more closely resemble some of the early orbital stations in
size and capabilities.
PHYSICAL FACTORS OF SPACEFLIGHT
Spaceflight implies a basic removal of human and hardware
from Earth’s surface, with vehicles operating well above the
more familiar aviation environment. There is no definitive
boundary of space, since the threshold of removal can be
seen in the context of different factors. Table  18.3  shows
some of these milestones and their corresponding altitudes
that all spacecraft will traverse in leaving the planet. The
most familiar aspects of spaceflight involve weightlessness
and the absence of atmosphere; however, this is realized
only after a highly dynamic rocket ascent. Simply put, leav-
ing Earth implies overcoming substantial physical forces, a
process that in turn involves counter-forces and substan-
tial energies. These impart physical loads on the human
body with physiological implications. Once in space, the
environment is far from benign with the combined factors
of radiation, chemical moieties in near Earth space, and
weightlessness itself.
An understanding of the forces associated with flight
dynamics and the characteristics of various altitudes is
germane to piloted space operations just as for aviation,
relevant to the level of protective methods and capabilities
required for human occupants as well as mishaps that might
occur at any of these altitudes.
The external spaceflight environment
It is natural to think of the spaceflight environment as devoid
of the basic elements that sustain human life. However as we
expand our thinking as an emerging spacefaring population,
it is increasingly appropriate to consider more of what Earth
is endowed with rather than what space is devoid of. The
three dominant elements that have shaped and influenced
Pressurized Cabin Orbit
volume (m3) atmosphere
90–100 Sea level 51.6º; 200–222 km (1)
219-270(4); 219–278 (7)
320 5 psi 50º; 434–442 km
70% O/30% N2
47.5 Sea level 51.6º, same range as Salyut
350 Sea level 51.6º; 354–374 km
916 Sea level 51.6º; 409–416 km
15 Sea level 42.8º; 363–381 km
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Table 18.3  Physiologically and operationally relevant milestones with increasing altitude
Altitude (m, km) Milestone or limit
1000 km Lower border of inner Van Allen radiation belt at equator (lower at poles). Higher radiation
threat because of trapped ionized particles.
700 km Collisions between atmospheric gas molecules become undetectable. Particle concentration
diminishes over several thousand km to free space density of 1–10 per cm3.
410 km Average altitude of International Space Station.
200 km Essentially no aerodynamic support and minimal drag such that sustainable orbit possible.
140 km Atmosphere ceases to provide significant protection from micrometeoroids.
120 km Atmospheric entry interface for returning spacecraft; initial onset of perceptible acceleration
forces, control surface resistance. Dysacoustic zone – insufficient atmospheric density to
facilitate the effective transmission of sound.
100 km Karman line, threshold of effectiveness of aerodynamic surfaces. Minimal active light scattering,
‘blackness of space’.
40 km Atmosphere ceases to protect objects from high-energy radiation particles.
37.65 km Highest altitude aircraft flight, conventional air breathing engines, pressure suit (non-sustained
altitude).
25–30 km Practical limit of ram-pressurized cabin; above this altitude, fully enclosed pressurized cabins
are required.
19,200 ‘Armstrong’s line’; ambient pressure equivalent to tension of water vapour at body temperature
(47 mmHg).
16,000 Practical limit of atmospheric weather processes and phenomena at equator (lower near the
poles).
12,192 Limit for breathing unpressurized 100% oxygen. Pressure environment (suit or cabin) needed
above this.
5000 Approximate limit of human acclimation for long-term dwelling.
3048 USAF requires supplemental oxygen for aircrew.
1525–2440 Cabin pressure of commercial airlines, typically operating up to 12 km in altitude.
Sea level Pressure 760 mmHg.
Convenient numbers are given, but there is a range associated with each milestone based on physiological variability and atmospheric pres-
sure dynamics. USAF, United States Air Force.

our physiology and function are gravity, pressure atmo- F = G(m1m2)/r2

sphere and background radiation level, all provided by our
home planet, the latter largely as a function of shielding. We
can vary any or all of these and still function, albeit with
consequences. Melding these physical conditions with adap-
tive physiology is a necessary discipline of space exploration.
GRAVITY
The standard gravitational acceleration of 9.8 m/s2 realized
at Earth’s surface represents a static and uniform load on
the body, with the gravitational force being the mass of an
object multiplied by this acceleration. However, we inter-
act with this force in a dynamic fashion by moving against
it in the process of locomotion and mass handling. We
constantly reorient our body position with respect to this
downward pull, which ties the force of gravity prominently
to such physiological processes as maintaining cerebral
perfusion, positional sense and musculoskeletal loading.
By convention, the specific force of gravity at Earth’s sur-
face is denoted as ‘g’, with multiples of this denoted by the
dimensionless quantity ‘G’. The force of gravity varies with
distance between two masses, and for an object orbiting
another is described by the equation:
where G is the universal gravitational constant, m1 and
m2 are the two masses, such as the Earth and a spacecraft,
and r is the radius of the orbit (distance between the centres
of masses). It is evident that in a LEO of 240 miles, the force
of Earth’s gravity on an object is still prominent at about
90 per cent of its surface value. The combination of forward
velocity around the Earth and resultant outward centrifugal
force counterbalances the inward force of gravity to produce
the state of weightlessness.
Human spaceflight involves short-duration accelera-
tion loads greater than 1 G during launch and landing as
described below, similar to high-performance aviation.
More importantly, prolonged exposures to gravity levels
between near zero and 1 G will be dominant in space medi-
cine for many decades to come. Zero G implies the absence
of a mechanical force on an object, such as is realized in the
freefall environment in orbiting spacecraft and during the
coast phases of trans-lunar and transplanetary flight, and
constitutes the vast majority of human spaceflight experi-
ence. Extra-terrestrial bodies of greatest interest to us, nota-
bly the Moon and Mars, will imply fractions of G (roughly

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one-sixth for the Moon, one-third for Mars). Since the body
undergoes physical deconditioning associated with reduc-
ing the normal force of gravity, prolonged periods in frac-
tional G will inherently involve active countermeasures
to ensure normal function with the assumed endpoint of
Earth return.
ATMOSPHERE
At near vacuum, the external spaceflight environment is
not survivable. So far as we know, the standard sea level
atmosphere with 14.7 psi pressure and roughly 80 per cent
nitrogen/20  per cent oxygen mix is unique to Earth, and
certainly exists nowhere else in our solar system. For the
foreseeable future, a pressurized breathable atmosphere will
be a take-along requirement and imply sealed and care-
fully controlled habitats. These two aspects of the human
atmosphere each have specific thresholds and must be
independently controlled.
Pressure must be at a minimum to hold gases in solution
in body tissues and blood vessels and support respiratory gas
exchange. A well-known milestone of atmospheric pressure
as one ascends is Armstrong’s Line, encountered at roughly
19 200  m (63 000  feet). Climbing through this altitude,
the ambient pressure transitions through 47  mmHg, the
vapour pressure of water at a normal body temperature of
37°C. Body fluids directly exposed to this pressure or lower
will ‘boil’ away, such as from the tongue or exposed mucus
membranes. As the ambient pressure decreases, elastic tis-
sue forces are overcome and dissolved gases throughout the
body will evolve into bubbles, including oxygen, nitrogen
and water vapour, a phenomenon known as ebullism.
Oxygen is actually the determinant of overall pressure
required for a habitable atmosphere, with a normoxic envi-
ronment containing an oxygen pressure of 160  mmHg,
or roughly 3  psi to support respiration and metabolism.
This is 21 per cent of the normal sea level atmosphere, but
a pressure of 3 psi and 100 per cent oxygen can support a
human for prolonged periods. The pressure suits used in the
Mercury and Gemini programs, including that used for the
first US spacewalk, were pressurized to 3.7  psi. Spacecraft
themselves have utilized a range of cabin atmospheres as
seen in Tables 18.1 and 18.2. It follows that at or above an
altitude with a corresponding ambient pressure of about
3 psi, roughly 15 250 m (50 000 feet), full pressure protection
is required either by pressurized cabins or suits.
RADIATION: SOURCES
The radiation milieu of the space environment is complex,
and a complete description is well beyond the scope of this
chapter. However, radiation is recognized as the major lim-
iter of human spaceflight because of the potential health
implications of exposure. Space medicine practitioners
must be aware of the basic factors of space radiation includ-
ing major sources, health consequences, protective mea-
sures, and impact on mission planning and risk prediction.
Unlike gravity and atmosphere, there are limited technical
solutions for the resulting health hazards.
K17577_C018.indd 327
Physical factors of spaceflight  327
Radiation involves the transfer of energy in the form of
charged and neutral subatomic particles or electromagnetic
energy propagated in waves. Space is a radiation environ-
ment, continually bathed in a wide spectrum of radiation
largely from stellar sources and processes involving high
energies and great distances. Although there are low level
emissions from naturally occurring radionuclides associ-
ated with Earth’s geology, the relatively small steady back-
ground radiation provided by Earth is largely a function
of shielding from the planet’s magnetic fields, atmosphere,
and mass. Even with this, high-energy radiation continually
encounters and traverses surface organisms. Radiation is
functionally partitioned into two categories: Non-ionizing,
in which electromagnetic waves such as light or radiofre-
quency energy impart thermal effects, and ionizing, in which
interactions with particles or waves displace electrons from
impacted atoms and give rise to charged ion entities. Both
may cause damage to biological systems.
Above the atmosphere, the dominant form of non-ion-
izing radiation relevant to humans is solar ultraviolet (UV)
light. Intensity relates directly to our proximity to the Sun,
and lessens with the square of the solar distance; in Mars
orbit, the intensity is less than half of near Earth space. UV
radiation exists in wavelengths between 100 and 400 nm in
the electromagnetic spectrum with the lower wavelengths
being the most biologically damaging. Wavelengths below
180  nm, nearly completely filtered out by Earth’s atmo-
sphere, are particularly hazardous in near Earth space.
Interestingly on the surface of Mars, the UV flux between
200  and 400  nm is similar to Earth’s, with the distance
being offset by the highly rarefied atmosphere. Compared
to Earth though, the shorter more damaging wavelengths
contribute relatively more to this flux, rendering the Mars
surface a more hostile UV environment.
Energy from UV radiation transfers to a physical object
as heat, and for the human space flyer, implications include
direct UV tissue damage and thermal effects on the habitat.
Eyes are particularly vulnerable to UV radiation, necessitat-
ing heavily filtered windows or space suit visors. This has
been inherent in hardware design, although some selected
windows have used unfiltered glass to maintain the high-
est optical purity to facilitate photography. Crewmembers
utilizing these windows are at risk for both superficial skin
burns and UV keratitis during orbital flight.
The more pervasive aspect of solar UV radiation is the ther-
mal energy absorbed by spacecraft and any exposed object. In
the relative vacuum of space, there is no conductive medium to
facilitate dissipation of absorbed heat, and large radiators that
are shielded by structure or feathered relative to solar radia-
tion flux are required. Thus rejecting heat is a greater relative
problem in near Earth space than generating it. Failure of cool-
ing systems for manned stations in LEO is a potentially cata-
strophic event. When shielded from direct sunlight, however,
physical objects may become quite cold. The surface tempera-
ture of an object in full sun may be 150°C, while in full shadow
may fall to –100°C. This has obvious implications for extrave-
hicular activity, which requires constant adjustment between
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 328  Space physiology and medicine

Table 18.4  Radiation sources and types of concern to human spaceflight

Origin Particle or wave type Energy range Comments
Solar particles Protons 100eV–3.5 KeV Moderate flux, low energy;
  Continually streaming Electrons effectively shielded by
  solar wind minimal structure.
  Solar particle events Protons 10s to 100s GeV range Large flux, high energies;
 (solar flares, coronal mass Electrons potentially very dangerous to
ejections), vary with solar crews in deep space.
cycle
Solar wave radiation X-rays KeV range Energy varies inversely with
Gamma rays MeV range wavelength.
Geomagnetically trapped particles Protons 600 MeV Flux increases with altitude and
Electrons 5–7 MeV inclination for LEO flights.
Galactic cosmic rays (GCRs) 98% Baryons (mass > a Wide range of Smaller flux, larger energy;
proton) energies depending isotropic distribution,
  Protons 85% on mass; 10 GeV up significant source of IR to
  Alpha particles 14% to 10s of GeV for space crews.
  Heavy nuclei heavier particles
2% Electrons Increased solar activity
correlates with reduced GCR
flux in inner solar system.
Secondaries from particle collision Neutrons 1 to several 10s MeV Short lived, 11-min half-life;
with spacecraft structure and deep tissue penetrance.
atmosphere
This is a simplified summary of the sources of ionizing radiation (IR) and rough energy ranges associated with those that contribute most to
human doses acquired during spaceflight. LEO, low Earth orbit.

heating and cooling depending on orbital phase (e.g. whether
in full sunlight or in eclipse on the ‘night’ side of the orbit).
Ionizing radiation comes from multiple sources and may
induce immediate and long-term tissue damage via several
mechanisms. The three main origins of ionizing radiation
are solar particles and wave radiation, geomagnetically
trapped radiation and galactic cosmic radiation (GCR).
Table  18.4  summarizes the sources and types of ionizing
radiation of most interest to human spaceflight.
Solar ionizing radiation consists primarily of continu-
ously streaming protons and electrons, known as the solar
wind. These particles are of high flux but relatively low
energy, are easily stopped by spacecraft structure, and pose
little threat to humans in space. Although the dynamic
pressure is extremely low, in the vacuum of space this con-
stant radiation pressure must be taken into account to accu-
rately guide transplanetary trajectories and even orbital
management. At about 1 Newton for a 128 000 square metre
area at the Earth’s distance from the Sun, it could actually
be harnessed by solar sails for propulsion. Periodically,
solar activity involves the episodic ejection of much more
highly energetic protons and electrons, known as solar par-
ticle events (SPEs). The Sun follows a roughly 11 year cycle
of activity, with solar particle events being more frequent
during the periods of maximal solar activity. Solar particle
events can produce particle energies and fluxes hazardous
to humans, particularly if outside the geomagnetic fields.
Geomagnetically trapped radiation consists primar-
ily of protons and electrons that are captured by Earth’s
magnetic fields, either from incoming solar and galactic
particles or from local decay of neutral particles into
charged species. These particles bounce back and forth
between the north and south magnetic poles, and follow
the curved dipole tracks. As such, altitude above Earth’s
surface where the lower inner belt begins varies, from
roughly 1000 km at the equator to as low as 200 km at high
latitudes. Trapped particles are of higher energies than
solar wind, and contribute significantly to the health threat
of humans. As Figure  18.1  shows, spacecraft operating at
higher altitudes or at higher inclination orbits will incur
greater exposure to trapped particles.
GCR particles likely emanate from violent stellar events
throughout the galaxy that generate high-energy species that
may attain relativistic speeds as they travel through space.
These are isotropic in distribution and fairly stable, and consist
primarily of protons (87 per cent), alpha particles (12 per cent),
and other higher atomic number high-energy species (1  per
cent) representing ions of all naturally occurring elements
(Zeitlin et al. 2013). These particles are of much lower flux but
much higher energies as compared with solar particles.
Because of their charged quality, ionizing radiation par-
ticles are influenced by magnetic fields that emanate from
the Sun and Earth, and of course other stars and planetary
bodies with magnetic fields. There are a couple of practical
implications. First, geomagnetically trapped particles are
held at predictable altitudes corresponding to the Earth’s
magnetic dipole. These fields, known as the Van Allen belts,
form an effective shield from incoming charged particles,
and define the practical upper limit of LEO for human
spaceflight. There is one geographically defined region

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Geomagnetic axis
11.5°
Inner
belt
Outer belt
Figure 18.1  Distribution of trapped radiation associated with the inner and outer Van Allen belts and influence of altitude
and inclination on exposure. Piloted low Earth orbit (LEO) flights are below the inner belt. The South Atlantic Anomaly rep-
resents a geographically centered area where the geomagnetic field is relatively weak due to the offset between Earth’s
rotational axis and geomagnetic dipole, allowing a greater flux of trapped particles at a given altitude.
where the inner belt extends to a lower altitude owing to
a misalignment of the Earth’s geomagnetic dipole and
the rotational axis about the gravitational centre. Passage
through this region, known as the South Atlantic Anomaly,
can account for 50 per cent of the radiation dose incurred
during a given orbit depending on the shielding depth of
the dose considered. At the 52° inclination of the ISS, the
South Atlantic Anomaly passage is expected roughly ten
times per day. Second, on a much larger scale, the stream
of charged particles emanating from the Sun, known as the
solar wind, also modulates the influx of GCR. During the
typical 11  year solar cycle, GCR in the inner solar system
is at its minimum during maximal solar activity; known in
shorthand as solar max, it can be thought of as maximal
solar protection from the more high-energy GCR.
RADIATION: HEALTH EFFECTS
Because ionizing radiation exists in different forms with
varying energies, defining the standard units and mea-
sures is helpful to understand exposures and scale human
health risks. The transfer of one joule of radiation energy
to one kilogram of matter defines the Gray (Gy), the SI
(International System of Units) unit of radiation absorbed
dose. The Gy describes a purely physical quantity of energy
transfer regardless of resulting biological effect, and reflects
what a physical radiation detector would register. Because
different particles and waves of the same physical energies
may lead to different effects on tissues, a scaling factor is
needed to correlate radiation type with biological outcome.
K17577_C018.indd 329
Physical factors of spaceflight  329
Rotational axis
Magnetic
field lines
Low earth Earth radii
orbit zone (6380 km)
above surface
1 2 3 4
Geomagnetic
equator
South
Atlantic Geometric
anomaly equator
The radiation weighting factor (WR), similar to the long-used
quality (Q) factor, is a value that is applied to specific radia-
tion types to allow direct comparison of resulting biological
effects. X-rays and gamma rays as well as electrons have a
WR of 1, whereas energetic protons may have values of 2 to
5, and alpha particles and heavier high-energy GCR spe-
cies may be 20  or higher for the same radiation absorbed
dose. The seivert (Sv) measures the actual biological effect
resulting from absorbed dose of a specific radiation type,
and thus is the product of the absorbed dose and the radia-
tion specific WR.
Ionizing radiation can induce tissue damage via sev-
eral different mechanisms and cause both acute and long-
term health effects. Broadly these effects are categorized
as deterministic and stochastic. Deterministic effects typi-
cally involve high relative doses of ionizing radiation and
describe direct damage or killing of multiple cells and tis-
sues. Greater absorbed dose, usually measured directly in
Gy, correlates with greater severity. The acute radiation
syndromes are clinical manifestations of ionizing radiation,
matched to dose in Table 18.5. These would be expected ter-
restrially in nuclear power accidents with leakage of radia-
tion or with nuclear weapon detonation, and in space from
solar particle events with minimal shielding. Since space
weather has been monitored since the 1950s or so, there
have been several solar particle events that would have
caused ionizing radiation exposures leading to acute clini-
cal syndromes for astronauts outside of the geomagnetic
field. Stochastic effects are associated with lower levels of
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Table 18.5  Acute radiation syndromes

Dose (sieverts) Syndrome Tissue effects Clinical manifestations
0–0.25 Threshold for acute effects None
0.25–1 Haematopoietic Bone marrow stem cell damage, Minimal; mild nausea, loss of appetite
lymphatic and splenic tissue damage
1–3 Haematopoietic Bone marrow stem cell depletion, mild Mild to severe nausea, infection,
to moderate leukopenia, eventual weakness, fatigue
pancytopenia
3–6 Gastrointestinal Moderate to severe leukopenia, Severe nausea, moderate diarrhoea,
gastrointestinal mucosal cell damage haemorrhage, epilation; mortality near
100% without treatment
6–10 Gastrointestinal, Extensive gastrointestinal mucosal cell Seizures, cognitive impairment,
cerebrovascular damage, direct CNS damage headache, severe diarrhoea,
hypotension
>10 Cerebrovascular Extensive CNS damage; cerebral Tremors, ataxia, incapacitation
oedema
These are broadly divided into haematopoietic, gastrointestinal and cerebrovascular syndromes in order of increasing ionizing radiation
dose required to elicit. Low dose effects carry over and combine with higher dose effects. CNS, central nervous system.

ionizing radiation below a threshold for significant acute greatest influence, may thus be associated with as much as
cell killing and may involve damage to a single cell, but pro- 110  mSv exposure. A Mars mission using existing chemi-
duce damage to DNA or other cellular elements that may cal rocket technology presents a particular challenge. The
lead to eventual induction of cancer or genomic instability. cruise phase will occur almost entirely in deep space with-
The probability rather than the severity of an adverse clini- out the protection of the geomagnetic fields. Radiation
cal outcome directly correlates with increasing exposure, instruments carried aboard the Mars Science Laboratory,
the signature concern being development of cancer in later which was launched towards Mars in 2011, provide direct
years. The risk probability for these stochastic outcomes is measurements that inform the human exposure on such
correlated to the dose equivalent expressed in Sv. There is a voyage. Data suggest that an astronaut would receive a
recent evidence that long-term stochastic effects may also dose of 662  mSv during the 360  days of cumulative out-
include degenerative vascular changes and central nervous bound and inbound deep space cruise associated with a
system (CNS) effects. realistic reference mission to Mars (Zeitlin et  al. 2013).
The implications of stochastic radiation effects have a In addition, surface data collected from the Mars Science
significant influence on human spaceflight. Radiation expo- Laboratory suggests that for a human exploration crew, the
sure for real time mission planning, from the standpoint of cumulative equivalent dose for the cruise phase and sur-
time in space and type of radiation dose received, must be face stay of 500 days will be roughly 1.01 Sv for this current
weighed against the long-term health risks. As an agency, solar cycle (Hassler et al. 2014).
NASA has set an upper limit of three per cent excess risk With the ubiquitous presence of radiation and the
of exposure-induced death (REID) due to cancer as a health health risks noted, space travellers must be considered
standard for flight in LEO. The actual exposure associated radiation workers and undergo strict monitoring for
with this risk level is not uniform between individuals. Risk
of eventual fatal cancer for females and those exposed at Table 18.6  Ionizing radiation exposure limits weighted
an earlier age is relatively higher owing to age at exposure for age and gender for a 1-year mission in low Earth orbit,
effects and differences in tissue types and susceptibilities; correlated with a 3% risk of exposure-induced death
therefore exposure limits are age and gender weighted. (REID)
Other factors that may affect lifelong cancer risk, such as
Ionizing radiation dose in sieverts,
smoking, also influence the allowable spaceflight acquired
3% REID
limit. Because there remains considerable uncertainty in
Age, years Males Females
translating radiation dose to clinical outcomes, particularly
25 0.52 0.37
with high-energy GCR, further conservative step limits are
added to ensure that these limits are met with a 95th percen- 30 0.62 0.47
tile upper bound confidence. 35 0.72 0.55
Table  18.6  shows representative exposure limits for 40 0.8 0.62
a one year mission in LEO. On the ISS, daily dose rates 45 0.95 0.75
range from about 0.4–0.6  mSv per day depending on the 50 1.15 0.92
solar cycle, with about 80 per cent contributed by GCR. A 55 1.47 1.12
six-month tour on the ISS at solar min, when GCR has its From Cucinotta and Durante (2009).

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radiation dose received. This includes personal dosimeters
that are worn by crewmembers at all times during mis-
sions as well as various dosimeters and detectors deployed
throughout a space vehicle. Human spaceflight neces-
sitates a comprehensive radiation monitoring capability
that tracks equivalent dose received by each individual
and applies this against future missions. Long-term sur-
veillance for defined clinical outcomes as for any industry
radiation worker should be in place. Prevention is key, with
mission planning accounting for crewmember’s accumu-
lated dose, duration of flight, solar activity, and shielding
characteristics of the vehicle or platform to keep the dose
equivalent as low as possible.
MONATOMIC OXYGEN
In the Earth’s atmosphere, oxygen predominantly exists in
its stable molecular form consisting of two bound oxygen
atoms (O2). In the upper reaches of the atmosphere, exposed
to harsh UV light in wavelengths less than 243 nm (UVB),
O2 readily dissociates into monatomic oxygen. As altitude
increases, the rarefied atmosphere precludes significant
recombination into O2  or ozone (O3), such that mona-
tomic oxygen becomes the most dominant species between
180 and 650 km (Banks et al. 2004). Monatomic oxygen is
highly reactive and contributes heavily to erosion and dis-
coloration of carbon-containing materials exposed to exter-
nal space in LEO. It is one component, along with ionizing
and direct UV radiation and orbital debris, that contributes
to the observed phenomenon of degradation of external
spacecraft materials. Special coatings, primarily silicate lay-
ers, are resistant to monatomic oxygen and are frequently
used to protect spacecraft exposed surfaces.
ORBITAL DEBRIS AND MICROMETEOROIDS
To add to the background flux of charged particles and
chemical moieties, Earth’s orbit is populated with material
from both natural and artificial sources. Meteoroids are nat-
urally occurring fragments resulting from collisions among
asteroids and from the evaporation of comets near the Sun,
and range in size from the micron level to large and (for-
tunately infrequent) metre- and decametre-sized objects.
As a point of reference, the Chelyabinsk meteorite that
exploded in the atmosphere over Russia in 2013 was about
18 m across. Orbital debris, as the name suggests, consists of
unused pieces of spacecraft or whole derelict satellites, shed
fragments from frangible bolts and spacecraft collisions,
vapour particles from metallic rocket fuels, and other mate-
rials associated with spaceflight activity. Collectively these
are frequently referred to as micrometeoroid and orbital
debris (MMOD). Orbital debris makes up the vast majority
of the mass of material over several microns in size and has
become increasingly problematic for spacecraft operations
in LEO owing to risk of collision. Average relative velocities
in LEO are roughly 10 km/s and may be as high as 15 km/s.
Natural meteoroids although of much lesser influence carry
great momentum, with greater average relative velocities
from 15 to as much as about 70 km/s.
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Physical factors of spaceflight  331
For convenience, orbital debris may be classified as small
(less than 1 cm), medium (1–10 cm), and large (greater than
10  cm) based on methods used to detect and track items.
Large objects can be seen and tracked by ground radars,
which permits spacecraft with propulsive capability to per-
form avoidance manoeuvres to prevent catastrophic colli-
sions. The ISS periodically performs such debris avoidance
manoeuvres, and on a few occasions ISS crews have taken
precautionary refuge in escape spacecraft when objects have
come particularly close. As of 2011, over 22 000 objects in
this category were being tracked by the international Joint
Space Operations Center (Committee for the Assessment
of NASA’s Orbital Debris Programs 2011). Medium-sized
objects may be seen and counted by ground radars but not
tracked, which gives an assessment of risk without the abil-
ity to predict and thus avoid collisions. It is estimated that
over half a million objects greater than 1 cm in size populate
LEO, which drives risk assessments and shielding require-
ments for manned spacecraft. MMOD collision and sudden
depressurization of the ISS and other spacecraft are possi-
bilities that must be prepared for with pressure refuges and
escape plans.
Smaller objects make up the vast majority of the mass
of artificial material and present less of an acute threat, but
contribute greatly to the degradation of materials continu-
ously exposed to the external space environment. Over time
the surface of structures becomes peppered with tiny, often
sharp-edged craters of sub-millimetre, millimetre and cen-
timetre sizes, with the preponderance being in the smaller
range as evidenced by spacecraft that have been returned
to Earth for analysis. An interesting hazard that has been
observed on the ISS is the formation of sharp-edged defor-
mations resulting from small objects colliding with metal
surfaces. These constitute a perforation and subsequent
decompression risk for spacesuits, particularly gloves, dur-
ing space walks.
Flight dynamics of ascent and entry
Suborbital spaceflight implies a profile that ascends to an
altitude above the threshold of aerodynamic surface con-
trol but follows a trajectory that re-intersects the atmo-
sphere rather than attaining a stable orbit. Implicit in this
rarefied atmosphere is the need for rocket propulsion and a
fully enclosed pressurized cabin. Alan Shepard’s 1961 flight
aboard the Mercury mission Freedom 7  was suborbital,
attaining an altitude of 187  km (116  miles) and lasting
15 minutes. There was a period of free fall experienced as
zero gravity which lasted about five minutes before the onset
of entry loads. This sortie was a deliberate test point en route
to orbital flight capability and by and large these were not
repeated.  Interestingly, the spaceflight tourist industry is
expected to begin offering suborbital flights to paying cus-
tomers on a large scale. The aim will be to afford tourists the
sensation of rocket ascent, a brief period of weightlessness
and a spectacular view of the Earth before re-entering. This
implies new spacecraft and flight operations that will support
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 332  Space physiology and medicine

such flights on a large commercial volume. Eventually this
flight profile may expand to include rapid suborbital transit
profiles between surface points.
Orbital spaceflight defines a condition whereby a space-
craft has attained an altitude and forward velocity matched
to that altitude sufficient to remain stable in that orbit for a
substantial period of time. The tendency to fall to Earth is
exactly balanced by the forward velocity so that the space-
craft essentially ‘falls’ around the Earth; the physiological
condition of weightlessness is realized by this condition
of freefall. Figure 18.2 depicts a sustainable Earth orbit. It
implies rising above the major part of the atmosphere such
that atmospheric drag is negligible over short periods of
time.  Minimum altitudes of typical spacecraft are around
160–200  km, where atmospheric drag is still enough to
require reboost after a few days. The ISS orbits at an altitude
of around 400 km. Even at this altitude, with the substantial
cross sectional area afforded by structure and solar arrays,
reboost requires several thousand kilograms of propellant
each year.
Often the term ‘outer space’ is used to describe any
vehicle in orbit or beyond, invoking impressions of great
distances, but this is misguided with typical LEO altitudes
of 200–400  km.  What really separates the occupants of
an orbiting spacecraft from the ground is a velocity dif-
ference.  Orbital velocity in LEO is roughly 28 160  kph at
the altitude of the ISS; for launch this must be attained
between lift-off and orbital insertion, and for return it must
be dissipated between deorbit burn and landing. Although
the relative velocity change is roughly the same for launch
and landing, the forces acting to realize this change differ
greatly. Insertion of a spacecraft into LEO involves transit-
ing the atmosphere to overcome drag and build sufficient
velocity to maintain a stable orbit. A typical ascent profile
will involve primarily vertical flight at first to loft to an alti-
tude where atmospheric drag is sufficiently low, then a turn
towards a predominantly downrange trajectory to build
orbital velocity. For ascent, the velocity is provided by pow-
erful rocket engines operating near the limit of materials
and systems capabilities. For entry and landing, a combina-
tion of rocket impulse, atmospheric drag, atmospheric lift,
and parachute descent (for capsules) is required to bring the
spacecraft safely to a desired point on the ground.
From launch pad lift-off to engine cut-off, the ascent to
orbit for contemporary spacecraft typically requires eight
to nine minutes, reflecting a balance between accelera-
tion loads on the human occupant and optimum hardware
performance. If the spacecraft is to eventually dock with
another orbiting platform, the launch is precisely timed to
occur as the launch site rotates through or near the orbit of
the target platform. Crewmember work and sleep schedules
are matched to this time well in advance to ensure optimal
performance during this demanding flight phase and the
associated physiological challenge. Figure  18.3  shows the
typical acceleration versus time profiles for the US Space
Shuttle and the Russian Soyuz. Tolerance to these loads is

Steering downrange Spacecraft

Early ascent to accelerate to
increases altitude to orbital velocity Instantaneous
loft above atmosphere LAUNCH forward velocity

Gravitational
force
Resulting
circular
orbit

Orbital altitude
400 K International
space station

Orbital velocity
28 160 kph
A T R E
M O S P H E

Figure 18.2  Simplified depiction of a circular spacecraft orbit (not to scale). The gravitational force on the spacecraft is
counterbalanced by the forward orbital velocity which is specific for a given altitude (and hence gravitational force), such
that the spacecraft continues to ‘fall’ around the Earth.

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4.5 Booster staging
4.0
3.5
Acceleration (G)
3.0 Booster staging
2.5
2.0
1.5
1.0
0.5
100 200 300 400
Time (seconds)
Figure 18.3  Acceleration versus time profiles of the
Russian Soyuz and US Space Shuttle during rocket ascent.
Crewmembers are oriented such that most of the G loads
are taken in the +Gx (chest to back) axis.
dependent on crew positioning with respect to the veloc-
ity vector. Thus far all crewmembers travelling to LEO have
been oriented during launch in a recumbent position so
that the ascent loads are taken in the +Gx (chest to back)
direction, and these loads are well within human tolerances.
Vibration forces are vehicle dependent, but are designed to
be within the tolerances of both spacecraft structure and its
human occupants. These come into play largely with read-
ing displays and tasks requiring fine motor control, such as
switch throws. The ascent phase ends as the engines shut
down and the spacecraft transitions abruptly from the final
acceleration loads to weightlessness, typically 3 Gs to zero.
For atmospheric entry and return, the spacecraft fires an
engine impulse into the orbital velocity vector, not so much
to slow down as to lower the orbital trajectory so that it
intersects the atmosphere. The deorbit burn is precisely con-
trolled for magnitude and direction of thrust, start time and
duration, and relative ground position to arrive at a specific
atmospheric entry point. The drag of the atmosphere then
does the work of dissipating the orbital velocity, inducing a
4
Acceleration (G)
3
2
1
Figure 18.4  Acceleration versus time profiles of the Soyuz and Space Shuttle during atmospheric entry. The Soyuz orients
crewmembers such that most of the G loads are taken in the +Gx (chest to back) axis for entry and landing. Shuttle crew-
members experienced a more prolonged but gentler G profile, but were oriented such that most of the G loads are taken
in the seated +Gz (head to foot) axis.
K17577_C018.indd 333
Physical factors of spaceflight  333
Main engine great deal of frictional heat on the spacecraft structure in the
cut off process. The atmospheric entry phase ends when a space-
craft is predominantly in a vertical descent for a capsule,
or has transitioned to predominantly aerodynamic control
for a winged spacecraft. Actual landing may involve a fairly
gentle runway touchdown as for the Shuttle, or a water or
land landing following parachute descent as for a capsule
Russian Soyuz that may involve a significant impact event.
U.S. Space Shuttle Entry following prolonged periods in weightlessness
500 involves spaceflight-deconditioned crew, which implies a
reduced tolerance for acceleration forces.  As will be dis-
cussed, the +Gz axis is particularly vulnerable owing to
this deconditioning, and most spacecraft have positioned
returning crewmembers such that entry forces are taken in
the +Gx axis. The exception has been the US Space Shuttle,
which returned crew in an upright seated position after
flights up to 18  days in duration. Figure  18.4  shows entry
acceleration loads of the Soyuz and Space Shuttle. Even with
the relatively low loads involved, deliberate protection for
crewmembers in the form of anti-G garments, saline fluid
loading, active cooling, and occasionally volitional straining
manoeuvres has been required. Several crewmembers were
returned on the Space Shuttle from long-duration flight,
arbitrarily defined as greater than 30 days in duration, from
the Mir and International Space Stations. This necessitated
devising a recumbent seat system to fit on the Shuttle mid
deck to orient long-duration flight crewmembers in the +Gx
direction with respect to the dominant acceleration vector.
As with aviation, there have been unfortunate mishaps
in the history of human spaceflight that have influenced the
crew protective equipment and procedures now routinely
used. All of the mortality associated with actual spaceflight is
attributed to accidents occurring during the dynamic phases
of ascent and entry. Fatal accidents have occurred during
launch, with the breakup of the Space Shuttle Challenger
(1986), and landing with the loss of Soyuz 1  (1967) due
to parachute failure, the Soyuz 11  crew due to high-alti-
tude cabin depressurization (1971), and the Space Shuttle
Soyuz
Space Shuttle
Landing
Landing
300 600 900 1200 1500 1800
Time (seconds) from atmospheric entry
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 334  Space physiology and medicine
Columbia (2003) breakup during entry due to structural
damage incurred on launch. In addition, acceleration forces
much greater than the nominal loads shown above have been
realized during launch aborts and ballistic entries.
Crewmembers wear pressure suits with safe breathing
sources as a refuge against cabin depressurization or con-
tamination during launch and entry phases. These may have
the unwanted effects of thermal loading, decreased reach
and visibility, and general discomfort, but are a necessary
safeguard in what remains a dangerous activity. Launch and
entry seating is designed to position and support crewmem-
bers optimally for standard and off-nominal acceleration
loads, typically as form fitting as possible with multi-point
restraints. Active cooling is provided in the form of suit
ventilation or liquid cooling garments. Various spacecraft
have utilized a variety of escape mechanisms, including
personal harnesses and parachutes (Space Shuttle), ejec-
tion seats (Vostok, Gemini and the first four Space Shuttle
flights), and escape towers to pull a capsule away from a
rocket stack (Mercury, Soyuz, Apollo). For the possibility of
off-target landing, crews are equipped with a minimum of
survival equipment.
Orbital flight
THE ORBIT ITSELF
The orbit attained is determined by the ascent trajectory and
is characterized by altitude, inclination, orbital period, and
other factors beyond the scope of this discussion. However,
medical support personnel should be familiar with basic
elements that might affect crew operations.
The altitude is typically an average; few orbits are truly
circular, instead consisting of an ellipse with a lowest point
(perigee) and highest point (apogee). The ISS orbit is nearly
circular, with typical perigee and apogee altitudes of 420 and
423 km, respectively (260 and 263 miles). Inclination refers
to the angle of the orbital plane with respect to the plane
of Earth’s equator. A spacecraft launching straight eastward
from a launch site on the equator would have an inclina-
tion of 0°, with a ground path that always traces the equator.
Launching from the same site on a trajectory angled 45° to
the north (or south) results in a 45° inclination orbit, with a
ground path that oscillates relative to the equator between
45° north and 45° south latitude. (The same orbit results
from launch straight eastward from a site located at 45°
north or south latitude.) It is easily understood by imaging
a hula hoop around a world globe tilted with respect to the
equator, with the hoop representing the plane of the orbit.
If the globe and the hoop were flattened out into a Mercator
projection, the familiar sine wave pattern seen on mission
control maps where spacecraft positions are tracked is eas-
ily visualized (Figure  18.5). The orbital period is the time
required to make one complete revolution.
The ISS orbits at an average altitude of 400 km, with an
inclination of 51.6° and an orbital period of roughly 90 min-
utes. The practical implications are that crewmembers can
directly see Earth features between 51.6° north and south
K17577_C018.indd 334
51.6° inclination
orbit
Equator
51.6° North
Equator
1
22.5°
2
51.6° South
Figure 18.5  Ground track for a circular orbit of 51.6° incli-
nation, similar to that of the International Space Station.
The centre of Earth’s mass coincides with the centre of
the orbit, which is tilted relative to the equator so that
the orbital track ‘ascends’ to 51.6° north latitude, then
‘descends’ to 51.6° south latitude. Each successive orbit
moves 22.5 degrees westward due to the Earth’s rotation
beneath the orbit. There are other more subtle influences
on the orbit such as the non-spherical nature and mass
distribution of Earth and the effects of lunar gravity.
latitude, and could possibly land anywhere in this broad
band for a normal landing or emergency station evacuation.
Crew survival training and equipment are provided accord-
ingly for both land and water landings. A 90-minute orbit
translates into 16 sunrise/sunset cycles per 24-hour period,
which requires artificial regulation of day and night cycles
for crew duty day and sleep considerations.
TRANSITION TO WEIGHTLESSNESS
The onset of weightlessness after the acceleration forces of
ascent is one of abrupt and stark contrast. There is an imme-
diate equalization of fluid pressures throughout the body,
sensed as a rush of fluids to the torso and head. The body
floats away from the surface of the launch seat and is held
lightly in place only by the restraining straps. Arm move-
ment for display activation, switch throws, checklist use,
etc. is suddenly different as motor control inputs must now
subtract out the absent weight of the limb. Anything not
restrained will float free, and management of equipment
and flight support items quickly takes on a new dimension.
Along with this, there are inevitable generic crew duties
that make this a labour and cognition intensive time.
A  combination of manual control inputs and monitoring
of automated processes require crewmembers’ attention,
and task focus is essential despite the novel physiological
changes occurring. Whatever structure carried the bulk
of the final ascent fuel, such as the third stage booster of
the Soyuz or the external tank of the Shuttle, will be jet-
tisoned. Navigation systems and thrusters will be enabled
to perform spacecraft attitude control, thermal control
18/11/2015 14:13

systems will come online to handle solar heat loads, and
life support systems will be thoroughly checked for proper
function. Significant crew attention is focused on verifying
cabin pressure integrity after the structural challenge of
ascent; only then can suits be doffed and a somewhat more
leisurely pace of spacecraft operations can ensue.
STEADY-STATE WEIGHTLESSNESS
In the absence of the dominating effect of gravity, some pro-
cesses which influence human habitability are diminished
and some enhanced. There is no buoyancy-driven separa-
tion of gases or liquids, so that the concept of heavier gases
accumulating at one’s floor has no meaning. Passive diffu-
sion remains, although this is a very slow mixing process
compared with buoyancy; gas concentrations will largely
accumulate wherever they are introduced or fall where they
are consumed. This necessitates forced convection to mix
atmospheric gases, preventing carbon dioxide accumulation
and replenishing oxygen around a human occupant. Active
fans, which require power and produce nuisance noise, are
a necessary component of life in weightlessness. There is no
gas-fluid separation, so a distinct air fluid level in a vessel or
a visceral organ will not exist, replaced instead by a suspen-
sion of gas distributed uniformly in a liquid. Sedimentation,
in which solids might fall to the bottom of a liquid column,
is also absent so that particulates in a liquid will also exist
in suspension. Capillary action and surface tension remain
and become more prominent. In addition, there is no ‘sump
effect’, in which fluids accumulate at a lower point in a con-
duit. This drives management of plumbing conduits moving
coolants and other fluids, but happily does not affect food
ingestion and digestion, which become totally dependent
on peristalsis.
From the standpoint of human activity, one can obvi-
ously move once-heavy objects with ease, though larger
mass items must be managed with care owing to their
inertia. The relatively small volume inherent in space-
craft becomes more habitable owing to the availability
of movement and object placement in three dimensions.
Locomotion shifts from a familiar upright posture powered
by legs to a variable orientation with respect to the internal
volume, determined by convenience of the task at hand and
largely powered by arms and hands. The ability to use all
dimensions is somewhat offset by the propensity for objects
to float away if not restrained, so that management and
memory of multiple items become critical skills for efficient
operation. A more problematic aspect of weightlessness is
that since small particles do not settle out onto surfaces,
chance encounters may lead to foreign bodies impacting the
eye or being inadvertently aspirated.
PHYSIOLOGICAL ADAPTATION TO
WEIGHTLESSNESS
In the normal terrestrial condition, we interact with gravity
in a highly dynamic fashion. Our upright posture involves
a re-orientation to the gravity vector and its resultant
K17577_C018.indd 335
Physiological adaptation to weightlessness  335
hydrostatic gradient many times daily in the activities of
lying down, sitting, standing, and locomotion. As such our
systems are designed to accommodate these variable chal-
lenges with protective mechanisms to maintain perfusion
pressure to the central nervous system, regulate fluid vol-
ume, and move in a mechanically efficient manner. The
complete effective removal of this dominant force places
the body into a relatively static, unchallenged state, ren-
dering many of these processes less necessary and in some
instances a hindrance. Adaptation to microgravity can
be thought of as a down-moding of many of these protec-
tive mechanisms, minimizing processes that are no longer
needed and reinterpreting mechanical and visual inputs to
process in a manner more suited to weightlessness.
With the 50 plus years of human spaceflight experience
accumulated, there is now an awareness of a constellation
of predictable physiological changes with timelines and
endpoints associated with adaptation to weightlessness. By
and large these can be thought of as physiological efficien-
cies that allow the body to function optimally in this novel
environment. With few exceptions, these are enabling and
only become problematic during return to unit gravity. This
section will review the most significant changes along with
their clinical implications.
Acute adaptation
Although all processes involved in adaptation to weight-
lessness begin upon engine cut-off following ascent, there
are three noteworthy phenomena with almost immedi-
ate clinical manifestations. These are sensorimotor effects,
fluid shifts, and anthropomorphic changes. Although each
of these will continue to change in a more benign fashion
towards new set points, it is important to appreciate the
acute changes for their implications to crew operations and
functional performance. There are overlaps in symptomo-
logy, and as with long-term adaptation each system must
be viewed in the context of the holistic changes occurring.
In fact these can be considered primary effects from which
many of the further changes seen cascade as secondary
responses to weightlessness.
NEUROSENSORY EFFECTS
There are many cues that guide positional awareness and
motion control of body and limb on Earth. The neuroves-
tibular system utilizes specialized organs that sense both
motion and motion rates. The inner ear otolith organs
and semicircular canals making up the vestibular system
function as tiny accelerometers for linear (translation) and
rotational motion, respectively. Proprioceptors in the mus-
culoskeletal system also provide positional input for motion
based on mechanical stresses, and tactile (haptic) sensors
provide inputs whether standing, sitting or recumbent.
These normally work in a steady-state gravity field and are
tightly tied to this background input that serves as a ref-
erence condition. Not directly related to gravity is visual
input, which provides powerful cues as to positional sense
18/11/2015 14:13
 336  Space physiology and medicine
that are integrated in the CNS with the familiar correspond-
ing inputs of the previously mentioned systems.
Humans adapt to and function in several novel motion
environments, such as sea surface, underwater and flight.
All of these involve some degree of disruption of normal
motion control cues, and all are associated with a set of neg-
ative reactions and illusions as well as adaptation responses
and strategies that enhance function. Weightlessness
induces a more global change by nullifying many of these
inputs. Simply put, the abrupt unloading of the body’s grav-
iceptors disrupts the integrated sum of these inputs, giving
rise to sensory conflicts. The tonic force of gravity no longer
pulls on the otoconia of the otolith organs, which in a pure
form emulates a state of falling (without the excitement).
An illusion of ‘inversion’ is commonly experienced at the
abrupt transition to weightlessness, tied to this sudden
unloading of the otoconia. Although visual cues will show
motion compared to a reference background, tilting one’s
head no longer involves a downward pull to one side, so
that the vestibular and visual inputs are mismatched. Two
immediate manifestations are space adaptation syndrome
(SAS) and motion control disturbances.
SAS, also known as space motion sickness, is a clini-
cally significant result of the mismatch of these sensory
cues and may be seen within minutes to hours after arriv-
ing in weightlessness. The incidence among first-time fly-
ers may be as high as 50–70  per cent. Nausea and emesis
may occur, often with very little warning. Lethargy, fatigue
and diminished appetite are common, and headache may
be present though this may overlap with symptoms caused
by the acute fluid shift. Rapid and radical motions are pro-
vocative, particularly rotational head motions that take the
body out of the sensed visual vertical plane based on the
spacecraft structural reference. As such, slower motions
are encouraged along with maintaining a visual vertical
reference frame for the first several hours of adaptation.
Interestingly, the incidence of SAS seems to be lower in
smaller vehicles, possibly owing to the diminished freedom
of movement compared to larger volumes such as the Space
Shuttle afforded and hence less provocative motion. Veteran
flyers show a lesser incidence of SAS, although whether this
is due to some degree of retained conditioning or learned
protective strategies is unclear.
Medications are frequently used in the clinical manage-
ment of SAS. Oral antiemetics may be taken prophylacti-
cally just prior to launch, though their use is discouraged
among critical flight crew members owing to possible seda-
tive effects. Once inflight, parenteral promethazine has been
found to be highly effective for symptomatic SAS. Readily
available emesis containers are a must, and often present the
first zero G fluid containment challenge to a new flyer. Oral
hydration should be encouraged. Fortunately the clinical
course is self-limited; most symptoms gradually improve
and abate within 48  hours. As frequent as SAS is seen, it
rarely has a significant impact on crew operations.
Motion control disturbances are seen with both limb and
whole-body movement, although practically no formal
K17577_C018.indd 336
investigations have been done in the acute phase of adapta-
tion owing to mission constraints. Arm motions for switch
throws and other control inputs must be made slowly and
deliberately as crewmembers become accustomed to the
lower muscular force required to move a limb that is now
weightless. For whole-body locomotion, there is a strong ten-
dency to maintain a vertical reference and ‘walk’ from point-
to-point utilizing foot restraints. An amusing observation is
the subconscious lofting correction for gravitation when an
object is thrown or passed, and when crewmembers launch
themselves a short distance from one surface to another. The
strong tendency to ‘aim high’ is eventually replaced by the
experience of all objects moving along the precise trajectory
imparted; usually this requires a few hours to a few days to
fully transition. As for SAS, repeat flyers show a much more
rapid adaptation. Significantly, this operationally inten-
sive period that may involve mechanical systems actuation,
rendezvous and docking, and other dynamic flight tasks is
typically executed without problems. Motion control dis-
turbances are apparently overcome by such factors as rapid
adaptation, task familiarity, greater reliance on visual inputs
and feedback, and in some cases displayed data.
ANTHROPOMORPHIC RESPONSE
In weightlessness, the human undergoes changes in body
shape as well as relative position of individual organs. Those
that are most closely related to gravity occur immediately,
while others that are tied to tissue composition, such as
hydration of intervertebral discs and muscle mass, change
over several hours to days. The most dramatic effect is the
neutral body posture, seen in Figure  18.6. This posture is
very definitive; if a crewmember forces himself into a rigid
position that mimics standing in 1 G then suddenly relaxes,
the body will snap into this position within a few seconds.
This is the position a body will naturally assume dur-
ing sleep, and restraints for both work and leisure should
be designed mindful of this position. Along with the pos-
tural change, the abdominal girth decreases as the viscera
are no longer suspended from the mesenteric connections
to the diaphragm; all shift cephalad. Chest circumference
increases, with a slightly greater anteroposterior diam-
eter resulting in a more circularly shaped rib cage. Other
anthropometric changes can be seen over time, but these
acute effects have direct bearing on physiological responses
to weightlessness as discussed below.
FLUID SHIFTS
The terrestrial conditions in which humans have developed
and thrive involve a hydrostatic gradient, as gravity con-
stantly pulls down on the water column created by the vas-
cular system and tissue fluids. This is primarily expressed
in the body Z axis when upright, shifting to the X axis
when recumbent. Once in weightlessness, this gradient is
abruptly abolished as venous and arterial pressures roughly
equalize throughout the body in their respective tracts.
Figure  18.7  shows this as a comparison with the upright
posture that represents the most extreme gradient as well as
18/11/2015 14:13
 Physiological adaptation to weightlessness  337

Body-centred
vertical reference

Body-centred
horizontal reference

Mic One-G li
rog ne of sig
rav ht
ity
line
of s
igh
t

Figure 18.6  Neutral body posture, which is assumed almost immediately upon transition into weightlessness.
From NASA Human Integration Design Handbook, NASA/SP-2010-3407/Rev1, June 2014.

Arrival into
Terrestrial standing
weightlessness

70 100

Cardiac
chambers
Thoracic dilate
100 diameter
100
increases
Abdominal Fluid shifts
girth to thorax and
Hydrostatic
decreases head; CVP
gradient
Vascular decreases
column
Fluid shifts to thorax and head;
CVP increases
No hydrostatic
Hydrostatic gradient
gradient
100 100 100

200 Terrestrial supine 100

Figure 18.7  The hydrostatic gradient of the vascular column on the human during standing in 1G and immediately upon
arrival into weightlessness. Mean arterial pressures are expressed in mmHg. The shift of fluid volume and vascular pres-
sure to the head may cause nasal stuffiness and mild facial oedema, which eventually improves as the plasma volume
down-regulates to a new setpoint appropriate for weightlessness. These pressure changes may be seen in brief 20 second
periods of weightlessness during parabolic flight. CVP, central venous pressure.

K17577_C018.indd 337 18/11/2015 14:13

 338  Space physiology and medicine

the terrestrial recumbent position. Along with this, vascu-
lar volume that normally resides as capacitance in the lower
extremity circulation and probably splanchnic vascular
beds (Petersen et  al. 2011) shifts quickly towards the tho-
rax and head, followed by a volume of mobilized interstitial
fluid from lower extremity musculature that is no longer
held in place by hydrostatic pressure. There is a sensation
of a fluid rush to the head, often described as similar to
hanging upside down – this most certainly contributes to
the inversion illusion noted above. In the first few hours in
weightlessness, fluid shift may be manifested by congestion,
stuffiness, mild headache, and facial oedema.
One of the more interesting and unexpected aspects of
adaptation to weightlessness becomes evident with these
fluid shifts. In ground analogues of weightlessness, such as
water immersion and head down tilt, the rapid thoracic shift
of one to two litres of vascular volume leads to an increase
in central venous pressure and triggering of atrial, aortic
and carotid stretch receptors in a sensed volume overload
condition. These in turn induce a parasympathetically
mediated vasodilatation to maintain a normal perfusion
pressure. The cardio-renal baroreceptor response, which
involves salt and water diuresis in response to this sensed
volume overload, is seen in both of these scenarios. During
spaceflight, echocardiographic results obtained on launch
days show an increase in cardiac filling, with atrial disten-
sion and increased cardiac output. However, compared
with the preflight supine position, central venous pressure
is seen to decrease immediately upon insertion into weight-
lessness as determined by direct central venous catheters
with pressure transducers worn during launch and entry.
The apparent resolution is that the increased thoracic diam-
eter noted above effectively decreases thoracic pressure to a
greater degree than the decrease in central venous pressure,
effectively increasing transmural pressure and augmenting
venous return and cardiac filling. The resulting lower inter-
pleural pressure compared with 1G supine simultaneous
with the central blood volume expansion represents a con-
dition unique to weightlessness. Figure 18.8 shows a central
venous pressure trace in an astronaut during launch and
insertion into weightlessness. This effect is rapid and can
also be seen during the 20–25  seconds of parabolic flight
(Videbaek & Norsk 1997). Other key physiological param-
eters may begin to change during this acute period, notably
intracranial pressure, but these await investigation.
The head fullness and facial oedema resulting from
fluid shift is usually little more than an unpleasant sensa-
tion. Infrequently decongestants and analgesics are used
for symptomatic relief. As for SAS these symptoms are self-
limited, reducing in magnitude over a period of a few days
as circulating vascular volume diminishes during further
adaptation of fluid regulatory mechanisms.
General adaptation
While our understanding of adaptation to weightlessness
is functionally useful, it is most certainly incomplete and
largely based on the purposeful study of systems involved
with the more detrimental clinical entities associated with
spaceflight. Further investigations are giving a methodical

30
A B C D

20
mmHg

10

–3
0.0
–2
G
Suit Launch –1
room pad Launch Microgravity
–10.0 –0
2:36 2:38 2:40 2:42 2:44 2:46 2:48 2:50
Hr:min

Figure 18.8  Central venous pressure (CVP) as measured by indwelling catheter during launch into weightlessness on the
Space Shuttle. CVP decreases slightly compared with preflight supine with the abrupt transition from launch acceleration
loads to weightlessness as the ascent engines cut off. A, prompt decrease in central venous pressure 2 minutes before
launch was due to closing of visor of helmet. B, Lift-off. C, Solid rocket booster separation. D, main engine cut-off and
onset of microgravity. Note that the suit room measurements were in the supine position, whereas the launch pad mea-
surements reflect a recumbent/legs elevated position of the ascent seats.
From Foldager et al. Central venous pressure in humans during microgravity. Journal of Applied Physiology 1996; 81:
408–12.

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and more holistic picture of the physiology of weightless-
ness. In the meantime, it is convenient for understanding to
classify the responses to weightlessness as primary and sec-
ondary. Along with the primary conditions of sensorimo-
tor effects, anthropometry changes and fluid shifts resulting
from abrupt unloading noted above, the unloading of the
musculoskeletal system serves as a fourth primary response
to weightlessness from which other significant changes cas-
cade. While the atrophic changes of bone and muscle also
begin immediately, these are not sensed as clinical entities
and become more of a long-term concern. Most of the pro-
cesses below can be considered secondary as all of these con-
tinue towards new set points for the weightless condition.
An exhaustive review of the physiology of weightlessness
is beyond the scope of this discussion; the significant effects
that should be understood by the space medical practitio-
ner are presented. There are some special considerations
in interpreting these findings. The final adapted state of an
individual system or the body itself reflects the sum total
of influences including atmosphere, countermeasure per-
formance, nutrition, activity, and other factors, and so may
differ between vehicles and programmes. Also, results of
inflight physiological investigations occasionally contradict
one another. This may be accounted for by the small subject
numbers available for study, differing methodologies which
themselves may have unforeseen nuances in this novel envi-
ronment, and influence of other physiological factors whose
relevance we have not yet determined. Finally, for effects
that are not clearly mapped to weightlessness, it may be dif-
ficult to untangle aspects related to gravitational loading
from influences of the enclosed cabin, novel diet, and other
factors related to the expeditionary environment.
NEUROSENSORY
Once clear of the first few days in weightlessness and the
frequent occurrence of SAS, humans continue down a path
of more generalized adaptation, in particular with improve-
ment in three-dimensional spatial orientation and motion
control. Overall CNS adaptation to weightlessness has been
reviewed by Clement and Ngo-Anh (2013). It is difficult to
completely differentiate specific mechanisms of neurosen-
sory system adaptation from cognitive strategies and grow-
ing environmental familiarity. However some predictable
findings and timelines can be seen.
From the beginning there is a shift to greater reliance
on vision for position and motion sense, which remains
throughout the time period in weightlessness. Body loco-
motion gradually shifts to primarily arm-powered transla-
tion, often with the Z axis in line with the direction of travel,
with feet being used more for restraint and optimizing the
upper body’s position at a worksite. Mass handling becomes
more fluid, often with larger objects being carried for lon-
ger distances between the feet. Occasionally crewmembers
may experience mild transient spatial disorientation when
moving between modules that may have different clocking
orientations; this resolves over time. An interesting marker
of neurosensory adaptation is being able to transition a
K17577_C018.indd 339
Physiological adaptation to weightlessness  339
perceived work volume from an allocentric reference frame,
based on the vehicle orientation, to an egocentric frame
based on the self. Complete neurosensory adaptation for
a first-time flyer typically requires several weeks based
on many of these observations, and contributes greatly to
human task performance. As might be imagined, this level
of adaptation to weightlessness becomes particularly prob-
lematic upon return to gravity.
FLUID REGULATION
Because fluid regulation and plasma volume changes were
noted very early in human spaceflight, several sophisticated
studies were conducted during the Skylab and Shuttle pro-
grammes to determine underlying physiological mecha-
nisms. These have included isotopically labelled body water
investigations (Leach et  al. 1996), chromium tagged red
blood cell studies (Alfrey et  al. 1996), intravenous fluid
challenges (Norsk et  al. 2006), and supporting serological
and urine studies. Coupled with the central venous pres-
sure observations, these studies have afforded a functional
understanding of fluid regulation in weightlessness. This
topic is nicely reviewed by Liakopoulos et al. (2012).
The distribution and regulation of body fluids are gov-
erned by the new and novel conditions described in the
acute adaptation phase. Following the increase in venous
return and sensed volume overload condition, the body
responds by beginning to decrease plasma volume, a pro-
cess which completes over about a one-week period and
results in a 12–15 per cent reduction. Rather than involving
salt and water diuresis, both sodium and total body water
are maintained. Instead, body water is redistributed as vas-
cular permeability increases to allow extravasation of both
water and sodium into extravascular spaces. This is presum-
ably facilitated by atrial natriuretic peptide, which is seen to
increase on the first flight day in response to atrial stretch.
In addition, antidiuretic hormone is elevated acutely upon
entering weightlessness, further opposing a saline diuresis.
Antidiuretic hormone is known to increase in response to
motion sickness, and this may be a significant contributing
factor to the acute response to fluid regulation in weight-
lessness. As plasma volume settles to its new set point, atrial
natriuretic peptide rebounds to a level lower than pre-
flight. Body water and sodium remain in intracellular and
interstitial storage spaces presumably throughout the stay
in weightlessness.
As plasma volume decreases, a state of relative haemocon-
centration results. This is apparently sensed and corrected
fairly quickly by the process of neocytolysis, the selective
splenic removal of newly released nucleated erythrocytes
until concentration is appropriately matched to the reduced
plasma volume. A similar phenomenon is seen in humans
transiting acutely from prolonged periods at altitude to sea
level. Though the actual trigger for this process is not known,
within about a week both plasma volume and red blood cell
mass are matched with a normal haematocrit and stabilized
at a new norm that persists unchanged while in weight-
lessness. The result is a euvolaemic state appropriate for
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 340  Space physiology and medicine
weightlessness, which almost instantly transitions to a hypo-
volemic and anaemic state upon return to Earth’s gravity.
CARDIOVASCULAR
The interpretation of cardiovascular findings associated
with spaceflight must be mindful of the preflight posture
(supine, seated, standing) to which inflight metrics are com-
pared. However the overall picture is consistent and pre-
dictable. In parallel with the fluid dynamics noted above,
echocardiographically measured atrial and ventricular vol-
umes increase acutely. Cardiac output increases while mean
arterial pressure and heart rate are maintained. In the brief
20-second period of weightlessness of parabolic flight, car-
diac output was seen to increase by 29 per cent compared
with the 1 G seated position. Systemic vascular resistance
decreased by 24 per cent to maintain heart rate and mean
arterial pressure unchanged. Corresponding studies per-
formed one week into spaceflight show similar results, with
cardiac output increased by 22 per cent and systemic vascu-
lar resistance decreased by 14 per cent, this in concert with
the plasma volume reduction (Norsk et al. 2006). Over the
long term, cardiac chamber dimensions decrease to preflight
values (Herault et al. 2000); heart rate and blood pressure
tend to settle on values equal to preflight supine, while mean
arterial pressure settles to a level between preflight supine
and seated and systemic vascular resistance remains lower
that preflight (Verheyden et al. 2010; Fraser et al. 2012).
There is imagery evidence of decreased left ventricular
mass following one to two week spaceflights (Perhonen
et  al. 2001); however, this may be at least partially attrib-
uted to fluid redistribution and loss of cardiac interstitial
fluid (Summers et al. 2005). Cardiac contractility and over-
all function seem to be normal throughout long periods of
weightlessness. In addition, arterial baroreflex sensitivity is
seen to increase during the first few days in weightlessness,
then return to a value unchanged from preflight supine
(Hughson et al. 2012). The cardiovascular response to exer-
cise is altered and is described below; however, in general
the cardiovascular system adapts very well to long periods
in weightlessness with no limitation on inflight crew per-
formance. An interesting observation is that in spite of the
decrease in vascular resistance, overall sympathetic nervous
activity remains increased during spaceflight, as evidenced
by elevated catecholamine levels and augmented response to
lower body negative pressure (Norsk & Christensen 2009).
PULMONARY
The lungs, involving tissues of significantly different densi-
ties, elastic recoil forces, and environmental gas exchange,
are known to be influenced by gravity and acceleration loads.
Lung structure and function is thus expected to be influ-
enced by the mechanical effects of thoracic shape change
and loss of the hydrostatic gradient. However, lung function
undergoes limited and fairly rapid adaptation to weightless-
ness, remaining constant and supporting oxygenation and
ventilation unimpeded. Lung function in weightlessness is
thoroughly reviewed by Prisk (2014).
K17577_C018.indd 340
The unloading of the abdominal viscera along with the
circularization of the thoracic rib cage causes a cephalad
shift of the diaphragm, which no longer bears the weight
of the abdominal viscera during respiration. The abdomi-
nal contribution to tidal volume increases significantly, as
abdominal wall compliance increases while thoracic rib
cage compliance decreases somewhat. A more even distribu-
tion between ventilation and perfusion would be expected
with the loss of the gravitational gradient on blood flow and
this is indeed seen. With the effective decrease in physio-
logical dead-space, tidal volume is reduced by about 15 per
cent. Respiratory frequency actually increases somewhat to
roughly 9 per cent, with a resulting decrease in ventilation
of about 7  per cent. The subjective sensation of shallower
breathing being adequate is perceptible to some crewmem-
bers. However, some inhomogeneity in ventilation and per-
fusion distribution does persist, suggesting that gravity may
not be the overall determinate it has been thought to be.
Vital capacity and forced vital capacity are reduced
slightly in the first days of weightlessness, possibly related to
the acute increase in central circulating volume, but recover
to preflight norms within a few days and remain constant
thereafter. Membrane diffusion across the alveolar–capil-
lary interface as measured by diffusing capacity for carbon
monoxide undergoes an abrupt and sustained increase, by
about 28  per cent compared with preflight standing, and
remains elevated. This is likely due to a more uniform pul-
monary capillary filling compared with the terrestrial con-
dition of decreased capillary filling in the apical regions.
This should be taken into account for physiological studies
and toxicity considerations for airborne agents.
MUSCULOSKELETAL SYSTEM AND AEROBIC
FITNESS
Both bone and skeletal muscle are vital tissues capable of
responding to sustained or repetitive physical loading
demands by altering mass and strength. Increasing tissue
mass in response to repeated or sustained loads ensures the
most energy-efficient state, so that the unloaded condition
does not match to excess capacity and its higher metabolic
demands. As the primary role of the musculoskeletal sys-
tem is moving the body against the background force of ter-
restrial gravity, it is no surprise that the absence of this force
has a profound influence on the mass and strength of both
of these. The physical unloading of the musculoskeletal sys-
tem that occurs in weightlessness is a primary effect from
which others cascade, including atrophy of both bone and
muscle, spilling of bone mineral constituents into serum
and urine, potential impacts on physical performance, and
risk of fractures and muscle injury. These are effects that
are most problematic on return to Earth, causing minimal
impact to operations during prolonged stays in space.
Bone tissue is constantly being remodelled, maintained
in a dynamic balance between the opposing processes of for-
mation and resorption. Even in the relatively short missions
of the Apollo program, it was known that spilling of bone
mineral constituents such as calcium and phosphate into
18/11/2015 14:13

the urine was accelerated in weightlessness. Through sub-
sequent long-duration missions on the Skylab, Salyut, and
Mir space stations, several key characteristics of the bone
loss of weightlessness have been determined. Chief among
these is that bone loss is regional, with the greatest losses
occurring in the prominent weight-bearing areas such as
the calcaneus, hip, pelvis and lumbar spine. Losses in these
areas show a greater degree of trabecular loss compared
with that of cortical, with total decreases typically exceed-
ing 1  per cent per month in weightlessness, significantly
greater than the rate of loss associated with terrestrial dis-
use osteoporosis or osteoporosis of the elderly (Shackelford
et al. 2004). Interestingly, the wrist typically sees no loss and
the skull may actually show an increase in density as deter-
mined by dual X-ray absorptiometry. Chemical markers of
bone resorption, such as increased urinary n-telopeptide,
calcium and phosphate are seen to increase within a day of
entering weightlessness and remain elevated until returning
to Earth. The resulting excess urinary calcium adds to a risk
of renal stone formation. The usual increase in bone forma-
tion seen in response to bone resorption seems attenuated
or absent in weightlessness, as these two processes appear to
be uncoupled (Smith et al. 2012). Recovery following Earth
return requires more time than that spent during the mis-
sion in weightlessness (Orwoll et al. 2013), perhaps by a fac-
tor of two or three. Ultimately, the overall concern is that
of increased fracture risk, either in a postflight period that
might involve rehabilitation on Earth or exploration activi-
ties on the surface of Mars, or years following a spaceflight
career owing to accelerated osteoporosis.
Skeletal muscle reacts in a similar fashion to bone, with
those regions most involved in the support of upright pos-
ture and locomotion most affected by the unloading of
weightlessness. Calf and thigh musculature is lost prefer-
entially, whereas thoracic muscle is less affected and upper
extremity is minimally affected (Gopalakrishnan et  al.
2010). This can be appreciated by measuring diminished
strength and muscle mass and volume in the lower extremi-
ties. A noticeable decrease in calf circumference occurs,
with more mass being lost in the soleus than the gastroc-
nemius (Fitts et al. 2013), which coupled with the fluid shift
from the lower extremities contributes to their thinning in
the phenomenon known as ‘bird legs’. A transition towards
fewer slow twitch and greater fast twitch fibres is seen on
biopsy studies of the soleus and gastrocnemius similar to
that seen in bed rest (Trappe et al. 2009), and diminished
lower extremity strength is common.
The equilibrium of bone and muscle attained in weight-
lessness is heavily influenced by the quality of physical
countermeasures available to compensate for the absence
of gravitational loading. There have never been crewmem-
bers that performed no exercise during long-duration
stays in space, so results must be interpreted along a con-
tinuum with an unknown control point at one end (repre-
senting total unloading) and Earth’s normal conditions at
the other. Countermeasures equipment has been steadily
improving since the beginning of human spaceflight, and
K17577_C018.indd 341
Physiological adaptation to weightlessness  341
has recently undergone drastic and measurable improve-
ment. Treadmill and cycle exercise devices have been used
for several decades, primarily supporting aerobic fitness
and the postural muscles and joints associated with loco-
motion. Resistance exercise has been on a more evolution-
ary path, with heavier loads emulating gravitational forces
becoming available only in recent years. The advanced resis-
tive exercised device (ARED) was deployed on the ISS in
2008, and represents an inflection point in maintenance of
bone and muscle. The ARED is capable of axial loads up
to 600 lb equivalent force with characteristics that emulate
free weights, and supports a variety of exercises that can
target postural sites. A typical day’s countermeasures activ-
ity during long-duration flight includes about two hours of
actual aerobic and resistive exercise.
Prescribed use of the ARED is associated with minimal
losses of bone and muscle and increase in lean body mass
during flight. There is also evidence that bone and muscle
maintenance is related to adequate calorie intake and main-
tenance of body mass inflight, which up until this point had
been suboptimal as a rule (Smith et al. 2012). Interestingly,
upgrades to the ISS galley system were implemented about
the same time as the ARED was deployed that greatly facili-
tated ad lib access to water for drinking and food rehy-
dration as well as food storage and meal preparation. It is
somewhat difficult to separate the relative effects of nutri-
tional support and heavy resistive exercise on bone and
muscle maintenance; however, it is clear that exercise is best
supported by adequate nutrition and energy intake. The
result has been significant to the point that investigations
dealing with musculoskeletal fitness in spaceflight must be
interpreted as prior to or after the deployment of the ARED.
In spite of the demonstrated effectiveness of heavy resis-
tive exercise in preserving bone and muscle, bone resorption
continues unabated during the non-exercise time. Recent
studies of bisphosphonates, a class of drugs that inhibit
bone resorption, have yielded very promising results as an
adjunct for bone protection in weightlessness. The bisphos-
phonate alendronate in combination with ARED exercise
was demonstrated to globally attenuate losses in bone min-
eral density in the postural areas of concern, as shown in
Figure 18.9. In addition, urinary and serological markers of
bone resorption along with calcium spilling were attenu-
ated, so that the risk of nephrolithiasis should be reduced as
well (Leblanc et al. 2013). Whether or not pharmaceuticals
are used as a standard addition to bone health in weightless-
ness, adjuncts are important as a backup means to preserve
bone in event of crew injury, exercise equipment failure, or
environmental control compromise that might limit perfor-
mance of physical countermeasures; all of these have hap-
pened during human spaceflight.
Aerobic fitness follows a characteristic profile during
long tours in weightlessness, with an initial inflight decline
followed by a gradual return back towards preflight baseline
over time, then an immediate postflight decline followed by
recovery. For several years inflight aerobic fitness measure-
ments had been determined by deriving maximal oxygen
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 342  Space physiology and medicine

15
Pre-ARED 2,3
ARED
10
Bisphosphonate
2
Means
5 2
2,3
% Change from Pre-Flight
2 1
1 1
1 1 1
0

–5

–10

–15

–20
Femoral Neck Trochanter Total Hip Pelvis Lumbar Spine

Figure 18.9  Change in bone mineral density from selected sites as assessed by dual X-ray absorptiometry (DXA) after
spaceflight with a mean of 5.5 months’ duration. Compared with once-standard countermeasures, bone is better pre-
served with heavy resistive exercise, with further preservation when bisphosphonates are added. ARED, advanced resis-
tive exercise device; 1, p<0.05, pre versus post; 2, p<0.05 (bisphosphonate group significantly different from pre-ARED);
3, p<0.05 (bisphosphonate group significantly different from ARED). Pre-ARED (n=18); ARED (n=11); bisphosphonate (n=7).
From Leblanc A, Matsumoto T, Jones J, et al. Bisphosphonates as a supplement to exercise to protect bone during
long-duration spaceflight. Osteoporosis International 2013 Jul; 24(7): 2105–14.

uptake (V. O2max) values from heart rate data and known
exercise loads. Recently actual measurements of V. O2max
were obtained on ISS crewmembers performing periodic
maximal cycle exercise along with heart rate data and met-
abolic gas analysis. Figure  18.10  shows the relationship of
aerobic fitness by the measures of peak aerobic capacity and
aerobic power from preflight, inflight and postflight phases
(Moore et al. 2014). The initial decline is likely multifacto-
rial, with the decrease in plasma volume and red blood cell
mass, acute neurosensory adaptation and familiarity with
motion and restraint in weightlessness all possibly contrib-
uting. Although variability is high, inflight trends suggest
gradual improvement over a six-month mission but not
quite back to preflight baseline; however, individuals that
undergo particularly intensive daily aerobic exercise inflight
are most likely to approach and maintain a near preflight
level. The postflight decline is more easily understood in the
context of the relative anaemia, hypovolaemia, and general
deconditioning associated with weightlessness. Postflight
crew condition and performance are discussed below.
ANTHROPOMORPHIC ADAPTATION
Following the increased thoracic diameter and decreased
abdominal girth, change in posture and visceral shifting
that occur within minutes of entering weightlessness, the
human body settles more gradually into a unique habitus
characteristic of weightlessness. Spinal lengthening is seen
owing to fluid imbibing of the intervertebral disks similar to
that while recumbent terrestrially, but that is now unopposed
by the compression of upright posture. In addition there
is a relative decrease in the natural thoracic kyphosis. As
a result, seated height and standing height are increased;
seated height may increase by as much as 6 per cent. Another
measureable change is the typical biphasic decrease in lower
extremity diameter. The fluid shift and redistribution of the
first few days in weightlessness cause a loss of volume from
diminished venous capacitance and interstitial fluid from
leg musculature, which is complete within seven to ten days.
Thereafter a further gradual decline may occur, dependent
on exercise-supported maintenance of postural muscula-
ture in the calf and thigh, and measurement of calf volume
has long served as a surrogate inflight muscle mass assess-
ment. This has been attenuated somewhat with the recent
introduction of heavy resistive exercise.
Periodic assessment of body mass has proven to be a use-
ful measure of health and nutrition, and is typically per-
formed on a monthly basis during long-duration flight.
Undue ‘weight’ loss is an indication of inadequate energy
intake and may be used to guide food selection and quan-
tity. Body mass is assessed using oscillating spring damper
systems or linear acceleration devices that set the body in
motion and derive the mass from the motion dynamics and
known mechanical characteristics of the systems (Zwart
et al. 2014).
The consequences of the inflight anthropometry changes
are mainly related to fit into body restraint systems and
highly customized critical flight crew equipment such as
pressure suits and landing restraint systems. As example,

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 Physiological adaptation to weightlessness  343

3.5

VO2 peak (L/mim)

3.0

•
2.5

0
0 30 60 90 120 150 180 210 0 15 30
Pre-flight Flight day Recovery

300

250
Peak power (W)

200

150

0
0 30 60 90 120 150 180 210 0 15 30
Pre-flight Flight day Recovery

Figure 18.10  Absolute peak aerobic capacity (V̇O2 peak) and peak aerobic power during and following ISS missions of 164
days’ mean duration. The horizontal broken line is a reference drawn at the preflight mean. The solid line ± dashes during
flight is the mixed-modelled linear regression predicted mean response ±95th% confidence interval (CI) for an average-
sized subject (77.2 kg). The values preflight and during recovery are also predicted means ±95th % CI. n = 14, 9 males and
5 females.
From Moore AD Jr, Downs ME, Lee SM, et al. Peak exercise oxygen uptake during and following long-duration
spaceflight. Journal of Applied Physiology (1985). 2014 Aug 1; 117(3): 231–8.

the Russian Soyuz capsule makes use of a highly custom-
ized entry couch that is molded around a crewmember pre-
flight. Allowances for spinal lengthening are made during
this process to ensure proper fit following prolonged stays
in weightlessness. It is possible to decrease spinal length
by heavy compressive exercise, but limited observations
suggest this effect will reverse within hours back to the
new norm for weightlessness. Finally, imagery surveys via
ultrasound are being made to better understand the ana-
tomical distribution of abdominal and thoracic viscera in
weightlessness as a reference for diagnosis and treatment
(Sargsyan et al. 2005).
Cerebrovascular response and ocular changes
The cerebrovascular response and cerebral autoregulation
associated with weightlessness have been incompletely stud-
ied, and there are seeming conflicting results from different
investigations. In recent years, interest in CNS fluid pressures
and cerebral venous drainage in weightlessness has increased
considerably with the recognition of a syndrome involving
ophthalmic and neuro-ophthalmic anatomy. While the find-
ings are recent, this is likely a recognition of a long standing
and previously overlooked aspect of adaptation that has now
been made possible by high-resolution MRI studies and other
modes as well as new onboard imagery capabilities. Unlike
most other system responses to weightlessness in which the
outcome involves a deconditioning that is primarily prob-
lematic only on Earth return, this syndrome carries clinical
implications during flight.
CEREBRAL AUTOREGULATION
The change in orientation to the gravity vector associated with
postural changes is felt most keenly at the level of the CNS,
which basically resides at the top of the hydrostatic gradient.
While standing, the CNS may be at a pressure of 70 mmHg,
the heart at 100  mmHg and the feet at nearly 200  mmHg.
Moving to a recumbent position or entering weightlessness
equalizes these pressures along the body axis. CNS function
depends on a tightly regulated blood flow to supply oxygen
intensive vital tissue encased in a non-expandable compart-
ment. Cerebral autoregulation is the process by which blood

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 344  Space physiology and medicine
flow to the CNS is dynamically controlled by cerebral arterial
resistance, with stretch receptors inducing vasoconstriction
or dilation in response to increases or decreases in cerebral
perfusion pressure respectively. This response is rapid, occur-
ring within seconds of sensed perfusion pressure changes
and to some chemical mediators such as carbon dioxide, and
maintains cerebral blood flow at a constant level for perfu-
sion pressures between 50 and 150 mmHg. This in turn is bal-
anced by venous outflow from the CNS.
With the disappearance of the hydrostatic influence and
subsequent fluid shifts and facial oedema that occur when
entering weightlessness, there was early interest in studying
CNS vascular responses. By measuring blood flow velocity
in the middle cerebral artery via Doppler ultrasound, it has
been repeatedly found that cerebral autoregulation is indeed
maintained in weightlessness (Iwasaki et  al. 2007; Blaber
et al. 2011; Zuj et al. 2012), even with an artificial orthostatic
challenge induced inflight by lower body negative pressure.
In the immediate postflight period, however, there appears
to be a separation of individuals into those more tolerant of
the orthostatic challenge of standing in gravity with nor-
mal cerebral autoregulation, and those less orthostatically
tolerant showing impaired cerebral autoregulation. In these
individuals, there is an attenuated autoregulation response
for the same blood pressure in more tolerant individuals. It
should be borne in mind that these studies measure blood
flow velocity, but without knowing real-time arterial diam-
eter actual blood flow cannot be assessed with certainty.
Even less is known about the venous drainage of the CNS
and cerebrospinal fluid dynamics in weightlessness and the
resulting steady-state tissue pressures. Cerebral autoregula-
tion in spaceflight is reviewed by Blaber et al. (2013).
MICROGRAVITY OCULAR SYNDROME
The microgravity ocular syndrome is an initial generic desig-
nation for a constellation of findings associated with the eye
and ophthalmic neural structures for which a mechanism
is not yet understood. It is also known as VIIP for vision
impairment/intracranial pressure syndrome for the entities
that first drew attention to it, though not all manifest vision
impairment and the role of intracranial pressure is as yet
unclear. For many years there have been anecdotal reports
from space crewmembers of vision shifting during flight,
primarily in a hyperopic direction such that near vision cor-
rection was required. The accumulation of long-duration
flight experience and availability of the tools noted above
has made possible a description of underlying clinical find-
ings that correlate incompletely with vision shift, thus far
the only subjective symptom. Mader et al. (2011) introduced
this entity with the first published series. The basic syndrome
involves the retinal and surrounding ophthalmic structures.
Retinal findings include folds in the fine, vascular choroid
layer, oedema of the optic disc and occasional cotton wool
spots indicative of axonal stasis. Distension of the optic
nerve sheath may be seen with posterior globe flattening,
suggesting a pressure phenomenon. The resulting decrease
in anteroposterior diameter gives rise to a hyperopic vision
K17577_C018.indd 344
shift. A number of crewmembers have undergone postflight
lumbar puncture for direct measurement of CNS pressure,
some of which have shown mild elevations.
Table  18.7  lists characteristics of the first 11  cases
described from a recent review (Marshall-Bowman et  al.
2013). Interestingly there is a preponderance for greater
weighting to the right eye and greater occurrence in male
astronauts. The incidence is fairly high, although depen-
dent on the clinical definition of this syndrome involving
multiple findings that may not be coupled. As can be seen,
the greatest degree of optic disc oedema seen was not asso-
ciated with a vision shift. In Mader’s series, nearly 50  per
cent of long-duration crewmembers on the ISS reported
near vision degradation, with 34  per cent demonstrating
objective refractive changes post flight. This compares with
approximately 11  per cent of short-duration Space Shuttle
flyers showing objective refractive changes. Myasnikov and
Stepanova (2008) reported transient postflight disc oedema
in 8 of 16 cosmonauts flying long-duration missions on the
Mir station. Table 18.7 represents approximately 40 per cent
of a set of crewmembers studied during this period, and
reflects 50 per cent of male crewmembers of that analysis.
Postflight MRI imagery data suggests that subtle changes,
in particular optic nerve and optic nerve sheath findings,
may be even more common (Kramer et al. 2012). This sug-
gests a syndrome with variable expression in frequency and
severity of findings, likely representative of a more global
cerebrovascular response to weightlessness. Many of these
changes reverse over time following return to Earth, but
some crewmembers have experienced permanent vision
shift and optic nerve sheath distension. Crewmembers have
remained functionally unimpaired with appropriate vision
correction and have been returned to flight duty.
The mechanism of microgravity ocular syndrome awaits
explanation. The findings of optic nerve sheath distension
and disc oedema point towards increased intracranial pres-
sure as a contributing or related factor, though there have
not been measurements during flight and no preflight
baseline assessments have been made to document actual
changes. However, several factors associated with space-
flight may contribute. The greater volume of thoracic fluid
and anthropomorphic changes may lead to a mild impair-
ment of CNS venous drainage, which may induce a slight
increase in intracranial pressure. Although cerebral auto-
regulation appears to be maintained, it is highly likely that
the fluid shift and new set points for vascular regulation
are involved. Without actual cerebral arterial diameter
measurements, increased blood flow cannot be ruled out.
In addition, carbon dioxide, a potent cerebral vasodilator,
exists at a level in the spacecraft cabin that is an order of
magnitude higher than atmospheric concentrations. Other
factors, including metabolic variations in the folate/vitamin
B12 pathway (Zwart et al. 2012) and the possible contribu-
tion of resistive exercise and associated peaks in intracra-
nial pressure are being studied.
It is likely that the microgravity ocular syndrome is
but one manifestation of a greater global response of the
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 Clinical problems during spaceflight  345

Table 18.7  Ophthalmic changes in 11 astronauts following long duration spaceflight aboard the ISS
Case Refraction change Choroidal RNFL Optic disc Cotton Globe ONS CSF pressure
(pre-/postflight) folds thickening oedema wool flattening distension (cm H2O)
(OCT) spots
1 OD:−1.50 OD:−1.25 OD — — OD Not Not Not measured
OS:−2.25 OS:−2.50 assessed assessed
2 OD:+0.75 OD:+2.00 Both eyes Present Grade OS OD and OD and Elevated
OS:+0.75 OS:+1.75 (OD>OS) 1(OD>OS) OS OS 22 at R+66
days;
26 at R+17
months;
22 at R+19
months
3 OD:−0.50 OD:Plano — Severe Grade 3 (OD), — — OD Elevated
OS:−0.25 OS:Plano (OD>OS) Grade 1 (OS) 21 at R+19
days
4 OD:−1.00 OD:+0.50 OD Mild (OD>OS) Grade 1 (OD) — OD>OS OD>OS Elevated
OS:−0.25 OS:+0.50 28.5 at R+57
days
5 OD:−6.50 OD:−5.75 — Mild/moderate — — OD and OD and Not measured
OS:−5.75 OS:−5.50 (OD) OS OS
6 OD:+0.25 OD:+1.75 OD Mild Grade 1 (OD) OS OD>OS OD>OS Not measured
OS:Plano OS:+1.00
7 OD:+1.25 OD:+2.75 Both eyes Moderate Grade 1 (OD — OD and OD and Elevated
OS:+1.25 OS:+2.50 (OD>OS) and OS) OS OS 28 at R+12
days
8 OD:+1.50 OD:+1.50 Both eyes Mild Grade 1 (OD — OD and OD and Not measured
OS:+1.50 OS:+1.75 (OS>OD) and OS) OS OS
9 OD:Plano OD:+0.50 — Mild (OD) Grade 1 (OD) — OD and OD and Not measured
OS:Plano OS:+0.50 OS OS
10 OD:+1.75 OD:+2.50 — — — OD Not Not Not measured
OS:+1.75 OS:+2.25 assessed assessed
11 OD:−0.50 OD:Plano Both eyes — — — OD and OD and Not measured
OS:−0.75 OS:−0.25 (OS>OD) OS OS
CSF, cerebrospinal fluid; OCT, optical coherence tomography; OD, oculus dexter (right eye); ONS, optic nerve sheath; OS, oculus sinister
(left eye); refraction change, spherical equivalent; RNFL, retinal nerve fibre layer; R+n = n days after return to earth. From Marshall-
Bowman (2013).

cerebral vasculature to prolonged weightlessness. While
this is being vigorously investigated, current clinical rami-
fications include universal monitoring for the eye changes
noted above and flying ‘anticipatory’ corrective lenses for
all crewmembers.
CLINICAL PROBLEMS DURING
SPACEFLIGHT
The previous section outlined the direct responses of vari-
ous systems to weightlessness, some of which carry clinical
implications that may require treatment for symptomatic
relief and optimal function; examples are head congestion
and space adaptation syndrome in the first few days of flight.
Beyond this there is a well-known set of clinical problems
that may occur owing to adaptive responses, cabin atmo-
sphere and environmental effects, or other occupational
aspects of contemporary spaceflight, alone or in combina-
tion. Unlike adaptation, these are not inevitable outcomes,
but constitute much of the day-to-day practice of space
clinical medicine. The ISS is first and foremost a working
laboratory, albeit in a novel environment. As in any work-
place, there is an obligation to characterize, mitigate and
occasionally treat the occupational medical problems that
arise. A more complete description of these clinical issues
and their treatment can be found elsewhere (Marshburn
2008; Barratt 2014). This section will highlight the major
clinical entities and their basic approach.
Clinical issues of weightlessness and the
spacecraft environment
HEADACHE
Headache is fairly common during spaceflight with many
possible identifiable causes and potentiators. Some are
uniquely associated with the first few days of spaceflight.
As noted above, the acute fluid shift may cause some head
discomfort, which usually abates within a few days as the
plasma volume decreases. SAS as an independent entity may
also involve headache in this same time period, and the two
may overlap. Caffeine withdrawal may also be a contributor,
as the unusual preflight and launch schedule may interrupt

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 346  Space physiology and medicine
a normal habit of coffee or tea intake. Although analgesics
typically are useful in all of these, determining and treating
the underlying cause is considered primary. Independent
of these early flight entities are factors more generic to
weightlessness. Carbon dioxide, which is present in a con-
centration of approximately 0.03 per cent in the terrestrial
atmosphere, is metabolically produced and must be delib-
erately scrubbed from the spacecraft atmosphere. Typical
concentrations on the ISS are between 0.26 and 0.5 per cent
(2–4  mmHg partial pressure), and might be much higher
in poorly ventilated areas. Headache is a well-recognized
symptom of early carbon dioxide toxicity. Crewmembers
are trained and develop experience to avoid prolonged pres-
ence in poorly ventilated areas, and the incidence of almost
any headache not related to easily attributable factors should
prompt localized monitoring for carbon dioxide levels.
Other atmospheric constituents may also induce head-
ache, and a particular concern is carbon monoxide from a
pyrolysis event. This can also be monitored on most space-
craft. The arrival of a new spacecraft and atmospheric
equalization may also be associated with off-gassing prod-
ucts that might induce headache in the enclosed cabin. This
should prompt environmental monitoring and sampling,
in particular if multiple crewmembers are affected, with
consideration to increasing atmospheric scrubbing activity.
Other aetiologies may include tension headache, reaction
to nuisance noise, and vascular mechanisms that may be
related to new vascular regulatory mechanisms. Treatment
should only begin once environmental factors are ruled out.
As yet there is no demonstrated correlation with the micro-
gravity ocular syndrome.
BACK PAIN
Back pain is common during spaceflight and is particu-
larly prevalent during the first few days in weightlessness,
prompting the moniker space adaptation back pain. This
had been noted as early as the Apollo programme and has
persisted as an expected entity. An extensive review of flight
medical records and results of questionnaires across several
flight programs has helped to elucidate the incidence and
distribution of space adaptation back pain (Kerstman et al.
2012). Out of over 700 records examined, the incidence of
space adaptation back pain was seen to be 52 per cent, with
peak prevalence on flight day two and nearly all resolved by
flight day six. Space adaptation back pain was reported as
mild (86 per cent), moderate (11 per cent), or severe (3 per
cent). Although the precise mechanism is not known, this
is likely associated with spinal lengthening and potential
stretching of interspinous ligaments and associated nerve
roots, or from the intervertebral discs that imbibe fluids
unopposed by gravity compression. Typically this is local-
ized to the lumbar region and crewmembers have found
empirically that assuming a tightly tucked position with
the knees flexed to the chest affords some relief. Analgesics
are used as a secondary treatment, and exercise on the
treadmill or ARED also helps, presumably owing to the
compressive loading.
K17577_C018.indd 346
Observationally, an increased incidence of herniated
nucleus pulposis is seen in the astronaut population, sug-
gesting a compromise in disc integrity (Johnston et al. 2010).
However, there does not seem to be a connection between
HNP and space adaptation back pain in astronauts.
FOREIGN BODIES
In weightlessness, there is no gravitational settling of dust,
particulates or other matter in the cabin atmosphere. These
items will be moved only by forced air movement and will
deposit in fan filter intakes or areas of baffled airflow around
structures. For crewmembers, these are occasionally dif-
ficult to avoid as the eyes tend to focus on the spacecraft
background while working or moving. Foreign bodies in the
eye are not uncommon, typically the result of low velocity
impact. As such they can usually be removed by blinking
or gentle application of water; a drink bag and straw work
nicely and water is easily contained in a towel. An elegant
approach if this is not successful is to carefully apply a large
volume of water to the orbit, perhaps 200–300 ml, allowing
surface tension to hold it in place while keeping the head
still and blinking repeatedly. Should this fail, fluorescein dye
and ophthalmoscopy are available and crewmembers are
specially trained for foreign body removal. Liquid or pow-
der chemical contamination into the cabin atmosphere is a
possibility should a containment system fail. Crew protec-
tion equipment such as mask and goggles should be immedi-
ately available. In the event of eye contamination, a constant
flow eye wash (similar to laboratory eyewash) is necessary.
Aspiration of foreign bodies is less common but occasion-
ally occurs; usually these are quickly dislodged by coughing.
The most important approach to foreign bodies in a
weightless cabin is prevention. Choosing spacecraft mate-
rials that do not fracture into small particles and fabrics
that shed minimal lint is standard. Certain activities may
be associated with a somewhat higher risk of shedding par-
ticulates, such as large volume cargo transfer from visiting
vehicles or internal structural work. Protective crew equip-
ment should be donned as a precaution.
MINOR INJURIES
The forces that cause most major terrestrial trauma, such
as falls and motor vehicle impacts, are absent during space-
flight with the as yet rare exception of lunar surface activi-
ties. Fractures have not occurred and significant sprain
injuries are uncommon. However, minor injuries do occur
in this work environment that may affect the ability to
complete mission objectives. Scheuring and colleagues
reviewed injuries across programs for all US astronauts
and documented 219 inflight musculoskeletal events from
medical records and medical consultations along with cor-
responding mechanisms of injury (Scheuring et  al. 2009).
This certainly underestimates the actual occurrence, but
the distribution is probably reflective of the actual experi-
ence. Figure  18.11  summarizes the findings of this survey
by injury location, type and associated mission activity. In
this series, the hand was the most frequently injured body
18/11/2015 14:13
 Clinical problems during spaceflight  347

80

Number of Injuries
70
60
50
40
30
20
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Ge e
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80
Number of Injuries

70
60
50
40
30
20
10
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n n in n in n
io sio ra io ra io
ras u St rat Sp cat
Ab nt ce slo
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Injury type

90
Number of Injuries

80
70
60
50
40
30
20
10
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Misssion activity

Figure 18.11  Summary of 219 musculoskeletal injuries among US astronauts during Mercury, Gemini, Apollo, Shuttle,
Shuttle/Mir, and early International Space Station missions. Crew activity includes translating through a vehicle, moving
objects, and operation of systems and payloads. ACES, advanced crew escape suit; EVA, extravehicular activity; LES,
launch and entry suit.
From Scheuring RA, Mathers CH, Jones JA, Wear ML. Musculoskeletal injuries and minor trauma in space: incidence
and injury mechanisms in U.S. astronauts. Aviation, Space, and Environmental Medicine 2009 Feb; 80(2): 117–24.

part, followed by shoulder and back injuries. These were
often caused by transiting through the vehicle using arms
for locomotion or by moving and stowing large hardware
items, involving low-speed impact injuries such as abra-
sions and contusions. Extravehicular activity occasionally
caused injury owing to contact with rigid elements in the
suit or exerting forces against foot restraints. Exercise coun-
termeasures were a third category, accounting for 12 of the
14  musculoskeletal injuries on the ISS. As this study was
performed prior to the introduction of the ARED with its
larger resistive loads, there is increased interest in preven-
tion and response to strain injuries.
Along with these, minor cuts and burns have occurred
as might be expected for a busy operational and labora-
tory environment. The awareness of this injury spectrum
prompts vigilance and prevention, and also informs the
planning for medical response to these events. Although the
vast majority of inflight injuries are minor with minimal
impact to scheduled work, some may limit the ability to per-
form physical countermeasures, which carries a more seri-
ous implication than the inability to exercise on the ground.
UROLOGICAL ISSUES
Nephrolithiasis was identified early in human spaceflight
as a clinical risk due to the urinary spilling of calcium and
phosphorus associated with accelerated bone resorption.
Low urinary volumes have also been seen inflight, further
contributing to a risk of superstation of stone forming con-
stituents. The inflight experience has not proven to be formi-
dable; there has been only a single case of probable inflight
nephrolithiasis in over 50 years of spaceflight. This passed
spontaneously, although was associated with considerable
discomfort. However, there does seem to be an increased
incidence of renal stones in the postflight period, with
stone formers showing urine chemistry profiles associated
with increased risk (Pietrzyk et  al. 2007). Whether these

K17577_C018.indd 347 18/11/2015 14:13

 348  Space physiology and medicine
stones are formed during flight to clinically manifest later
or formed in the somewhat vulnerable postflight period is
unclear. Urine chemistry assessment for renal stone risk
should be performed in all candidates for spaceflight, and in
particular long-duration flights. Risk factors that are ame-
nable to dietary influence may be identified and addressed,
and maintaining hydration and adequate urinary output
should always be encouraged.
Urinary retention is occasionally seen during spaceflight,
and is primarily a problem of the first few days in weight-
lessness. Several factors may contribute, beginning with
the launch pad recumbent position. Fluid shifting towards
the thorax actually begins to some extent during this time,
though in the normal gravity during prelaunch a diuretic
response and bladder filling does occur over the typical
two to three hour period. Crewmembers usually wear an
absorbent pad, but may find urination difficult with the
constraints of the suit and in this position. Once in weight-
lessness, a busy initial timeline may further defer urination.
For crewmembers requiring large doses of medications
for SAS, the anticholinergic effects of some of these may
decrease bladder detrusor function. The absence of gravita-
tional assist may also play a role. Increasing bladder disten-
sion may then contribute to a physical outlet obstruction.
Crewmembers should be aware of these factors and
make purposeful attempts to urinate as needed. If retention
does occur, bladder catheterization can be easily performed.
Periodic straight catheters are preferred over indwelling
catheters, since the problem is usually self-limited. Both
should be available in onboard medical supplies.
IMMUNOLOGY AND INFECTIOUS DISORDERS
The spacecraft environment represents an exquisitely iso-
lated, enclosed habitat with operational controls on the influx
of human pathogens. Crewmembers are medically certified
to be free of clinical infectious disease prior to launch and are
required to be current on recommended vaccinations. A pre-
launch quarantine programme is routinely provided to con-
servatively cover the incubation period of the most common
infectious entities, typically 10 days to 2 weeks. During this
period, any person having direct contact with crewmembers
must be medically screened themselves. By and large this has
been a successful means of controlling infectious events and
should be considered a mandatory practice in human space-
flight. However there are suggestions that infectious issues
may be problematic during long-duration missions. An
increased incidence of reactivation and shedding of latent
herpes viruses has been noted and correlated with certain
immune modulators (Mehta et al. 2013), and several changes
are noted both in cytokine production and T-cell function
during short-duration flight (Crucian et al. 2013). Also, long-
duration flight is associated with increases in tumour necro-
sis factor-α, thrombopoietin, vascular endothelial growth
factor and other various immune modulators and cytokines
(Crucian et al. 2014).
Determining the relative contributions of the
enclosed environment, stress and possible true factors of
K17577_C018.indd 348
weightlessness is difficult, and it remains unclear whether
the immune dysregulation seen correlates with actual
increased clinical risk. In particular, the incidence of post-
flight infectious disease following long periods in weight-
lessness and fairly free access to a normal population does
not appear to be increased. While the science progresses,
the prudent practice of preflight quarantine should be
rigorously continued.
SLEEP AND FATIGUE
The spaceflight environment is an operational theatre not
unlike military missions aboard surface ships, submarines
or remote base deployments. The surroundings are physi-
cally hostile, and the work is high profile and intensive. Often
sleep schedules are manipulated to accommodate dynamic
flight events such as launch, rendezvous and extravehicular
activity; this may disrupt circadian cycles. The background
noise level is moderately high owing to fans, pumps and
other equipment. With 16 Earth orbits in a 24-hour period,
light–dark cycles must be artificially regulated. Coupled
with these factors are the physiological processes described
above and the novelty of weightlessness. Sleep quantity and
quality have been observed to be degraded for short and
long-duration spaceflight in the Skylab, Shuttle, Mir and ISS
programmes, in spite of a significant usage of sleep-induc-
ing medications (Dijk et al. 2001; Barger et al. 2014). In gen-
eral, space crews complete complex activity timelines and
do not demonstrate cognitive or performance decrements.
However the observed sleep disruption creates concern for
fatigue related performance effects.
To optimize sleep during spaceflight, positive controls
should be enacted against as many of the above factors as
possible. Work schedules during the typically intensive pre-
launch period as well as during flight should be carefully reg-
ulated and time blocks to protect a sleep period from official
work or ground communication strictly observed. Shift work
should be avoided if possible to prevent sleep interruption by
other crewmembers working in the relatively small confines
of the spacecraft. Mechanical hardware should be designed
and insulated to minimize noise generation. Spacecraft
lighting adjustable for intensity and frequency spectrum can
optimize circadian entrainment. A private enclosure that
is further sound and light isolated is highly recommended.
Sleep-inducing medications may be judiciously used. It is
recommended that crewmembers perform preflight toler-
ance testing to the medications commonly used in space-
flight, such as zolpidem and zaleplon. If onboard use is
frequent, medical personnel should re-examine the physical
factors noted and ensure they are adequately addressed.
EARTH RETURN AND READAPTATION
Whereas the human can be viewed as ‘over-conditioned’
upon arrival to the weightless environment, the eventual
adaptation to weightlessness becomes a deconditioned
state relative to the demands of gravity. Although return
acceleration forces may be similar to launch depending on
18/11/2015 14:13

vehicles, atmospheric entry and landing present a greater
physical challenge considering the direction of change. The
weightless adapted human invariably transitions from 0 G
to 1 G via a dynamic hyper-G flight event (see Figure 18.4).
The discussion below centres on return to terrestrial gravity,
but could also apply to arriving in a fractional gravity field
such as the 0.38 G surface of Mars, with effects generally
expressing lesser clinical implications.
Dynamic entry phase
Atmospheric return presents weightless adapted humans
with the first acceleration loads since launch not associated
with self-locomotion. Crewmembers are strapped tightly
into restraint seats or couches, so that strength and fitness
are not particularly required. The main functional concerns
during this period are related to neurosensory decondition-
ing and the effects on spacecraft systems monitoring and
control inputs. Otolith organs are once again sensitive to
tilt; however, this input has been interpreted only as transla-
tion up to this point. Head movements may produce vertigo
and illusory motion. Limbs will feel particularly heavy, and
reach and accuracy are reduced during purposeful move-
ments. Acceleration forces may be compounded by vibra-
tion and buffeting to further degrade sensory performance.
Neurosensory effects associated with entry are reviewed
thoroughly by Paloski et  al. (2008). Although almost no
formal investigational information has been collected dur-
ing dynamic flight phases, there are suggestions of perfor-
mance effects on piloting. The ability to manually attain
target touchdown parameters of the Space Shuttle has been
shown to be degraded in association with greater postflight
neurovestibular deconditioning.
Many of these effects can be countered by a strong visual
input to suppress conflicting neurovestibular signals and
by limiting head movements. While some crewmembers
attempt to make adaptive head movements during entry, a
survey of Shuttle crewmembers showed that these trial head
movements were associated with more than twice the rate
of illusory sensations compared with those who made none
(Small et al. 2012). Instrument panels should accommodate
critical flight displays so that minimal head movements are
required and limited to a single plane if possible. Limb move-
ments must be slow and deliberate, and flight profile and
vehicle margins should accommodate potentially degraded
vestibular–ocular function. For returning crewmembers
with critical flight duties, digital data and task familiarity
also help to modify conflicting neurovestibular input.
Orthostatic intolerance may be a factor during entry
and landing, but unlike neurosensory degradation has a
set of physical solutions. G protection strategies in the form
of crew positioning, anti-G garments, active cooling, and
vascular augmentation via oral fluid loading prior to entry
serve to limit this effect, as noted above in the dynamic
flight section. These enabled successful manual landings of
the Space Shuttle with upright seated crewmembers follow-
ing maximal missions of 18  days. Currently NASA limits
K17577_C018.indd 349
Earth return and readaptation  349
+Gz accelerations during entry to 0.5 G for those returning
from missions of 30 days or longer.
In addition to the problems above, heat stress is common
in the immediate post-landing period during which crew-
members are recovered from the return vehicle owing to the
re-entry heat transferring to the inside cabin as well as the
pressure suits worn for dynamic flight phases. Fatigue is also
a frequent factor, since landing usually occurs at the end of a
very long operational day. The typical freshly landed crew-
member on appearance is diaphoretic, fatigued, and very
guarded in movement. Doffing the suit to manage heat and
beginning volume repletion are immediate priorities.
Acute readaptation
Once landed, the steady process of readaptation to ter-
restrial gravity begins. Each affected physiological system
recovers along a characteristic timeline that may influence
activity and performance. The first hours to couple of days
are dominated by three main clinical entities: neurosensory
disturbances, orthostatic intolerance, and decreased physical
fitness. These may be expressed alone or in any combination
and are influenced by post-landing demands on the crew,
such as landing conditions or physical actions required spe-
cific to a vehicle. The relatively gentle runway landing of the
Space Shuttle may be contrasted with the ocean landing of
US space capsules, with their own motion disturbances and
recovery hazards. Thus a complete understanding of these
entities is crucial to crew management. One word of cau-
tion in interpreting findings: our understanding of recov-
ery, like that of adaptation to weightlessness, is based on a
patchwork of targeted system investigations and observa-
tions with relatively few studies looking at overall function.
Almost any of these systems will show changes or compro-
mise when examined in an isolated fashion, whereas the
overall level of functional performance is typically better
owing to the recruitment of other sensory cues and cogni-
tive control strategies.
NEUROSENSORY
As the vehicle comes to a stop, the meaning of sensory cues
that guide position sense and motion control once again
shifts. The horizon is definitive and constant, independent
of crew reference frame, and proprioceptive and haptic
cues are once again centrally integrated with visual inputs.
Unlike transitioning from 1 G to 0 G, this is a return to
a more familiar condition. Vestibular input requires time
to normalize as signals must be reinterpreted to different
motion vectors; tilting the head no longer correlates with
translation as it did in weightlessness. Such head move-
ments may be provocative, causing motion illusions and
contributing to frank entry adaptation syndrome, with
nausea and emesis not unlike SAS. Newly returned seated
crewmembers are often seen to splint their necks to avoid
provocative motions, and to limit head rotation while seated
to the yaw axis, which is devoid of tilt inputs. Like SAS, entry
adaptation syndrome is self-limited, typically resolving
18/11/2015 14:13
 350  Space physiology and medicine

within hours, and is amenable to treatment with antiemet-
ics. However, neurovestibular readaptation follows a more
protracted course, correlated directly with the duration of
exposure to weightlessness. Locomotor dysfunction, evident
by a wide somewhat ataxic gait and difficulty cornering, and
postural instability are hallmarks of neural readaptation.
Table 18.8 shows postflight neurological findings associ-
ated with Shuttle flights, assessed retrospectively from flight
surgeon debriefs over an 18 year period (Bacal et al. 2003).
These were present at some time between landing and three
days following return. The vast majority of these resolved
within hours of landing, and most crewmembers were
able to conduct a ‘walk-around’ of their vehicle in the first
hour of landing. However, this gives a sense of the signifi-
cant prevalence of neurological findings in freshly returned
crewmembers. A similar spectrum of neurological findings
and impairments are seen in long-duration crewmembers,
but requiring a longer time period for resolution. Even long-
duration crewmembers are typically able to walk with-
out assistance within a few hours but should avoid undue
motion or terrain challenges.
ORTHOSTATIC INTOLERANCE
Postflight orthostatic intolerance (OI) was noted as a com-
plication of spaceflight from the early manned capsule pro-
grams. Compared with the terrestrial norm, the weightless
adapted state implies hypovolaemia and anaemia as given
conditions. Decreased cardiac mass is observed, although
as noted previously may be owing more to physiological
fluid shifts of weightlessness than to actual cardiac mus-
cle atrophy. Baroreflex sensitivity, which helps to sense an
orthostatic challenge and trigger an appropriate protective
response, is preserved inflight but appears to be degraded
in the immediate postflight period (Hughson et  al. 2012).
Together these factors render freshly returned crewmem-
bers vulnerable to vertical postures and the G-induced
hydrostatic gradient. This can be seen clinically as pre-
syncopal and syncopal symptoms in the first few minutes
to hours following landing and degraded performance on
orthostatic challenge assessments.
Crewmembers have often been assessed postflight for OI
by means of a controlled stand or tilt test. Published results
vary widely owing to differing test parameters among
investigators, such as tilt angle and time duration, as well
as endpoints such as heart rate or blood pressure change,
subjective presyncope, etc. A few things can be said with
certainty. OI in the immediate post-landing period is an
expected consequence of weightless adaptation. Incidence is
higher in those flying long-duration multi-month missions
than short-duration missions (Lee et  al. 2012). Protective
methods such as anti-G garments, thermal management to
avoid peripheral vasodilatation and vascular volume aug-
mentation (orally or intravenously) are proven and should
be applied during landing and postflight. Although efforts
at predicting postflight OI have not been entirely success-
ful, subjects assessed by stand tests can be divided into two
groups based on their adrenergic response. Fritsch-Yelle
and others first demonstrated that those able to complete
a postflight stand test showed a greater reflexive increase
in norepinephrine and vascular resistance than those who
could not (Fritsch-Yelle et al. 1996). Overall, evidence and
prudence dictate that OI must be clinically considered and
accommodated in all returning crewmembers by recovery
teams and mission designers.
PHYSICAL FITNESS
Of the three main entities associated with postflight per-
formance decrements, physical fitness is the most amenable
to enhancement with inflight countermeasures. Otherwise
stated, prediction of postflight performance can be based
on the countermeasures programme available and realized.
Muscle mass and strength loss in the lower extremities have
been well known for decades, and in general show progres-
sive preservation as increased exercise loads have become
available for spacecraft. Early ISS countermeasures were
still associated with volume losses in the range of 10–20 per
cent in the calf and up to 10 per cent in the thigh with cor-
responding losses in strength. These losses have been cur-
tailed considerably with the most recent countermeasures
hardware on ISS, notably with the addition of the ARED

Table 18.8  Post-landing neurological findings among Space Shuttle crewmembers

Percentage % and absolute number (n) of subjects
Symptom (total number subjects assessed) None Mild Moderate Severe Present,
not graded
Clumsiness in movements (410) 31 (128) 53 (214) 12 (50) 2 (7) 3 (11)
Difficulty walking straight line (403) 34 (136) 45 (180) 14 (58) 4 (15) 3 (14)
Persisting sensation aftereffects (324) 40 (130) 30 (98) 4 (12) 1 (3) 25 (81)
Walking vertigo (393) 68 (269) 20 (78) 7 (28) 3 (12) 2 (6)
Standing vertigo (397) 71 (282) 17 (67) 6 (25) 4 (17) 2 (6)
Nausea (346) 85 (295) 6 (22) 5 (16) 1 (5) 2 (8)
Difficulty concentrating (284) 90 (255) 8 (23) 1 (2) 0 (0) 1 (4)
Vomiting (347) 92 (319) 2 (7) 2 (6) 1 (5) 3 (10)
Dry heaves (291) 97 (283) <1 (3) <1 (1) <1 (2) <1 (2)
Blurred vision (396) 98 (389) 1 (4) <1 (1) 0 (0) <1 (2)
Data from flight surgeon observations and assessment, ranked in top-down order of most commonly seen. From Bacal and Billica (2003).

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 Earth return and readaptation  351

(Figure  18.12). Variability in strength loss remains quite
high, and compliance with onboard exercise protocols and
frequent tracking of the loads and repetitions enhances
postflight strength predictions. As shown in Figure  18.10,
aerobic capacity is typically degraded compared with pre-
landing levels, and should be expected to be about 15  per
cent below prelaunch levels. This is driven by the now abso-
lute anaemia and volume depletion coupled with some
degree of work against gravity performed during the post-
flight assessment, and may well involve a neurosensory
component. Practically, even the strength losses and decre-
ment in aerobic capacity in the fairly fit astronaut popula-
tion supports most normal daily activities within a day or
two of landing.
Long-term readaptation and recovery
There is considerable variability and dispersion in recovery
data following spaceflight, so that a thorough time profile of
postflight recovery metrics is still pending. This is particu-
larly true of the longer recovery tissues such as bone and
muscle as well as neurosensory adaptation. The discussion
below should help to describe the processes and bound the
timelines for these systems to provide a general understand-
ing of reconditioning back to Earth’s gravity.
RECOVERY BY SYSTEM
Vascular volume and fluid regulation recover fairly rapidly
following landing and are independent of flight duration
beyond about 10 days. Increased thirst is seen post landing
and fluid intake should be encouraged. Vascular volume is
typically restored to preflight normal within two to three
days, and performance on standardized stand tests show
baseline orthostatic tolerance along with volume repletion.
Crewmembers may benefit from wearing anti-G support
garments during these early days until volume is completely
restored. As red blood cell recovery lags behind volume
repletion, haematocrit will be slightly low in the first several
days. Erythropoietin production will increase by the day
after landing and reticulocytes will follow, with restoration
of red blood cell mass within about six weeks. Iron stores
should be monitored, particularly in females with active
menses who may require supplementation during this time.
Aerobic capacity is typically recovered by about 30 days fol-
lowing long-duration flight, no doubt helped by the near
restoration of preflight volume and red blood cell mass.
Neurosensory readaptation is the clinical entity slow-
est to complete and is directly dependent on time in flight.
For short-duration spaceflights, balance control normalizes
within a two- to four-day period as assessed by posturogra-
phy testing; however, following multi-month space station
missions, two weeks or more may be required to recover
to near preflight levels (Mulavara et al. 2010). Subjectively,
returning crew may sense motion disturbances during nor-
mal activities such as walking, cornering and stair climbing
early on. Eventually these resolve, but with certain abrupt
motions or unusual external cues, transient motion dis-
turbances may recur. For this reason, return to full duty,
including high-performance aviation training, is delayed
for a minimum of 30  days following long-duration flight.
Sensorimotor reconditioning is nicely reviewed by Wood
et al. (2011).
Musculoskeletal recovery is dependent on the degree of
deconditioning based on flight duration, countermeasures
performance and postflight rehabilitation. Early entry into
a reconditioning programme that includes progressive
physical challenges under normal gravity and increasing
exercise loads is standard. Muscle volume typically replen-
ishes faster than strength, associated in part with plasma
volume and tissue fluid repletion. After short-duration
flight, where heavy resistive exercise is not performed,
muscle volume and strength are typically recovered within
about two weeks. Recovery of mass and strength following
long-duration flight is not thoroughly characterized, but

(iRED22; ARED = 26) (BMD iRED = 24; ARED = 11)

0

–5
% Decline

–10
iRED
ARED +T2
–15

–20

–25
th
th

th
th

e
e

nc
nc

ng
ng

ng

ng
ra
ra

tre
tre

tre

re
du
du

st

rs
rs

rs

n
en

or
re

so
so

xo

ns
or

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en
n

fle

ns
te

te
fle

xt
ee
ex

ex
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ke
ee
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Figure 18.12  Strength changes associated with long duration spaceflight, prior to and after the deployment of the
advanced resistive exercise device (ARED). The interim resistive exercise device (iRED) was a predecessor with much lower
loads available. T2 = second generation treadmill.

K17577_C018.indd 351 18/11/2015 14:13

 352  Space physiology and medicine
is probably on the order of four to six weeks for the lower
extremities. Note that upper extremities do not typically see
appreciable loss of mass and strength. Bone recovery is per-
haps the most protracted aspect of readaptation, although
the clinical implications are related to theoretical risk of
fracture rather than performance decrements. In a study
of 45 crewmembers flying four- to six-month missions, the
50 per cent recovery time for bone density of the trochanter,
pelvis, femoral neck, lumbar spine and calcaneus based on
dual X-ray absorptiometry was modelled to be about nine
months (Sibonga et al. 2007). This was prior to the deploy-
ment of the current countermeasures suite, and it is possible
that enhanced onboard loads may improve the rate of recov-
ery beyond the decreased absolute loss.
FUNCTIONAL CAPABILITY
Expectations for functional performance are based on
an extensive experience base with short-duration flight
thanks largely to the US Shuttle programme and smaller
but increasing experience with long multi-month flights.
Following spaceflight of one to two weeks, the vast major-
ity of crewmembers can be expected to walk safely within
minutes to a few hours of landing. During this time a flight
surgeon or other practitioner familiar with space medicine
should be on hand to assess for the major clinical entities
noted above and manage as needed. Even with the high
prevalence of neurosensory findings described, recovery is
rapid. With instructions to avoid abrupt movements, rapid
standing and any heat stress (including hot showers), crew-
members are almost invariably allowed to go home on land-
ing day. Family members are instructed to be vigilant for
OI and neurosensory compromise. Following the landing
day medical assessment, a three-day follow-up health check
is performed to clear crewmembers for standard duty and
activity to include driving and high-performance aviation.
After returning from long-duration missions, a simi-
lar but protracted sequence is seen. Individual variability
is high, with some crewmembers able to ambulate freely
within minutes and others needing to remain recumbent
owing to OI or entry adaptation syndrome. Crewmembers
are typically able to walk with assistance in the first few to
several hours, though must limit abrupt orthostatic chal-
lenges and body movements. In spite of working through
the acute adaptation entities, most long-duration crew-
members are discharged to home with family within one
to three days. Physical activity is advanced as tolerated, but
must be conservative for several days to avoid falls and inju-
ries related to OI or neurosensory disturbances. A greater
reliance on vision is evident by significant degradation of
performance on a standard Romberg’s test for propriocep-
tion and dynamic posturography testing for neurovestibu-
lar adaptation. Both of these are used to track recovery. In
an assessment of postflight functional recovery, Mulavara
compared time and accuracy in completing an ambulatory
obstacle course. On average, long-duration crewmembers
were able to complete the course one day after landing, but
required 48  per cent more time to do so (Mulavara et  al.
K17577_C018.indd 352
2010). It was estimated that recovery to 95 per cent of pre-
flight baseline would require 15 days. This bolsters the prin-
ciple of conservative locomotion and reasonable limits to
postflight physical performance expectations.
SUMMARY
●● Aspects of the space environment that require
crew protection include absence of a breath-
able atmosphere and pressure, harsh ultraviolet
radiation, ionizing radiation, weightlessness, and
acceleration loads associated with dynamic flight
events.
●● The human adapts to weightlessness with a
predictable sequence of physiological changes.
Early effects include neurosensory perturbations
such as space motion sickness, anthropomorphic
changes, and headward fluid shifts.
●● Later and more chronic effects include decrease
in circulating blood volume, atrophy of bone and
muscle, decline in aerobic fitness and strength,
and deeper neurosensory adaptation.
●● With physical countermeasure and adequate
nutrition, weightless-adapted humans function
well for multi-month missions aboard orbiting
platforms.
●● Common clinical issues associated with weight-
lessness and the combined spacecraft environ-
ment include foreign body effects, headache, back
pain, sleep disorders, and a recently described
microgravity ocular syndrome.
●● Return of weightless-adapted humans to Earth is
associated with a readaptation sequence involving
neurosensory perturbations such as entry motion
sickness and locomotor dysfunction, cardiovas-
cular challenges such as orthostatic intolerance,
and relatively lower levels of strength and fitness.
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FURTHER READING
Barratt MR, Pool SL (eds). Principles of Clinical Medicine
for Space Flight. New York: Springer-Verlag, 2008.
Clement G. Fundamentals of Space Medicine, 2nd edn.
New York: Springer-Verlag, 2011.
Johnston RS, Dietlein LF (eds). Biomedical Results from
Skylab. Washington, DC: Scientific and Technical
Information Office, NASA/SP-377, 1977
Stepaniak P, Risin D (eds). Biomedical Results of the Space
Shuttle Program. Washington, DC: Scientific and
Technical Information Office, NASA/SP-2013-607, 2013.
18/11/2015 14:13
 Part     III
Clinical Aviation Medicine

19 International regulation of medical standards 357

Anthony D. B. Evans, Sally Evans and Gwynne Harper
20 Aeromedical risk – A numerical approach 373
Anthony D. B. Evans
21 Cardiovascular disease 385
Gordon Williams
22 Hypertension 421
Edward Nicol
23 Respiratory disease 427
Gary Davies
24 Aviation gastroenterology and hepatology 441
Gareth D. Corbett
25 Metabolic and endocrine disorders 449
Raymond V. Johnston
26 Renal disease 461
Andrew Timperley
27 Haematology 467
Paul L. F. Giangrande
28 Malignant disease 477
Revised by Tania Jagathesan
29 Neurological disease 493
Damian Jenkins and Ralph Gregory
30 Ophthalmology 507
Robert A.H. Scott and Paul Wright
31 Otorhinolaryngology 527
Revised by Saliya Caldera
32 Aviation psychiatry 535
Geoffrey Ewing Reid
33 Orthopaedics and trauma 557
Ian D. Sargeant and Jon M. Kendrew
34 Decompression illness 567
Jane E. Risdall
35 Medication in aircrew 579
Andrew Timperley
36 Aviator fatigue and fatigue countermeasures 583
John A. Caldwell
37 Infectious disease and air travel 601
Andrew D. Green, David Hagen and David W. Mulvaney
38 Human immunodeficiency virus 615
Ewan Hutchison

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 356  Clinical Aviation Medicine

39 Cabin crew health 623

Nigel Dowdall
40 Commercial passenger fitness to fly 631
Michael Bagshaw
41 Military aeromedical evacuation 641
Ian A. Mollan
42 Civilian aeromedical retrieval 649
Geoff Tothill
43 Patient transfer: the critically ill 659
Neil McGuire

K17577_C019.indd 356 17/11/2015 15:54


International regulation of medical standards
ANTHONY D. B. EVANS, SALLY EVANS AND GWYNNE HARPER
Accident rates 357
Framework for regulatory activity of civil aviation 358
Mental health issues 361
Overview of regulatory medical requirements 362
Classes of civil aviation medical certificate 363
Designated medical examiners 363
It is an expectation of most societies that certain aspects
of daily life, such as health, education, safety, security and
the environment, should be maintained at a high stan-
dard, and continue to improve with time. Public transport
is expected to be safe, and perhaps the greatest demands
in this area are reserved for commercial flight operations.
Flight safety or, more accurately, risk reduction to an
acceptable level is achieved in many ways, and a complex
set of rules has developed to ensure that air travel does
not pose an unacceptable risk to society, given that zero
risk is not possible. This chapter will explore the aero-
medical practitioner’s contribution to flight safety. It will
concentrate mainly on aspects that are of relevance to
commercial pilots.
ACCIDENT RATES
The overall risk of air travel can be measured crudely by the
fatal accident rate, a fatal accident being defined as one in
which one or more people are killed. The fatal accident rate
per million flights has been falling over the past 50 years,
due to the industry’s continuing efforts to create an effi-
cient air transport system using modern, reliable technol-
ogy and a regulatory framework designed to ensure certain
minimum standards (Figure 19.1). The main technological
advances over the past half century that have contributed to
the improvement in flight safety are the increasing use of jet
engines, the use of flight simulators for pilot training and
more accurate navigation systems. More recently, increased
K17577_C019.indd 357
19
Licence versus medical certificate 364
Airline medical requirements 365
Requirements for military aircrew 368
References 370
Further reading 371
automation and avoidance systems for terrain and other air-
craft have played a part.
The best safety figures are for passenger-carrying large
jet aircraft: worldwide fatal accident rates for cargo aircraft
are almost six times higher and the fatal accident rate for
turbo-propeller aircraft is about three times greater than
that of jet aircraft, excluding business jet operations (which
have a relatively high fatal accident rate) (UK Civil Aviation
Authority 2008).
For long-distance journeys, the speed of air transport
makes it the preferred mode of travel. When compared with
other modes on a fatality per kilometre basis, air is the safest
means of travel, although occasionally matched by rail trans-
port. However, when calculated in terms of deaths per travel
hours, travel by ferry and by rail may be safer (Table 19.1).
There is a strong correlation between the efficiency of
a country’s economy (e.g. the gross national product) and
achieved safety levels. Local socioeconomic factors ulti-
mately determine acceptable levels of flight safety in each
part of the world, and safety levels vary according to region
(Table 19.2).
Measurement of accident rates
Various methods are used to present aircraft accident
rates. A commonly used index is fatal accidents per mil-
lion departures (flights) (Figure  19.1, Table  19.2). Other
methods are the number of fatalities per 100  million
person-kilometres travelled (person-kilometres = number
357
17/11/2015 15:54
 358  International regulation of medical standards

50 1500
All accident rate
Fatal accident rate
Hull loss accident rate

Annual accident rate (per million departures)

Onboard fatalities
40 1200

Annual onboard fatalities

30 900

20 600

10 300

0 0
60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12

Figure 19.1  Accident rates and onboard fatalities for a major manufacturer, 1959–2011.
Source: Boeing Commercial Aircraft: http://www.boeing.com/news/techissues/pdf/statsum.pdf.

Table 19.1  Death risk for different modes of travel in the that when accidents are rare, a single major accident can
European Union over distance and time for 2001–2002 dramatically affect the calculated accident rate and num-
ber of fatalities for the particular year in which it occurs.
Deaths per 100 million Deaths per 100 million
Taking an average over a number of years is likely to be a
person-kilometres person travel hours
more effective way of assessing trends.
Road (total) 0.95 Road (total) 28
Motorcycle/ 13.8 Motorcycle/ 440 Fatal accident rate per year
moped moped
Foot 6.4 Foot 25 Scheduled airline traffic generally is increasing, which is
Cycle 5.4 Cycle 75 reflected in the increased number of passengers. During
Car 0.7 Car 25 2011, approximately 2.7  billion passengers were car-
Bus and coach 0.07 Bus and coach 2 ried on international and domestic scheduled services
Ferry 0.25 Ferry 8 (International Civil Aviation Organization 2012a), and
Air (civil aviation) 0.035 Air (civil aviation) 16 with an anticipated growth rate of 4.7  per cent this
Rail 0.035 Rail 2 number will more than double during the years 2010–
2030  (International Civil Aviation Organization 2011a).
From European Transport Safety Council, Brussels, Belgium, 2003
(http://www.etsc.eu/wp-content/uploads/2003_transport_safety_
Given this scenario, a continuous reduction in the num-
stats_eu_overview.pdf). ber of fatal accidents per million flights is necessary to
ensure that the number of fatal accidents per year does
not increase.
of persons carried × distance travelled) or per 100  mil-
lion person hours flown (see Table  19.1). There are other
methods and each has advantages and disadvantages. FRAMEWORK FOR REGULATORY
When assessing the relative risk of travel between dif- ACTIVITY OF CIVIL AVIATION
ferent modes of transport and between different airlines,
care must be taken to ensure that like is compared with Chicago Convention
like. For example, a long-haul airline may have a good
record in comparison with a short-haul operator when The current safety regulation framework of the large and
based on accidents or incidents per million flight hours; growing aviation industry dates back to the Second World
however, because accidents/incidents tend to occur more War, when there was rapid development of both air-
frequently at the beginning and end of flights, the former craft technical standards and networks of passenger and
may have a poorer record based on the rate per million freight services. Political questions were raised concern-
flights. Differences in presentation of statistics can also ing the right of airlines registered in one country (state)
account for variations in relative safety levels between dif- to fly through the airspace of another, and with the prac-
ferent transport modes, as seen in Table  19.1. Note also ticalities regarding the maintenance of global navigation

K17577_C019.indd 358 17/11/2015 15:54


Table 19.2  Accident rates for commercial flight departures broken down according to United Nations regions in 2011
UN region Traffic (thousands)
Africa 891
Asia 7561
Europe 7143
Latin America and the Caribbean 2625
North America 10 979
Oceana 855
World 30 053
Note one accident occurred in international waters and is not associated with any region. The “World” total in column 2 (“Traffic”) does not
equal the sum of regional traffic figures as a result of rounding.
a The accident rate is defined by the number of accidents per million departures.
From International Civil Aviation Organization Safety Report 2012. (http://www.icao.int/safety/Documents/ICAO_SGAS_2012_final.pdf.)
facilities, particularly if located in sparsely populated areas
or in non-technologically advanced states. To address such
issues, the government of the USA invited 55  neutral and
allied states to meet in Chicago in 1944; 52 states attended.
The outcome, after five weeks of deliberations, was the
Convention on International Civil Aviation, commonly
known as the Chicago Convention (International Civil
Aviation Organization, 2006). By the start of 2015 a total of
191 contracting states had signed the Chicago Convention,
thereby agreeing to abide by its requirements and automati-
cally becoming members of the International Civil Aviation
Organization (ICAO).
International Civil Aviation Organization
The ICAO was created to promote the safe and orderly
development of civil aviation. A specialized agency of
the United Nations (like the World Health Organization
and the International Maritime Organization), it works
with the Convention’s 191 member states and global avia-
tion organizations to develop international Standards and
Recommended Practices (SARPs), which states reference
when developing their legally enforceable national civil
aviation regulations. The organization serves as the forum
for cooperation in all fields of civil aviation among its mem-
ber states. ICAO is responsible for updating the 19 annexes
of the Chicago Convention, each addressing a particular
aspect of civil aviation (personnel licensing, flight opera-
tions, rules of the air, airworthiness, safe transport of dan-
gerous goods by air, etc.).
STANDARDS AND RECOMMENDED PRACTICES
ICAO Standards and Recommended Practices (SARPs) are
developed by ICAO in accordance with the wishes of its
member states. Consequently, SARPs represent the consen-
sus view of all 191 member states of ICAO and are found in
the 19 annexes to the Chicago Convention.
An ICAO ‘standard’ is defined as a specification ‘recog-
nized as necessary for the safety or regularity of interna-
tional air navigation and to which contracting states will
K17577_C019.indd 359
Framework for regulatory activity of civil aviation  359
Accidents
Number Ratea Fatal accidents
7 7.9 3
22 2.9 3
39 5.5 4
15 5.7 4
38 3.5 0
4 4.7 2
126 4.2 16
conform in accordance with the Convention’. Annex 1  to
the Chicago Convention deals with personnel licensing,
and Chapter 6  of Annex 1  is devoted entirely to medical
aspects. As with other annexes, Annex 1 contains SARPs,
and the medically related SARPs underpin the regulation of
civil aviation medicine practice throughout the world, the
aim being to harmonize the global system. An example of a
medical standard applicable to all classes of medical certifi-
cate is that an ‘applicant shall have no established medical
history or clinical diagnosis of … epilepsy’ (International
Civil Aviation Organization 2011b).
An ICAO standard is mandatory: if a state is unable or
unwilling to comply, it must notify ICAO, thereby ‘filing a
difference’. Other states may, if they wish, refuse permission
for airlines regulated by the non-compliant state to overfly
or land in their territory. In practice, while many differences
have been filed, this rarely occurs.
An ICAO ‘recommended practice’ is defined as any spec-
ification ‘recognized as desirable in the interests of safety,
regularity or efficiency of international air navigation, and
to which contracting states will endeavour to conform’. It
is therefore not mandatory to comply with a recommenda-
tion or to notify any non-compliance to ICAO, although
states are encouraged to do so on a voluntary basis. An
example is the ICAO recommendation for Class 1  appli-
cants that ‘Chest radiography should form part of the ini-
tial examination.’ Some states choose not to impose this
recommendation. Because this is a recommendation and
not a standard, a pilot who has had a medical assessment
(certificate) issued at his/her first issue cannot be refused
entry into another state’s airspace under the terms of the
Chicago Convention if the initial examination does not
include chest radiography. Note that the word ‘shall’ is the
operative verb for a standard, as opposed to ‘should’ in a
recommended practice.
ICAO annexes are not available free of charge, but the
relevant medical provisions are discussed in detail in the
ICAO Manual of Civil Aviation Medicine, which is posted
on the ICAO public website (International Civil Aviation
Organization 2012b).
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 360  International regulation of medical standards
ACCREDITED MEDICAL CONCLUSION AND
FLEXIBILITY
Although the SARPs specified in Annex 1, Chapter 6, pro-
vide useful information for the assessment of medical fit-
ness of pilots, they cannot cover every circumstance that a
designated medical examiner (also called ‘authorized medi-
cal’ or ‘aeromedical’ examiner by some states) or a licensing
authority, is likely to encounter. In some places, the stan-
dards themselves are open to interpretation (e.g. ‘The sys-
tolic and diastolic blood pressures shall be within normal
limits’). Sometimes a particular medical condition is not
mentioned in the SARPs and the examiner has to determine
whether a particular medical problem could, in the words
of Annex 1, ‘render [an] applicant likely to become suddenly
unable either to operate an aircraft safely or to perform
assigned duties safely’ and issue or withhold a medical cer-
tificate as appropriate.
There exists a special procedure for assessing cases where
an ICAO medical standard is not achieved but which may
nevertheless permit a certificate to be issued in an indi-
vidual case. This involves obtaining ‘accredited medical
conclusion’ and applying ‘flexibility’. Accredited medical
conclusion is defined in Annex 1 as the ‘conclusion reached
by one or more medical experts acceptable to the licensing
authority for the purposes of the case concerned, in consul-
tation with flight operations or other experts as necessary’.
The licensing authority (part of the national aviation regula-
tory authority) oversees the training of the required medical
experts. For example, in the UK the licensing authority is
the Civil Aviation Authority (CAA) and in the USA it is the
Federal Aviation Administration (FAA).
If accredited medical conclusion indicates that an indi-
vidual applicant’s failure to meet any medical standard is
not likely to jeopardize flight safety, then a fit assessment
may be made. In reaching such a conclusion, relevant abil-
ity, skill and experience must be considered and the licence
endorsed with any necessary limitations required to protect
flight safety (i.e. ‘flexibility’ can be applied and no ‘differ-
ence’ needs to be filed with ICAO because the ICAO stan-
dards are being followed).
An example is the assessment of a professional pilot
who loses all sight in one eye. An ICAO standard is that
the visual acuity shall be at least 6/9  (20/30) in each eye,
and a pilot with no sight in one eye clearly cannot achieve
this. However, some regulatory authorities, after due con-
sideration of the individual circumstances (which is likely
to involve a practical flight test to ‘demonstrate ability’ to
overcome the potential functional impairment), may con-
sider such applicants to have a sufficiently low risk to per-
mit medical certification. In such cases, the ICAO flexibility
standard can be used to aid decision making.
Annex 1, Paragraph 1.2.4.9, the flexibility standard reads
in full, as follows:
If the Medical Standards prescribed in Chapter 6
for a particular licence are not met, the appro-
priate medical assessment [certificate] shall not
K17577_C019.indd 360
be issued or renewed unless the following con-
ditions are fulfilled:
a) Accredited Medical Conclusion indicates
that in special circumstances the applicant’s
failure to meet any requirement, whether
numerical or otherwise, is such that exercise
of the privileges of the licence applied for is
not likely to jeopardize flight safety;
b) relevant ability, skill and experience of the
applicant and operational conditions have
been given due consideration; and
c) the licence is endorsed with any special limita-
tion or limitations when the safe performance
of the licence holder’s duties is dependent on
compliance with such limitation or limitations.
Accredited medical conclusion in an ophthalmic case will
usually involve a medical officer employed by the licens-
ing authority in consultation with one or more consultant
ophthalmologists, who will between them reach an assess-
ment on future risk to flight safety. If judged ‘acceptable’,
paragraphs (b) and (c) need to be considered before a medi-
cal certificate may be issued. With respect to paragraph
(b), although continued certification might be regarded
as acceptable in an experienced pilot, it might not be con-
sidered so in an applicant embarking on a flying career
and whose lack of operational experience is an additional
flight safety risk in addition to his or her medical condi-
tion. When applying paragraph (c), a limitation permitting
a professional pilot to fly only in multi-pilot aircraft may be
applied to the licence by some licensing authorities.
Such flexibility, which permits applicants to be cer-
tificated who cannot fully meet ICAO standards, can
undoubtedly benefit individual pilots who develop medi-
cal problems, but it has led to variability in the application
of SARPs throughout the world. For example, in the case
of a pilot, or a potential pilot, who has no sight in one eye,
depending on his or her licensing authority he or she may
be refused all further medical certification (following the
ICAO standard), issued a certificate that permits multi-
pilot operations only, or issued a certificate without opera-
tional limitation. This issue is mentioned in the section on
European Union medical requirements.
It is worth noting that the flexibility standard of ICAO
applies only to Chapter 6 (Medical Provisions) of Annex 1.
Such a standard does not feature in any other of the ICAO
Annexes, in recognition of the particular challenges in the
medical field of applying rigid rules across different member
states. For example, the upper age limit for pilots engaged in
international commercial air transport operations is found
in Annex 1, Chapter 2. As the age limit is outside Chapter
6 there is no opportunity to apply flexibility to an individual
who is above the limit, no matter how medically fit he may
be (except for operations within national borders, or if an
agreement is made between individual states that a higher
age limit is acceptable). The upper age limit for pilots is con-
sidered further in Chapter 20.
17/11/2015 15:54

Another point of note is that the flexibility standard can
only be applied to individual cases. In the example above
of sub-standard vision in one eye, the licensing author-
ity that issues a medical certificate to an individual after
applying the requirements of the flexibility standard does
not have to file a difference with ICAO. However, if that
authority chose to routinely certificate all pilots with sub-
standard vision in one eye, without individual assessment
(e.g. a practical flight test), a difference would need to be
filed and another state may refuse entry of such certificated
pilots into its airspace.
The fact that flexibility can be applied to the medical
provisions and the variable interpretation in their applica-
tion may encourage a pilot who has been refused medical
certification by his national regulatory authority to seek a
different one that is more liberal, in an attempt to obtain,
or maintain, his licence. The pilot may be successful in this
search and can then fly quite legally in aircraft registered in
the state that has granted him or her a medical certificate
and also into the airspace of the country that previously
refused such a certificate. Clearly, such ‘medical tourism’
is not an ideal situation and ICAO attempts to minimize
such practice by harmonizing the application of the medical
SARPs as far as possible – a major challenge.
MENTAL HEALTH ISSUES
The ICAO medical SARPs address aspects of both physical
and mental health. However, the emphasis at the routine
periodic medical examination has traditionally been placed
on the former.
In a survey of fatal accidents ascribed to medical causes
during the period between 1980 and 2000 presented at the
Aerospace Medical Association’s annual scientific meeting
in 2003, it was demonstrated that physical incapacitation
rarely featured in medical-cause fatal accidents in multi-
pilot aircraft (Evans 2003). Evans reviewed information
on all fatal accidents that was available to the UK CAA
Accident Analysis Group as part of its Global Fatal Accident
Review (UK Civil Aviation Authority 1998, 2008) and
found 20 fatal accidents that had medically related causes.
Excluding hypoxia and in-flight fire, 15  accidents had a
medical factor. Of these, only one involved a physical cause
(vomiting) and cardiovascular disease was not reported as a
causal or circumstantial factor in any accident.
Mitchell and Lillywhite (2013) utilized similar methods
to extend the survey and found a total of 31 medical-cause
fatal accidents over the 32-year period between 1980  and
2011. They noted that the most common (24 out of 31) causes
were related to psychiatric conditions, including illicit/psy-
chotropic drugs and alcohol, and concluded that undetected
and undeclared psychiatric conditions continue to pose a
policy and regulatory challenge.
Evans and Radcliffe reviewed the incapacitation rate of
airline pilots over a one year period (2004) and found that
in-flight incapacitations were predominantly of psychiatric
cause (Evans & Radcliffe 2012).
K17577_C019.indd 361
Mental health issues  361
Following an incident in which a commercial pilot expe-
rienced a serious in-flight disturbance of mental health, the
Aerospace Medical Association established a working group
to analyze the current requirements for evaluating mental
health. The group found that extensive psychiatric evalua-
tions were not warranted in the routine periodic medical
examination, but that greater attention should be given to
mental health issues by aeromedical examiners (Aerospace
Medical Association 2012).
While cardiovascular disease in the general population
is declining in many countries (British Heart Foundation
2012), the incidence of mental illness, including the prob-
lematic use of psychoactive substances, is on the increase.
Worldwide suicide rates have increased by 60  per cent in
the last 45 years, constituting 1.8 per cent of the total dis-
ease burden in 1998, and are predicted to rise to 2.4 per cent
by 2020. Furthermore, the prevalence of major risk factors,
including depression and alcohol/drug misuse, are more
common than is indicated by the suicide rate alone (World
Health Organization 2012).
Taking into account the shift in epidemiological patterns
and the demonstrated risk to flight safety from impaired
mental health (including illicit drug use and alcohol mis-
use) ICAO amended its SARPs in 2009 to recommend that:
In alternate years, for Class 1 applicants under
40 years of age, the licensing authority should,
at its discretion, allow medical examiners to
omit certain routine examination items related
to the assessment of physical fitness, whilst
increasing the emphasis on health education
and prevention of ill health (International Civil
Aviation Organization 2011b).
The aim was to encourage an applicant/medical examiner
dialogue on aspects of health, both physical and mental, that
were not necessarily causing concern with respect to fitness
to fly at the time of the examination, but which might in the
future develop into a flight safety hazard. In the younger
pilot age group (under 40 years of age), it was felt that flight
safety would benefit in the longer term by such an approach.
This was the first time that preventive medicine was
included in the ICAO SARPs, and questions on men-
tal health were suggested in the ICAO Manual of Civil
Aviation Medicine that could be posed by the designated
medical examiner to help uncover undesirable behaviour
patterns with a view to addressing them prior to the devel-
opment of any serious condition. These were based, as far
as possible, on questions that had been validated as effec-
tive in the general population. ICAO suggests that while
a record that such discussions have taken place should be
indicated on the medical examination form, the detailed
contents need not be forwarded to the licensing author-
ity unless a flight safety concern is discovered. This is to
encourage a more open discussion between the medical
examiner and the applicant (International Civil Aviation
Organization 2012b).
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 362  International regulation of medical standards
An informal review of the 2009 SARP indicated that it
was not being implemented by the great majority of ICAO
member states. To consider the possible reasons for this, in
2014 ICAO convened an international Medical Provisions
Study Group, which noted that the provision was focussed
on health education’s being provided by medical examiners
when other methods may also be suitable, and only Class
1 applicants under 40 years of age were to be considered.
With its reference to different procedures in alternate years,
it was also felt to be a challenge to implement. Nevertheless,
the study group endorsed the importance of health educa-
tion for licence holders and proposed that the provision
be strengthened (to a mandatory standard, from a recom-
mended practice) but that it should apply to all classes of
medical assessment and to all age groups. This proposal will
be considered by ICAO and its member states. Whatever
the outcome, it is hoped that in the future, mental health
issues will continue to receive increasing attention by all
those involved in improving aeromedical flight safety.
OVERVIEW OF REGULATORY MEDICAL
REQUIREMENTS
The dilemma facing the writer of aeromedical policies and
guidelines is to make the requirements sufficiently pre-
scriptive to facilitate consistent decision making and yet to
enable regulatory authorities to exercise flexibility to deal
with individual cases. In addition, medical expertise, treat-
ment and investigation facilities vary greatly throughout
the world. Further, the view of different licensing authori-
ties concerning what is an acceptable level of fitness varies
from state to state, as illustrated by the application, or not,
of the ICAO flexibility standard.
The ICAO has largely succeeded in forming a set of med-
ical SARPs that has worldwide application, because it has
concentrated on writing standards achieved by consensus,
and by permitting flexibility. Most authorities can agree on
international standards, as long as in their own state they
can impose higher standards and additional examinations
or investigations if they wish (and many do). At the other
end of the spectrum, for those states that feel that even the
ICAO standards are too demanding, there is the option of
‘filing a difference’ or, in an individual case, applying the
flexibility standard. Although this has resulted in hetero-
geneous medical requirements throughout the world, the
system has been successful in facilitating international air
transport operations, while minimizing the number of
medically related fatal accidents. This is, however, not due
only to the application of regulations, since airlines them-
selves have a keen interest in promoting safe operations for
commercial reasons. In the past, large airlines, often state-
owned and accounting for most international traffic, set
higher medical requirements for their personnel than the
licensing authority demanded, particularly on recruitment.
More recently the various disability discrimination and
human rights legal constraints now in place have tended to
reduce the differences.
K17577_C019.indd 362
A belief that more stringent medical standards and a
greater number of routine examinations and investigations
than those established by ICAO will result in an increased
level of flight safety is a factor in many states. This view can
be challenged and is discussed below. Further, the incidence
of disease in the general (and flight crew) population var-
ies throughout the world. It may be reasonable for countries
with a high incidence of, for example, diabetes or tuber-
culosis to incorporate additional measures to detect such
conditions. It is known that the prevalence of heart disease
varies from country to country as well as over time (Levi
et al. 2002; British Heart Foundation 2012). A diverse preva-
lence of disease between states will tend to result in hetero-
geneous medical requirements for medical certification.
One reason for the small number of medically related
fatal accidents is that the two-pilot flight deck is relatively
forgiving of pilot incapacitation. In the derivation of the one
per cent rule (see Chapter 20), it was calculated that there
would on average be 1000 in-flight sudden incapacitations
for each fatal accident. On long-range flights, there are often
three or even four pilots, and so there is a further in-built
safety factor should one become unwell. The situation for
single-pilot operations is very different. DeJohn et al. (2006)
concluded: ‘The most important factor that appears to be
responsible for the exceptionally good U.S. airline safety
record associated with in-flight medical incapacitations is
the presence of a second pilot.’
Any incapacitation with only one pilot on board is seri-
ous, and even a slowly developing event that would not be
difficult to contain in a multi-pilot aircraft can be problem-
atic. However, single-pilot operations tend to be of short
duration and to occur within easy reach of a diversion air-
field. Furthermore, the aircraft flown are relatively small
and carry few passengers, and the public seems to have a
greater tolerance of fatal accidents involving small commer-
cial aircraft (and therefore fewer deaths) than those involv-
ing large aircraft. There are, however, relatively few accidents
per year in this category, because the number of hours flown
is low in comparison with those flown by larger aircraft. The
higher accident rate in small aircraft is not, in the main, due
to reasons of medical incapacitation. Typically, as with acci-
dents in larger aircraft, it is due to pilot error; however, with
a single pilot there is no opportunity for a second pilot to
monitor the flight path and correct errors.
Single-pilot public-transport operations tend to utilize
relatively unsophisticated aircraft with simple avionics
compared with large jet airliners. The overall accident rate
due to technical reasons can, therefore, be expected to be
greater when compared to larger aircraft (Federal Aviation
Administration 2011). It may, therefore, be acceptable to
have a greater medical-cause fatal accident rate for such
operations. The ideal situation is for all public-transport
aircraft operations to require two pilots, but this may not
be possible because some are not certified (from an airwor-
thiness viewpoint) to operate in a multi-pilot configura-
tion, and to require two pilots would make some operations
financially unviable.
17/11/2015 15:54

ICAO has recognized in its medical SARPs the safety
benefit of having a second pilot. In 2005  the relevant
Annex 1  standard was changed to allow airline transport
pilot licence holders to continue with an annual medical
examination when aged over 40 years (i.e. the same as for
the under 40s), but only if they are operating in a multi-
pilot flight deck. Previously, such pilots were obliged to
undertake a six-monthly examination when over 40. On the
other hand, for pilots engaged in single-crew commercial
air transport operations carrying passengers, the annual
examination increases to six-monthly (from annual) for
those over 40 years.
As mentioned previously, evidence from fatal accident
reports over more than 30  years indicates that licensing
authorities may have paid insufficient attention to psychiat-
ric illnesses (including problematic use of psychoactive sub-
stances) since, in this time period, there was no recorded
fatal accident in a two-pilot airline operation caused by car-
diovascular incapacitation. It may be argued that the reg-
ulatory system has resulted in this situation, in that those
with an unacceptable cardiovascular risk are discovered
and prevented from flying. However, it is more likely that
the presence of a second pilot on the flight deck is the main
mitigation factor. It is worth noting that training for pilot
incapacitation usually involves the simulation of a sudden
and complete incapacitation, whereas simulation of an inca-
pacitating mental condition, which typically does not occur
suddenly and presents very differently, is rarely practiced.
The lack of incapacitation training for mental conditions
may also contribute to the relatively greater rate of fatal
accidents caused by them.
Airline accidents are well investigated. Since they occur
mainly in large aircraft with monitoring equipment such
as flight-data and cockpit-voice recorders, it is likely that a
physical incapacitation contributing to the accident would
be discovered. On the other hand, there have been many
recorded physical incapacitations in two-pilot aircraft,
including sudden cardiac deaths and seizures, that have not
resulted in an adverse outcome for the flight involved. Two
points are apparent from this. First, sudden (and, indeed,
insidious) incapacitation cannot be prevented in flight
crew. The techniques for discovering cardiac or neurologi-
cal disease in asymptomatic pilots are insufficiently sensi-
tive to predict accurately those who are likely to succumb in
the next 6 or 12 months, and so it is likely that most inca-
pacitations will occur in pilots who have no known medi-
cal problem. Second, as there is no apparent difference in
medical-cause accidents between countries with restric-
tive medical requirements and those with a more liberal
approach, it seems that the mandatory incapacitation train-
ing in two-pilot aircraft is normally adequate to mitigate the
flight safety risk of an in-flight physical incapacity.
During the period 1980–2000, the only recorded fatal
accident in an aircraft over 5700 kg in which physical inca-
pacitation played a part was caused partially by vomiting
in a co-pilot when the captain flew the aircraft into terrain
and it was assumed that the co-pilot was not monitoring the
K17577_C019.indd 363
Classes of civil aviation medical certificate  363
flight profile properly (Evans 2003). However, there have
been several fatal accidents since 1980 in two-pilot opera-
tions when the inappropriate use of drugs or alcohol has
been implicated in the accident, or when suicidal intent of
the pilot has been proven or suspected. The last reported fatal
accidents in a large aircraft having at least two pilots that
cited cardiovascular incapacitation as a contributory cause
that is known to the author occurred in 1972  (Accidents
Investigation Branch 1973).
Although at first it seems that the removal of pilots from
the flight deck because of stringent medical standards might
appear to be beneficial to flight safety, the opposite may also
be the case. There is some evidence that experienced, older
pilots (i.e. those more prone to degenerative disease such as
a cardiac-related illness) are safer pilots than their younger
counterparts, especially those aged below 60 years (Broach
et  al. 2004a,b). If this is the case, then since the majority
of accidents are caused by human error, medically retiring
experienced pilots by the application of stringent standards
may be increasing the accident risk. This possibility should,
at least, be considered when assessing the fitness or other-
wise of experienced professional pilots.
CLASSES OF CIVIL AVIATION MEDICAL
CERTIFICATE
Different medical requirements apply to the various classes
of medical certificate. The ICAO standard for some licence
categories are as follows, together with the periodicity of
routine renewal examinations:
●● Class 1 – Airline transport, commercial and multi-crew
pilot (aeroplane and helicopter): 12 months (6 months
after age 40 years for those engaged in single-crew com-
mercial air transport operations carrying passengers
and for all pilots aged 60 years and over).
●● Class 2 – Private pilot (aeroplane and helicopter), glider
and balloon pilot: 60 months (24 months after age 40). It
is recommended that an annual examination be under-
taken for those over 50 years.
●● Class 3 – Air traffic controller: 48 months (24 months
after age 40). It is recommended that an annual exami-
nation be undertaken for those over 50 years.
For a complete list of licences and their routine periodicity,
refer to ICAO Annex 1 – Personnel Licensing (International
Civil Aviation Organization 2011b).
It can be seen that the most frequent medical examina-
tions apply to professional flight crew. Whereas an annual
medical is required for most professional pilots, for private
pilots the standard requires only a 5-yearly medical for pri-
vate pilots under 40 years, and two-yearly over 40 (with a
recommendation that it is undertaken annually at 50 years
and over).
It would be inconsistent to apply the same requirements
to all licence holders with respect to periodicity of routine
examinations or the required level of medical fitness, since
17/11/2015 15:54
 364  International regulation of medical standards

the regulations in other safety areas vary with the type of Medical certificate refusal
operation undertaken. For example, a private pilot will nor-
mally fly a single-engine aircraft capable of carrying only a Medical certificate refusal by a licensing authority or desig-
small number of passengers (or perhaps none). Compared nated medical examiner is not uncommon. In the majority
with an airliner, the aircraft will be maintained and of cases, the ‘unfit’ assessment is temporary and once recov-
inspected to a lower level of safety, the instruments will be ery has occurred a certificate can be re-issued. However,
less sophisticated and the airspace in which he or she flies, there are situations when it is not possible to quickly return
at much lower speeds, is likely to be less congested. Given a pilot to flying, and he or she may remain unfit for several
that the overall operation of a private flight is conducted to months or longer.
less rigorous flight safety requirements, it is reasonable to The single most common reason for termination of career
accept a lower level of medical scrutiny of the private pilot on medical grounds has, in many countries, been consis-
in comparison to the professional, even though the private tently ascribed to cardiovascular disease, reflecting not only
pilot will more often fly as a single pilot. the high prevalence of such disease that has existed but also
the opportunity, compared with certain other diseases, for
DESIGNATED MEDICAL EXAMINERS detecting pilots at increased risk. The long term unfit data
for the UK in 2001 can be seen in Table 19.3.
While ICAO does not itself designate medical examiners In comparing the common causes of in-flight incapacita-
to undertake medical examinations on licence applicants, tion (Table 19.4) with those of long-term medical certificate
it sets out in the SARPs the requirements for such desig- refusal (see Table  19.3), it will be seen that they are dis-
nation. There are two common methods of administration similar. In the former, gastrointestinal illness can be seen
regarding medical examinations for pilots. The first is a cen- to be the leading cause of in-flight incapacitation, whereas
tralized system, whereby the applicant can attend only one cardiovascular disease is the most frequent cause of career
place for examination, where facilities and trained staff are termination. This is not surprising since most causes of in-
concentrated. Often, this will be associated with a hospi- flight occurrences of gastrointestinal illness are temporary
tal so that any investigations can be undertaken easily and in nature and cannot be predicted from the routine peri-
quickly. It may be run by civilian or military personnel. The odic medical examination. Gastrointestinal disease usually
second system is decentralized, whereby a network of des- occurs relatively slowly, whereas sudden incapacity has tra-
ignated medical examiners carry out the examinations and ditionally been of greatest concern to the licensing author-
forward a report to the licensing authority with the result. ity. As mentioned above, psychiatric illness and problematic
In this system, any investigations are carried out locally. use of psychoactive substances is of increasing concern.
There are variations between these systems, and some states Note that the term ‘incapacitation’ is not used consis-
undertake the initial Class 1 medical examination centrally tently in the literature and while some authors use the word
with later examinations being undertaken by a designated to encompass all types of incapacity, others may use it to
medical examiner. No preference for any particular sys- describe complete incapacitation, reserving the word ‘impair-
tem is indicated by ICAO, but it requires as a standard that ment’ to describe a partial incapacity for an event that allows
‘medical examiners shall have received training in avia- the pilot to continue operating, but in a reduced capacity.
tion medicine’ (International Civil Aviation Organization
2011b). It also requires that they ‘shall have practical knowl- Table 19.3  Causes of long-term unfit assessments in UK
edge and experience of the conditions in which the holders professional pilots, 2001
of licences and ratings carry out their duties’.
% of Average
Primary cause n total age (years)
LICENCE VERSUS MEDICAL CERTIFICATE
Cardiovascular 22 36.1 54
Some confusion exists concerning the terms ‘licence’ Neurological 11 18.0 48
and ‘medical certificate’. This is partly because the ICAO Psychiatric 5 8.2 50
requires only a medical ‘assessment’ be provided when an Diabetes 4 6.6 45
applicant is evaluated as ‘medically fit’ and no mention of Otorhinolaryngological 4 6.6 53
a medical certificate is made. Some contracting states do Neoplasm 3 4.9 47
not issue medical certificates but indicate on the licence Musculoskeletal/ 4 6.6 50
that the appropriate medical standard has been reached. In orthopaedic
these states, a new licence may be issued each time a medi-
Cerebrovascular 2 3.3 55
cal examination is passed. However, other states (probably
Ophthalmological 2 3.3 38
most) do issue a certificate that is attached to the licence and
Gastrointestinal 2 3.3 57
without which the privileges of the licence cannot be exer-
cised. Whichever system is in place, the licence and medical Immunology/allergy 1 1.6 57
certificate/assessment are separate entities, and one is of no Genitourinary 1 1.6 58
operational value without the other. Total 61

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Table 19.4  Causes of incapacitation in airline pilots
Rank (1967) Rank (1987) Condition
1 1 Uncontrolled bowel action
2/3/4 2/3/4 Other gastrointestinal symptoms
5 5 Earache/blocked ear
6 6 Faintness/general weakness
7 7 Headache, including migraine
8 8 Vertigo/disorientation
From Buley (1969) and James and Green (1991).
Insurance companies may ask the licensing author-
ity how long a pilot is likely to be unfit for work. In some
cases there may be little doubt, but in others the decision
is not clear cut. It may be argued that a licensing author-
ity has no mandate to answer this question, since it has
no bearing on flight safety: once a decision of unfitness is
made, the pilot stops flying and flight safety is protected.
The decision on how long a pilot may be unfit may not be
simple, particularly when an unfit assessment is based on
symptoms reported by the pilot (e.g. back pain or tinnitus),
which may vary over time. Licensing authorities handle this
problem in different ways, but it is rare for a permanently
unfit assessment to be made by an authority, and often an
insurance company will have to determine itself, using its
own medical advisers, whether to pay out on a loss-of-
licence insurance request.
AIRLINE MEDICAL REQUIREMENTS
In states where human rights laws allow it (and historically
in most states), airline medical requirements for pilots may
differ from those of a licensing authority, especially at the
recruitment stage. This is because the untrained potential
pilot requires a substantial training investment. Airlines
prepared to make such an investment will demand reassur-
ance that a trainee is unlikely to fail training due to a medi-
cal reason and that the potential pilot has the best chance of
returning a reasonable length of service. The excess of appli-
cants over available places for sponsored training ensures
that applicants with any significant medical history are
likely to be rejected.
The licensing authority, on the other hand, requires only
confirmation that an applicant for a medical certificate will
remain fit for certification for the period of validity of the
certificate (although in recent years more attention has
been given to the longer term fitness of licence holders as
mentioned above). Certain relatively stable medical condi-
tions that are unlikely to deteriorate in the near future may,
therefore, be acceptable to the regulator but unacceptable to
an airline.
Many airlines rely on ex-military pilots, pilots who have
funded their own training or those who have been trained
by other operators. In these cases, where training costs are
less, the medical standards for pilot entry into the airline
K17577_C019.indd 365
Airline medical requirements  365
1967 1987
n (%) n (%)
450 23 336 19
1042 54 950 54
153 8 186 7
120 6 124 7
118 6 109 6
68 3 63 4
may be less exacting, and holding a Class 1 medical certifi-
cate may be sufficient.
The selection criteria that airlines might apply to pilot
applicants may also differ, depending on the supply and
demand of aircrew in the job market. An expanding air-
line and a shortage of pilots may make a medical limitation
acceptable if the alternative is to not operate some services.
European Union Medical requirements
A basic principle of the European Union (EU) is freedom
and fairness of movement and trade for European citi-
zens. The Joint Aviation Authorities (JAA) created require-
ments with the ambition of achieving common high safety
standards that were consistent across Europe. However,
this could only be implemented with a robust European-
wide legal system and there was no underpinning legisla-
tion in place to compel member states to comply with the
requirements set by the JAA. To address this difficulty, in
2003 the European Aviation Safety Agency (EASA), based
in Cologne, Germany, was created to direct and oversee
the development of new rules for the regulation of aviation
safety that would be enacted as EU law. Unlike the Joint
Aviation Requirements (JAR) these EU Regulations apply
directly in all member states of the EU and also in other
European states, known as ‘EASA associated states’ who
have signed formal agreements with EASA.
Rulemaking has progressed in a number of areas during
the decade following the establishment of EASA. Initially
rules were developed for airworthiness, in particular the
certification of new aircraft (which is a task for which EASA
now has direct responsibility). Rules for operations and per-
sonnel, flight crew licensing and medical requirements, were
subsequently developed. Individual member states retain
national responsibility for all operations and licensing tasks.
Medical certification, including appeals against decisions
that have adverse implications for an individual applicant
and the oversight of aeromedical centres and aeromedical
examiners (AMEs) continue to be a member state function.
The overarching principles are that there should be a com-
mon system of medical assessment, a common set of stan-
dards and mutual recognition of medical certificates issued.
Developing European rules for aviation medical cer-
tification is complex not least because healthcare is not a
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 366  International regulation of medical standards
Community competence and most aspects of medical prac-
tice and health legislation are covered by national rather
than European law. There are many differences in medical
education and practice between different European states
and the healthcare systems and cultural practices vary
between countries.
Delegation of authority to a central body, EASA, by
European states presents an interesting situation with
respect to the application of ICAO SARPs. While EASA
provides an overarching framework for regulation in
Europe, the Convention on International Civil Aviation,
written in 1944, recognizes only individual ICAO member
states. This provides challenges to the management of inter-
national regulation at a global level, since only individual
ICAO member states are, under the Chicago Convention,
responsible for the implementation of the ICAO SARPs.
There may be certain circumstances when the EU decides
to enact a requirement in Europe that is at variance with
an ICAO standard and under EU law a European state is
obliged to implement such a requirement. However, under
the Chicago Convention ICAO can only negotiate with the
state, and not with the European Commission or EASA
concerning non-compliance with such an ICAO standard.
A method of dealing with such situations is evolving.
The structure of the rules
The EU took a holistic approach to the creation of rules for
aviation safety in Europe. This meant that the structure
of the rules across the various disciplines had to be con-
sistent and derived from a common stem. The foundation
for the medical requirements is laid out in what is known
as the ‘basic regulation’ (Commission Regulation [EU] No
216/2008). This requires pilots to comply with essential
requirements for pilot licensing (to hold a medical certifi-
cate appropriate for the operation), for aeromedical centres
to be approved and for aeromedical examiners to hold a
certificate. Air traffic control officer licensing requirements
followed a separate process (see below).
The ‘aircrew regulation’ consists of several annexes
(Commission Regulation [EU] No 1178/2011). Annex I
is Part FCL (flight crew licensing) and Annex IV is Part-
MED (medical). Part-MED contains implementing rules
(IRs) that are binding in European law. Acceptable means
of compliance (AMC) with the IRs are published by EASA
to enable member states to comply with the IRs, alterna-
tive means of compliance to be adopted provided that it
meets the IRs and an equivalent level of safety can be dem-
onstrated. Some additional guidance material (GM) is also
published by EASA. An important difference is that the IRs
have to be agreed by comitology (committee procedure)
at the level of the European Commission and Parliament,
whereas acceptable means of compliance and GM can be
agreed and amended by EASA.
The acts required of the national aviation safety regu-
latory authorities, the authority requirements, are defined
in Annex VI of an amendment to the basic regulation, the
K17577_C019.indd 366
‘amending regulation’, which also contains requirements
applicable to aeromedical centres in Annex VII, organ-
isation requirements (Commission Regulation [EU] No
290/2012).
These regulations form part of the total European Union
aviation safety legislation, known collectively and colloqui-
ally as the ‘EASA Regulations’.
The European medical assessment system
An applicant for a medical certificate attends for assess-
ment with an AME. All initial Class 1  applicants are
assessed at an aeromedical centre. Some assessments for
a light aircraft pilot’s licence medical certificate may be
undertaken by a general medical practitioner (see sec-
tion on light aircraft pilot’s licence). All Class 1 (commer-
cial pilot), 2  (private pilot) and some light aircraft pilot’s
licence assessments involve a medical examination. The
regulations require some medical assessment decisions,
mainly Class 1, to be undertaken by a medical assessor in
the licensing authority’s medical section and these cases
are referred to the licensing authority by the AME. Class
2 decisions may be made by the AME ‘in consultation with’
the authority. Some licensing authorities have an advisory
service for AMEs, whereas others issue guidance material
for their AMEs to follow.
LICENSING VERSUS COMPETENT AUTHORITY
The EASA regulations distinguish between the licensing
authority and the competent authority. In this sense ‘com-
petent’ means ‘responsible’. The licensing authority is in the
state where the licence is issued and has responsibility for
the medical fitness of the pilot. The competent authority for
an AME is the one that issued their AME certificate and is
determined by the state in which they have their principal
place of practice.
FLEXIBILITY
The basic regulation states that where medical fitness cannot
be fully demonstrated, if mitigation measures that provide
an equivalent level of flight safety can be applied, a cer-
tificate may nevertheless be issued – a process that reflects
the application of ICAO’s flexibility standard (described
above). This flexibility is enshrined in Part MED and limi-
tations can be applied if an applicant does not fully com-
ply with the requirements for the relevant class of medical
certificate but is considered to be not likely to jeopardize
flight safety. One consequence of permitting flexibility in
this way is that harmonization of decision making in dif-
ferent EU member states is more difficult to assure. This
is balanced by the fact that it ensures each applicant ben-
efits from a decision based on individual assessment and
mitigating factors can be taken into account. In an age
of increasing human rights legislation and with an onus
on regulators to oversee a fair and transparent system of
assessment, flexibility is important, provided flight safety
is maintained.
17/11/2015 15:54

DIFFERENCES BETWEEN JOINT AVIATION
REQUIREMENTS AND EU MEDICAL CERTIFICATION
EU Class 1 medical requirements are similar to the corre-
sponding Class 1 JARs.
EU Class 2  medical requirements are based on ICAO
Class 2  requirements, rather than the JARs. The Class 2
JARs, written in the mid-1990s, were heavily influenced by
the JAA Class 1 requirements that were driven by the need
for a level playing field for commercial pilots. The private
pilot licence with its Class 2 medical certificate was seen as a
stepping stone to a commercial licence, rather than a goal in
itself. The move towards ICAO Class 2 was introduced dur-
ing the drafting of the medical IRs to introduce a risk-based,
proportionate level of certification for private pilots.
The EU requirements introduced the possibility of medi-
cal certification for a pilot taking an anticoagulant or an
anti-depressant, liberalized the refractive error require-
ments and permitted flexibility using the internation-
ally agreed concept of accredited medical conclusion, as
described in ICAO Annex 1.
Instruction for private pilot licence training is possi-
ble under EASA regulations using a private pilot’s licence
rather than a commercial pilot’s licence, so a flight instruc-
tor only requires a Class 2  medical certificate rather than
a Class 1. Instructors are therefore subject to less medical
oversight, in particular much less cardiovascular surveil-
lance, than previously, when a JAR Class 1 medical certifi-
cate was necessary.
MEDICAL CERTIFICATION FOR THE LIGHT AIRCRAFT
PILOT’S LICENCE
The EASA regulations have introduced a new licence for
recreational flying, the light aircraft pilot’s licence for aero-
planes, helicopters, sailplanes or balloons.
The corresponding medical certificate is intended to
reflect the fact that the licence is restricted to the ‘light’
sport end of the aviation spectrum. A medical examina-
tion is required at the initial assessment and at assessments
over the age of 50. In between, recertification is permitted
on the basis of there being no change in the medical history
of the applicant. Although the requirements comply with
the vast majority of ICAO Class 2 standards, the assessment
may be undertaken by either an AME or a general medical
practitioner who has not undertaken training in aviation
medicine, and is thus not qualified (under ICAO SARPs) to
make such an assessment. At the time of writing only the
UK has permitted a general medical practitioner to act as
an AME and has issued alternative means of compliance to
ensure that general medical practitioners are restricted to
the assessment of applicants with uncomplicated medical
histories; applicants with conditions of potential aeromedi-
cal significance have to be assessed by an AME.
AIR TRAFFIC CONTROL OFFICERS
The requirements for European Class 3 medical certification
of air traffic control officers (ATCOs) were developed from
K17577_C019.indd 367
Airline medical requirements  367
ICAO Class 3  SARPs in conjunction with the JAR Class  1
requirements for pilots and published by Eurocontrol in
2003 (http://www.eurocontrol.int/sites/default/files/content/
documents/nm/safety/requirements-for-european-class-3-
medical-certification-of-atcos.pdf). They were subsequently
incorporated into a European Directive for EU member
states to adopt under national legislation. In 2011  EASA
gained competence for ATCO licensing and medical certifi-
cation (http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?
uri=OJ:L:2011:206:0021:0038:EN:PDF) and the imple­ment­
ing rules for EU ATCO medical requirements and acceptable
means of compliance are being developed.
EU CABIN CREW MEDICAL ASSESSMENT
Annex IV of the basic regulations concerns air opera-
tions. It requires cabin crew to be periodically medically
‘assessed’. Part MED contains the cabin crew medical
requirements for a medical certificate report to be issued.
An examination is required at the initial assessment; there-
after the assessment may be history based unless there is an
indication for a clinical examination. The assessment may
be undertaken by an AME, general medical practitioner
or an occupational health medical practitioner if they have
knowledge of aviation medicine as relevant to the cabin
crew working environment.
Non-EU medical requirements
In the EU, medical requirements for flight engineers, flight
navigators, microlights, gyroplanes, research, historic,
military and other state aircraft remain under national
legislation.
REGULATORY PHILOSOPHY
The EU basic regulations state that a crew member on duty
must not be under the influence of psychoactive substances,
alcohol, or unfit due to injury, fatigue, medication or ill-
ness. These categories cover the most important medical
risks to the crew which, in the case of flight crew, present
a direct threat to the safety of the flight. In Europe, public
perception of risk heavily influences the balance of regu-
lation introduced by governments. Although fatal public
transport aviation accidents are rare, when they occur they
often represent a catastrophic failure with a high number of
casualties. This contrasts with road accidents that generally
happen more frequently but with fewer fatalities occurring
in each accident.
Analyses of public transport aviation accidents have
demonstrated the over-representation of drugs and alcohol
as causal or contributory factors. The main causes of gen-
eral aviation accidents are major adverse cardiac events,
undeclared medication, drugs and alcohol. Studies of sud-
den, complete in-flight incapacitation events have shown
that cardiac, neurological and psychiatric diseases are the
most common, whereas gastroenteritis is the most common
cause of impairment while operating. Psychiatric condi-
tions that occur in-flight can present a major risk to flight
17/11/2015 15:54
 368  International regulation of medical standards
safety. These range from a sudden and obvious presentation
of panic disorder, a sudden psychotic episode or flight pho-
bia to much less obvious signs from an underlying depres-
sive or post-traumatic stress disorder.
Aeromedical surveillance is predicated on being able to
screen for conditions that could lead to a future incapacita-
tion and to mitigate any recognized risks whenever possible.
For some conditions there is no known reliable screening
method. Past medical history is recognized as being the best
predictor of future events and aeromedical assessment relies
substantially on the honesty of individuals to report past ill-
ness and new symptoms to the examiner.
An ideal scenario would be for AMEs to be able to access
every applicant’s aeromedical record online and for flight
operations inspectors to access a single global database to
check the current medical fitness status of a pilot. However,
the lack of compatibility of the various electronic systems
around the world and the different attitudes and legislation
on data protection mean that this is unlikely to occur in the
near future, despite the global nature of flight operations.
It is essential to educate pilots about the need for them
to obtain aeromedical advice if they develop any new symp-
tom, are diagnosed with a new medical condition, are
started on a new medication or if a known condition pro-
gresses. Access to this advice is also imperative and knowl-
edgeable and experienced AMEs are an essential part of this
safety system. AMEs are best placed to assess an applicant’s
mental state, and to advise on lifestyle factors such as sun
protection, smoking, alcohol consumption, diet and other
cardiovascular risks that could lead to ill health and be a
risk to continuation of their career in later life. This infor-
mation could be targeted depending on age.
Europe has demonstrated the safety and economic ben-
efits of harmonization and increasingly the trend is likely to
increase cooperation between aviation regulators to achieve
the common goal of maximizing aviation safety.
REQUIREMENTS FOR MILITARY AIRCREW
In most countries, civil aviation licensing authorities
have no jurisdiction over aircraft on the military register.
Furthermore, the medical standards set for commercial avi-
ation aircrew are not always sufficient to satisfy the safety
demands of military operations. For example, military air-
crews are subject to a variety of additional stressors, both in
and out of the cockpit, including:
●● Physiological stresses. The flight envelope of a mili-
tary fast jet is an extreme example of physiological
stress in aviation. However, perhaps more insidi-
ously, military helicopters and transport aircraft are
often more austere than their civilian counterparts,
being noisy and cramped with relatively poor cabin
environmental controls.
●● Aircrew equipment assemblies (AEA). Unlike their
civilian counterparts, military aircraft are rarely a ‘shirt
sleeve’ environment. The layering of AEA can add a
K17577_C019.indd 368
thermal burden and limit mobility, while helmets can
be heavy, even without additional mounted equipment
(such as night vision equipment or helmet-mounted
displays). Operations in contaminated environments
(nuclear, biological or chemical) are uniquely stressful,
with additional thermal, mobility, visual and respira-
tory burdens from the necessary impermeable clothing
and aircrew respirators.
●● Escape systems and evasion. In addition to fitness to
fly, military aircrew are also required to be fit for the
escape system of their aircraft, be it ejection or para-
chute. Personnel operating over water also have to be fit
to use underwater emergency breathing systems. After
successful escape, military aircrews have to be fit to
hide and survive unsupported in austere environments,
including enemy territory.
●● Single-pilot operations. Modern fast jets are increasingly
single-seat, with the pilot responsible for all routine and
emergency duties of flight, plus offensive and defensive
actions and manoeuvres.
●● Unpredictable operations. By their nature and design,
civilian operations are stereotypical, both within a
given flight and from one flight to another. Indeed,
strict adherence to standard operating procedures and
predetermined flight plans is part and parcel of civilian
operations, including written procedures to deal with
both normal operations and the majority of emergency
situations. By contrast, military operations may require
repeat replanning several times before mission execu-
tion and entail rapid and independent decision mak-
ing based on continuously variable input parameters.
Perhaps the ultimate expression of this unpredictability
is aerial combat, but all military platforms are affected
to a greater or lesser degree.
●● Austere basing. Forward operating bases often lack
the comforts of a home station or airfield, with factors
such as field cooking, temporary accommodation and
force protection requirements adding additional stress
to military aircrew. Military helicopters and tactical
transport aircraft may be required to land at unprepared
locations, sometimes under enemy fire.
Militaries have therefore developed separate standards and
regulatory systems to meet their requirements. These differ-
ences are expressed both at recruitment and selection and
once in service.
Initial and periodic medical examinations
Due in part to both their small numbers and the cost and
duration of training, military personnel have to be deploy-
able in as wide a range of military roles as possible. Even a
minor pre-existing medical condition may therefore result
in rejection for military service. However, once in service a
trained military pilot is a valuable asset. Militaries therefore
often have an occupational mechanism to redeploy a limited
pilot while protecting both the individual and employer.
17/11/2015 15:54
 Requirements for military aircrew  369

Table 19.5  UK military initial and in-service tests

Test Recruitment and selection In service (while in a flying appointment)

Lung function testing Yes Annually
Electrocardiography Yes Ages 25, 30
Age 31–39: two-yearly
Age 40–49: Annual
Age >50: six-monthly
Routine blood testing Total cholesterol and HDL Age 40:
HbA1c Total cholesterol and HDL
Haemoglobin HbA1c
Thyroid stimulating hormone
Audiometry Yes At least every two years
Ophthalmic examination Formal refraction Snellen acuity
Accommodation and convergence
Muscle balance
Visual fields
Stereopsis
Corneal topography
Colour perception
Exercise (stress) ECG No Every two years from age 60
Annual age above 65

Examples include transfer from helicopters to fixed wing fitness to fly (A), fitness for ground duties (L), fitness for
aircraft or from solo fast jets to a multi-pilot platform. maritime duties (M) and fitness to operate in particular cli-
As in civilian operations, military medical licensing may matic zones (E). To illustrate, the air (A) categories are given
be centralized to a medical board (acting as the medical in Table 19.6.
assessors), or delegated to military AMEs. The initial and A series of codes are used to qualify the ‘A’ grading to
in-service medical tests to be considered for UK military add detail, for example unfit ejection seat aircraft, unfit solo
flying are summarized in Table 19.5. pilot and fit RPAS flying only are all A3 limitations. At entry,
The smaller number of military aircrew means that an potential pilots need to meet A1 L1 M1 E1 standards.
evidence base for best practice is much slower to accumulate
than in civilian operations. Nonetheless, by benchmarking UK military regulation
against civilian standards and aggregating data between
both different services and other nationalities, military In his 2009 review of the crash of Nimrod XV230, the Hon.
initial and in-service medical standards remain under con- Mr Justice Haddon-Cave made a series of sweeping recom-
stant review and revision. This ensures the risk to flight mendations concerning the regulation of military safety and
safety is minimized while employing the greatest number airworthiness. This resulted in the founding of the Military
of people in the safest manner possible. To illustrate, the UK Aviation Authority (MAA) the following year. The MAA is
abandoned the routine electroencephalogram on selection part of the Ministry of Defence, but lies outside the conven-
in 2004 and significantly reduced the required blood tests tional chain of command. This gives it the necessary inde-
in 2014 (from 23 measured parameters to 3). Corneal refrac- pendence and autonomy to function as the regulator for all
tive surgery is unusual in the usual applicant age group; aspects of flight safety across defence. The MAA regulatory
however, the UK and other militaries now accept candidates document set includes much of significance to aviation
following PRK, LASEK or LASIK subject to additional con-
ditions (e.g. stable refraction and pre-operative ametropia Table 19.6  UK aeromedical employment categories
within –5.00  to +2.00  dioptres in any meridian). Colour Code Applicability Description
perception screening has been with the Ishihara pseudo-
A1 Aircrew Fit for flying duties without
isochromatic plates for many decades, but as with civilian
restriction
aviation, other colour vision testing methods remain under
A2 Fit for flying duties but has
active consideration.
sub-optimal hearing or
Most militaries have an assessment protocol that classi-
eyesight
fies personnel with respect to their medical fitness. In the
A3 Fit for limited flying duties
UK, all three branches of the military use the Joint Medical
Employment Standard, which is a common grading system A4 All personnel Fit to be flown in a passenger
to communicate an individual’s employability and deploy- aircraft
ability to the executive. This system specifically addresses A5 Unfit to be taken into the air

K17577_C019.indd 369 17/11/2015 15:54

 370  International regulation of medical standards

medicine, including medical requirements for aviators and

air traffic controllers, AEA requirements and aircrew avia- SUMMARY
tion medicine currency and training. Also in response to the
Nimrod Report, since April 2011 the MAA has also incor- ●● The lowest aircraft accident rates occur in large
porated the Military Air Accident Investigation Branch passenger-carrying jet aircraft.
(MilAAIB). This joint service investigator is co-located ●● The 1944 Chicago Convention provides the global
with, and fulfills a similar role to, its UK civilian equivalent. legal framework for regulation of aviation safety.
Annex 1 to the Convention sets out the interna-
Setting and monitoring of international tionally agreed medical standards for pilots and
military medical standards other licence holders.
●● The ICAO “flexibility standard” in Annex
There is no military equivalent to ICAO; each nation reserves 1 enables some pilots with a significant medical
the right to set its own standards to meet national require- condition to continue operating internationally
ments. However, in order to facilitate interoperability, share but results in a more heterogeneous implementa-
costs, foster cooperation and further evidence-based prac- tion of ICAO standards across different ICAO
tice, allied forces have formed interoperability agreements. member states, since it is not applied in the same
As an example, the countries in the North Atlantic way by all states.
Treaty Organization (NATO) have a set of standardized ●● Mental health conditions in pilots may be more of
NATO agreements (STANAGs), the medical aspects of a flight safety concern than physical ill health in
which are compiled by a joint, international aeromedical professional pilots operating multi-pilot aircraft.
panel. STANAGs mandate minimum medical standards ●● European Union Law provides the legal basis for
within NATO, allowing the host nation to accept the stan- harmonized regulation of aeromedical require-
dards of a deploying nation. However, if a medical problem ments in the European Union.
develops during the period of detachment, then the host ●● Military operations are more complex, ad hoc
nation’s medical standards and management pathways can and stressful than civilian equivalents. Individual
be applied. It should be noted that STANAGs set only a nations often set their own standards separate
common minimum standard; member states are free to set from civil frameworks.
higher standards as required (and often do so).
Separately, the Air and Space Interoperability Council
Broach D, Joseph KM, Schroeder DJ. Pilot Age and
(ASIC) is responsible for similar international cooperation
Accident Rates. Report 3: An Analysis of Professional
between its member states: Australia, Canada, New Zealand,
Air Transport Pilot Rates by Age. Oklahoma City: Civil
UK and USA. ASIC has an Aerospace Medicine Working
Aerospace Medical Institute 2003a. http://www.faa.
Group made up of representatives for the Surgeon General
gov/library/reports/medical/age60/media/age60_3.
of each of the member nations. Their remit is to maintain
pdf.
‘a focus on all matters concerning aviation medicine such
Broach D, Joseph KM, Schroeder DJ. Pilot Age and
as anthropometrics, aeromedical evacuation, effects of alti-
Accident Rates. Report 4: An Analysis of Professional
tude, breathing oxygen and exposure limits for noise, vibra-
ATP and Commercial Pilot Accident Rates by Age.
tion, heat and cold.’ ASIC publications may be binding (air
Oklahoma City: Civil Aerospace Medical Institute
standards), advisory (advisory publications) or an exchange
2003b. http://www.faa.gov/data_research/research/
of information (information publication).
med_humanfacs/age60/media/age60_4.pdf.
Buley LE. Incidence, causes and results of airline pilot
REFERENCES incapacitation while on duty. Aerospace Medicine
1969; 40: 64–70.
Accidents Investigation Branch. Report of the Public
DeJohn CA, Wolbrink AM, Larcher JG. In-flight medi-
Enquiry into the Causes and Circumstances of the
cal incapacitation and impairment of airline pilots.
Accident near Staines on 18 June 1972. London:
Aviation, Space, and Environmental Medicine 2006; 77:
Her Majesty’s Stationery Office; 1973. Available
1077–9.
from http://www.aaib.gov.uk/cms_resources.
Evans ADB. Medical factors in fatal accidents during
cfm?file=/4-1973%20G-ARPI.pdf. Accessed 5 March
multi-pilot operations 1980–2000. Aviation, Space, and
2015.
Environmental Medicine 2003; 74: 396.
Aerospace Medical Association. Ad hoc working group
Evans S, Radcliffe S-A. The annual incapacitation rate of
on pilot mental health. Pilot mental health: expert
commercial pilots. Aviation, Space, and Environmental
working group recommendations. Aviation, Space, and
Medicine 2012; 83: 42–9.
Environmental Medicine 2012; 83: 1184–5.
Federal Aviation Administration. Advisory Circular:
British Heart Foundation. A Compendium of Health
System Safety Analysis and Assessment for Part 23
Statistics, 2012 edition. London: UK. http://www.bhf.org.uk.
Airplanes. AC No: 23.1309-1E, 17 Nov 2011. Available

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from http://www.faa.gov/documentLibrary/media/
Advisory_Circular/AC%2023.1309-1E.pdf. Accessed 5
March 2015.
James MR, Green R. International Federation of Airline
Pilots Associations in-flight incapacitation survey.
Aviation, Space, and Environmental Medicine 1991; 62:
1068–72.
International Civil Aviation Organization. Doc 7300,
Convention on International Civil Aviation. Montreal,
Canada; 2006. Available from http://www.icao.int/
publications/Pages/doc7300.aspx. Accessed 6 March
2015.
International Civil Aviation Organization. Doc 9956,
Global and Regional 20-Year Forecasts. Montreal,
Canada: ICAO, 2011a.
International Civil Aviation Organization. Annex 1 to the
Convention on International Civil Aviation, 11th edn.
Montreal, Canada: ICAO, 2011b.
International Civil Aviation Organization. Doc 9975,
Annual Report of the Council, 2011. Montreal, Canada:
ICAO, 2012a. Available from http://www.icao.int/
publications/pages/publication.aspx?docnum=9975.
Accessed 6 March 2015.
International Civil Aviation Organization. Manual of Civil
Aviation Medicine. Montreal, Canada: ICAO, 2012b.
Available from http://www.icao.int/publications/pages/
publication.aspx?docnum=8984. Accessed 6 March
2015.
Levi F, Lucchini F, Negri E, La Vecchia C. Trends in mortal-
ity from cardiovascular and cerebrovascular diseases in
Europe and other areas of the world. Heart 2002; 88:
119–24.
Mitchell S, Lillywhite M. Medical cause fatal commercial
air transport accidents: analysis of UK CAA worldwide
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Further reading  371
Sternstein E. Over age 60 airline pilots. Aviation, Space,
and Environmental Medicine 2013; 84: 331.
UK Civil Aviation Authority, 1998. CAP 681, Global Fatal
Accident Review 1980–1996. Available from http://
www.caa.co.uk/docs/33/CAP681.PDF. Accessed 6
March 2015.
UK Civil Aviation Authority, 2008. CAP 780, Aviation
Safety Review 2008. Available from
http://www.caa.co.uk/docs/33/CAP780.pdf. Accessed
6 March 2015.
World Health Organization. Public Health Action for
the Prevention of Suicide: Comprehensive Mental
Health Action Plan 2013–2020. Geneva: World
Health Organization, 2012. http://www.who.int/
mental_health/en.
FURTHER READING
ASIC: http://www.airstandards.org.
Joy M (ed). Introduction and summary of principal
conclusions to the first European workshop in aviation
cardiology. European Heart Journal 1992; 13 (suppl.
H): 1–9.
Peterson S, Peto V, Rayner M. Coronary Heart Disease
Statistics. London: British Heart Foundation, 2003.
The MAA. http://www.maa.mod.uk/index.htm.
NATO STANAG. http://nso.nato.int/nso/nsdd/listpromulg.
html.
The Nimrod review. https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/
229037/1025.pdf.
UK Military aircrew medical standards are published in
AP1269A: http://www.raf.mod.uk/rafcms/mediafiles/
298A6475_5056_A318_A8C5219348FB4F72.pdf.
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Aeromedical risk: A numerical approach
ANTHONY D. B. EVANS
In-flight incapacitation 373
Practical decision making in aeromedical certification 374
The management of aeromedical risk is the cornerstone
of work undertaken by medical examiners designated by
licensing authorities. Most applicants who have passed an
initial medical evaluation will remain fit for many years,
and during this period the work of the examiner is relatively
straightforward. Challenges occur, however, when an appli-
cant’s health deteriorates for some reason, mental or physi-
cal, and the question arises as to whether any restrictions
need to be applied to the licence holder, either temporar-
ily or in the longer term, in order to maintain flight safety
levels. This chapter describes the principles underlying one
method of such decision making.
IN-FLIGHT INCAPACITATION
The primary purpose of aeromedical examinations is to
identify and exclude, temporarily or for longer periods,
those who have an unacceptably increased risk of physical
or mental incapacitation during the relevant period of cer-
tification subsequent to the examination. Episodes of inter-
current illness that may lead to incapacitation are deemed
to be self-regulatory, in that an International Civil Aviation
Organization (ICAO) standard requires of a pilot that they
will not exercise the privileges of their licence if they are
aware of any medical condition that might be a flight safety
hazard (International Civil Aviation Organization 2011).
However, for any illness other than minor self-limiting con-
ditions, formal assessment by, or at least guidelines from, a
specialist in aviation medicine is required before a licence
holder returns to duty.
In-flight incapacitation is defined by the ICAO as ‘any
reduction in medical fitness to a degree or of a nature that
is likely to jeopardize flight safety’ (International Civil
K17577_C020.indd 373
20
References 382
Aviation Organization 2012). It can occur in any pilot of
any age, although the frequency from particular causes is
normally related to the age-specific incidence in the general
population. In-flight incapacitation may be of physical or
mental origin. A study in 1991 revealed that 29 per cent of
airline pilots had experienced at least one such incident dur-
ing their career. The majority of incapacitations are caused
by gastrointestinal symptoms, most of which are caused by
self-limiting minor illnesses, a finding shown to be stable
over time (Table 20.1).
Incapacitations may present suddenly or relatively slowly.
Here is an example of the latter:
Shortly after reaching cruise, I experienced
severe abdominal pains, which soon rendered
me incapable of operating a safe flight. I turned
command over to the first officer and put the
second officer in the first officer’s seat, while I lay
in great pain on the cockpit floor (International
Civil Aviation Organization 2012).
This may be regarded as a ‘typical’ incapacitation, which
happens relatively slowly and represents only a small risk to
flight safety, since control of the aircraft is maintained and
a coordinated handover of control can be effected. Rarely
(and, therefore, unexpectedly) the pilot may collapse sud-
denly at the controls:
The first officer removed the checklist from its
stowage and tried to read it. Although at this
stage she looked normal, she was unable to
read the check list sensibly and uttered what
the commander described as ‘gibberish’. After
373
17/11/2015 15:55
 374  Aeromedical risk: A numerical approach
Table 20.1  Causes of incapacitation in airline pilots
Rank (1967) Rank (1987) Condition
1 1 Uncontrolled bowel action
2/3/4 2/3/4 Other gastrointestinal symptoms
5 5 Earache/blocked ear
6 6 Faintness/general weakness
7 7 Headache, including migraine
8 8 Vertigo/disorientation
From Buley (1969) and James and Green (1991).
a few seconds, she suddenly twisted violently in
her seat and her body went rigid, causing her to
apply a significant amount of rudder, the effect
of which was felt by those in the passenger
cabin (Accidents Investigation Branch 1999).
Both of these examples may be classed as ‘obvious’ incapaci-
tations, in that it was clear to the crew that an incapacitation
had occurred. ‘Subtle’ incapacitation, on the other hand, can
present difficulties in identification. A pilot who has suffered
a heart attack may continue to sit upright, with hands on the
controls and with open eyes, and yet make no further use-
ful control inputs. A subtle incapacitation occurred to the
captain of a McDonnell Douglas DC10 (a three-engine jet
airliner) on the approach to an airport in North America:
Immediately after the hard landing, the captain
was observed by the co-pilot and flight engi-
neer to be incapacitated. The co-pilot took con-
trol of the aeroplane and guided it onto a high
speed taxiway…. The captain was found to have
died of a myocardial infarction (US National
Transportation Safety Board 1987).
Fortunately, the DC10 aircraft has a relatively high nose-up
attitude on approach, such that the main wheels contact the
ground well before the nose wheel, even without any input
from the pilot.
Incapacitation due to physical causes is usually relatively
easy to detect and manage. Mental (also called ‘cognitive’)
incapacitation, however, is often subtle and the affected pilot
may not agree that he or she is incapacitated. It can be defined
as a pilot who is ‘mentally disoriented, mentally unwell or
obstinate, while physically able and vocally responsive,
and yet whose behaviour represents a risk to flight safety’
(International Civil Aviation Organization 2012).
Mental incapacitation may be due to a number of causes,
for example organic brain disease, psychiatric illness,
extreme anxiety, or flying under the influence of drugs or
alcohol. An example follows:
On two occasions, we descended through our
assigned altitude. I was the non-flying pilot and
made all the call outs ... On both occasions, in
K17577_C020.indd 374
1967 1987
n (%) n (%)
450 23 336 19
1042 54 950 54
153 8 186 7
120 6 124 7
118 6 109 6
68 3 63 4
addition to the required call outs, I informed the
handling pilot that we were descending through
our assigned altitude. His corrections were slow
and on one occasion we went 400  feet below,
and on the other, 500 feet below the assigned
altitude. In addition, his airspeed and heading
control were not precise ... (International Civil
Aviation Organization 2012).
It is easy to see the difficulties that mental incapacitation
might entail if incapacitation occurs in a captain who refuses
to accept he or she has a problem and demands that his com-
mands are followed, especially if the first officer is inexperi-
enced or unassertive. In 1982, a co-pilot failed to report his
captain for carrying out an unnecessary 70-degree banked
turn in a McDonnell Douglas DC8  (a four-engine jet air-
liner). The following day, at 164 feet above the ground, on the
approach, the same captain retarded all four thrust levers and
selected reverse thrust on two engines. The aircraft crashed
short of the runway, with the loss of 24 lives. It was discov-
ered later that the pilot was suffering from schizophrenia
(Aircraft Accident Investigation Commission, 1983).
PRACTICAL DECISION MAKING IN
AEROMEDICAL CERTIFICATION
Most airline operations are undertaken with two pilots
and this provides a remarkably effective fail-safe advantage
should one become incapacitated. It may also enable some
pilots who become unfit for solo commercial flying (demand-
ing the lowest medical incapacitation risk) to continue their
career in two-pilot operations. A pilot who has made a good
recovery from a myocardial infarction is likely to have a sta-
tistically increased risk of incapacitation compared with his
or her age-matched peer group but may be permitted to con-
tinue flying, with the limitation (at least in some parts of the
world, such as the European Union and European Aviation
Safety Agency [EASA] associated states) that they fly ‘as or
with a qualified co-pilot only’. This has enabled many pro-
fessional aircrew personnel who have developed a medical
problem to continue their careers in two-pilot operations.
With a lack of good data on which to determine risk, an
examiner, quite reasonably, would tend to err on the side of
caution when faced with a condition whose prognosis was
17/11/2015 15:55
 Practical decision making in aeromedical certification  375

not predictable with accuracy. However, with advances in

medical science many applicants with the same potentially
incapacitating medical conditions can be classified into Overall risk of Risk of pilot
a particular risk group, enabling some relatively low-risk fatal accident failure fatal accident
individuals to continue operating when previously all those = 1 in 107 hours = 1 in 108 hours
with the condition would have been automatically disquali-
Risk of pilot
fied (e.g. myocardial infarction). incapacitation
For a number of common conditions, there is sufficient fatal accident
knowledge of incapacitation on which to base a reasonably = 1 in 109 hours
objective decision with respect to future risk. Objectivity has
the advantages of facilitating consistency of decision making Figure 20.1  Medical incapacitation as a proportion of all-
and enabling audit of past decisions, so that standards can be cause fatal accident risk.
compared and refined more easily. It helps to explain the dif-
ference between an acceptable and unacceptable aeromedi- Acceptable risk in two-pilot operations: the
cal risk when training designated medical examiners and one per cent ‘rule’
it assists with global harmonization of medical standards.
Cardiovascular disease (comprising mainly major adverse
Objective risk assessment cardiac events, coronary heart attacks and strokes),
although not the only cause of sudden incapacity in pilots,
In May 1973, Ian Anderson presented a paper at the 44th is a disease that is amenable to prediction of individual risk
Annual Scientific Meeting of the Aerospace Medical by a licensing authority or aeromedical examiner. Decisions
Association, Las Vegas, drawing on both his experience as made by a licensing authority concerning cardiovascular
senior consultant to the Civil Aviation Medicine Service disease are numerically likely to be the most important in
of Canada and his engineering knowledge concerning the the professional pilot community, thereby having a great
airworthiness requirements of airliners (Anderson 1973). impact on flight safety. For these reasons, such disease has
It was apparent to Anderson that the risk of pilot ‘fail- been afforded much attention.
ure’ could be assessed in a similar way and could provide A cardiovascular mortality rate of 1 in 109 hours is, on
a method of determining, for the first time, an objective average, not achievable for a European male, except perhaps
method of assessing medical fitness. for those in their early twenties. Mortality from coronary
This idea was taken up by the UK CAA, which, in 1982, heart disease and cerebrovascular disease, the main contrib-
convened the first of four cardiological workshops to refine utors to cardiovascular mortality, are given in Table 20.2 for
the concept of risk assessment with respect to cardiovascular England and Wales.
disease in pilots (Joy & Bennett 1984). At that time, the fatal In order to achieve this very low level of risk, two-pilot
accident rate for large jet transport aircraft in the UK was operations are necessary to provide a fail-safe system in the
somewhat greater than 0.2 per million flying hours. This was event of one pilot’s incapacitation. A simulator study indi-
the all-cause rate, including poor weather, engine failure, air- cated that subsequent to pilot incapacitation at a critical
craft system failure, pilot error, etc. For the purpose of assess- part of the flight (takeoff and initial climb, approach and
ing medical risk, a target fatal accident rate was set at no greater
than 0.1 fatal accidents per million flying hours (0.1 in 106 or Table 20.2  Death rates (in accordance with the WHO
1 in 107 flying hours), approximately half the rate at that time. International Classification of Diseases, ICD 10)
Having chosen (no greater than) 1 in 107 as the all-cause per million population by sex and age group, 2010,
target fatal accident rate, the contribution from aeromedical England and Wales.
causes to the overall operational risk that could be regarded
as acceptable remained to be decided. It was felt that the Ischaemic heart Cerebrovascular
flight crew could be viewed in the same way as an aircraft Age diseases (ICD-10: disease (ICD-10:
system, and that no single system should contribute more (years) 120–25) 160–69)
than 10 per cent to the total risk. Risk of pilot ‘failure’ (the Male Female Male Female
sum of the risks of pilot error plus incapacitation), when
15–24 3 1 5 4
treated in the same way as any other system failure, should,
25–34 21 8 13 9
therefore, result in a fatal accident no more often than 1 in
35–44 147 35 48 28
100 million (108) flying hours. Finally, it was felt that medi-
cal incapacitation should account for only a small propor- 45–54 576 128 119 97
tion (10 per cent) of the overall risk of crew failure, accepting 55–64 1597 382 302 207
that human error will comprise the majority. Medical inca- 65–74 3751 1368 1094 801
pacitation, from all medical causes, should therefore cause 75–84 10 217 5264 4510 4237
a fatal accident no more often than 1 in 1000 million (109) Data from UK Office for National Statistics, Mortality Statistics:
flying hours (Figure 20.1). Deaths registered in 2010 (Series DR) Table 8. www.statistics.gov.uk.

K17577_C020.indd 375 17/11/2015 15:55

 376  Aeromedical risk: A numerical approach
landing) the second pilot would take over successfully on
399  occasions out of 400  such events (Chapman 1984). It
was felt that this was probably optimistic for routine opera-
tions, where anticipation of a significant failure (aircraft or
pilot) is likely to be less acute than in the environment asso-
ciated with a simulator check. Taking this into account, it
was assumed that a trained pilot should be able to take over
safely on 99 occasions out of 100 (Bennett 1988).
Stated another way, 1  incapacitation per 100  occurring
at a critical period of the flight could be expected to result
in a fatal accident. Therefore, a second pilot on the flight
deck reduces the risk of any such incapacitation at a critical
period causing a fatal accident by a factor of 100. Further, if
the following is assumed, then only 1 in 10 incapacitation
events during flight has the potential to result in a fatal acci-
dent (those occurring at a critical part of the flight).
●● The critical portions of flight represent 10 per cent of
total flight time (assumed to be approximately one hour).
●● Incapacitations occur randomly during flight.
●● The second pilot safely takes over control on all incapac-
itations occurring outside the critical portions of flight.
In addition, in only 1  in 100  such events will the second
pilot fail to take over safely. As one-tenth of one-hundredth
is one-thousandth, it can be assumed that, on average, only
1 in 1000 pilot incapacitations occurring during a flight of
one hour is likely to cause a fatal accident (Figure 20.2).
As stated previously, the target fatal accident rate from
medical causes was (no greater than) 1 in 109 flying hours. If
airliners were flown by one pilot, this would be an ‘accept-
able’ risk of pilot medical incapacitation, but it cannot be
achieved for cardiovascular disease for males in England
and Wales except perhaps for those in their early twenties.
However, since at least two pilots invariably are required
to operate large aircraft, an incapacitation rate greater
than 1  in 109  flying hours is acceptable for an individual
Critical
period
Take Initial
off climb
Figure 20.2  Critical and non-critical phases of flight with respect to medical incapacitation.
K17577_C020.indd 376
pilot operating such aircraft. In two-pilot aircraft, only
1  in 1000  in-flight incapacitations is anticipated to result
in a fatal accident, so the acceptable risk for a pilot can
be increased by a factor of 1000: from 1  incapacitation in
109 hours to 1 in 106 hours.
Since there are 8760  hours in a year, approximating to
10 000 (104) hours, an incapacitation rate of 1 in 106 hours is
equivalent to a rate of one per cent in 104 hours, or one per
cent per annum (Figure 20.3). This is known as the ‘one per
cent rule’ and forms the basis of aeromedical decision making
in several countries. It is recommended as an acceptable risk
for individual professional pilots by ICAO and was adopted
as guidance by the European Joint Aviation Authorities.
Not all regulatory authorities have adopted one per cent
per annum as the maximum acceptable risk. Some apply
a greater risk (e.g. two per cent per annum), whereas oth-
ers may choose a lower risk for specific medical conditions
that are considered to pose a greater than usual risk to flight
safety (e.g. seizure). Some authorities do not explicitly uti-
lize any form of numerical risk assessment, preferring to use
precedent and expert opinion as the main determinants of
fitness. The ICAO provides guidance on the use of numeri-
cal risk-based aeromedical decision making but does not
include any particular system in its SARPs: the national
licensing authority decides on the method of decision mak-
ing it wishes to adopt.
Applying the one per cent rule
In order to ensure that no individual with an incapacitation
risk of over one per cent per annum operates as a commer-
cial pilot, it is essential that the risk of incapacitation for
various medical conditions and at different ages is known.
Cardiovascular mortality rates (primarily coronary heart
disease and cerebrovascular disease) are well documented
and increase exponentially with age, reaching, for males in
England and Wales, one per cent per annum (approximating
Non-critical Critical
period
App- Landing
roach
1 hour
(average flight time)
17/11/2015 15:55

1 in 106 hours
An incapacitation rate
of 1 in 106 hours is
= 0.01 in 104 hours
= 1/100 in 104 hours
approximately equivalent
= 1% in 104 hours
to a rate of 1% per year
= 1% in 1 year
Figure 20.3  Derivation of one per cent in one year.
to a cardiovascular mortality rate of 10 000 per million) at
approximately 70 years of age (see Table 20.2).
There are marked differences in mortality rates between
different nationalities (British Heart Foundation 2012; Levi
et  al. 2002). Death rates from coronary heart disease and
strokes are falling in most European countries as they are
in the USA, Canada and some Latin American countries
(Rodríguez et al. 2006). However, a common finding is an
increase in mortality of approximately 100-fold between the
ages of 30 and 65 years and a lower overall rate in females.
Currently no formal difference in medical certification
policy applies to females as compared with males. Mortality
rates for professional pilots are likely to be lower than for the
general population (De Stavola et al. 2012).
For a number of states the one per cent rule has provided a
useful objective standard against which to assess the medical
fitness of professional pilots. However, several points have
been raised concerning its use, which are addressed below.
CARDIOVASCULAR MORTALITY RATES DO NOT
NECESSARILY CORRESPOND TO INCAPACITATION
RATES
For licensing authorities, whether a pilot dies from a par-
ticular disease is not an important flight safety issue. More
important is an assessment of the pilot’s risk of becoming
incapacitated during flight and whether that incapacitation
will occur suddenly or insidiously, the former posing a much
greater risk to flight safety, at least with respect to physical
incapacity. A ‘subtle’ incapacitation also poses a greater risk
than an ‘obvious’ incapacitation. As coronary heart attacks
have statistically the greatest likelihood of causing a sudden
incapacity (followed by neurological disease), especially sei-
zures (DeJohn et al. 2004), and because accurate data con-
cerning the risk of incapacitation in the professional pilot
population are not readily available, existing general-popu-
lation data have been applied to this group to assess the risk.
Tunstall-Pedoe (1984) reviewed the data from a study of a
population in the Tower Hamlets area of London and found
the coronary heart attack rate in males aged 55–64 years to
be 2.3 times that of the same cause mortality rate for this
group, indicating the majority who suffer a heart attack do
not immediately die as a consequence. If this group com-
prised pilots, they could suffer incapacitating symptoms but
not appear in the cardiovascular mortality statistics for that
age group. Cardiovascular mortality statistics alone there-
fore underestimate the actual number of major adverse car-
diac events, each one potentially incapacitating.
On the other hand Tunstall-Pedoe also reported that of
those suffering an infarct, about 50 per cent have a history of
conditions, such as insulin-treated diabetes, that normally
K17577_C020.indd 377
Practical decision making in aeromedical certification  377
would exclude a professional pilot from flying. Therefore,
although they may eventually contribute to the cardiovas-
cular mortality statistics, they do not pose a flight safety risk
because these pilots would be taken off flying duties before
they could suffer in-flight incapacity. Further, Tunstall-
Pedoe estimated that 30–50 per cent of heart attacks are not
likely to be immediately incapacitating, and pilots suffering
such an event are likely to be removed from flying duties
after their first cardiac event.
So, although the raw cardiovascular mortality statistics
underestimate the total number of cardiovascular events
in the general population, many of those dying from the
disease would already have been assessed unfit for flying
duties. Tunstall-Pedoe therefore concludes that the gen-
eral-population cardiovascular mortality statistics give an
approximation to the cardiovascular incapacitation rate for
professional pilots.
When considering the incapacitation rates of pilots, it is
also important to note that even if the cardiovascular mor-
tality of a population is reducing, as it is in many states, the
initial cardiovascular event may not necessarily be falling
at the same rate. For example, the mortality rate may be
declining because of improved treatment, such as stent-
ing or by-pass grafting, but the incidence of cardiovascular
events, such as first myocardial infarction or angina onset,
may be unchanged or at least not declining at the same rate.
A 2007 study concluded that approximately half the decline
in US death rates from coronary heart disease between
1980 and 2000 may be attributable to reductions in major
risk factors (Ford et al. 2007).
CARDIOVASCULAR INCAPACITATION IS NOT
CAUSED ONLY BY MYOCARDIAL INFARCTION
Serious cardiac arrhythmias from causes other than cor-
onary artery disease can cause sudden incapacitation.
However, these are not as common as coronary artery dis-
ease as a cause of incapacitation. The other common cause of
sudden cardiovascular incapacitation in the general popula-
tion is stroke, but this is comparatively uncommon in the age
range of airline pilots (i.e. up to age 65 years; see Table 20.2).
The most common potential cause of a sudden cardiovascu-
lar incapacity therefore is coronary artery disease.
PROFESSIONAL PILOTS ARE IN SOCIAL CLASS 1
People in the higher social classes in Europe and North
America have a lower cardiovascular risk than the general
population. It seems that professional pilots live longer than
the general population (Irvine & Davies 1992; Besco et al.
1996; De Stavola et al. 2012). Using general-population data
will therefore tend towards a cautious outcome if used in
aeromedical certification decisions.
CARDIOVASCULAR DISEASE IS NOT THE ONLY
CAUSE OF SUDDEN INCAPACITATION
An International Air Transport Association (IATA) study
documented epileptiform seizures and syncope in addi-
tion to cardiovascular disease as the causes of sudden
17/11/2015 15:55
 378  Aeromedical risk: A numerical approach
incapacitation in 36 000 pilots followed for 10 years. Some
degree of underreporting is likely; however, if taken at face
value, and assuming the pilots were flying 600  hours per
year, these 26  events represent a rate of sudden incapaci-
tation of about 1  in every 10  million flying hours. In this
series, no accident resulted – an expected outcome since
having a second pilot on the flight deck reduces the chance
that an incapacitation will cause a fatal accident by a fac-
tor of 1000 (according to the derivation of the one per cent
rule). Even taking other causes of risk into account, it would
appear from this study that the average pilot has a risk of
sudden incapacitation of less than one per cent per annum
(1 in 106 hours). The study is from a period when coronary
heart disease in the United Kingdom was more prevalent
than today: the age-standardized coronary heart disease
death rate per 100 000 population in men in the United
Kingdom was 380  in 1980  and 114  in 2010  (British Heart
Foundation 2012), a remarkable reduction due mainly to
reduced prevalence of smoking, treatment of risk factors
and improved primary treatment of cardiovascular disease.
A survey of all types of in-flight incapacitations in UK
airline pilots over the 10-year period 1990–99 found an inci-
dence of 127 such events, but only 20 were ‘serious’, that is,
resulting in loss of consciousness or inability to contribute to
the flight operation for a prolonged period (Evans 2002). Two
of the serious events were of cardiac origin (both resulted in
in-flight death) and four were neurological (including two
seizures). Most of the other events were due to gastrointesti-
nal upset, which, although ‘serious’, did not occur suddenly.
A similar record of such incidents was reported by Mitchell
for 2000–2005  in which there were 145  incapacitations,
with three being cardiovascular and five neurological. Over
60 per cent were gastrointestinal (Mitchell 2007).
Although the one per cent rule was initially developed
for cardiovascular risk assessment, a number of regulatory
authorities have been applying a similar risk assessment pro-
cess for other diseases for more than two decades. It would
appear that this approach has been justified in terms of the
number of incapacitations actually observed, although to
demonstrate this statistically is a challenge.
THE ONE PER CENT RULE MAY BE TOO RESTRICTIVE
The one per cent rule has proved to be useful over the years,
but some have claimed it is too restrictive. This argument
maintains that if the maximum acceptable risk for an indi-
vidual is capped at one per cent per annum, then the average
risk of incapacitation for the whole pilot population must be
less than this, on the order of 0.1 per cent per annum (1 in
107 hours). The addition of a second pilot reduces the risk by
a factor of 1000. So one might expect, on average, a medical-
cause fatal accident rate of less than 1 in 1010 flying hours
in two-pilot operations (i.e. at least 10 times lower than the
target rate of 1 in 109 hours).
This argument has merit if the risk assessment is consid-
ered per one million flight hours rather than per individual
flight. If, in a cohort of 10 000 pilots, each flying 500 hours
per year, one has a high risk of incapacitation, say 10  per
K17577_C020.indd 378
cent per annum, and the remaining 9999 have an average
risk of 0.1  per cent per annum (this is not a realistic sce-
nario, but it illustrates the point), then the overall decrease
in in-flight safety (i.e. the additional risk per million flying
hours because of the ‘unfit’ pilot) is insignificant.
However, for each individual flight that the ‘unfit’ pilot
operates as the handling pilot, the risk is increased com-
pared with those operated by an average crew (by a factor of
100, the difference between 0.1 and 10 per cent per annum).
The risk per one-hour flight of a fatal accident during such
a flight is increased from 1 in 1010 to 1 in 108. A risk of 1 in
108 is greater by a factor of 10 than the acceptable medical-
cause fatality rate as calculated in the derivation of the one
per cent rule. Since airworthiness risks are considered in
terms of failure rates per hour of flight, for comparison
purposes it is helpful if incapacitation rates also use this
measure (European Aviation Safety Agency 2013; Federal
Aviation Administration 2011). This was the approach taken
in the derivation of the one per cent rule.
ONLY SUDDEN INCAPACITY IS TAKEN INTO
ACCOUNT IN THE ONE PER CENT RULE
The analysis of risk and derivation of the one per cent rule
assumes that an incapacitation that occurs slowly or during
a non-critical portion of flight is inconsequential for flight
safety, but this is probably unrealistic. Gastrointestinal ill-
ness is the most common cause of in-flight incapacitation
(see Table  20.1), but it rarely causes a serious flight safety
problem because it occurs slowly. However, the reduction in
experience and absence of crew monitoring on the flight deck
caused by the loss of function of one crew member clearly may
affect flight safety for the remainder of the flight – but it is dif-
ficult to quantify by how much. It is challenging to regulate
for gastrointestinal illness because such illness is unpredict-
able, and the main responsibility is usually left to the airlines
in terms of flight crew education in preventive hygiene mea-
sures and with the aircrew to follow the advice given.
Mental incapacitation from psychiatric illness represents
a clear and important risk to flight safety, which like gastro-
intestinal illness is challenging to quantify in terms of aero-
medical risk to flight safety. Although the onset of episodes
of overt psychiatric illness is normally measured in hours
or days, the presentation of symptoms that represent a risk
to flight safety may occur within the time period of a single
flight. A short section on mental health issues is provided
in Chapter 19.
FLIGHTS, ON AVERAGE, LAST FOR MORE THAN
ONE HOUR
The average flight time is increasing. In UK airline opera-
tions, by 2011  the average flight stage (takeoff to landing)
was 2.6 hours (UK Civil Aviation Authority 2011) compared
with 1.42 hours in 1983, a reflection of improved technol-
ogy allowing aircraft to stay airborne for increasingly long
periods. In the derivation of the one per cent rule, it was
assumed that flights lasted one hour on average. Since the
critical periods for physical incapacity are at the beginning
17/11/2015 15:55

and end of a flight, longer sectors are beneficial to safety
with respect to the risk of medical-cause accidents. Note
that although statistics often refer to ‘flight time’, what is
actually recorded is ‘block time’ (i.e. ‘chock to chock’), so
the figures include a proportion of time spent taxiing before
takeoff and after landing. This is why the term ‘flight stage’
is sometimes used, to account only for the time between
takeoff and landing. If the one per cent rule was derived
today, using a flight time (or strictly speaking flight stage) of
two hours instead of one, then an acceptable risk of two per
cent per annum would be derived (Mitchell & Evans 2004).
At least one licensing authority of a major ICAO member
state currently uses two per cent as its risk limit.
A CRITICAL PERIOD OF THREE MINUTES AT THE
BEGINNING AND END OF A FLIGHT IS TOO LONG
Modern aircraft have improved performance and sophis-
ticated autopilots, which may mean that three minutes is
too long a period to be assumed ‘critical’. The Commercial
Aviation Safety Team and the International Civil Aviation
Organization define the takeoff and initial climb phases to
last until an elevation of 1000  feet (or below in some cir-
cumstances) is reached and the final approach to commence
at the final approach fix, likely to be between 1000  and
1500  feet above runway elevation (Commercial Aviation
Safety Team 2013). The time taken to reach such a height
from the start of the takeoff roll or between passing the final
approach fix to the end of the landing roll is likely to be less
than three minutes. Mitchell and Evans (2004) argued that
the critical periods in a flight could be reduced from six to
four minutes per flight, and that a one per cent rule in con-
sequence would be too conservative
MODERN AIRCRAFT ARE EASIER TO FLY
In a study carried out in the 1980s, it was found that
399 incapacitations out of 400 that occurred in a simulator
during a critical flight phase were handled safely by the crew
(Chapman 1984). In the derivation of the one per cent rule
it was assumed that in actual flight operations 1 incapacita-
tion out of 100  that occurred in the critical period would
result in a fatal accident. Modern airliners are probably eas-
ier to fly single-handed and are more forgiving of mistakes,
the most modern airliners having protection devices that
prevent certain pilot inputs likely to jeopardize flight safety.
The assumption that 1 incapacitation out of 100 would result
in a fatal accident may, therefore, be pessimistic. Although
plausible, this has yet to be demonstrated in an up-to-date
simulator study.
Statistical uncertainties
Although it is possible to derive an acceptable objective risk
using assumptions as outlined above, human performance
and medical illness are often not easy to analyze statisti-
cally. Psychiatric illness is probably the most difficult to
assess objectively and is more likely than physical illness to
lead to subtle incapacitation.
K17577_C020.indd 379
Practical decision making in aeromedical certification  379
As more medical data become available, objective risk
assessments may be refined. Already introduced by one
licensing authority is the use of a cardiovascular risk evalu-
ation based on allocating points for various risk factors,
including age, sex, blood pressure and blood cholesterol
level. Pilots whose total points exceed a certain value would
be subjected to further testing, such as an exercise ECG.
POLYMORPHIC RISK
Polymorphic (absolute) risk is the sum of separate, lesser
single risks, each known as an attributable risk. The one per
cent rule has tended to be used in the context of determin-
ing whether an attributable risk (e.g. cardiovascular risk)
is acceptable for medical certification. It has been argued
that a pilot with a single medical problem, such as success-
fully treated single-vessel coronary disease (an attributable
risk), may fall within the acceptable risk of a future event
to continue flying, but if he or she also has diabetes (also
an attributable risk) controlled by diet, then the total (poly-
morphic) risk may be above the acceptable threshold. For
two-pilot operations, with their greatly increased safety
margins when compared with single-pilot operations, con-
centrating on the most important single attributable risk
may be acceptable when reaching an aeromedical decision
on certification. However, for single-pilot operations, more
attention should probably be given to polymorphic risk,
since single-pilot flights are critically disadvantaged in the
event of an incapacity (Chamberlain 1999).
Age is an important attributable risk. A disease that
might be acceptable in a young person may not be accept-
able in an older pilot. The effect of age is particularly
important in pilots engaged in aerial work, such as flying
instruction, where there are no age limits and the activity
is usually undertaken in small aircraft with only one pilot.
Upper age limit for pilots
The upper age limit for pilots is a controversial area of regu-
lation. When ICAO was established in 1944  there was no
upper age limit for any class of medical assessment included
in Annex 1. In 1963 an upper age limit was introduced by
ICAO, shortly after the establishment by the US Federal
Aviation Administration of 60 years as the upper limit for
pilots in command (PICs) and co-pilots. The International
Air Transport Association also recommended that its mem-
ber airlines adopt these requirements. However, ICAO
introduced a limit for PICs only – as a recommendation.
Co-pilots remained unrestricted.
In 1978  the situation changed when the ICAO limit of
60  years became a standard, i.e. mandatory, for PICs and
was introduced as a recommended practice for co-pilots.
This was the situation until 2006, when the limit was raised
to 65 years, for PICs and co-pilots, the limit remaining as
a standard for the former and a recommended practice for
the latter. However, only one pilot over age 60 was allowed
at the controls simultaneously, the so-called ‘one over one
under’ rule. In addition, the limit remained at 60 years for
17/11/2015 15:55
 380  Aeromedical risk: A numerical approach
single-pilot operations to take into account the increased
risk to flight safety in the event of incapacitation of a pilot
in a single-pilot operation. These limits apply only to those
engaged in international commercial air transport opera-
tions. No upper age limits apply to any other types of opera-
tion, commercial or private, or for air traffic controllers.
In 2014 the 'one over one under' rule was removed by
ICAO and the co-pilot limit was amended from a recom-
mended practice to a standard, thereby mandating for both
the PIC and the co-pilot an upper age limit of 65 years.
Since 2014, therefore, a combination of two 60- to 64-year-
old pilots at the controls has been permitted (International
Civil Aviation Organization 2011).
The upper age limit is important (and often controver-
sial) for a number of reasons:
●● A PIC and (since 2014) a co-pilot above the ICAO limit
in ICAO Annex 1 cannot operate into another state’s air-
space without first obtaining permission from that state.
●● Risk of incapacitation increases with age.
●● Pilot performance declines with increasing age.
●● Increasing the upper age limit delays promotion to
captain for co-pilots.
●● Many professional pilots would choose to continue to
operate, if possible, after the current limit is reached.
From an aeromedical viewpoint, the two main issues con-
cern the risk of incapacitation and performance degradation.
RISK OF INCAPACITATION WITH INCREASING AGE
In the general population the risk of suffering a medical
incapacitation increases with age. This risk in professional
pilots follows a similar trend (DeJohn et al. 2004; Evans &
Radcliffe 2012). General population physical incapacitation
rates demonstrate a much steeper increase with increasing
age than do mental incapacitation such as depression or use
of psychoactive substances.
The population cardiovascular mortality rate reaches
1  per cent per annum in males aged about 70  years in
England and Wales (see Table  20.2) and Tunstall-Pedoe
argued that the cardiovascular mortality rate approximates
to the cardiovascular incapacitation rate (Tunstall-Pedoe
1984). Further, using current general population data and
incapacitation rates in the professional pilot population in
the UK, it can be observed that the all-cause mortality rate
in the UK approximates the observed all-cause incapacita-
tion rate in professional pilots (Evans & Radcliffe 2012). As
the incapacitation rate continues to increase with increasing
age there comes an age, for all individuals, at which the risk
will become too great for continued operations. Individuals
will face this situation at different chronological ages, due to
biological variation.
Regarding the risk of double incapacitation, if two pilots
each have an incapacitation risk of one per cent per annum
(one in 106 hours), then the risk of a double incapacitation
in one hour is one in 106 × 106, which is one in 1012 hours, a
figure that may be discounted as insignificant.
K17577_C020.indd 380
While somewhat arbitrary, the current limit of
65  years therefore does have some basis in science, and is
socially acceptable.
It has been demonstrated over time that such a limit
appears satisfactory with respect to incapacitation risk and
at this stage it would be a challenge for ICAO to achieve
global consensus to increase the retirement age to a figure
above 65 years. The Aerospace Medical Association (2004)
has proposed to abandon the upper age limit completely.
However, to do this with confidence requires that medi-
cal examination techniques have sufficient sensitivity and
specificity to reliably detect the inevitably increasing num-
ber of pilots who will fall below the fitness level required
for commercial operations as they get older. It is not certain
that such confidence is as yet well founded. For example it
is difficult to accurately predict the initial onset of atrial
fibrillation, seizures, strokes and early dementia, four
important medical conditions that are more common in the
ageing population.
RISK OF PERFORMANCE DECREMENT AND
INCREASING AGE
As the risk of incapacitation inevitably increases with
increasing age, so does the risk of performance degrada-
tion. Again, individual variation may be observed with
respect to the rate of decline (Glisky 2007). Reaction time is
adversely affected, although this may not be of great signifi-
cance in the modern flight deck where most (although not
all) emergency situations demand a teamwork approach to
any required action and do not need an immediate control
input or decision.
A survey undertaken by IATA of nine international
airlines found that none had any major performance con-
cerns with pilots aged between 60 and 64 years. While there
were some significant differences recorded in performance
between those approaching 60  years and those over 60,
these were considered operationally insignificant and the
overall performance was well above the required minimum.
The operators were satisfied that if a pilot was having dif-
ficulty he/she would be identified during routine simulator
checks and operational checks (International Civil Aviation
Organization 2013).
The results from one large airline are illustrative and are
shown in Figure 20.4. The airline assessed pilots in four per-
formance areas both in the simulator and during routine
line operations under the following four performance cat-
egories: Crew Resource and Threat and Error Management;
Automation Proficiency; Policy and Procedural Compliance;
and Stick and Rudder Skills. Performance was plotted
against the age ranges of 49 years and under, 50 to 60 years
and more than 60 years (up to age 65 years). No operationally
important differences were observed between those above
and below 60 years of age.
The checks an airline pilot undergoes may be more effi-
cient at identifying those individuals whose performance is
approaching, or has fallen below, an acceptable level, when
compared to medical checks designed to detect those whose
17/11/2015 15:55
 Practical decision making in aeromedical certification  381

CRM/TEM Grades by Age Group

Automation Grades by Age Group
80
100
70 90

60 80
70
50
Percentage

Percentage
60
40 50
30 40
30
20
20
10
10
0 0
49 50 60 49 50 60 49 50 60 49 50 60 49 50 60 Age 49 50 60 49 50 60 49 50 60 49 50 60 Age
Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus
60 60 60 60 60 60 60 60 60
1 2 3 4 5 Grade 1 2 3 4 Grade

Policy/Procedure Grades by Age Group Stick and Rudder Grades by Age Group

100 80
90
70
80
60
70
Percentage

Percentage
60 50
50 40
40
30
30
20
20
10 10

0 0
49 50 60 49 50 60 49 50 60 49 50 60 Age 49 50 60 49 50 60 49 50 60 49 50 60 49 50 60 Age
Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus Less to Plus
60 60 60 60 60 60 60 60 60
1 2 3 4 Grade 1 2 3 4 5 Grade

Figure 20.4  Performance of airline pilots in a large airline during simulator and operational checks for the following age
groups: 49 and under, 50 to 60 and over 60 years. Grades 3-5 are regarded as ‘satisfactory’. Automation and Policy/
Procedure checks are only assessed to grade 4. CRM/TEM, Crew resource management/threat and error management.
From Sternstein 2013.

incapacitation risk is too high. However, as with medical no longer provides a barrier for international commercial
examinations little analysis has been undertaken to con- operations, ‘failure’ would need to be seen as a more normal
sider just how effective the process is in identifying indi- end point for a pilot’s career than it is at present.
viduals whose performance is slowly deteriorating below an
acceptable minimum.
It appears that current achieved safety levels are for the SUMMARY
most part acceptable, although ICAO, national regula-
tors and airlines strive for even better results year on year. ●● The determination of future aeromedical risk
However, if the upper age limit were to be abandoned with- to flight safety in licence holders is both a major
out adequate consideration of the consequences, safety challenge and an important component of the
margins could be eroded. In an ageing pilot population the aeromedical assessment process.
ability of medical examinations and performance checks to ●● Safety margins must be maintained, yet any fit-
accurately identify those pilots slipping below an acceptable ness decision should also be fair to the individual.
level of performance, or developing an unacceptably high ●● A numerical approach to risk assessment is one
incapacitation risk becomes critical. It remains to be dem- method that is recommended by ICAO and has
onstrated if adequate tools are yet available to identify ‘at been adopted by a number of states.
risk’ individuals with sufficient accuracy to ensure that cur- ●● Some states do not utilize a numerical risk
rent safety levels are maintained. assessment, and it is not very suitable for mental
One other aspect that is rarely mentioned is that if the (including behavioural) diseases.
upper age limit were to be abandoned, a potential exists ●● Lack of data on the condition under review may
for all pilot’s careers to end in a ‘failure’: a failed medical make an objective risk assessment a challenging task.
assessment, a failed simulator or line check. If the age limit

K17577_C020.indd 381 17/11/2015 15:55

 382  Aeromedical risk: A numerical approach
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K17577_C020.indd 384 17/11/2015 15:55

Cardiovascular disease
GORDON WILLIAMS
Introduction 385
The initial issue of medical certification 386
Cardiological aspects of the medical renewal 390
Coronary artery disease 390
The cardiomyopathies 393
Valve disease 396
Pulmonary hypertension 397
Cardiac rhythms 398
Bradycardias 402
Atrio-ventricular block 402
Cardiac pacing 403
Syncope 403
Coronary artery surgery 403
Cardiac valve surgery 404
Endocarditis 405
INTRODUCTION
Whilst the fundamentals of cardiology remain largely
unchanged, there has been recent rapid advancement in the
understanding of underlying mechanisms of cardiac disor-
ders. This particularly applies to cardiac arrhythmias and
to cardiomyopathies, aiding recognition of those at risk.
The rate of advancement, particularly of the genetic basis
of these conditions, has resulted, since the previous edition
of this text book, in the appointment in many of the larger
cardiac centres of Cardiologists with a speciality interest of
‘Inherited Cardiac Disease’.
Genetic mutations can result in fundamental defects, e.g.
affecting cell membrane ion transfer pathways, this being
one of the substrates for arrhythmias. This type of pathol-
ogy is referred to as ‘the channelopathies’ and is recognized
to underlie the mechanisms involved in some instances of
sudden cardiac death. Inherited functional abnormalities
are progressively being recognized to be the basis of vari-
ous types of cardiomyopathy. For these reasons, the aviation
K17577_C021.indd 385
21
Pericardial disease 405
Myocarditis 406
ECG interpretation – normal values 408
Cardiological diagnostics 409
Echocardiography 412
Stress echocardiography 413
Myocardial perfusion imaging 413
Cardiac CT 415
Cardiac magnetic resonance imaging (CMR or
cardiac MRI) 416
Diagnostic coronary angiography 417
Percutaneous coronary intervention (PCI) 419
Further assessment of coronary lesions by debatable
severity 419
Further reading 420
medical examiner has to pay particular attention to a detailed
clinical history both of the individual and of the family.
Current applications for aviation medical certification
now incorporate those who have undergone corrective
surgery for congenital heart defects. Although relatively
uncommon their frequency is increasing, with several con-
ditions in principle being licence compatible, depending on
the individual’s clinical circumstance.
Many medications previously thought safe are now known
to adversely affect ventricular repolarization leading to high
risks of arrhythmias. Any form of prescriptive or ‘over the
counter’ medication is an essential component of the clinical
history. Sporting and athletic pursuits equally are important
to document, particularly for ECG interpretation.
Modern cardiology enjoys sophisticated diagnostic imag-
ing modalities. These are essential to current cardiology. For
the aviation medical examiner, after a clinical examination,
the resting ECG forms a major component of the applicant’s
suitability for flying duties. Therefore, the normal and abnor-
mal ECG is described in some detail. Avoidance of technical
385
18/11/2015 14:14
 386  Cardiovascular disease
errors saves pilots considerable stress and often non-refund-
able expense, with alternatively accurate high-quality ECGs
often detecting problems at an early stage.
Investigations not within the control of the aviation
medical examiner but undertaken within Cardiology are
described in a separate section of this chapter in terms of
their appropriate application and expected usefulness for
resolving specific issues.
In the text for each disorder, the suitability for con-
tinuing or temporarily suspending flying duties is made.
However, decisions may vary, dependent upon individual
circumstances, investigation results and continuing regu-
latory changes. Hence, the United Kingdom Civil Aviation
Authority make available to medical examiners (and to
pilots) flow charts for most cardiac conditions outlining the
investigations required and licensing alternatives. These are
obtainable from www.caa.co.uk/flow charts and are recom-
mended to be used as supportive guides to this text book.
Finally, most practising physicians working as aviation
practitioners may not wish to seek the minute detail of pub-
lished research papers on any specific topic, but may wish
to obtain a current review. Hence, the bibliography of refer-
ences has been limited to ‘suggested further reading’, these
articles providing the relevant references for the work upon
which they are based.
The sequence of presentation through this chapter fol-
lows the presentation and progress of cardiac disorders
through life, covering the aspects of cardiology the avia-
tion medical practitioner will encounter within the pilot
population with guidance on disorders, their management
and regulatory requirements. Individual variability within
some conditions may require an aeromedical section review
for certification and some opinion expressed is that of the
author and not necessarily of the authority.
THE INITIAL ISSUE OF MEDICAL
CERTIFICATION
Cardiological aspects
CLINICAL HISTORY
The majority of applicants for aviation medical examiner are
young, well, and asymptomatic with no previous cardiological
history and are not taking any prescriptive medications. Even
so, the progressive recent understanding of inherited cardiac
disorders has been such that a more detailed clinical history,
including that of ‘the family’, for cardiac events is now essential.
An additional change to current applications now incor-
porates those who have undergone corrective surgery for
congenital heart defects. Although relatively uncommon,
their frequency is increasing, with several conditions in
principle being licence compatible, depending on the indi-
vidual’s clinical circumstance.
Careful questioning, not only at the initial issue but
at all reviews should include details of ‘over the counter’
(OTC) medications, several of which may have cardiologi-
cal consequences.
K17577_C021.indd 386
CLINICAL EXAMINATION
It is accepted within this text that the aviation medical
examiner is familiar with the clinical techniques of cardio-
vascular examination. However, attention is drawn to the
detection and documentation of palpable thrills, cardiac
murmurs, delayed femoral pulses and resting supine blood
pressure and pulse rate. The blood pressure and pulse may
require to be repeated after an approximate 10 min settling
down period. This may to some extent be dependent on the
age of the applicant at initial issue.
ECG
A resting 12-lead ECG forms part of the clinical assess-
ment. For details in respect of correct recording technique,
recording errors and ECG interpretation refer to the cardiac
investigation section of this chapter.
Congenital heart disease
Considerable changes in the management of congenital
heart defects have resulted in many individuals so afflicted
now living effectively normal lives in quality and duration.
Should an applicant for aeronautical licensing present
giving an outline description of having a congenital heart
defect, this having been surgically corrected or not, the first
essential element is to request (with the applicant’s permis-
sion) copies of previous medical records. These will clarify
the diagnosis, detailed investigations undertaken, surgery
and post-surgical status. There are considerable differences
in the findings, repair procedures and subsequent clini-
cal outcome between individuals having the same overall
diagnosis, to make each applicant very individual. With the
same condition some may be licensable, others not.
Taken in order of least complexity the conditions most
likely to be encountered are given below.
Patent ductus arteriosus
The ductus arteriosus is an essential communication
between the pulmonary artery and the aorta in foetal life,
diverting blood from the lungs as the lungs in fetal life are
non-functional, therefore not requiring blood flow. Once
the lungs inflate after birth the muscular walls of the ductal
vessel constrict within hours, shutting off this diversionary
route. The ductus seals, with no further blood flow, finally
fibrosing and remaining as a vestigial structure for the rest
of life. If, however, the ductus fails to close, then as a result
of the now higher pressure within the aorta compared to the
pulmonary artery, the direction of flow reverses to become
a left to right shunt, aorta to pulmonary artery. Respiratory
difficulties may develop, the ductus requiring surgical
closure by ligation through a left thoracotomy. In older
children it is now possible to close a ductus by inserting a
closure device through a cardiac catheterisation procedure
when no surgical scar will be apparent.
The effects of ductal closure are to restore normal hae-
modynamics. Follow-up is undertaken intermittently until
18/11/2015 14:14

adulthood with the aim of identifying the occasional ductus
which may recanalize; thereafter recanalisation in adult-
hood is unlikely to occur.
Individuals having undergone satisfactory ductal closure
should be considered as normal and appropriate for unre-
stricted medical certification.
Ventricular septal defect
There is a spectrum of defects under the overall title of ‘ven-
tricular septal defect’ (VSD). Isolated VSDs vary both in
their size and location within the intraventricular septum.
A VSD is the most common congenital heart defect.
In the context of aviation medicine we need only con-
sider those VSDs which are small and those that have been
surgically closed. A VSD like a patent ductus may be a con-
tributor to and present in more complex congenital defects,
again highlighting the necessity for complete past medical
records scrutiny.
A small VSD is referred to as a ‘restrictive’ defect in that
being small it restricts the blood flow (or shunt) from the
high-pressure left ventricle to the low-pressure right ven-
tricle. The shunt magnitude in a restrictive VSD varies
between too small to quantify, i.e. negligible, to a maximum
of 1.4:1. For comparison and to put into context with a non-
restrictive VSD, it would have a shunt greater than 2:1, i.e.
the flow to the right ventricle and hence to the pulmonary
artery being greater than twice the systemic blood flow. The
‘restriction’ of a small VSD is not only a restriction of shunt
magnitude but also the restriction or prevention of increased
pressure within the right ventricle and pulmonary artery.
The small high-velocity jet across the ventricular sep-
tum with a small VSD accounts for the often found physical
sign of a palpable precordial thrill and a loud pan systolic
murmur. A common occurrence is for a clinical history of a
small VSD having been present in childhood but of the mur-
mur not being detectable in adulthood. This is due to over
50 per cent of small childhood VSDs closing spontaneously
with age. Even if a small VSD remains present in late teenage
life, it may still close spontaneously although many remain
throughout life. Given, however, that the blood flow across a
small VSD produces a negligible effect on increased ventric-
ular workload, then it is standard practice not to surgically
close a restrictive small VSD. Individuals with this defect are
normally active and asymptomatic. The risk of endocardi-
tis exists and as such an applicant for military service may
be rejected on the grounds that endocarditis would involve
complex logistical management if posted to remote locations.
A small restrictive VSD applicant is suitable for unrestricted
certification for civil aviation. An unrestricted VSD in child-
hood associated with a significant shunt will, unless compli-
cated by pulmonary hypertension, or closed by the insertion
of a percutaneous closure device, require surgery. VSD clo-
sure by whatever method is not always complete and a small
residual leak may persist that will be too small to require fur-
ther surgery. Such residual leaks are usually not progressive
although long-term follow-up data for device therapy are not
yet available. Surgical closure of a VSD in infancy is usually
K17577_C021.indd 387
The initial issue of medical certification  387
associated with a normal or near-normal life expectancy.
However, some later developments are known to occur, prin-
cipally the development of aortic regurgitation or the devel-
opment of atrio-ventricular conduction defects.
If given satisfactory haemodynamic status based on
recent cardiological assessment, an applicant for aviation
certification may be acceptable for any class of certification
but with conditions applied. There will be a requirement
for intermittent cardiological assessment to include echo-
cardiography and 24-hour ambulatory ECG recordings in
addition to resting ECGs. The time interval for assessment
would normally be three yearly or less depending on ven-
tricular function, defect and valve status and the presence
or otherwise of a conduction defect.
VSDs may be ‘associated’ with other cardiac defects, e.g.
an atrio-ventricular septal defect or as an associated com-
ponent of complex congenital heart defects. These are there-
fore not isolated VSD’s, the majority of complex conditions
being medically non-licensable.
Pulmonary stenosis
This may be simple pulmonary valve stenosis or complex
with restriction to pulmonary blood flow at varying levels.
The medical records are essential to clarify.
The most severe form of pulmonary valve stenosis pres-
ents in infants and may have been treated by a balloon
valvuloplasty procedure. This can provide excellent long-
term results although such valves are always abnormal and
require long-term cardiac monitoring and probable pulmo-
nary valve surgery at some stage. This type of pulmonary
stenosis is not compatible with aviation certification.
Mild pulmonary valve stenosis in childhood may prog-
ress in later childhood or teenage life and despite increas-
ing severity may be symptomless, being detected by the
presence of an ejection systolic murmur. Sub-pulmonary
right ventricular muscular outflow stenosis may develop.
Interestingly, if so, with the relief of the valve stenosis usu-
ally by balloon valvuloplasty, the sub-valvular muscular
hypertrophy tends to largely resolve with minimal ongoing
stenosis through adult life. Once of adult status the majority
of patients remain well, asymptomatic and stable with little
or no change in their degree of residual stenosis, however
some progress requiring surgery. Although well there is a
small but recognized risk of developing atrial arrhythmias.
This type of pulmonary stenosis may be compatible with
aviation certification but with the restriction of intermittent
long-term cardiac monitoring.
Pulmonary stenosis may be sited within the main pul-
monary artery (supra valve stenosis) or further into the
lungs within the branching pulmonary artery system.
These patients are very individual but as a general rule this
pathology is not compatible with aviation certification of
any category.
Atrial septal defect
Defects within the intra-atrial septum, when not associ-
ated with any other defect are common and in childhood
18/11/2015 14:14
 388  Cardiovascular disease
asymptomatic. The majority present following the detection
of an ejection systolic murmur reflecting increased pulmo-
nary blood flow. When diagnosed, all defects other than the
smallest are closed either by a catheter-based closure device
or, if anatomically not suited for that, by surgical closure.
Virtually all atrial septal defects (ASDs) are closed in child-
hood and it is now rare for presentation in adulthood. With
the closure being undertaken in childhood the majority
have not sustained ventricular overload damage. Rarely,
however, a large ASD in infancy may cause heart failure and
although closed there may be residual long-term right ven-
tricular dysfunctional features, despite being asymptomatic.
This again highlights the importance of obtaining detailed
previous medical records. There can be a large spectrum of
individual variations.
There can be an increased tendency to atrial arrhyth-
mias, principally atrial flutter or atrial fibrillation, although
this tends to be confined to the few individuals with late
correction of their ASD. The resting 12-lead ECG may con-
tinue to display the ASD features of right bundle branch
block throughout adulthood. Occasionally an ASD may not
be detected until late teenage or early adult life on the basis
that they are asymptomatic. It is extremely unusual for the
complication of pulmonary hypertension to develop at that
age, although when not detected until aged over 30  occa-
sionally pulmonary hypertension, particularly in females,
may develop.
Echocardiography in adulthood following childhood
ASD closure occasionally demonstrates an insignificant
surgical patch or closure device leak but these almost always
are small and do not require further intervention.
Given that long-term data, particularly after device clo-
sure of an ASD, are unknown it is still standard practice for
an intermittent cardiology review.
In summary, the vast majority of repaired secundum
type ASDs are suitable for unrestricted certification subject
to intermittent cardiological review.
Occasionally a small ASD is identified with a shunt
considered too small to justify closure. These individuals
require intermittent review only.
Patent foramen ovale
A small central atrial communication exists in foetal life to
divert blood from the lungs, but soon after birth a ‘flap’ on
the left side of the atrial septum should adhere to the septum
rendering the atrial septum intact. Failure of this adhesion
effectively results in a potential flap valve existing and being
termed a patent foramen ovale (PFO). A PFO is estimated to
exist in up to 25 per cent of the adult population, its pres-
ence remaining silent and asymptomatic unless a systemic
embolic event occurs. In adulthood when intermittent right
atrial pressure temporarily exceeds the left atrial pressure,
e.g. during a cough or Valsalva or physical effort manoeu-
vre, the flap may be pushed open briefly allowing right atrial
blood to enter the left atrium. That is without consequence
unless on rare occasions there happens to be a small throm-
bus circulating within the venous system, returning to the
K17577_C021.indd 388
right atrium, when it could cross to the left atrium and from
there become a systemic embolus resulting in a transient
ischaemic attack (TIA) or cryptogenic stroke. In addition
to being causally related to a paradoxical embolic event,
there has been much interest in the possible association of a
PFO with migrainous headaches. This association currently
remains debatable. The relationship of a PFO to decom-
pression sickness in diving is accepted. Should a TIA epi-
sode occur in an adult of pre-retirement age, the standard
investigations to identify the cause have to be undertaken,
which include assessment for the presence of a PFO. A PFO
is detected by a bubble contrast echocardiogram.
Should a TIA have occurred and a PFO been detected,
treatment to prevent a recurrence is initially by anti-plate-
let medications. Should a further episode occur, consider-
ation may be given for closure of a PFO by percutaneous
closure device.
A TIA occurring in a pilot requires suspension of certi-
fication, investigation as above, treatment and observation.
Each individual will be different, requiring case conference
discussion to consider if restricted re-licensing is acceptable.
Atrio-ventricular septal defect
This congenital defect which used to be termed atrio-
ventricular canal defect or primum ASD is structurally
complex and associated with a common AV valve leaflet.
Surgical correction may resolve the lower atrial septal defect
and may reduce the AV valve regurgitation, but some regur-
gitation always persists. There is frequently an associated
atrio-ventricular conduction defect.
This type of atrial septal defect has too many ramifica-
tions, even after surgical repair for any type of aeronautical
certification.
Aortic stenosis
There is a wide spectrum of clinical presentations and indi-
vidual aspects to this condition.
Congenital aortic stenosis which is of such severity that it
presents in infancy and requires childhood surgery, results
from a dysplastic non-formed valve with a narrowed left
ventricular outflow tract. This is a complex type of aortic
stenosis and it is unlikely that anyone with this condition
would apply for licensing. If they should, almost all would
be non-licensable.
However, individuals with a reasonably well formed but
abnormal aortic valve, mainly of a bicuspid variety, are usu-
ally asymptomatic and the valve defect is often not detected
until late teenage, early adult life or even later. Aortic ste-
nosis of rheumatic origin is now exceedingly rare except in
those countries where rheumatic fever still exists.
Congenital bicuspid aortic valves are common, occur-
ring in approximately 2  per cent of the population. They
may have a familial history and are more common in males.
Presentation is invariably by detection of an ejection sys-
tolic murmur in an asymptomatic individual and as such
may be detected for the first time in an applicant presenting
for initial aeronautical medical licensing.
18/11/2015 14:14

The severity of aortic stenosis gradually progresses but
does not become symptomatic until severe in the late stages
of the disorder and for the majority of pilots this may be
near or past normal retirement age. Aortic regurgitation
similarly progressively develops. The combination of both
stenosis and regurgitation may result in the need for an aor-
tic valve replacement from aged 30 years onwards.
A coarctation of the aorta commonly accompanies a
bicuspid aortic valve and requires exclusion when a bicus-
pid aortic valve is initially recognized. Details of degrees
of severity of aortic valve dysfunction with echocardio-
graphic parameters and surgery for aortic valve disease are
addressed later under ‘Acquired conditions’.
Bicuspid aortic valves are frequently associated with
abnormal development of the aorta, referred to as an aortopa-
thy which results in gradual progressive dilatation of the aor-
tic root above the aortic valve involving the ascending aorta.
The aortic root enlargement is not dependent on the severity
of the aortic stenosis or valve dysfunction, it may progress as
a separate entity resulting, when significantly dilated, in a
sudden rupture or dissection of the aorta. Currently an aortic
root dimension greater than 4.5 mm requires surgical referral
although it is the trend or rate of progression of the dilata-
tion of the aorta which is the more important factor, hence
the necessity for dimensional documentation at each evalua-
tion. Echocardiography is the standard investigative modal-
ity for assessing aortic valve function and for measurement of
the aortic root. Transthoracic echocardiography is unable to
visualize the ascending aorta further than a few centimetres
above the aortic valve and chest CT or cardiac MRI imaging
is required to evaluate and complement echocardiography in
assessing the presence and extent of an aortopathy.
The aortic valve may only be mildly dysfunctional with
normal left ventricular size and function on echocardiog-
raphy with normal aortic root dimension. This situation is
licensable including a Class I but with the proviso that reas-
sessment, including repeat echocardiography on both the
valve and the aortic root dimensions, are undertaken regu-
larly. In the young with no significant abnormality a follow-
up at two-year intervals is advocated with that shortening
to annually as soon as valve dysfunction is classified as
moderate (stenosis or regurgitation) and aortic root dimen-
sions reach upper normal limits. Further discussion of the
degrees of severity of aortic valve dysfunction, surgery and
post-surgical status are addressed later under ‘Acquired
cardiac conditions’.
Coarctation of the aorta
Coarctation of the aorta occurs up to five times more com-
monly in males and is often associated with a bicuspid aortic
valve and sometimes also with a ventricular septal defect.
Presentation commonly is in infancy when correction is
by surgical repair. In later childhood detection may occur
following the finding of a systolic murmur or elevated blood
pressure and weak femoral pulses. Correction at this age
may, depending on the anatomy, be by balloon dilatation of
the coarctation, otherwise again by surgery.
K17577_C021.indd 389
The initial issue of medical certification  389
The outcome into adulthood following coarctation repair
is excellent. Individuals with this history may present as
applicants for aviation certification. Provided the appli-
cant is normotensive, with normal non-delayed femoral
pulses and with nothing untoward in the medical records in
respect of the correction procedure, unrestricted certifica-
tion can be considered. The co-existence of a bicuspid aortic
valve mandates a closer follow-up strategy.
The presence of a coarctation undetected in a late teen-
ager or asymptomatic young adult may only come to light
due to the findings of hypertension which again may be a
feature presenting for the first time at an initial aviation
medical. The occurrence or reoccurrence of hypertension
in adulthood following a childhood coarctation repair is
not uncommon and if found, clarification of the coarcta-
tion status is required in that recoarctations can occur, oth-
erwise hypertension with a previous coarctation history is
invariably of renal origin. Such hypertension, in the absence
of recoarctation, when treated with conventional antihy-
pertensive therapy and when satisfactorily controlled, may
allow consideration of unrestricted certification.
Current conventional adult congenital practice is that
patients who have previously undergone surgery or balloon
dilatation treatment for coarctation of the aorta will always
have intermittent occasional long-term cardiology follow-
up for reasons of recoarctation or developing hypertension.
At initial assessment, provided satisfactory status is
obtained from the most recent cardiological review, includ-
ing being normotensive, unrestricted medical certification
may be granted, subject to continuing satisfactory cardio-
logical review.
Marfan’s syndrome
A patient with Marfan’s syndrome may be immediately
recognizable. Some can be subtle and difficult to recognize.
If the features are overt and typical then the diagnosis will
already have been made. Such individuals usually have the
more severe form of the syndrome and due to the potential
and probable complications are not licensable candidates.
However, some individuals may only have minor features
and the syndrome may not have been recognized by late
teenage life. A detailed family history as previously men-
tioned is a mandatory requirement for every initial appli-
cant and may reveal or provide clues to a familial inheritance
of Marfan’s syndrome which may then be confirmed by
genetic testing. The FBN1  gene identifies over 90  per cent
of the mutations which cause the various characteristics of
the condition. If, with only some features, referred to as a
‘forme fruste’ of Marfan’s syndrome the condition may not
have been diagnosed prior to attendance for initial certifica-
tion if not previously recognized will become apparent in
early adulthood, often by the detection of a cardiac murmur.
Echocardiography clarifies whether mitral or aortic regurgi-
tation is present with particular attention made to recording
the dimensions of the aortic root at the level of the aortic valve
sinuses, the sinotubular junction and ascending aorta. These
measurements are required for comparison in subsequent
18/11/2015 14:14
 390  Cardiovascular disease
follow-up echo studies to identify if a trend of aortic enlarge-
ment is occurring. These are the typical cardiac pathologies
associated with the syndrome. With mild physical features
the heart may be structurally and functionally normal and
restricted certification is possible from a cardiac perspective
subject to annual review to include echocardiography. Other
non-cardiac, e.g. ocular, issues may be disbarring.
The entire thoracic aorta requires assessment upon diag-
nosis of the condition by CT or MRI scanning as the ascend-
ing aorta, aortic arch or descending thoracic aorta may be
involved and not identified by echocardiography. At reas-
sessment the rate of change for any aortic dimensions is the
relevant parameter rather than aortic dimension as such but
surgery is required when an aortic dimension reaches 5 cm as
a preventative to dissection occurring. An aortic dimension
in excess of 4.5 cm becomes incompatible with certification
due to the risk of rupture. Post-aortic surgery, complications
are significant with further dissections occurring, proximal
or distal to the repair together with progressive aortic and/
or mitral valve regurgitation. Hence few, if any, individuals
post-surgery are acceptable even for restricted licensing.
Tetralogy of Fallot
Of all the complex congenital heart lesions, Tetralogy of Fallot
is the most common and the one which with surgical help has
enabled survival well into adult life. The defect comprises pul-
monary stenosis at varying levels, right ventricular hypertro-
phy, a ventricular septal defect and the aorta overriding the
septal defect. Surgical repair has been undertaken since the
1960s but the surgical technique used initially involved repair
through an incision of the right ventricle. This, years later,
caused problems with right ventricular dysfunction and the
propensity to arrhythmias and occasionally sudden death.
For the last nearly 30  years with the surgical repair being
conducted through a right atriotomy only, far fewer compli-
cations occur in the long-term follow-up. However, complica-
tions naturally occur principally related to progression of the
pulmonary valve dysfunction. Patients are never discharged
from long-term adult congenital cardiology follow-up. Even
the best surgical repair candidates have some pulmonary
valve regurgitation and with the cardiological inability to
confidently predict that arrhythmias will not occur only a few
applicants may obtain unrestricted certification, that being
subject to regular review both from an aviation and specialist
cardiology perspective. Most, at best, will only be suitable for
restricted certification, that again requiring reconsideration
after detailed annual reassessments.
Other more complex initially cyanotic congenital heart
defects, despite surgery, are in most cases non-certifiable.
Pulmonary hypertension
Primary pulmonary hypertension occurs more frequently
in females and most will already have been diagnosed pre-
senting with breathlessness. The individual is unlikely to
apply for aviation medical certification. There are varying
degrees of severity but generally this condition is not com-
patible with certification.
K17577_C021.indd 390
Pulmonary hypertension may, however, be acquired,
developing in an individual already licensed and will be
discussed later in the section of Medical renewal.
CARDIOLOGICAL ASPECTS OF THE
MEDICAL RENEWAL
The pilot’s previous medical history, family and medication
history should be either present or accessible. This is par-
ticularly relevant if attending a different aviation medical
examiner (AME) than previously. New medications, medi-
cation changes and the use of ‘over the counter’ medications
require documentation as they may be of cardiac relevance.
Although a tick box questionnaire may be utilized, care-
ful questioning in respect of any symptoms experienced or
symptomatic changes since the previous examination require
documentation. Documenting physical activity, particularly
sporting involvement with the type and duration of exercise
being undertaken, may be useful for future reference, particu-
larly in respect of ECG interpretation. For years renewals of
all classes generally continue uneventfully but inevitably with
age disorders may develop. The following considers the recog-
nition and management of acquired cardiological conditions.
CORONARY ARTERY DISEASE
Clinical aspects
The Framingham Heart Study quotes the lifetime risk of devel-
oping symptomatic coronary arterial disease after the age of
40 years as 49 per cent for men and 32 per cent for women. Even
making allowance for the current widespread prescribing of
preventative medications for lipid lowering, hypertension
control and for lifestyle changes, nevertheless a significant
number of pilots will develop this condition before retirement.
The underlying pathology within the coronary arteries is
the progressive deposition of lipid material forming a plaque.
The plaque also contains inflammatory cells and fibrous tis-
sue with the deposition of calcium in established plaques.
It is a progressive disorder, usually asymptomatic for
years during the development stage until blood flow through
the artery becomes compromised, termed ‘flow limiting’.
Presenting symptoms vary, mainly based on plaque
stability. A stable flow-limiting plaque, which restricts
increased myocardial blood flow and with it oxygen sup-
ply to meet the demand of increased work, results invari-
ably in effort symptoms, typically central chest tightness.
The symptoms are variable with throat, jaw, arm, back dis-
comforts, dyspnoea or effort limitation. Occasionally it may
be asymptomatic or confused with ‘indigestion’. The effort
relationship, easing with rest, is termed ‘stable’ in that it is
predictable angina.
The atheromatous plaque may partially rupture result-
ing in an acute vessel occlusion. Thrombus formation
at the plaque site may also cause a partial occlusion to
become a complete acute vessel obstruction. Such an event
is unpredictable with acute onset of symptoms. The chest
18/11/2015 14:14

pains may fluctuate depending on the vessel having some
patency and flow, resulting in intermittent pain, hence the
term ‘unstable angina’ which now is termed ‘an acute cor-
onary syndrome’.
Should the coronary artery be acutely obstructed an
acute myocardial infarction occurs. Depending on the ves-
sel involved, an ECG may record elevation of the ST seg-
ments with the term ‘ST elevation myocardial infarction’
(STEMI) being applied. An acute infarction may not induce
ST segment changes, with the term non-ST elevation myo-
cardial infarction (NSTEMI) applied. The clinical manage-
ment for each of these presentations differs.
Chronic (stable) angina
Continuing recurring or even single episode symptoms of
chest discomfort would prompt a pilot to attend his general
practitioner. Subsequent cardiological investigation should
readily confirm or exclude underlying coronary artery dis-
ease. A pilot with symptomatic coronary disease will have
his Medical Certification suspended pending these investi-
gations and subsequent treatment. The initial investigations
include an exercise stress ECG, looking for induced ECG
changes under physical stress. If the exercise test is positive
or indeterminate, clarification of the coronary artery sta-
tus is required by diagnostic coronary angiography. Much
debate exists over the diagnostic reliability of a treadmill
exercise test. This test is still utilized extensively within the
aeromedical environment, however. Alternative initial non-
invasive tests are more commonly utilized within a hospital
environment namely a nuclear myocardial perfusion scan
(Myoview) or a stress echo study. These non-invasive stress-
based tests are referred to as ‘functional tests’. If there is a
positive or indeterminate result or if unexplained symp-
toms persist, then these are followed by a clarification coro-
nary angiographic procedure.
Coronary angiography images the coronary arteries pro-
viding details of the sites and severity of coronary arterial
atheromatous disease. The findings may be:
●● Angiographically normal coronary arteries. If no
angiographic disease is identified then the clinical
diagnosis of angina is likely to have been incorrect.
Very occasionally, and more so in females, functional
testing may reveal some evidence of inducible isch-
aemia yet with normal epicardial coronary arteries at
angiography. The presumption then is that microvas-
cular angina may exist in which small arteries within
the myocardium, which are too small to be identified
by angiography, intermittently constrict resulting in
anginal symptoms. This condition is referred to as ‘syn-
drome X’. More commonly with normal angiographic
coronary arteries, alternative clinical explanations exist
for chest pain symptoms. The most common misinter-
pretation is that of oesophageal spasm or dysmotility
being mistakenly interpreted as angina. Exclusion of
anaemia is required.
K17577_C021.indd 391
Coronary artery disease  391
●● Angiography may demonstrate early, minor coronary
disease often termed ‘slight irregularity’ of the coronary
arteries. Minor plaque disease amounting to less than
30 per cent luminal compromise may be identified. Such
minor lesions would be unlikely to have caused clinical
anginal symptoms and would not have resulted in flow-
limiting disease on functional testing, the reason for
angiography being to ascertain the cause of chest pain
symptoms. Minor coronary artery disease, particularly
when secondary preventative medications are pre-
scribed, carries a good prognosis. If the coronary arter-
ies are normal or have only minimal disease, a return to
flying duties is acceptable.
If the coronary arterial disease is considered to have
lesions amounting to approximately 30–50% per cent steno-
sis at any site within the coronary arteries, regular (annual)
reviews with functional testing with an OML restriction is
required. If any lesion, particularly in one of the major coro-
nary arteries, is considered to be greater than 50 per cent,
it is either incompatible with flying or may be subject to an
assessment by a medical review panel given that significant
individual variability exists on angiography. Should the
lesion(s) be considered to underlie the anginal symptoms,
generally, interventional management should be consid-
ered. It should always be clarified with the pilot that seeking
interventional treatment, be it an intra-coronary stent or
surgical coronary bypass grafting (CABG) decisions should
be based on medical criteria of necessity and appropriate-
ness and not for reasons of wishing to pursue a procedure
purely in an attempt to regain a licence.
●● Significant coronary artery disease. Clinical man-
agement decisions are based on collating symptoms,
functional testing and angiographic findings. If there
is a clinical indication for a coronary interventional
procedure, be that by percutaneous stenting or CABG
surgery, then flying duties are suspended for a mini-
mum six months post procedure. Following the proce-
dure, secondary preventative medications are routinely
prescribed, conventionally in the form of aspirin with
an anti-platelet agent, ace-inhibition, lipid lowering
with a statin and low dose beta-blockade. Avoidance
from smoking, physical rehabilitation and undertaking
a subsequent regular fitness maintenance regime are
strongly advocated.
Following a post-procedural interval of six months,
provided the pilot is well and asymptomatic, re-evaluation
investigations are required in the form of an exercise ECG,
myocardial perfusion scan or stress echo and review of the
pre-interventional angiogram. A subsequent angiogram at
six months may be required. The interventional procedure,
stent(s) or grafts have to be functionally satisfactory with
no evidence of inducible myocardial ischaemia. The other
coronary arteries, i.e. not the stented or grafted vessel(s), are
scrutinized for the presence of atheromatous disease. If any
18/11/2015 14:14
 392  Cardiovascular disease
other major epicardial vessel contains atheromatous plaque
disease resulting in greater than a 50 per cent luminal com-
promise, this is debarring from licensing. If all parameters
are satisfactorily achieved, including a well-functioning
left ventricle assessed by echocardiography with an ejec-
tion fraction of at least 50  per cent, then relicensing with
an OML restriction and subject to an annual review can
be permitted.
Acute coronary syndrome (ACS) or acute
myocardial infarction
Following an acute presentation to hospital an ACS will ini-
tially be treated with antiplatelet medication, an NSTEMI
probably receiving similar treatment or with additional
early angiography. A STEMI, if admitted early enough after
symptom onset, will in most instances be managed with a
primary percutaneous interventional procedure or throm-
bolysis if acute intervention facilities are not available. Any
of the sub-groups may be referred for urgent CABG surgery
if that is considered the optimum treatment regime.
Subsequent to treatment provision, the clinical thera-
peutic management is similar to that described following
elective PCI or CABG detailed earlier. The mandatory six
months post-procedure and re-evaluation requirements are
the same with the same criteria for re-licensing.
Whilst an acute myocardial infarction (MI) is readily
diagnosed following hospitalization by ECG and serum tro-
ponin estimations, other causes of chest pain present daily
to A&E and Cardiology Departments with these param-
eters being normal. The potential diagnostic possibilities
for chest pain of questionable cause are considerable but
the aviation medical examiner is reliant upon the hospital
to provide the clinical diagnosis and management details.
The question of re-licensing is then dependent upon the
particular condition.
Stunned myocardium
Ischaemic episodes can have variable consequences rang-
ing from an area of myocardial cell death and replacement
fibrosis (myocardial infarction) with a well demarcated bor-
der between that and normal viable myocardium or blend-
ing with an area surrounding the infarction where reduced
but sufficient coronary flow has maintained viability of the
surrounding myocardium but with reduced function. This
is particularly apparent in the early post-acute myocardial
infarction period, the peri-infarction viable myocardium
being referred to as ‘stunned’. Restoration of adequate blood
flow post myocardial infarction to this surrounding area may
occur due to natural small vessel collateral increased flow or
to a coronary revascularization procedure being conducted.
Following restoration of adequate flow there is a delay in
recoverable function but return to near normal function
often occurs. Hence, in the acute myocardial infarction stage,
imaging of the left ventricle may demonstrate significant
left ventricular systolic impairment, yet follow-up imaging
K17577_C021.indd 392
may reveal significant LV functional recovery. Reassessing a
pilot’s functional cardiac status six months post-infarction
is therefore an accepted and valuable requirement.
Hibernating myocardium
The presence of flow-limiting coronary artery disease to an
area of myocardium exposes that myocardium to recur-
rent episodes of ischaemic insult and resultant damage. The
accumulative effect of recurrent injury results in functional
impairment of that segment. This may be isolated related
to a previously unrecognized coronary lesion or related to
coronary flow-limitation in close proximity to a previous
infarction. Recognition of this state is typically by anginal
symptoms. Once recognized, if the flow-limiting area of
stenosis is alleviated by revascularization either by percuta-
neous intervention or a CABG procedure, the area of myo-
cardium being still viable will improve often to near normal
systolic function. The myocardium so affected by this
chronic hypoperfusion is referred to as hibernating myocar-
dium. Again, LV systolic function, which is a mainstay of
pilot cardiac assessment, may improve back to near normal
parameters following revascularization, the requirement
being a reassessment by echocardiography for overall left
ventricular function and ejection fraction six months after
treatment when considering re-licensing.
Variant (vasospastic) angina
The term ‘variant’ is applied in that this type of angina as
opposed to effort angina occurs usually at rest. It is asso-
ciated with the ECG changes of ST segment elevation. The
episodes are usually of short duration of 2–5 minutes and
often occur during the night or early morning with spon-
taneous resolution, this distinguishing it from an acute
coronary syndrome. Coronary arteries, in keeping with
other arteries, have a muscular component to their wall and
are capable of contraction or spasm. It is episodic spasm
which underlies vasospastic angina. Spontaneous coro-
nary arterial spasm is unusual in normal coronary arter-
ies but is recognized to occur in association with an area of
atheromatous disease.
These nocturnal chest pain symptoms are very similar to
oesophageal spasm associated with reflux and oesophageal
dysmotility. The two conditions are often confused or mis-
diagnosed, accepting that any one individual at any time
may have either or both conditions.
Effort or exercise may be a precipitant, not only of flow
limiting coronary symptoms but occasionally also of coro-
nary spasm.
Previously provocative testing to demonstrate spasm was
undertaken. Injecting Ergometrine derivatives (Ergonovine)
or Acetylcholine directly into a coronary artery at the time
of angiography would in susceptible individuals precipitate
acute coronary arterial spasm. Such provocative procedures
have virtually disappeared from cardiological practice on
risk/benefit grounds.
18/11/2015 14:14

Syndrome X
Episodes of chest pain clinically suggestive of angina may,
after detailed investigation, be referred to as ‘syndrome X’.
The chest pain investigations typically are an exercise ECG
which is positive in that ST segment depression is noted,
followed by coronary angiography which demonstrates
normal atheromatous free coronary arteries. There is then
evidence of inducible ischaemia from a positive exercise
test yet no evidence of large vessel epicardial coronary
arterial disease. The explanation is accepted to be that of
small vessel or microvascular coronary dysfunction. Such
vessels are too small to be visualized by angiography. The
small myocardial vessels are not affected by atheroma but
have a functional defect of the endothelial lining in that
intermittently these vessels may constrict inducing isch-
aemic symptoms. Confirmation of the diagnosis is made by
assessing coronary flow reserve. This can be accomplished
invasively with a Doppler flow catheter or non-invasively by
echocardiographic Doppler flow data of a coronary artery
or alternatively by impairment of myocardial perfusion
nuclear imaging. Coronary flow is detected in a main ves-
sel, typically the left anterior descending coronary artery
and a coronary vasodilating agent, usually adenosine then
injected in a peripheral vein as a bolus. The resulting coro-
nary vasodilatation normally increases the coronary flow
temporarily by 2–3 times the resting flow rate, this increase
being referred to as the coronary flow reserve. In syndrome
X subjects the increase in coronary flow or the reserve is
markedly reduced compared to normal individuals.
The intermittent anginal symptoms of syndrome X
respond to coronary vasodilatation medication, typically
nitrates or calcium antagonists (diltiazem and related com-
pounds) with a variable response only to beta-blockade. The
endothelial dysfunction has a hormonal relationship with the
majority of sufferers being pre-menopausal females who may
respond to HRT medication. The chest pains are unpredict-
able, usually not effort-related and clearly incompatible with
pilot certification. The long term prognosis of the condition
is excellent although the symptoms may be disabling. This
condition should not be confused with the metabolic syn-
drome X which is related to obesity and insulin resistance.
Oesophageal related cardiac disorders
Although oesophageal reflux and associated pathologies are
discussed within the gastro-enterological section, mention
and consideration of particularly oesophageal dysmotility
and oesophageal spasm has to be considered in the con-
text of intermittent, recurrent central chest pain. Indeed,
oesophageal spasm is a frequent cause of acute cardiologi-
cal hospital admission. The differentiation between this and
angina can be confusing, given many symptomatic similari-
ties. Patients may be somewhat overweight (although this
is not an absolute prerequisite for oesophageal reflux), they
may provide a symptomatic reflux descriptive history and
almost always the chest pain symptoms occur at rest. The
K17577_C021.indd 393
The cardiomyopathies  393
description of oesophageal spasm pain is similar to cardiac
pain including its radiation to the throat and sometimes the
arms. Administration of sub-lingual nitrate (GTN spray)
promptly resolves oesophageal spasm due to its muscle
relaxing properties, but in so doing often compounds the
initial belief that the pain is cardiac.
Oesophageal reflux with or without spasm is commonly
associated with palpitation symptoms due to the mesh of
autonomic nerves related to both the oesophagus and the
heart. Oesophageal dysfunction or inflammation may
present with frequent atrial or ventricular ectopic beat
activity. Treatment with a protein-pump inhibitor or H2
antagonist invariably resolves the palpitations as well as the
reflux symptoms. Occasionally symptomatic runs of atrial
ectopics or self-limiting atrial tachycardias may be precipi-
tated by and accompany swallowing.
THE CARDIOMYOPATHIES
Within the strictly correct interpretation of the title there
are many pathological disorders of heart muscle. The gen-
eralistic term ‘Cardiomyopathy’ has, however, become syn-
onymous with a limited number of myocardial pathologies
which will be briefly considered.
Hypertrophic cardiomyopathy (HCM)
Cardiac hypertrophy (such as left ventricular hyper­
trophy [LVH]) for no apparent reason constitutes HCM.
Hypertension has to be excluded as an underlying cause.
The type of hypertrophy classically is described as asym-
metrical, in that the ventricular septum is markedly more
hypertrophied than the other walls of the left ventricle. This
feature, is however, variable in that in all cases the left ven-
tricle is significantly concentrically hypertrophied. HCM
has an autosomal dominant inheritance trait. Several genes
(the total not yet fully recognized) which encode cardiac
structural proteins are recognisable but with a very consid-
erable and yet undetermined number of mutational vari-
ants. Gene testing is clinically available but for the above
reason may or may not fully identify or confirm an HCM
diagnosis. The condition is equally distributed between
the sexes. A detailed family history is essential. Close fam-
ily relatives of individuals diagnosed with HCM should be
advised to undergo cardiac screening. HCM may be sub-
categorized as follows.
APICAL HCM
Here the distal or apical LV segments are hypertrophied and
in systole obliterate the distal LV cavity. The patient is often
asymptomatic. Deeply inverted T waves are almost always
present on the ECG. The diagnosis is readily made by echo-
cardiography, with an MRI scan providing further details.
Treatment, as with most of the hypertrophic cardiomyopa-
thies, is inotropic suppression by beta-blockade unless con-
tra-indicated. Generally there is only slow progression with
few symptoms although the underlying risk which exists in
18/11/2015 14:14
 394  Cardiovascular disease
all HCMs of an arrhythmic tendency exists. Pharmacological
suppression of arrhythmic risk is unpredictable, hence the
diagnosis of HCM excludes aeromedical certification.
HCM WITHOUT OUTFLOW TRACT OBSTRUCTION
All LV segments and not infrequently the right ventricle are
hypertrophied, the degree being from moderate to severe,
the latter obliterating the LV cavity in systole. Effort intoler-
ance or palpitations are the common presenting symptoms.
The ECG again invariably (but not always) is abnormal in
terms of LV voltage increase and deep T wave inversion, the
condition usually having been present for a significant time
period prior to presentation and diagnosis. The investiga-
tion to establish the diagnosis is similar to that described
above under ‘Apical HCM’, although it is recognized that
in many cases although there is no evidence of dynamic LV
outflow obstruction due to the mitral anterior leaflet coapt-
ing with the intra-ventricular septum at rest, obstruction
may be induced on effort. Stress echocardiography is there-
fore frequently undertaken to clarify. Differentiation from
hypertensive LVH and from athletic heart-related LVH
must be made, as a positive diagnosis of HCM precludes
aeromedical  certification, whereas physiological LVH is
compatible with licensing.
HCM WITH OUTFLOW TRACT OBSTRUCTION
This variant was for years considered as a separate entity
from the non-obstructive hypertrophic variant and termed
hypertrophic obstructive cardiomyopathy being given the
abbreviation HOCM. It is recognized now that many HCM
patients are intermittently obstructive to varying degrees.
The degree of LV outflow obstruction can be severe, result-
ing in progressive hypertrophy. Symptoms are more fre-
quent in this sub-group, both of effort intolerance, chest
pains, light headedness and pre-syncope. The latter may be
a consequence of the severity of outflow obstruction or the
presence of ventricular arrhythmic episodes. Sudden death
is well recognized. An implantable defibrillator may be
indicated depending on the severity of hypertrophy, docu-
mentation of arrhythmias and symptoms.
Relief or reduction of the outflow obstruction may be
helpful. This may be undertaken by catheter delivered alco-
hol into a small coronary artery branch supplying the basal
intra-ventricular septum resulting in a limited infarction of
that area, or by surgical reduction of the basal septum.
Provided sudden cardiac death (SCD) does not occur,
in the longer term the hypertrophy may slowly change
to become thinner, the ventricle dilating and eventually
failing. Clearly this is a condition not compatible with
flying certification.
Restrictive/infiltrative cardiomyopathy
The term ‘restrictive’ describes the ventricles being lim-
ited or restricted in their ability to relax or dilate in dias-
tole to accommodate filling. Initially systolic function may
be well maintained but eventually diastolic failure induces
K17577_C021.indd 394
breathless limiting symptoms. The underlying pathology
causing restriction in a number of instances is due to sys-
temic disorders depositing material within the myocar-
dium resulting in its impaired function. Limitation of the
heart to dilate in diastole can also be caused by pericardial
constriction. The diagnostic distinction between a restric-
tive cardiomyopathy or pericardial constriction can be dif-
ficult. Current echocardiography and MRI imaging usually
resolve any diagnostic dilemma. The most common (yet
rarely encountered) conditions resulting in this type of car-
diomyopathy are detailed below.
AMYLOIDOSIS
This is a complex disorder which results in the deposition
of proteinaceous material within the myocardium with dif-
fering classifications of amyloidosis. There is a senile vari-
ant predominantly in elderly men which is unlikely to be
relative to the pilot population. Primary amyloidosis other-
wise termed ‘acquired’ has an immunological basis that can
be related to blood cell dyscrasias designated AL amyloid.
There is a variant termed ‘secondary amyloidosis’ with AA
designated protein deposits and which is less likely to be
associated with myocardial dysfunction. Initial recognition
of the disorder may be through a change in the surface elec-
trocardiogram with conduction defects. The condition may
also present to other specialities with renal or neurological
issues, the condition generally presenting in middle age or
later and being more frequent in males. Amyloidosis has a
poor prognosis and once diagnosed the individual is not
acceptable for any category of aviation medical certification.
FABRY’S DISEASE
This is an inherited X linked recessive disorder of an
enzyme deficiency alpha-galactosidase, the consequence
being the accumulation of glycolipid material within the
heart. There are many differing mutations of the disorder.
This condition is often described as the greater masquerade
in that it can present with so many different features and
manifestations, often relating to renal or skin problems.
Infiltration within the myocardium can be detected by
cardiac enlargement and conducting system (ECG) abnor-
malities and valve incompetence. Males usually present
with cardiac involvement whereas female carriers may be
asymptomatic. MRI imaging may differentiate Fabry’s dis-
ease from other cardiac infiltrations although the test for
a low plasma alpha-galactosidase A level provides a precise
diagnosis. The missing enzyme replacement is available as
a therapy and can provide a clinical benefit in the younger
individual. Fabry’s is a rare condition and if cardiac involve-
ment is diagnosed in an adult, the condition is unlicensable.
HAEMOCHROMATOSIS
An iron storage disorder which is uncommon and very
uncommon in females can result in the deposition of iron
within the myocardium.
It is an inherited recessive disorder which is genetically
identifiable but also may be acquired following long-term
18/11/2015 14:14

over-dosage with oral iron. Repeated transfusions may be
responsible but would be an unlikely cause in the pilot pop-
ulation. Iron is also deposited within the liver and liver dys-
function may be the presenting feature. The ECG changes in
terms of T wave abnormalities and conduction defects may
be an early presenting feature. While repetitive venesec-
tions may be clinically helpful a degree of cardiac involve-
ment invariably is incompatible with aviation certification.
SARCOIDOSIS
This is an inflammatory condition which may present
with dermatological features (erythema nodosum) or pul-
monary symptoms. There may be cardiac involvement in
approximately a quarter of patients suffering the condition.
Inflammation and infiltration within the myocardium pro-
duces conduction abnormalities identifiable on the ECG,
although when more advanced there may be significant
arrhythmias, cardiac enlargement or heart failure. Fibrosis
within the lungs may result in pulmonary hypertension and
consequential right heart failure. In the early stages a chest
X-ray may be suggestive of pulmonary tuberculosis in that
the features can be similar. The inflammatory process can
involve other tissues and the presentation may be with ocu-
lar or arthritic symptoms. In the early stages patients are
generally constitutionally well.
The inflammatory status is generally treated with anti-
inflammatory medications, principally steroid therapy and
immunosuppression. Many patients respond well to treatment
and sometimes the condition can be self-limiting. Evidence for
cardiac involvement has to be strenuously sought as the impli-
cations are serious, particularly in respect of development of
arrhythmias. The diagnosis may be strongly suspected from
echocardiography with MRI imaging often diagnostic.
When the condition has settled or responded to treat-
ment and provided the heart is not involved then restricted
Class I certification is possible subject to six monthly car-
diopulmonary follow-up. At follow-up, repeated echocar-
diography, exercise stress ECG and ambulatory 24  hour
ECG recordings are required and all should be normal.
Pulmonary follow-up should also document acceptable
pulmonary function. If there is evidence of cardiac involve-
ment then despite therapy the fibrotic scarring and poten-
tial arrhythmic basis is unacceptable for future restoration
of any grade of aviation medical certification.
Dilated cardiomyopathy
The term ‘dilated cardiomyopathy’ applies to myocardial
dysfunction not related to or as a consequence of ischaemic
heart disease, with the term non-ischaemic cardiomyopathy
often used.
The presence of this condition may go unnoticed for a
significant time period as initially there may be minimal
symptoms. Reduction in effort tolerance usually becomes
the presenting symptom. Minor ECG changes may lead to
further investigation which establishes the diagnosis. There
are variants of this condition with differing prognostic
K17577_C021.indd 395
The cardiomyopathies  395
features. If presenting soon after childbirth (postpartum
cardiomyopathy) this can be severe yet can recover. Other
dysfunctional left ventricles of the dilated DCM type may
remain relatively stable for a number of years whereas oth-
ers may progress despite pharmacological treatment or
assistance from biventricular (cardiac resynchronisation)
pacing. It is recognized that there is a genetic relationship
although genetic testing and the understanding thereof is
still being developed. However, a family history of a similar
disorder is important to register. Although the individuals
with no family history or immediately apparent cause may
be referred to as ‘idiopathic DCM’ a number of associations
are recognized which can result in a similar clinical picture
of a dilated failing left ventricle. These include alcohol, viral
infections, metabolic disorders principally of thyroid func-
tion and some medications, particularly cancer treatments.
The diagnosis is achieved by echocardiography and MRI
imaging. Support for the dysfunctional LV is provided by
ACE inhibition and beta-blockade.
Although symptomatic benefit and improved prognosis
can be expected from modern pharmacology, particularly
in terms of heart failure treatment, the condition is asso-
ciated with arrhythmias and sudden death. Mild variants
of the disorder where left ventricular function measured by
ejection fraction is still within the normal range (an ejec-
tion fraction of 50 per cent or more) and where there is no
evidence of electrical instability, restricted certification may
be possible on an individual basis.
Non-classified cardiomyopathy
NON-COMPACTION
Modern imaging techniques have enabled the recognition of
this pathological entity. It is a late adult presentation of the fail-
ure of fetal development of the left ventricle in which trabecu-
lar myocardium compacts or consolidates to form the normal
thickened smooth walled left ventricle. Non-compacted seg-
ments are thin and hypocontractile with marked trabecula-
tions and deep recesses in the segments affected. If most of the
LV segments are affected, death will occur in infancy from
heart failure. If, however, only the apical or distal LV seg-
ments are involved, overall LV function may be adequate to
be asymptomatic until adulthood. Symptoms may be of effort
intolerance or the condition may be recognized through
family screening given that there is a hereditary trait. This
condition may not have been identified at the time of initial
issue. However, when symptoms present and investigation,
particularly initially echocardiography, identifies segmental
non-compaction, by inference left ventricular systolic func-
tion will at that stage be impaired. Associated complications
are the development of heart failure, thromboembolic events,
ventricular arrhythmias and sudden death. When diagnosed,
the condition is incompatible with certification.
ARRHYTHMOGENIC VENTRICULAR DYSPLASIA
This is a genetic inherited condition which generally presents
in adulthood and is alternatively termed arrhythmogenic
18/11/2015 14:14
 396  Cardiovascular disease
ventricular cardiomyopathy. Presentation is usually with
symptoms of palpitations or possibly pre-syncope or syn-
cope. Individuals with this type of presentation require
detailed imaging as the condition is related to fibro-fatty
infiltration of the ventricular myocardium. Classically the
free wall or outflow tract of the right ventricle is involved but
similar pathology is increasingly being recognized within
the left ventricle either alone or in conjunction with right
ventricular involvement. Occasionally this can be identified
or at least suspected on echocardiography but with cardiac
MRI being the more definitive diagnostic modality. The pro-
gressive risk of malignant ventricular arrhythmias and the
association with sudden cardiac death render all flying cer-
tifications unacceptable. Complex arrhythmogenic pharma-
cology often together with the insertion of an implantable
defibrillator constitutes the clinical management together
with heart failure therapy when that develops.
Athlete’s heart
Regular significant physical exercise results in myocardial
adaptation in a similar manner to that of skeletal muscle.
Hence, regular athleticism results in ‘body build’ and car-
diac enlargement. Alternatively, a heart exceeding normal
dimensions in the absence of hypertension may be con-
sidered to reflect a hypertrophic cardiomyopathy. The dif-
ferentiation between athletic adapted cardiomegaly and
pathological cardiomyopathy is therefore an important and
often challenging question. Both may display excellent sys-
tolic function. The principal initial clue is that fit athletic
hearts relax normally to promptly accept diastolic filling,
otherwise fitness would not be present. The characteristic
of a hypertrophic cardiomyopathy is that the LV does not
relax normally due to stiffness hence parameters of diastolic
filling, readily evident on echocardiography generally dif-
ferentiate the conditions. The most basic parameter is early
diastolic filling recorded as the E wave of mitral diastolic
flow on echocardiography.
The myocardial hypertrophy of athleticism may persist
for some years after regular athletic activity ceases. The fit-
ness element deteriorates, making the distinction between
athletic heart and cardiomyopathy more difficult, taxing
cardiological expertise. The establishment of athletic heart
presents no problem to licensing although an intermittent
review to monitor cardiac dimensions and function may
be required.
VALVE DISEASE
Acquired heart valve disease, mainly as a consequence of
previous rheumatic fever, is now rare in the western world.
Almost all valve disease within the pilot population is
congenital or degenerative. Some initially mild valve dys-
function may be rendered significant due to an episode
of bacterial endocarditis and some may be functional
related to the consequences of previous ischaemic heart
disease damage.
K17577_C021.indd 396
Aortic valve disease
CONGENITAL AORTIC VALVE DISEASE (PRESENTING
IN ADULTHOOD)
The aortic valve may congenitally have between one and five
leaflets or cusps. The normal aortic valve is tri-leaflet and
the most common abnormal valve is a bicuspid valve. There
may only be two cusps or there may be fusion between two
leaflets of what would have been a tricuspid leaflet valve,
resulting in only two functional cusps.
Although such valves may not become significantly
functionally abnormal until middle or later adult life, their
presence is usually revealed by a systolic murmur invari-
ably present in childhood. Patients with a mildly dysfunc-
tional valve are licensable, subject to review either alternate
years or annually depending on the severity. In respect of
a bicuspid aortic valve, there is frequently an associated
aortopathy which results in aortic root and ascending aorta
dilatation. This is an independent variable in that the aortic
dilatation is not specifically related to the severity of aor-
tic stenosis, the dilatation may progress independently. The
rate of progression of the aortic root dilatation between
echocardiographic reviews is the important parameter with
dilatation to approximately 5 cm (diameter) requiring sur-
gical aortic root replacement together with valve replace-
ment. When aortic root dilatation is noted to be significant,
chest CT imaging is required to assess the extent of ascend-
ing aortic dilatation as this is out of the field of view of
transthoracic echocardiography.
DEGENERATIVE AORTIC VALVE DISEASE
An originally normal tricuspid aortic valve may undergo leaf-
let thickening with calcification and become progressively
obstructive. Rheumatic heart disease is now rarely respon-
sible, the aetiology being age-related degenerative changes.
Aortic regurgitation frequently coexists with either
a bicuspid aortic valve or a degenerative tricuspid valve.
Aortic regurgitation as the predominant lesion with little if
any stenosis may be the consequence of a previous inflam-
matory process affecting the aortic valve, namely rheuma-
toid arthritis, ankylosing spondylitis and inflammatory
bowel disease. These inflammatory conditions may also
affect the aortic root resulting in dilatation.
Aortic valves are invariably not amenable to any form of
surgical repair. Minor or mild degrees of aortic regurgita-
tion, being a volume overload rather than a pressure over-
load on the left ventricle, are tolerated without symptoms
or without detectable left ventricular dysfunction for many
years. Depending on age and the magnitude at which aor-
tic regurgitation is detected, a routine follow-up both clini-
cally and particularly with echocardiography is required.
For mild lesions, a two-yearly assessment reduces to annu-
ally if and when the regurgitation is considered to be of
moderate degree.
Aortic stenosis again may be asymptomatic for many
years, yet is more rapidly ominous once symptoms occur.
18/11/2015 14:14

For this reason, regular review again clinically and by echo-
cardiography is required with measurable parameters of
the degree of stenosis assessed by echocardiography. The
limits may be incompatible with licence renewal despite the
patient being asymptomatic.
Once aortic valve disease is identified the pilot may
require a temporary suspension pending further investi-
gation. The principal initial investigation is echocardiog-
raphy. The peak to peak withdrawal gradient between the
left ventricle and aorta across the aortic valve which has tra-
ditionally been used to assess aortic stenosis is a different
measurement to that obtained by echocardiography which
is an instantaneous peak pressure drop. The echocardio-
graphic measurements of aortic valve gradient are higher
than a withdrawal gradient and approximate nearer to the
mean aortic valve gradient. The mean gradient can be cal-
culated echocardiographically and the values and degrees of
severity correlating with certification are as detailed:
Mean
Valve aortic
area gradient Severity Certification
Echo-normal flow condition
>1.5 cm² 0–20 Mild Unrestricted
mmHg Class 1 or 2
1.0– 20–40 Moderate Class 1 OML
1.5 cm² mmHg Class 2
Unrestricted
<1.0 cm² >40 mmHg Severe Unfit*
NOTE:
Indexing valve area to body surface area (BSA) can be
useful in cases of unusually large or small BSA
Hence: Moderate 0.6–0.85 cm²/m²; severe <0.6 cm²/m²
Other factors need to be considered in each
  case including:
Left ventricular hypertrophy
Reduced left ventricular diastolic function
Reduced left ventricular ejection fraction
Aortic regurgitation
*Cases with a mean gradient of 40–50  mmHg and favourable
other factors may be considered for class 2 OSL.
Annual follow-up with echocardiography and an elec-
trocardiogram is required in all instances where the mean
pressure gradient is in excess of 20 mmHg. The values are
slightly different for the European Class 3 certification for
air traffic control officers. These are tabulated on the CAA
website charts.
Mitral valve
Pure mitral stenosis is not a relevant issue with the decline
of rheumatic disease. Congenital mitral stenosis will have
been detected in childhood and excluded at an initial issue
K17577_C021.indd 397
Pulmonary hypertension  397
assessment. Mild mixed mitral valve disease with a degree
of stenosis and regurgitation may be detected by a murmur
rather than symptoms. The aetiology of this if of rheumatic
origin would be identified echocardiographically. If only
mild, with no significant LA enlargement, certification with
restriction is permissible. The restriction applies due to the
unpredictable occurrence of atrial fibrillation. Pure mitral
regurgitation therefore is the disorder most likely to present,
either at initial assessment or subsequent review. The most
common underlying aetiology is that of mitral valve leaflet
prolapse. This is related to a degree of underlying myxoma-
tous degeneration of one or both mitral leaflets. Leaflet(s)
may prolapse back towards the left atrium during mid and
late systole, resulting in degrees of mitral regurgitation. The
presence of the condition is usually detected by auscultation
when there is a late systolic crescendo murmur. Occasionally
patients present with symptomatic palpitations. The condi-
tion is readily recognized by echocardiography. Assessment
in terms of the magnitude of mitral regurgitation and the
presence of arrhythmias by ambulatory ECG recording are
required and if satisfactory flying is permissible subject to at
least annual cardiological review.
Mitral regurgitation may also be a later consequence of
a previous myocardial infarction or ischaemic left ventricu-
lar dysfunction. As described within the Ischaemic heart
disease section, licensing may be possible following an
ischaemic heart interventional procedure. Ventricular dila-
tation with a degree of dysfunction following an ischaemic
injury may result in mitral valve papillary muscle dysfunc-
tion or mitral annular dilatation, both resulting in degrees
of mitral regurgitation. Recognition and investigation of
the mitral regurgitation would normally be undertaken in
conjunction with assessment of the individual’s coronary
artery status. A functional left ventricular ejection fraction
of 50 per cent or more is required with no more than moder-
ate regurgitation may permit restricted licensing.
Right heart valves
Pulmonary stenosis as a congenital defect would have
been detected and assessed at initial issue. Tricuspid ste-
nosis would not be encountered within the pilot popula-
tion as this is a relatively rare consequence of previous
rheumatic heart disease. Minimal tricuspid regurgitation
if detected on echocardiography is not of significance, pro-
vided cardiac dimensions and function are normal. More
readily detectable regurgitation would require further
investigation, particularly to exclude the presence of degrees
of pulmonary hypertension.
PULMONARY HYPERTENSION
The normal pulmonary artery (PA) pressure at rest averages
25 mmHg systolic and 10 mmHg diastolic. In the normal
circulation the output of the right ventricle must equal that
of the left ventricle (effectively two pumps in series in a closed
circuit circulatory system) the smaller vascular capacity of
18/11/2015 14:14
 398  Cardiovascular disease
the lungs compared to the rest of the body has to accommo-
date the same blood volume per minute. The pulmonary cir-
cuit is that of high volume, low pressure and low resistance.
With age there are changes in the pulmonary vascula-
ture in that the capillaries become thicker with some loss
of elasticity resulting in a small rise in resting pulmonary
artery pressure. Within the pilot age group there should
be no significant increment with the rise beginning in the
more elderly. The low resistance of the pulmonary vascu-
lature allows a very considerable increase in flow from
the increased cardiac output generated by exercise to be
accommodated with only a minor rise in exercise induced
PA pressure.
Exposure from long-term or recurrent hypoxia, the most
common of which is living at high altitudes, can result in
pulmonary vaso-constriction and a consequential rise in
PA pressure. Brief exposure to the reduced partial pressure
of oxygen from high altitude has no significant initial effect
on PA pressure. The cardiac consequence from a persistent
altitude hypoxia is the inducement of cardiac ischaemia
should coronary artery disease be present, which may in
turn induce ischaemic symptoms or electrical instability
(arrhythmogenesis). For further discussion of exposure to
reduced atmospheric oxygen pressure refer to Chapters 2
and 3. Pilots would not normally be exposed to low atmo-
spheric oxygen pressure so it would be unlikely for recur-
rent hypoxia to be an explanation for a later presentation of
the symptoms of dyspnoea or the discovery of an elevated
PA pressure. Other causes are more probable. It should be
noted that a reasonably accurate estimate of pulmonary
artery pressure can be obtained non-invasively in many
subjects from an echocardiographic study.
Pulmonary hypertension in childhood may be the conse-
quence of congenital heart disease causing increased pulmo-
nary blood flow, either at systemic pressure or the pulmonary
volume flow initiating a pulmonary vascular contractile
response termed Eisenmenger syndrome. Rarely, the fetal
pulmonary hypertension may not resolve as it should in
infancy with continued pulmonary hypertension. Any of
these situations would have presented and been recognized
long before an individual was being considered for an avia-
tion medical certificate and consequently these aetiologies of
pulmonary hypertension are not an issue in the context of
aviation certification. In the context of individuals already
flying and by inference having normal pulmonary artery
pressures at initial issue, we need only be concerned with
the causation of pulmonary hypertension in adults.
Primary or idiopathic pulmonary hypertension is the
consequence of multiple factors, including pulmonary vas-
cular endothelial dysfunction, probable inflammation and
the variables of endocrine factors, genetic and metabolic
components also being involved, hence no single precise
identifiable cause. However, in clinical practice, the condi-
tion is more frequently seen in young adult females present-
ing with insidious, progressive dyspnoea for no immediately
apparent reason. Referral may initially be to the respiratory
department or to cardiology for the clarification of the
K17577_C021.indd 398
dyspnoea. If well established, the presence of pulmonary
hypertension may be suspected clinically and the elevated
pressure confirmed by echocardiography. It is a relentless
progressive disorder. Some current pharmacological treat-
ments may reduce its progression but the condition is, from
an aviation perspective, non-licensable.
Pulmonary embolic disease, usually resulting from a
peripheral venous thrombosis, is an acute dyspnoeic illness.
The aetiology of the peripheral thrombosis may be as the
result of accidental trauma or as a consequence of a period
of immobility, the classic example being long distance
passenger air travel. An acute pulmonary embolic event
may be seriously disabling or fatal. If survived, degrees
of functional disability may persist reflecting acute then
consequential right ventricular damage, from persisting
pulmonary hypertension. Symptomatic effort intolerance
requires detailed cardiorespiratory investigation with the
question of relicensing being on an individual basis.
CARDIAC RHYTHMS
Introduction
Normal sinus rhythm results from impulse discharge from
the sinus node, positioned high in the right atrium, recorded
as the P wave of the ECG. Sympathetic nerve activity influ-
ences the sinus node discharge resulting in increased heart
rates, whilst parasympathetic nerve stimulation (vagal)
slows the rate.
In the healthy adult, at rest, the sinus heart rate is between
60 and 90 beats/min. Below 50/min the rate is termed brady-
cardia and above 100/min tachycardia. Electrical activation
spreads from the sinus node through the atrial myocardium
to the atrio-ventricular (AV) node, that time period being
recorded as the PR interval on the ECG, then via the His-
Purkinje system to activate (depolarize) the ventricular
myocardium recorded as the QRS complex with the subse-
quent T wave reflecting ventricular repolarization.
Disorders of atrial rhythm
SINUS ARRHYTHMIA
A variation in the sinus rate, common in young adults, is
a normal finding. The heart rate may vary with respira-
tion, increasing slightly with inspiration by inhibiting vagal
tone. Temporary breath holding may stabilize the heart
rate. Rarely, pronounced sinus arrhythmia may slow the
heart sufficiently to induce transient light headedness at
rest. The heart rate responds normally to effort or stress.
Sinus arrhythmia is a benign normal finding, being less fre-
quently recognized with advancing age.
ECTOPIC ATRIAL RHYTHM
Electrical activity can originate and be propagated from
within the atria from sites other than the sinus node (SN)
when the normal upright ECG P wave in standard leads
I, II and aVF may be seen as inverted and with a reduced
18/11/2015 14:14

PR interval. The heart rate may or may not be within the
normal range.
SINUS TACHYCARDIA
With normal P wave activity, sinus tachycardia rates are
normally between 100 and 180/min, although occasionally
can reach 200/min. The rate increases in response to activity
or if resting, to sympathetic stimulation or systemic illness,
the rate changing progressively rather than abruptly.
Sinus tachycardias are usually of short duration resolving
after physical activity or emotional stress. They settle after
the resolution of a transient systemic illness. Occasionally a
sinus tachycardia may be persistent. Longer term systemic
disorders then require exclusion, notably thyrotoxicosis,
anaemia or the indulgence of excessive stimulants. Caffeine
or alcohol excess may be seen in the pilot population, with
more serious associations for example heart failure being an
unlikely explanation.
If the individual considers his pulse to be ‘always fast’, a
24 hour ECG recording may confirm this or may record a
slowing of the rate when asleep, disproving the sinus tachy-
cardia to be persistent. If the tachycardia is persistent or
inappropriate, cardiological referral is required.
ATRIAL EXTRASYSTOLES (ECTOPIC BEATS)
These are common, although less common than ventricu-
lar extra beats. Ectopic beats of either origin may be the
cause of an irregular pulse and readily clarified on an ECG
recording as a complex occurring earlier than expected fol-
lowed by a compensatory pause before the subsequent P
wave initiated normal complex. The ectopics are invariably
single but may be multiple. Atrial ectopics are often asymp-
tomatic, or the post-ectopic beat recognized as a ‘bump’
resulting in palpitation symptoms. Invariably no treatment
other than reassurance is required. Occasionally, if frequent
atrial ectopy is occurring it may precede the development
of an atrial arrhythmia the commonest being atrial fibrilla-
tion. Twenty-four hour ECG recording providing an ectopic
beat count and percentage of ectopics to normal complexes
clarifies if cardiological assessment is required.
ATRIAL TACHYCARDIA
Atrial flutter
Classically this is a right atrial re-entrant rhythm circu-
lating counter-clockwise within an area bounded by the
tricuspid annulus anteriorly and the crista terminalis and
Eustachian ridge posteriorly referred to as the cavo-tricus-
pid isthmus (CTI). Direction of rotation can be reversed, i.e.
clockwise. Strictly ‘typical’ flutter refers to all flutters using
the cavo-tricuspid isthmus. Thus clockwise flutter is still
‘typical’ whereas atypical flutter refers to flutter circuits not
using the CTI.
During an episode of flutter the atrial rate is approxi-
mately 300/min. Fortunately conduction at this rate to the
ventricles rarely occurs, the more common presentation
being of every other atrial complex resulting in a ventricular
K17577_C021.indd 399
Cardiac rhythms  399
rate of approximately 150/min., i.e. 2:1  AV block. Other
degrees of block occur, e.g. 3 or 4:1 and may be continuously
variable so the pulse may be regular or irregular. Flutter
may also exist in conjunction with atrial fibrillation.
Atrial flutter may temporarily slow with carotid sinus
massage but is unlikely to be terminated. Termination of
flutter is invariably promptly achieved by a DC cardiover-
sion procedure. Pharmacological treatment is unpredictable
and often ineffective for restoring sinus rhythm although
it may increase the AV block and slow the ventricular rate.
Relapse after cardioversion at varying time intervals is
common. An atrial flutter ablation procedure is a low risk
and highly effective treatment for flutter prevention.
Following an ablation procedure medical certification is
suspended for at least three months to observe satisfactory
clinical status with no recurrent arrhythmia. An electro-
physiological (EP) study is required post-ablation after an
approximate two-month interval. This is to confirm that a
satisfactory bi-directional block and abolition of the flutter
circuit has been achieved.
Given that atrial fibrillation (AF) often accompanies flut-
ter and the re-emergence of AF is unpredictable, relicensing
initially is with an OML restriction for one year after which
it may be removed pending satisfactory follow-up, there-
after with subsequent annual reviews to include 24  hour
ECG recording. Class 2 holders may be re-certified but also
require annual follow-up.
Atrial fibrillation
The atria cease contracting and ‘twitch’ or fibrillate that
activity being recorded on the ECG as low amplitude oscil-
lations with the ventricular QRS complexes spaced irregu-
larly. The pulse classically is irregularly irregular. Sometimes
diagnostic ECG confusion can exist as the fibrillatory waves
in chest lead VI look suggestive of atrial flutter waves, but
the absence of any consistent atrial activity in the other
leads together with the irregularly spaced QRS complexes
confirms the diagnosis.
AF may initially occur as brief paroxysms. These may last
minutes, hours or up to seven days. If AF continues beyond
seven days it is referred to as persistent AF, particularly if
cardioversion to restore sinus rhythm has failed. Recent
changes in nomenclature now mean that permanent AF is
regarded as AF when it cannot be reverted or when the phy-
sician has elected not to attempt reversion. AF occurring in
the absence of any identifiable related causation and par-
ticularly in the younger adult is referred to as lone AF. The
underlying mechanism initiating AF is predominantly rapid
electrical activity originating from the areas where the pul-
monary veins enter the left atrium. Electrical isolation of the
pulmonary veins is the basis of an AF ablation procedure.
At initial onset of AF the ventricular rate is usually
fast, between 100  and 200/min. resulting in a spectrum
of patient awareness symptoms, including palpitations,
fatigue, and dyspnoea to being functionally incapacitated.
Light headedness and pre-syncopal symptoms may result
from the fast rate or from a brief period of asystole following
18/11/2015 14:14
 400  Cardiovascular disease
reversion of AF to sinus rhythm in the presence of sinus
node dysfunction.
The incidence of AF is unknown as it can be asymptom-
atic and not recognized but it is the most common of the
cardiac arrhythmias, increasing with age, with an estimate
life risk occurrence after age 40 of some 25 per cent. Medical
conditions associated with the development of AF are prin-
cipally those involving left atrial overload, namely hyper-
tension, ischaemic heart disease, thyrotoxicosis and valve
disease. All may invoke subtle atrial stretch, some dilata-
tion or stretching of the left atrium also invariably occur-
ring after the first episode of AF, rendering the recurrence
of further episodes of AF more probable.
Acute-onset symptomatic AF may be managed with oral
or intravenous medications, the latter usually amiodarone
with beta-blockade or digoxin as oral agents. Atrial fibril-
lation of less than 48 hours’ duration can be cardioverted if
covered with heparin as the risk of clot is considered to be
low. Atrial fibrillation persisting longer than 48 hours may
also be cardioverted with a synchronized DC shock with
heparin cover but also requires a transoesophageal echo
study (TOE) pre-procedure to exclude a left atrial append-
age thrombus. If the AF had been present for more than a
few days this mode of management is unlikely unless there
is evidence of ventricular decompensation and a degree of
urgency required to restore sinus rhythm. Following a first
presentation with a low risk of recurrence, establishment
on warfarin or a newer anticoagulant may not be required.
From the aviation medical perspective, acute-onset AF
results in medical suspension.
Medication to reduce the frequency and duration of
AF paroxysms is the target of pharmacological therapy.
Digoxin is not effective for paroxysm suppression with beta-
blockade often being reasonably effective. There may be a
requirement for a combination with other anti-arrhyth-
mics, namely flecainide, although this is on an individual
basis and for re-certification requires aeromedical section
approval. Long term amiodarone is not an acceptable med-
ication due to the frequency of side effect, namely ocular
(with relevance to night vision) together with thyroid, pul-
monary and hepatic potential complications.
The natural history of AF is for the paroxysms to become
more frequent and of longer duration until permanent AF
results. Symptomatically, patients are less troubled when in
stable controlled permanent AF. Those who are very symp-
tomatic, particularly with paroxysmal AF, may be consid-
ered for an AF ablation procedure. This is a more significant
undertaking than a flutter ablation, with less predictable
outcomes. It is more effective for the paroxysmal AF patient
rather than those with permanent AF. The procedure may
have to be repeated with late recurrence of AF having
to be accepted. The current one-year success rates are in
the region of 70  per cent in carefully selected individuals
with paroxysmal AF in whom drug therapy has failed and
approximately 50 per cent after one procedure for the per-
manent AF group, although doubtless these outcomes will
be improved upon. Patients with AF have to be considered
K17577_C021.indd 400
for anti-thrombotic therapy given their risk of thrombo-
embolism. The clinical assessment method for the decision
of who requires treatment is based on the basic Chads₂ score
or for low risk individuals the Chads CHA₂DS₂-VASc score.
The majority of professional pilots would not be consid-
ered to require thrombo-embolic (TE) prophylactic medi-
cation in the form of anticoagulation by warfarin or the
newer novel oral anticoagulants (NOACs) as they would be
unlikely to score above one on the scoring regimen.
Reference to the Score Chart reveals:
C = Congestive heart failure point score 1
H = Persistent hypertension, above point score 1
140/90 or treated hypertension
A = Age 75 years or over point score 1
D = Diabetes mellitus point score 1
S2 = Prior CVA or TIA or arterial point score 2
embolic event
Scores of zero with no valve disease are considered not to
require TE therapy. A score of 1 is classified as an interme-
diate risk and a score of 2 or more requires TE treatment.
There is an expanded formula containing additional factors
aiming to identify the lower risk category. This formula is:
CHA₂ DS₂ – VASC
where A₂ = age over 75 scoring 2 points; V = vascular dis-
ease (peripheral or coronary) point score 1; A = 65-74 years
point score 1; Sc = female gender (counted provided at least
one other risk factor is present) point score 1.
Some Class 2 licensed pilots may score more than 2.
In respect of pilot certification the above scoring is inter-
preted as follows:
Score Certification
0 Class I OML restriction
Class 2 unrestricted
1 Individual assessment
2 Class 1 unfit
Class 2 OSL
>2 Unfit all classes
Warfarin, the only anticoagulant until recently, was pre-
viously a disbarring medication for flying status, but is now
accepted. NOACs, which are gaining rapid clinical accep-
tance, are expected to be approved.
It is accepted that medical certification requires normal
blood biochemistry for thyroid and liver function and nor-
mal full blood count parameters, with echocardiography
confirming the AF to be non-valvular and satisfactory LV
systolic function with an ejection fraction of at least 50 per
cent. Ambulatory 24  hour ECG recording is required to
confirm satisfactory rate control with no pauses longer
than 2.5 seconds when awake and a ventricular ectopic beat
18/11/2015 14:14

count of not more than 2  per cent of the total ventricular
complexes with no runs of ventricular ectopic activity. An
exercise ECG is required mainly for confirmation of effort
related rate control.
Clarification is required that the AF is not ischaemic
based with appropriate investigations to exclude this
(Myoview, stress echo, MRI or coronary angiography at the
discretion of the Cardiologist or Aeromedical Section).
Atrial fibrillation with these satisfactory results and no
symptoms is certifiable as detailed in the above table.
Initial follow-up after re-certification is required at six
months to include a 24 hour ECG. Thereafter normally an
annual review with 24  hour ECG and echocardiography
is undertaken. Rarely, a pilot who has had only one docu-
mented episode of AF with no recurrence over two years
may obtain Class 1 re-certification.
Re-certification following an AF ablation procedure
would require a three-month observational period, to
include 24-hour ECG monitoring and echocardiography for
ventricular function, following which restricted certifica-
tion may be permissible with a reassessment after six months
to include a 24-hour ECG and thereafter annual review.
Atrio-ventricular tachycardias
These are usually referred to as supraventricular tachycar-
dias (SVTs) although the mechanism involves the ventricles
as well as the atria. The term ‘reciprocating tachycardia’ is
also sometimes used. The mechanism involves additional
pathway(s) between the atria and ventricles.
The accessory AV pathway(s) have fibres outside the nor-
mal AV nodal-His Purkinje system. The accessory fibres
may intermittently conduct antegradely pre-exciting the
ventricles displayed as a delta wave or slurred onset upstroke
of the QRS complex with a shortened PR interval. When
this type of tachycardia occurs it is generally referred to as
a Wolff–Parkinson–White (WPW) syndrome. If the acces-
sory pathway only conducts retrogradely with antegrade
conduction through the normal system no pre-excitation
and no delta wave is seen on the ECG so the presence of
the accessory pathway is ‘concealed’. Hence the individual
may at times have a normal ECG if conducting through the
normal mechanism, or sometimes a delta wave if activat-
ing the ventricles via the accessory pathway. Intermittently,
following ventricular activation via the normal pathway,
retrograde accessory fibre conduction back to the atrium
followed by further antegrade conduction results in a tachy-
cardia termed orthodromic AV reciprocating tachycar-
dia. The reverse mechanism, i.e. antegrade conduction via
the accessory pathway, is termed antidromic tachycardia.
Some patients may have multiple accessory pathways. The
presence of a WPW syndrome carries a small but defined
risk of sudden arrhythmic death due to atrial fibrillation
being rapidly conducted down the accessory connection.
This risk and attendant arrhythmias can be eradicated by
a catheter based procedure to ablate the accessory pathway
which affords high rates of success at low risk and should be
regarded as the treatment of choice.
K17577_C021.indd 401
Cardiac rhythms  401
AV nodal tachycardias
This is a regular tachycardia at approximately 200/min
starting abruptly with a narrow QRS complex and P waves
not visible. The most common form is of having two intra-
nodal pathways with antegrade conduction down the slow
pathway with retrograde conduction via the fast pathway
back to the atrium, the cycle then repeating.
Commonly the tachycardias commence in adult life in
previously well individuals with no apparent heart disease.
The fast ventricular rate causes sudden awareness of palpi-
tations, recognition of the fast heart rate, often with some
light headedness, anxiety, perhaps chest pain and breath-
lessness or even a brief syncope at the spontaneous termina-
tion of the tachycardia.
The tachycardia may be slowed or terminated by apply-
ing vagal stimulation manoeuvres but if not, attendance at
an A&E Department is required where IV adenosine will
invariably (in approximately 90  per cent) terminate the
tachycardia by suppressing antegrade conduction in the
slow pathway. IV verapamil may also be successfully used.
Alternatively, prompt reversion is usually achieved by a DC
cardioversion procedure.
Radiofrequency (RF) ablation is an effective permanent
treatment and the treatment of choice, although there may be
some individuals where there is a risk of inducing AV block
from AV nodal damage. Should this occur this would preclude
future flying, the individual being pacemaker dependent.
Ventricular rhythms
PREMATURE CONTRACTIONS (VENTRICULAR
ECTOPICS)
Extra beats, which appear on the ECG as a wide complex
with an inverted T wave, occurring earlier than the next
expected sinus beat are common, particularly at rest. These
contractions are invariably considered to be of ventricular
origin although their precise origin cannot necessarily be
confirmed on the surface ECG as possible atrial activity
may be obscured.
A compensatory pause following the ectopic, with the
subsequent sinus beat often being felt as noticeably force-
ful is a common description. The awareness of such beats
often causes anxiety and presentation to a general practi-
tioner often with subsequent cardiological referral. The
ectopic beat, being relatively close to the preceding sinus
beat, resulting in two beats together is termed bigeminy.
Trigeminy refers to an ectopic beat that follows two sinus
beats. Ectopics may follow each other in pairs or triplets or
even more when the term ‘non-sustained VT’ is utilized.
Multiple ectopics of presumed ventricular origin may have
different shapes or configurations, may arise from different
parts of the ventricles or may be conducted differently but
are, by convention, termed multi-focal ectopics. Generally
ectopic beat activity increases in frequency with age and are
classically noticeable or symptomatic when at rest, reduc-
ing or resolving with activity and increasing heart rates.
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 402  Cardiovascular disease
Traditionally, although not necessarily correct, ectopics
which resolve with increasing heart rate are considered to be
benign. Investigation to establish the number of ventricular
ectopics in 24 hours and to confirm normal LV function are
required before continuation of flying duties. If greater than
7 per cent of the total beat count over 24 hours are ectopics
then assessment of cardiac structure and function by at least
echocardiography and exercise testing is required.
Ventricular tachycardia
Symptoms of light headedness or near-syncope require
investigation searching for a cardiac arrhythmia. If runs
of VT are recorded, flying must be suspended with inves-
tigations searching for a cause. Assessment of ventricular
function and exclusion of cardiac ischaemia are essential
with consideration given to possible Brugada syndrome and
prolongation of the QT interval. A detailed history for any
and all medications is essential particularly over the coun-
ter medications, for hay fever, rhinitis, allergies and anti-
biotic usage. Any of these plus many others may adversely
lengthen the QT interval, rendering the individual at risk of
developing ventricular tachycardias with a high risk of sud-
den death. Clearly, cardiological referral is required.
Brugada syndrome
An ECG pattern with three variables (Figure  21.1) recog-
nizable in the ECG chest leads V1  to V3  may raise suspi-
cion of the presence of this syndrome. A pilot may have
presented with the symptoms of palpitations or light head-
edness. This is an inherited autosomal dominant trait but
with some cases occurring unexpectedly and sporadi-
cally. The significance is that there is the risk of develop-
ing polymorphic ventricular tachycardias with a risk of
sudden cardiac death (SCD). The ECG pattern may arouse
I
aVR
II
aVL
III
aVF
Figure 21.1  Brugada syndrome ECG. Note the S-T elevation in the anterior chest leads V1 and V2 with T wave inversion.
An isolated ventricular ectopic beat is an incidental finding.
K17577_C021.indd 402
suspicion but may not be necessarily diagnostic. If sus-
pected referral to cardiology is required. Confirmation
may be made by an Ajmaline or other provocation testing.
BRADYCARDIAS
Heart rates are continually varying, slowing when at rest or
asleep. Fit, athletic individuals have a resting bradycardia. A
rate of less than 50/min is termed bradycardia, but as in the
above examples may be physiologically normal. Rates may
also be slowed by medications. Twenty-four hour ambula-
tory ECG recordings frequently detect nocturnal bradycar-
dias and it is important to avoid over-interpretation of these.
Normally a sinus bradycardia when sleeping can result in
pauses between QRS complexes of up to 2 seconds. Noting
that the rate normalizes when awake and active essentially
excludes a sinus bradycardia being significant (see also
‘Sinus arrhythmia’).
Sick sinus syndrome
This is a generalistic term covering disorders of sinus node
function. The sinus node may intermittently fail to func-
tion, or its electrical discharge may fail to activate the atria
(exit block) resulting in bradycardias or there may be bursts
of rapid sinus node activity with resultant tachycardias.
Uncommon in the pilot population but more common with
advancing age, but if present, and symptomatic, treatment
involves cardiac pacing to prevent bradycardias and phar-
macology (usually beta-blockade) to prevent tachycardias.
ATRIO-VENTRICULAR BLOCK
This describes the impairment of electrical conduction
between the atria and ventricles, usually at or below the AV
node. Impulses may get through but be delayed or may fail
V1 V4
V2 V5
V3 V6
18/11/2015 14:14

to reach and activate the ventricles. These defects are termed
first, second or third degree (complete) AV block.
First degree AV block describes all atrial contractions
reaching the ventricles but being delayed in doing so result-
ing in prolongation of the ECG PR interval (exceeding
0.20 seconds). This finding is not uncommon, particularly
at rest with slow heart rates, the PR interval shortening on
activity as the heart rate increases
Second degree AV block occurs as two different types.
One, termed Mobitz type I or Wenckebach phenomenon,
describes progressive lengthening of sequential PR inter-
vals until the P wave is not followed by a QRS. Following
the missed beat the PR interval then reverts as before with
progressive prolongation with subsequent beats with the
cycle repeating.
Mobitz Type II second degree AV block describes the
sudden blocking and failure of an impulse to the ventricles
without progressive lengthening of the PR interval. This
conduction defect may be recorded nocturnally and not
present during daytime activity.
Type I second degree AV block is generally benign and
type II second degree is considered to be the forerunner of
third or complete AV block.
Third degree (complete) AV block describes no atrial
activity being conducted to the ventricles, the ventricles
contracting by their own spontaneity. The conduction block
occurs at the AV node or below at the bundle of His Purkinje
fibre system.
With complete AV block the surface ECG atrial P waves
have no correlation to the ventricular QRS complexes. A
ventricular pacing site near the AV node or relatively high
within the ventricular myocardium results in a ventricu-
lar rate of approximately 50/min whereas a pacing site
lower or more apically in the ventricles results in a rate
of approximately 30/min. Spontaneous ventricular pacing
sites may be unreliable resulting in pauses causing tran-
sient loss of consciousness termed ‘Stokes Adams’ attacks.
Complete heart block (CHB) may be congenital, when
the heart rate in teenage or young adult life may be rea-
sonable with no symptoms, the condition sometimes not
being recognized until the first ECG recording at an initial
issue examination.
CARDIAC PACING
When clinical evidence indicates the requirement for car-
diac pacing, principally that of atrio-ventricular block,
pacemaker implantation should not be a bar to future fly-
ing. There are provisos, namely regular pacemaker follow-
up, functional checks and confirmation that the pilot has an
underlying stable ventricular rhythm. In other words, that
the pilot is not pacemaker dependent.
SYNCOPE
A syncopal episode is a transient loss of consciousness of
sudden onset and spontaneous recovery. A significant
K17577_C021.indd 403
Coronary artery surgery  403
reduction in cerebral blood flow results in syncope within
seconds. Pre-syncope is a term for near loss of consciousness.
Young individuals may have a history of ‘fainting’ dating
from their teenage years. With adulthood this vagally medi-
ated syncope, caused by bradycardia associated with hypo-
tension, reduces in frequency for those affected. Triggers
may be emotional stress in the form of the sight of blood,
vomit, trauma or prolonged standing. The diagnosis of the
syncope being vaso-vagal can invariably be obtained from
the clinical history. Other reflex syncopes frequently can
be recognized from the history, principally micturition or
defecation syncope.
Postural or orthostatic hypotension whilst not common
in the pilot population can and does occur, again being
recognized by the description. A drop of 20 mmHg in sys-
tolic or 10 mmHg in diastolic (or greater) defines postural
hypotension, although falls of greater magnitude may be
required to be symptomatic. Postural hypotension may be
induced or exaggerated in treated hypertensive individuals
by the use of peripheral vasodilatory medications, princi-
pally alpha blockers or ace inhibitors. Occasionally a tilt test
may be helpful diagnostically.
In the pilot population, valve disease particularly aortic
stenosis would have been detected at earlier medicals and
would not be of sufficient severity to cause syncope and
hence would normally be initially excluded as an underly-
ing cause. Tachy-arrhythmias would usually present with
mainly palpitation-related symptoms. Brady-arrhythmias
therefore should be considered, of which vasovagal bra-
dycardia is one; otherwise, sick sinus syndrome, the onset
of termination from a paroxysm of atrial tachycardia, or
transient AV block. Ambulatory ECG recording may be
required over several days to capture or exclude these pos-
sibilities. Suspension from flying activity may be required
for recording longer time periods than is practical with an
ambulatory ECG recorder.
If no cardiac rhythm cause is found a neurological
explanation should be sought, including migraine, minor
convulsive episodes or other autonomic dysfunction. If no
recurrence occurs and no cause is found, either cardiologi-
cally or neurologically, after an observation period of at least
six months discussion at a Medical Advisory Panel may lead
to a return to flying duties with an OML restriction.
CORONARY ARTERY SURGERY
The wide application of percutaneous coronary intervention
in current cardiological practice has significantly changed
the practice of cardiac surgery.
Rather than surgical grafting of single or of two coro-
nary arteries the patients referred for surgery are now those
with complex multi-vessel coronary disease. Typically, left
main stem stenosis involving the origins of the left ante-
rior descending and circumflex vessels, or often with right
coronary artery lesions (referred to as triple vessel disease)
invariably with multiple stenoses in each artery is the type
of patient not suited to PCI and referred for surgery.
18/11/2015 14:14
 404  Cardiovascular disease
Admittedly the majority of patients having coronary
artery disease of the type and extent described above are
the more elderly and hence less likely to be encountered
within the pilot subset. There are, however, pilots with high
risk factors, namely family history, diabetes, hypertension,
hyperlipidaemia, who have smoked and who may develop
widespread extensive disease whilst still in the working
age group.
There is an additional group of patients, including pilots,
who may have previously undergone one or more PCI pro-
cedures who have developed recurrent stenoses and are then
referred for surgery.
Following coronary artery bypass graft surgery (CABG)
there is a minimum licence suspension of six months fol-
lowing which an application for relicensing may be consid-
ered. Rehabilitation exercise classes, lifestyle modification,
correction of lipids by diet and pharmacology should occur
during the months immediately following surgery and be
continued thereafter. For consideration of relicensing a min-
imum of a cardiological clinical review, an exercise ECG,
stress echo or myocardial perfusion scan, Echocardiogram,
24 hour ECG and blood biochemistry are required together
with a review of the pre-surgical coronary angiography. The
data would normally be considered by a Medical Review
Panel who may request a post-surgical graft restudy angio-
gram. Should there be significant (50  per cent or greater)
disease in an ungrafted major vessel or significant sized
branch vessel, that would normally disbar the applicant
from relicensing. If all investigation requirements are sat-
isfactory, relicensing with an OML restriction is possible,
subject to annual review.
CARDIAC VALVE SURGERY
With the recognition that leaving asymptomatic but signifi-
cant valve disease until non-recoverable progressive ven-
tricular dysfunction occurs, patients are generally referred
for surgical management earlier in the progression of the
disease than has been the practice in previous years.
Within the pilot population degrees of mitral regurgita-
tion, usually secondary to prolapse of one or other or both
cusps, is not uncommon. This classically presents with an
easily audible apical murmur commencing in mid-systole
and being of crescendo type to the second heart sound.
Although the murmur may appear impressive the indi-
vidual is invariably asymptomatic. Surgical experience
and expertise is such that many asymptomatic patients are
referred for valve repair. The advantages are that the repair
may precede significant left atrial dilatation thereby reduc-
ing the risks of later onset atrial fibrillation and the left
ventricle may be spared from long-term volume overload
and subsequent functional damage. There is a risk of con-
tinuing or recurring mitral regurgitation despite surgery
which not only defeats the above advantages but increases
the risks for a subsequent mitral valve replacement opera-
tion. However, the cardiac surgical advice for any individ-
ual patient should be accepted and the decision for surgery
K17577_C021.indd 404
taken on medical advice, not taken on a consideration of
maintaining an aviation certificate in an asymptomatic
individual. In post-mitral valve repair after a six-month
medical suspension period, reassessment requiring simi-
lar criteria to that for coronary artery surgery is required.
If there was no requirement for accompanying coronary
surgery at the time of mitral valve repair the assessment
is reduced to that for mitral and ventricular functional
status only. Although atrial fibrillation may not have been
experienced or documented pre-operatively, there remains
an increased risk of that condition developing partly due
to the natural history of the disorder of mitral regurgita-
tion and partly due to the left atrium having been opened
and repaired at the time of the surgical repair approach.
Long-term anticoagulation is not required provided sinus
rhythm is maintained but may have to be considered
should paroxysms of AF commence at any time in subse-
quent follow-up. An annual review with ambulatory ECG
recording is required, with an OML limitation for at least
two years post-surgery.
It can never be guaranteed that even though a mitral
repair has been planned, for various technical reasons the
operation may result in the valve having to be replaced. A
mitral valve replacement, with either a tissue or a mechani-
cal prosthesis, is usually a disbarring procedure for licens-
ing. This has previously been due to the anticoagulation
with warfarin being unacceptable for certification. The
new oral anticoagulants (factor 10a and thrombin inhibi-
tors) now being popularized for AF anticoagulation are not
licensed for mechanical valve anticoagulation. Warfarin
has relatively recently been accepted for certification but the
INR levels for safe maintenance for mechanical replacement
valves are higher than for AF stroke prevention, thereby
increasing the bleeding risk. At present, mitral valve
replacement surgery is generally disbarring from licensing.
In younger females, should surgery be required for a
stenotic bicuspid aortic valve, the valve choice is often for
a biological prosthesis to avoid anticoagulation whilst still
being in the child bearing age. The downside is the reduced
lifespan of a tissue prosthesis compared to a mechanical
one. The average life of a tissue aortic valve is in the region of
10 years before a further valve replacement may be required.
A mechanical aortic prosthesis, providing anticoagu-
lation is correctly maintained and endocarditis does not
occur, can function satisfactorily almost indefinitely and
certainly outspanning the aviation working age. The issue
of anticoagulation with warfarin remains debatable in this
context. Until recently when warfarin was not permitted as
an aviation medication, the situation was straightforward
in that a mechanical valve prosthesis prevented subsequent
certification. Now that warfarin is licensable, restriction fol-
lowing an aortic valve replacement is theoretically possible
with attention being paid to the stability of the INR con-
trol and each pilot being considered on an individual basis.
The younger male pilot would be unlikely to be offered a
tissue aortic valve replacement for the reasons of reduced
valve longevity.
18/11/2015 14:14

ENDOCARDITIS
A focus of infection anywhere may result in a bacteraemia.
Should the bacteria settle and propagate on an intracardiac
valve, a septicaemia results with the illness being bacterial
endocarditis. Normal heart valve surfaces are smooth mak-
ing it unlikely that bacteria would be able to propagate on
the valve, but even minor congenitally malformed valves
are susceptible to being the site of endocarditis.
Endocarditis generally occurs where a jet lesion of blood
flow exists, hence a missed patent ductus arteriosus or a
coarctation may be the site of infection, however this is very
rare in pilots who have previously been granted certification
at initial issue.
Endocarditis should be considered when symptoms of
malaise and lassitude develop for no immediately apparent
reason, particularly if episodes of fever or nocturnal sweat-
ing occur. The long-held view that it is a sub-acute illness
developing over several months has largely changed mainly
due to the change in current responsible bacteria. Hence,
the peripheral stigmata of splinter haemorrhages, Janeway
lesions or Roth spots are now rarely seen, these being small
distal arterial septic emboli. In essence, if a murmur exists
indicating a potential site for endocarditis or if there is a his-
tory of previous cardiac surgery (other than coronary artery
surgery) then endocarditis must be at the top of a differen-
tial diagnostic list of a pyrexial illness. Raised inflammatory
markers, principally a CRP, a raised white blood cell count
or ESR, are highly significant. Obtaining positive blood
cultures clinches the diagnosis. Blood cultures may, how-
ever, be frustratingly difficult when perhaps only one of six
bottles has a growth suggesting that to be a contaminant.
Often treatment is commenced solely on clinical grounds
with negative blood cultures. Transoesophageal echocar-
diography can be very helpful in identifying the presence of
valvular vegetations and in the resolution of vegetations fol-
lowing treatment when assessment of residual valve func-
tional damage is required.
Following antibiotic treatment for an endocarditis epi-
sode, return to flying is dependent on the residual valve sta-
tus. In the pilot group we are mainly concerned with aortic
valve endocarditis. Due to fibrotic healing after the inflam-
matory episode aortic regurgitation is the predominant
issue and may progress with later further scarring, hence
regular, annual clinical and echocardiographic assessment is
required. Functional valve assessment also requires left ven-
tricular systolic function to be well maintained with an ejec-
tion fraction of at least 50 per cent and stenosis of the valve
being as detailed under ‘Aortic stenosis’ with an estimate of
aortic regurgitation being no more than mild.
After years of advocating antibiotic prophylaxis for indi-
viduals undergoing surgical, mainly dental procedures, to
avoid bacteraemia, this practice has been abandoned as a rou-
tine, being used sparingly now for those estimated to be of
higher risk for endocarditis. Such individuals are those with
prosthetic heart valves and patients who have had previous
endocarditis or previous surgery for congenital heart disease.
K17577_C021.indd 405
Pericardial disease  405
PERICARDIAL DISEASE
The pericardium consists of two layers, an inner or visceral
pericardium adherent to the outer or epicardial surface of
the heart and an outer parietal pericardial sac with nor-
mally a small volume of fluid, approximately 50 mL between
the two pericardial layers.
In addition to providing lubrication for the heart to move
freely during systole and diastole, the parietal pericardium
provides significant mechanical support, preventing over
dilatation of the heart during filling and providing pres-
sure assistance for cardiac contraction. A modest increase
in the pericardial fluid volume can be accommodated with-
out mechanically interfering with cardiac function but a
significant increase in pericardial fluid causes mechanical
functional cardiac problems. The causes of increased peri-
cardial fluid or pericardial effusion are outlined below, but
from a functional perspective, once the pericardial fluid
(between the two layers of the pericardium) volume becomes
significant, it limits further stretching or distension of the
parietal pericardium, with the pressure within the contained
pericardial fluid then rising. Once that pressure exceeds the
diastolic pressure within the right ventricle and/or the right
atrium during diastole it results in the right heart chambers
‘collapsing’ during diastole and therefore being unable to
accommodate filling from venous return. The consequence
is reduced pulmonary blood flow and reduced filling of the
left heart with reduced systolic blood pressure. This is the
clinical condition of cardiac tamponade. When it occurs,
tamponade is serious and can be fatal. The condition would
not normally occur without preceding symptoms of being
unwell and symptoms reflecting the underlying illness.
Though tamponade is unlikely to develop within the pilot
population conditions which may lead to tamponade could
be a presenting problem within the pilot age group.
Acute pericarditis
This acute inflammatory illness may be termed idiopathic
but in practice is invariably of viral aetiology. The inflam-
mation affecting the adjacent layers of the pericardium
results in symptoms of chest pain. Those symptoms are
often atypical, being augmented by inspiration due to this,
causing increased filling of the right heart and approxima-
tion of the two inflamed pericardial surfaces, heart move-
ment then being frictional. Chest pain during inspiration
may also have a pleural component as the viral inflamma-
tory illness may also cause varying degrees of pleurisy.
The normal response to inflammation is to exude fluid
which does occur within the pericardial space but not usu-
ally to a significant degree in relation to an acute inflam-
matory pericarditic illness. The condition primarily affects
young adults becoming infrequently seen with advancing
age (over 50  years). The diagnosis may be made clinically
based on the presenting symptoms and confirmed if a peri-
cardial friction rub is detected by auscultation. Supporting
evidence from classic ECG changes of high take off and
18/11/2015 14:14
 406  Cardiovascular disease
concave upward ST segments may be seen in multiple ECG
leads. Differentiation from an ST segment elevation myo-
cardial infarction can sometimes pose diagnostic difficul-
ties but usually the patient age and clinical status allow the
differentiation. Modest elevation of troponin may co-exist
due to associated myocardial inflammation.
Acute viral pericarditis is usually a self-limiting illness
and recovery is expedited by the use of non-steroidal anti-
inflammatory agents. Occasionally colchicine may be uti-
lized should recurrent pericarditis occur.
Occasionally there may be a bacterial rather than a viral
aetiology for acute pericarditis resulting in a pyo-pericar-
dium. This, should it occur, is usually related to an adjacent
area of consolidated pneumonia. Developing rapidly, from
what may initially be considered a respiratory infection, it
is a very serious illness usually requiring surgical drainage.
The illness of acute viral pericarditis symptomatically
resolves over 3–6  weeks with the majority of individu-
als having a full recovery. However, from a certification
perspective an observational time period is required after
the resolution of acute symptoms. There may be ongo-
ing constitutional symptoms for a few months. Resolution
of ECG changes is a requirement. The ECG during the
recovery phase may develop widespread inverted T waves
before normalization. With a normalized ECG, resolu-
tion of symptoms, further basic investigations in the form
of echocardiography and 24-hour ECG recordings are the
basic requirements before re-certification. Should ECG
changes persist further, investigations to exclude underly-
ing or coexistent coronary artery disease may be required.
On the basis that acute viral pericarditis can have a relaps-
ing pattern with secondary recurring episodes, albeit of less
severity than the initial episode, a restricted certification
of 3–6 months after the initial episode providing the indi-
vidual is asymptomatic with normal investigations is appro-
priate. The restriction may be removed provided no further
symptomatic episodes have occurred by 12 months.
Although complete recovery from viral pericarditis
generally occurs, relapses or recurrent episodes of peri-
carditis are not uncommon. The relapse episodes usually
occur within a year of the initial episode and the recur-
rent episodes are less severe, both in symptoms and dura-
tion. However, the symptoms of a relapse episode can be
disabling from an aviation perspective. Longer-term use of
anti-inflammatory agents is required, with colchicine often
being helpful.
Other pericardial conditions
The pericardium can become involved in a number of sys-
temic disorders or malignant conditions. Inflammatory
states, related to rheumatoid type arthritis or polyserositic
conditions in which conjunctivitis, the pleura and pericar-
dium become inflamed, are well recognized. As a site for
malignant secondary deposits either from thoracic malig-
nancies or blood-borne dissemination the pericardium
is often involved. The presentation of these conditions is
K17577_C021.indd 406
usually with symptoms related to the primary condition
although the development of a significant pericardial effu-
sion and possible tamponade can present with reduced
effort tolerance and dyspnoea.
Other chronic infections, the classic being tuberculosis,
can involve the pericardium, again with the insidious onset
of a large effusion. Other metabolic disorders, e.g. hypothy-
roidism, may result in an effusion, although the probability
would be that the symptoms of the primary disorder would
result in its detection before those of a cardiac nature. For
these more uncommon conditions, should they occur in
the aviator, the question of licensing would be based on the
primary pathology.
Constrictive pericarditis
The longer term consequence of previous pericardial infec-
tion, inflammation or a previous haemopericardium from
trauma is that of healing with fibrous formation. The peri-
cardium given time may calcify, in which case the condi-
tion is readily recognized. Otherwise the constrictive effect
of the pericardium being adherent to the heart is that of the
heart not being able to distend and accommodate diastolic
filling plus some limitation on inwards systolic movement.
The intraventricular septum being intracardiac and not
affected by the pericardium may develop swinging move-
ments to the left and right to aid ventricular systole. This
feature is readily recognized by echocardiography but if
not present, the condition can present diagnostic difficul-
ties in differentiation from a restrictive cardiomyopathy.
Cardiac MRI is invariably helpful. Symptomatically, grad-
ual onset effort dyspnoea occurs. It is an uncommon con-
dition but can occur within those of flying age. Surgical
treatment in the form of pericardectomy provides effective
relief of constriction. Clearly when diagnosed the condition
precludes licensing. Following treatment the question of
re-licensing is very much on an individual basis, requiring
cardiological investigation to confirm resolution of the con-
dition, maintenance of ventricular function and freedom
from arrhythmias.
MYOCARDITIS
Viral inflammation of the pericardium surrounding the
heart may be associated with the heart being involved in the
same inflammatory process. The consequence is myo-peri-
carditis. The condition can equally be the reversal of that,
with the primary issue being viral myocarditis with subse-
quent pericarditis. Myocarditis is significantly more seri-
ous than isolated pericarditis. The inflammation within the
myocardium results in degrees of muscle cell destruction,
the subsequent consequence being of impaired myocardial
function and electrical instability leading to arrhythmias.
The disorder may initially be mild and little different from
an influenza like episode, but followed within weeks or a
few months by reduced effort tolerance from ventricular
damage and dysfunction. Although difficult to prove, viral
18/11/2015 14:14
 Myocarditis 407

I aVR
V1 V4

II
aVL V2 V5

III aVF V3
V6

VI
150 Hz 25.0 mm/s 10.0 mm/mV 4 by 2.5s + 1 rhythm lds MAC 8 002B 12SLtm v250

Figure 21.2  Close examination of the intermittent thicker trace reveals it to be the regular sawtooth pattern of AC elec-
trical mains interference. Unplugging other nearby mains-powered equipment may eliminate the electrical ‘noise’; other-
wise, operating the ECG on battery mode will remove it. The trace reveals the rhythm to be atrial flutter.

myocarditis is considered to be the most common cause of
a dilated cardiomyopathy. Some, and probably the majority,
of viral myocarditic episodes resolve spontaneously, with
maintained ventricular function, with the illness passing
unnoticed. Some suggestive features may be non-specific T
wave inversion on the ECG for no other apparent reason.
Evidence of previous myocarditis is found not infrequently
at post mortem in cases of cardiac death, this being due to
an arrhythmic event. If diagnosed as an acute event, treat-
ment involves rest and anti-inflammatory agents, with sus-
pension of certification until evidence is available that the
condition has resolved, followed by a period of observation
for stability. Again, there is individual variation but a licence
suspension of six months would normally be required with
evidence of maintained ventricular function by echocar-
diography and freedom from arrhythmias on ambulatory
recording before re-certification.
Whilst virus infection is the most common cause of
myocarditis, with that condition mainly being in the
younger adult, there are a number of other aetiologies for
myocarditis. The myocardial inflammation may be chronic
rather than acute and reflect the consequence of exposure to
substances ‘toxic’ to the heart. Arguably the most common
of these is alcohol. Other causations may be previous cyto-
toxic drugs given in childhood for neoplastic conditions,
gases (principally carbon monoxide) or illicit recreational
drug use (principally cocaine). Presentations with a dilated
cardiomyopathy for which no recognizable genetic or previ-
ous acute or chronic illness can be identified, probably are
the consequences of previous unrecognized myocarditis.
Once presentation is made, primarily with a symptom-
atic reduction of effort tolerance, investigation identifies
impairment of left ventricular systolic function (LV dilata-
tion and an ejection fraction of less than 50 per cent) and
licence suspension is inevitable for Class I privileges. Some
flexibility based on symptoms and stable minor reduction
in LV function may be permissible on an individual basis
for Class II certification.
The normal ECG
The surface ECG plays a fundamental role in the clinical
assessment of an applicant for aeromedical certification.
Errors in recording technique may incur significant stress
and expense upon a healthy pilot.
The essentials to obtain a quality recording are:
●● A suitable, digital recorder, preferably capable of operat-
ing on battery mode.
●● A three channel recorder printing on A4 size paper.
●● An environment free of AC electrical mains interference
(Figure 21.2).
●● Good quality adhesive electrodes.
●● Appropriate skin preparation, clear of moisturising
cream, sweat and with localized hair removal if neces-
sary. Light rubbing of the electrode site with an emery
or abrasive pad for optimum skin contact.
●● Correct electrode positioning (Figure 21.3).
●● Patient supine, relaxing, avoiding muscle tension
or tremor.
●● Patient data entered via keypad (not subsequently hand-
written on the recording).
●● Repeat recording, if necessary, if artefacts apparent.
●● Check standard amplification marker of 10 mV gener-
ated by the equipment at commencement of the record-
ing. The gain may be increased or decreased by the
operator if necessary if complexes are too small or too
large avoiding overlapping signals.

K17577_C021.indd 407 18/11/2015 14:14

 408  Cardiovascular disease

or down. In chest lead VI the P wave is normally upright but

the second half of the P wave may become negative (inverted)
reflecting left atrial enlargement. Atrial repolarization volt-
age is too low to be identified on the surface ECG.
The PR interval is taken from the onset of the P wave to
the onset of the QRS complex.
The QRS reflecting ventricular activation or depolariza-
tion spreads throughout the ventricular myocardium as
wave fronts from the inner endocardial surface, the activa-
V2
V1
V3 V5
V6 tion spreading from myocardial cell to cell until reaching
V4 the outer epicardial surface. The initial Q wave is negative,
the following R wave positive with the subsequent S wave
negative. The QRS complex also reflects the axis or the posi-
tion of the heart which normally is between –30° to +90°. If
>90° it is termed right axis deviation; if –30° or more, left
axis deviation. Rapid and reasonably reliable visual rec-
Figure 21.3  Electrode positions of the chest leads used
for the standard 12-lead electrocardiogram (ECG). The ognition of the cardiac axis can be obtained by looking at
limb leads are placed on the right and left arms and right the ECG trace. If the QRS complexes are diverging, being
and left legs. The right leg is an indifferent electrode. upright in standard lead I and negative in standard lead
III then they are leaving each other and that almost always
●● The diagnostic printout to be read whilst the patient still establishes the presence of left axis deviation. The R wave
attached. If abnormalities are indicated, check all of the signal normally increases in magnitude in subsequent chest
above and particularly electrode attachment and repeat leads from V4 to V6. Failure to do so may reflect incorrect
before accepting. lead positioning or myocardial disease. The normal ST seg-
ment lies on the isoelectric or horizontal line of the ECG
ECG INTERPRETATION – NORMAL VALUES with the T wave commencing as a gradual slope, the ST–T
wave junction referred to as the J point from which the ST
Each small square of the ECG recording paper when the level is measured (in cases of ST segment depression). The T
recording is made at the standard operating speed of wave is normally upright in leads I, II, aVL, aVF and the lat-
25 mm/sec equates to 0.04 seconds, i.e. three small squares eral (V4–V6) chest leads. T waves are negative in aVR, may
equate to 120  milliseconds. The normal time intervals for be up or down in standard lead III and usually down in the
each section of the ECG are listed below. These are generally chest leads V1 and V2. A small amplitude ‘U’ wave may fol-
accepted values recognizing that slight variations can occur low the T wave. Usually, if present, a U wave is best seen in
between genders, race, age groups, habitus and differing chest leads V1 or V2. It is part of the repolarization process.
equipment manufacturer. These changes are, however, very Of major importance in each ECG interpretation is the
small, hence the normal values quoted serve as the accepted. Q-T interval. This is measured from the onset of the QRS to
the end of the T wave (see Long QT syndrome).
Duration
ECG Reflecting (milliseconds) QT interval prolongation
P wave Atrial activity <120
The QT interval is measured from the onset of the QRS
PR interval Conduction between <200 complex to the end of the T wave. Determining the pres-
atria and ventricles ence of the end of the T wave can be difficult as it often
QRS Activation <110 slopes down to meet the isoelectric line, the precise point
(depolarization) of being difficult to define and may not be measurable at all
ventricles in some leads. To aid recognition if a line is drawn on the
T wave Ventricular recovery Variable, taken in down sloping terminal second half of T wave, noting the
(repolarization) conjunction point where this line crosses the isoelectric or baseline of
with Q-T the ECG, it effectively marks the end of the T wave and is
interval the usual measuring point. There is no difficulty in identi-
QT interval Ventricular recovery <450 (see text) fying the Q wave at the start of the QRS complex. All ECG
corrected leads should be studied to obtain the most recognizable
for heart end of the T wave but generally standard lead II is often
rate preferred with leads III, aVL and V1  generally avoided.
The computerized interpretation in ECG machines takes
The P wave is normally upright (positive) in standard an average from multiple leads from the earliest Q wave
leads I and II, aVL and aVF. In lead III and aVL it may be up to the latest end of T wave as the value in each lead may

K17577_C021.indd 408 18/11/2015 14:14


differ. The QT interval shortens with increasing heart
rate such that the QT interval has to be corrected for rate
and is expressed as QTc (corrected QT). The QTc varies
between gender, the normally accepted adult female QTc
being up to 470  milliseconds and that for the male up to
450  milliseconds (msec). The interval frequently varies
slightly in the same individual and there are clear racial
differences. Several methods exist for calculating the cor-
rected QT interval, the common one being that of Bazett
from 1920, the equation being:
QT
QTc =
√RR
where the RR interval is measured in seconds and is equiva-
lent to heart rate.
Another formula often used is:
QTc = QT + 1.75 (HR-60)
(HR = heart rate in beats per minutes)
The significance of the QT interval is the risk of develop-
ing fatal ventricular arrhythmias if the QT interval is
significantly prolonged.
Prolongation of the QT interval may be congenital,
inherited as an autosomal dominant. Some individuals
have a hearing defect which would identify and exclude
them at initial issue. This may be confirmed by genetic stud-
ies. Such individuals would normally have been identified,
principally from a family history of individuals having sud-
den death and such applicants would not have obtained an
aviation medical. However, an acquired form of long QT
can be exposed or unmasked by several commonly used
medications. The copious lists of such medications are read-
ily available on the Internet but include some antihista-
mines and several antibiotics. In practice, for a ventricular
arrhythmia to develop the QTc would normally be in excess
of 500  msec. The classic type of ventricular tachycardia
which may occur in this syndrome is termed ‘Torsade de
pointes’ which is a high risk unstable polymorphic ventric-
ular tachycardia arrhythmia, which may progress to ven-
tricular fibrillation and sudden death. This emphasizes the
importance of obtaining a history of medications, including
over the counter preparations, particularly if a long QTc is
recorded or if a pilot presents with symptoms of dizziness,
light headedness or palpitations.
QRS abnormalities
LEFT VENTRICULAR HYPERTROPHY (LVH)
Increased muscle mass produces increased ECG voltages,
particularly in the chest leads. The T wave in the lateral chest
leads reduces from upright to flattening and then becomes
inverted. The voltages on the resting ECG if increased are
taken to represent left ventricular hypertrophy but it is rec-
ognized that this can be unreliable. A slim body build may
K17577_C021.indd 409
Cardiological diagnostics  409
underlie apparent increased voltages such that in an oth-
erwise well individual with no evidence of hypertension
such increased voltage criteria may require further clari-
fication by imaging. The basic imaging modality is echo-
cardiography. Assessing heart size on a plain chest X-ray is
notoriously unreliable.
There are several methods of estimating the presence of
left ventricular hypertrophy on the ECG, the most common
being to measure the S wave in V1 adding it to the R wave in
leads V5 or V6 (whichever is the larger) and if the summa-
tion equals or is greater than 35 mm (which equates to seven
large squares) with the R wave in aVL equal to or greater
than 11 mm, left ventricular hypertrophy should be consid-
ered (the Sokolow-Lyon index).
RIGHT VENTRICULAR HYPERTROPHY (RVH)
The changes of RVH are virtually never seen in the pilot
population given that a considerable time is required for the
right ventricle to hypertrophy. Acute RV strain changes may
be seen following an acute pulmonary embolic event. The
changes of RVH with right axis deviation of greater than
90° are right atrial enlargement and an R/S ratio of >1  in
lead V1. There are several other indicators but none specific.
LEFT BUNDLE BRANCH BLOCK (LBBB)
Impaired conduction within the left bundle widens the QRS
to 120 m/sec or greater. Partial or incomplete LBBB may occur
appearing similar to a left ventricular hypertrophy pattern.
Anterior hemi-block is a subtle variant but the significance
of LBBB is that the majority have an underlying reason for
it. The most common is LVH consequent upon whatever
underlies the LVH. New onset LBBB requires investigation.
RIGHT BUNDLE BRANCH BLOCK (RBBB)
Right bundle branch block, a conduction block or a delay
in the right sided conduction system, may be present from
birth. Many normal individuals have this conduction
defect. A predominantly upright widened QRS in chest lead
V1  readily establishes RBBB. However, new onset RBBB
may reflect ischaemic heart disease. A variant, having some
similar resemblance to RBBB and termed the Brugada
syndrome can identify individuals at risk of developing
lethal arrhythmias.
Bundle branch block patterns both left and right may
be rate dependent in that conduction is normal at rest, the
block reflecting impaired conduction being exposed at
higher heart rates commonly being identified on an exercise
ECG test.
CARDIOLOGICAL DIAGNOSTICS
Resting ECG
This is in the hands of the aviation medical examiner and
requires particular care in recording to avoid precipitating
subsequent unnecessary expensive investigation and unjus-
tified license suspension. See Figure 21.4.
18/11/2015 14:14
 410  Cardiovascular disease
I aVR
II
aVL
III
aVR
VI
II
V5
150 Hz 25.0 mm/s 10.0 mm/mV
Figure 21.4  Resting 12-lead ECG. Noise is seen on the standard (limb) leads, but not on the chest leads. This is a typical
example of muscle tremor.
Exercise ECG
This sometimes is mistaken by pilots as a fitness test in that
it is associated with gymnasium equipment. It should be
explained that while a degree of fitness is apparent from the
workload achieved, heart rate response and recovery times,
the basis is that physical exercise is undertaken to stress the
heart rather than assessing fitness.
In the UK the convention is to utilize a treadmill pro-
grammed to operate to the standard Bruce Protocol which
controls the speed and slope of the treadmill, parameters
changing at three minute intervals. Continuous ECG moni-
toring by a 12-lead ECG system with intermittent ECG
recording is undertaken. For a normal result, a minimum
of nine minutes’ exercise is required during which time the
ECG should, apart from rate increase, remain unchanged
from the resting recording. Particular attention is made to
the ST segment observing for horizontal depression from
the baseline. A depression of 2 mm or more is taken to be an
abnormal test reflecting the possibility of cardiac is­chaemia.
Isolated complexes with ST segment depression with no
depression on the preceding or following beats should not
be interpreted as abnormal. Although digital ECG recorders
provide a more stable baseline than the previous analogue
machines, there is still some respiratory influence on the ST
segments. Symptoms associated with the exercise should be
noted and the ECG monitoring continued for 10  minutes
following cessation of exercise. This is due to ECG changes
sometimes developing after the onset of the ischaemic pro-
cess and to monitor for any arrhythmic activity during
recovery. The blood pressure should be monitored through-
out and should rise commensurate with the heart rate during
exercise, returning during recovery. The BP may be lower at
the end of recovery reflecting vasodilatation. A stress test can
K17577_C021.indd 410
V1 V4
V2 V5
V3 V6
4 by 2.5s + 3 rhythm lds MAC 8 002B 12SLtm v250
often provide helpful information regarding the adequacy of
blood pressure treatment or expose and confirm the presence
of debatable hypertension. If there are symptoms of effort
dyspnoea the arterial oxygen saturation may be monitored
throughout using a fingertip oximeter. A similar evaluation
utilizing a bicycle ergometer may be performed and is the
preferred method in some European centres. Beta-blocker
medication should be discontinued for at least 24 hours prior
to an exercise stress test unless that medication is essential
for arrhythmia or blood pressure control.
In the presence of left ventricular hypertrophy reflecting
established hypertension, there may be a mismatch between
coronary arterial oxygen supply and the mass of myocar-
dium to be supplied. ST segment depression towards peak
exercise may be observed but if reflecting left ventricular
hypertrophy and not flow-limiting coronary arterial dis-
ease, the ST segments return to the isoelectric line promptly
and within approximately one minute of exercise termina-
tion. Genuine induced ischaemia usually induces ST seg-
ment change taking several minutes to slowly recover.
The diagnostic accuracy of an exercise stress ECG for pre-
dicting flow-limiting coronary disease has been the subject
of numerous studies since the 1970s. Diagnostic tests are cat-
egorized by their sensitivity and specificity. As a reminder:
1. Sensitivity = true positives/(true positives + false nega-
tives). It reflects the percentage of all patients with
coronary disease with an abnormal test.
2. Specificity = true negatives/(false positives + true
negatives). It reflects the percentage of negative tests in
subjects without coronary disease.
3. Positive predictive accuracy = true positives/(true
positives + false positives). It reflects the percentage of
abnormal responses in subjects with coronary disease.
18/11/2015 14:14

4. Negative predictive accuracy = true negatives/(true
negatives + false negatives). It reflects the percentage of
negative responses in subjects without coronary disease.
An exercise ECG is generally accepted to have a 70 per cent
sensitivity and a specificity of 80–90 per cent. There is a lower
predictive accuracy in females where false positive results
occur more frequently. However, if ST segment changes occur
within the first few minutes of exercise (before six minutes)
there is a high probability of underlying disease, whereas if
exercise continues to the conclusion of a normal test (which
can continue longer than nine minutes and be terminated
when the peak predicted maximum heart rate is achieved or
at the limit of the patient’s effort tolerance) and is associated
with no ECG changes, there is a high probability of no flow-
limiting disease. The test does not predict the presence or
otherwise of coronary arterial disease for that can be present
without inducing any coronary flow restriction. The test is
intended only to expose evidence of significant flow-limiting
coronary arterial disease. Much debate is now centred on the
diagnostic value of conventional exercise ECG testing in that
the UK Government NICE guidelines protocol for chest pain
has advocated alternative functional testing, principally
stress echocardiography or Myoview (myocardial perfusion
scan) or cardiac CT imaging. However, within the aviation
environment the exercise ECG evaluation is still accepted as
a fundamental evaluation technique, with the requirement
for further information should ST changes, with or without
symptoms, occur during the test. Additionally if the blood
pressure does not rise progressively with exercise this is con-
sidered to be abnormal. The predicted maximum heart rate
should be achieved (220-age) or at least nine minutes of the
standard Bruce Protocol test should be completed.
I V1
aVR
II
aVL
III
aVF
VI
II
V5
150 Hz 25.0 mm/s 10.0 mm/mV
Figure 21.5  This ECG illustrates a combination of artefacts. The wandering baseline is caused by poor electrode skin con-
tact. Hair, skin cream, poor quality or out-of-date electrodes are the most common causes. Muscle tremor is also evident.
K17577_C021.indd 411
Cardiological diagnostics  411
Ambulatory ECG monitoring
Recording an ECG whilst continuing normal daily activ-
ity or during sleep has been available since the late 1960s.
Sometimes still referred to as ‘Holter’ monitoring after its
inventor, the term ‘ambulatory ECG’ or ‘24-hour ECG’ is
more frequently used.
The recording device has been miniaturized in recent
years, principally due to using flash memory cards simi-
lar to those used in digital cameras. The small lightweight
devices are very patient acceptable with the extended mem-
ory enabling recordings to be continuous for up to seven
days. The principal advantage is of recording the ECG con-
tinuously, rather than being activated intermittently by the
patient. Self-activation implies the patient is aware of symp-
toms and is able to activate a device in sufficient time to cap-
ture an event, clearly not practical if asleep or experiencing
a transient loss of consciousness. Patient activated devices
currently have little application.
The ambulatory ECG conventionally utilizes three chest
leads providing two channels of ECG recording. The second
channel provides clarification should an artefact appear or
suggest a dubious event in one channel (Figure  21.5). The
system has an inbuilt clock enabling the precise timing of
events. Additionally, there is a patient activation button to
mark the recording should the patient experience symp-
toms. Transient changes of cardiac rhythm and heart rate
are readily detected together with the detection of ectopic
beats, pauses or any variation of cardiac rhythm. When
analyzed the data are expressed both in ECG format with
selected portions printed at normal size and speed, and also
in a full disclosure of the 24  hours on a smaller scale for
the practicality of record keeping. Beat counts are printed
V4
V2 V5
V3 V6
4 by 2.5s + 3 rhythm lds MAC 8 002B 12SLtm v250
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 412  Cardiovascular disease

enabling, e.g. the number of ectopic beats and their percent-

age occurrence over the 24 hours to be identified.
The technique is not intended to detect episodes of isch-
aemia and should not be requested for that purpose.
Ambulatory recording technology has been extended to
incorporate 24 hour blood pressure and EEG recording.
Wearing a conventional recorder with skin electrodes is
impractical for continuous recording beyond several days
although repeated week-long recordings can be made if
searching for a possible cardiac event. In respect of pilots
this is usually searching for an explanation for a previ-
ous episode of dizziness or transient syncope. For lon-
ger periods of recording a small implantable recording
device termed a ‘loop recorder’ is implanted under local
anaesthetic subcutaneously on the anterior chest wall, the
recorder monitoring the heart rate continuously capturing
abnormal rate rhythm episodes. Originally the devices were
approximately the size of a USB computer memory stick but
recently have been miniaturized to be implanted through a
needle delivery system and with the capability of recording
for up to three years (Figures 21.6 and 21.7). Recordings can
be downloaded at any time by placing a receiving device on
the skin over the recorder or transmitted from the patient’s
home by a wifi system to the hospital with a nominated per-
son emailed if an arrhythmia detected.
ECHOCARDIOGRAPHY
Ultrasound applied to the heart and termed ‘echocardiogra-
phy’ (echo) is a mainstay principal investigation undertaken
within clinical cardiology. As with all technology the equip-
ment has been reduced in its physical size but at the same
time vastly improved in terms of resolution and diagnostic
reliability. Small portable handheld devices can be used to
complement a physical examination, sometimes referred to
as an electronic stethoscope. However, when an individual,
and particularly a pilot, is required to undergo an echocar-
diographic examination a full detailed departmental study
Figure 21.6  A subcutaneous implantable loop recorder,
capable of monitoring the ECG for up to three years.
Recorded data can be transmitted from a home wifi sys-
tem. An example print out of a recorded episode is shown
in Figure 21.7.
is required. The requirements for a complete data set are
published by the British Society of Echocardiography and
the individuals undertaking and reporting the examination
should have British Society of Echocardiography accredi-
tation. Hospital departments are now obtaining depart-
mental echocardiographic accreditation. The reasons for
these requirements are to ensure that an echocardiogram is
undertaken to a reproducible standard. A full study requires
approximately half an hour and is very patient acceptable
with no radiation emission.
In principle, echocardiography provides dimensions of
all the cardiac chambers and of wall thicknesses. Assessment
of function is readily appreciated visually and by inbuilt
calculation packages the most frequently assessed, being
that of ejection fraction which in a normal heart would be
a value in excess of 55  per cent. Intracardiac valve struc-
ture and function is assessed in all studies together with an
assessment of the right heart and pericardium. Pathological
pericardial fluid present is immediately detectable and in
some individuals if there is a small degree of tricuspid valve
regurgitation (which commonly occurs without necessarily

23:33:02

23:33:15

23:33:28

Figure 21.7  Print out from a Loop recording demonstrating sinus rhythm with the onset of a narrow complex tachycardia.

K17577_C021.indd 412 18/11/2015 14:14


having cardiac pathology), an estimate from the signal can
be made of the pulmonary artery systolic pressure.
Transthoracic echocardiography now provides 3-dimen-
sional moving image data of the heart, this being particularly
helpful for assessing chamber volumes. The scanning tech-
nique can be augmented by the administration of echo con-
trast which is available in two forms. Small gas-filled bubbles,
the bubbles being approximately the size of red blood cells,
if injected into a peripheral arm vein, are small enough to
transit the lungs and therefore appear within the left heart.
The bubbles reflect ultrasound waves and as a consequence
the left heart chambers are highlighted. This can vastly
improve the imaging of the heart in individuals who present
with imaging difficulties, e.g. obesity or respiratory issues.
An alternative type of contrast is that of mixing a small vol-
ume of saline solution with a small proportion of air and a
few mLs of patients’ blood; when agitated this forms a frothy
medium due to bubble formation. The bubbles are too large
to transit the lung but highlight the right heart chambers.
This is particularly useful for assessing the presence of a pos-
sible patent foramen ovale; if present the contrast would be
imaged entering the left atrium (normally this type of bubble
contrast is confined specifically to the right heart only).
For clarification of specific issues, namely in an individual
who may have experienced a systemic embolic event where a
patent foramen ovale may be suspected, or in an individual
with cardiac rhythm issues (namely atrial fibrillation) when
a possible left atrial thrombus may have been the source of
embolic event, cardiac ultrasound can be undertaken by the
transoesophageal technique. A miniaturized echo trans-
ducer incorporated within a gastroscopic-type mechanism
can be introduced under light sedation into the oesophagus.
The close proximity of the high-frequency transducer to the
heart and the avoidance of the ultrasound waves having
to transit the skin, subcutaneous tissues, muscle and lung
result in fine detail of intracardiac structures. The technique
is also utilized to provide finer images of functional and
structural defects of valve dysfunction.
STRESS ECHOCARDIOGRAPHY
An extension of conventional resting echocardiography
(echo) to acquire cardiac images at rest and then after a
period of cardiac stress allows the evaluation of stress
induced changes. The technique is readily suited to be
undertaken as an outpatient procedure with completion in
less than an hour. Frequently, advice to the patient regard-
ing the result is given before leaving the department.
There are variations in technique depending on the
patient’s cardiac and non-cardiac conditions. If generally
well and without physical limitation, following the acqui-
sition of the resting images, physical stress is undertaken.
This usually is a conventional exercise ECG on a treadmill
to the standard Bruce Protocol. Alternatively, horizontal
bicycle exercise may be undertaken utilizing pedals fitted to
the end of the examination couch. Peak image acquisition is
undertaken when the peak predicted maximum heart rate
K17577_C021.indd 413
Myocardial perfusion imaging  413
has been achieved. ECG monitoring is conducted through-
out as for an exercise ECG test.
Alternatively, pharmacological stress, with the most
commonly used stressor being dobutamine, may be under-
taken. The operator may undertake this as a 2-stage (rest
and peak stress) or a 3-stage test acquiring an image data set
at rest, after a low dose of dobutamine to assess the heart’s
inotropic or contractile response, then at peak dose. Some
institutions also record an image set in recovery.
The advantage of transpulmonary echo ‘contrast’ (as
described under ‘Echocardiography’) injected into a periph-
eral vein has greatly improved the diagnostic accuracy of
the stress echo technique enabling high quality image data
sets in the breathless peak exercise patient.
The resting images are studied for evidence of previous
infarction damage, the size and overall systolic function of
the left ventricle (LV) and in particular each LV segment
being scrutinized for normality of systolic function. The low
dose images, if acquired, are compared to the resting ones
for an assessment of increase in segmental systolic thick-
ening and reduction in LV end systolic volume. The peak
dose images again are interpreted for increasing segmen-
tal systolic thickening and a further reduction in end-sys-
tolic volume. If each stage produces images meeting these
requirements the test is normal. Should, for example, the
images at rest be normal and the peak images fail to show
a significant reduction in end-systolic volume (or the end-
systolic volume may even be larger than that at rest), then
by inference some of the LV segments will be thickening less
in systole than they did at rest. It is then readily apparent
that ischaemia has been induced by stress. Identifying dys-
functional segments and correlating them to the anatomy of
the coronary arteries provides a strong indicator of which
coronary artery may have flow limiting coronary disease.
Other cardiac dysfunctional features are also readily detect-
able during a stress echo study, namely overall ventricular
function or dysfunction, the size and magnitude of previous
infarctions, valve dysfunction and frequently an estimate of
pulmonary artery pressure, both at rest and on stress.
Stress echo is an extremely safe procedure. Reactions to
echo contrast are rare with an allergic type reaction occur-
ring in only approximately 1:5000 although caution should
be exercised if asthmatic. The risks of dobutamine infusion,
which can also be used for nuclear myocardial perfusion
imaging (MPI), are very low.
It should be emphasized, however, that both nuclear MPI
imaging and stress echo imaging do not visualize the coro-
nary arteries. These tests cannot say whether some degree
of coronary arterial disease is present or not, only if disease
exists to the extent that a lesion(s) limits coronary blood
flow as both techniques image the myocardium rather than
the arteries per se.
MYOCARDIAL PERFUSION IMAGING
This nuclear medicine investigation referred to as MPI
is conducted on an outpatient basis. The original MPI
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 414  Cardiovascular disease
scintigraphy was a technique obtaining two-dimensional
images from a Gamma camera after radio-tracer injection
and myocardial uptake with three standard planes. It is a
straightforward rapid acquisition technique and relatively
robust in terms of avoiding movement artefact. The tech-
nique, however, has been replaced by tomographic single
photon emission CT (SPECT) imaging.
Ventriculography in isolation by radionuclide tech-
niques is possible but has little or no application in the
pilot population as the information on ventricular func-
tion is obtained from echocardiography and cardiac
MRI scanning.
For nuclear myocardial perfusion two tracers are com-
monly used, thallium (Tl 201) or two variants of technetium
(99mTc), these being sestamibi and tetrofosmin.
The isotope is taken up by cardiac myocytes and distrib-
uted within the myocardium with photon emission detec-
tion by a gamma camera. Images are compared following
stress and resting injections of the tracer (or redistribution
for thallium). The higher energy of technetium produces
improved image quality and permits ECG gating which can
help minimize artefact. After tracer injection and myocyte
uptake it is retained for some time. Photons are emitted
from the myocardium in proportion to the magnitude
of tracer uptake reflecting perfusion. The gamma camera
captures gamma ray photons which are then digitized. The
photon emissions collide with the detector and are con-
verted into visible light events otherwise termed a ‘scintil-
lation’ event. After passing through a photo multiplier the
electrical signals are converted into images and presented
as multiple tomographic slices. The tomographic data are
obtained from three-dimensional data from the heart by
sampling from multiple angles. Short axis tomographic
stress images are similar to short axis echocardiographic
images with long axis vertical and horizontal slices also
obtained. Thus, from all the slices the myocardium in its
three dimensions is analyzed. Acquisition times have been
reduced from approximately 15  minutes to approximately
5 minutes by high speed SPECT technology, this also reduc-
ing movement artefacts.
Thallium 201,  which has been in clinical use from the
1970s, acts similarly to potassium ions and is transported
into the myocyte cells by the sodium, potassium, ATPase
system; in other words, entering living muscle cells but not
scar tissue.
In respect of thallium the peak uptake is obtained within
5 minutes of the injection time and equilibration between
blood and tissue in 10–15  minutes. It does, however, have
a longer half-life and a lower emitted energy, both fac-
tors that limit the dose which can be given while avoiding
excessive radiation.
The principle of the test is to subject the patient to a
form of cardiac stress. This may be by treadmill or bicy-
cle exercise or pharmacological stress with dobutamine.
Alternatively, drugs which rapidly vasodilate the coronary
arteries, e.g. adenosine or dipyridamole, may be injected as
an intravenous bolus (this is a substitute for stress increased
K17577_C021.indd 414
blood flow). Scarred areas are fixed defects and apparent
and unchanged on both stress and rest images.
Technetium has a shorter half-life than thallium and
emits more photon energy. The isotope enters the myocyte
cell via an electro-chemical gradient process. There is little
redistribution from the blood so two injections are required,
one at stress and one in resting conditions. The test may be
conducted within one day or over two days (a stress study
followed later by rest). The images are studied to identify
filling defects on the stress images and to assess if they are
reversed or normalized at rest. If so, it is termed evidence
of ‘reversible ischaemia’. Defects are described in terms of
the extent of myocardium involved and the severity, which
refers to the magnitude of reduction of tracer uptake.
Interpretation may be visible or can be computer quantified.
Soft tissue differences and obesity can underlie inter-
pretation artefacts referred to as attenuation artefact. The
identification of such an artefact (of no apparent isotope
uptake in a particular area or myocardial segment) can
reduce the diagnostic specificity of the test. Such defects
are often in the inferior segments. Recent developments
have incorporated the use of CT combined with SPECT
as a hybrid scanner to aid attenuation identification and
correction.
Positron emission tomography (PET) has a higher
resolution and is less subject to attenuation than SPECT.
However, at the time of writing PET scanning facilities,
although improving due to its increasing application within
oncology, have not yet become an established cardiological
investigation technique.
Nuclear myocardial perfusion scanning is reliant as
with all forms of cardiac imaging on the expertise of the
individual interpreting the images. It is a safe investigation
with currently low radiation emissions although it is unac-
ceptable during pregnancy. The capital cost of the equip-
ment and the provisions for handling and disposing of the
isotope together with the time taken even if the image sets
are in close proximity renders it a more expensive investiga-
tion than stress echocardiography. Both cardiac perfusion
imaging and stress echocardiography have overall similar
specificity and sensitivity outcomes in identifying flow lim-
iting coronary artery disease. The choice of diagnostic test
between MPI and stress echocardiography is largely depen-
dent on local provision (Figure 21.8).
CARDIAC CT
Obtaining images of the coronary arteries without having
to undergo an invasive angiographic procedure has been a
long-term cardiological aim.
Computerized tomography (CT) is a radiographic tech-
nique. The X-rays are transmitted from the source tube and
aligned by a collimator, with the transmitted X-ray photons
recorded by detectors. The number of detectors describes
the equipment.
The current systems mainly have 64 row multi detection,
with some systems having 320 detectors. From the detector
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 Cardiac CT  415

Stress Rest Stress

Rest

Figure 21.8  SPECT myocardial perfusion imaging. The tomographic sliced images acquired after stress identify failure of
the isotope uptake in the inferior segments. This can also be seen on the central bull’s-eye image. The later resting images
demonstrate some, but not complete, isotope uptake. The features are of flow limiting coronary artery disease to the infe-
rior segments inducing reversible ischaemia. Coronary angiography would identify the causative lesion(s).

array the data are reconstructed through computer algo-
rithms to recognizable images. The detector rows or slices
are very thin, just over 0.5 mm, such that a 64-slice system
produces image data from approximately 4  cm of cardiac
coverage at a time resulting in shorter scanning time and
less radiation exposure than the earlier four or 16-only slice
scanners. A 64-slicer scanner therefore needs to collect data
over several heart beats, synchronized to the ECG, during
a short breath hold while a 320-slice scanner covers 16 cm,
which is full cardiac coverage.
To produce clear images with the heart moving, fast
acquisition times and slow heart rates are required with
limitation of data acquisition from just part of each heart
cycle, usually from end-systole to mid-diastole. Patients
attending who have heart rates faster than 60/min may be
given a low dose of a beta-blocker or Ivabradine to opti-
mize the heart rate. There are two basic scan modes. In the
first, the radiation exposure is continuous with the patient
within the scanner moving slowly through the X-ray beam,
this being termed helical acquisition, enabling cine evalu-
ation of cardiac function but at the cost of higher radia-
tion. An alternative is for intermittent on/off scanning with
prospective gating with the patient being moved between
the snap shots. This reduces the X-ray exposure but limits
information on cardiac function although both techniques
produce images of similar resolution with the latter being
the preferred technique.
Calcium score
Development of arterial atheromatous disease involving
localized arterial inflammation and deposition of lipoma-
tous and fibrous tissue (the atheromatous plaque) is asso-
ciated with the deposition of calcium. Coronary artery
calcium was recognized by the initial type of scanning,
referred to as electron beam tomography. This has now
been replaced by multi-detector CT scanning as described
above, but recognition and quantification of the coronary
artery calcium score continues to be a principal component
of cardiac CT scanning. The scoring of detected coronary
artery calcification (the Agatston score) is derived from the
area of a calcified lesion and the maximum CT attenuation
within the lesion. A young healthy individual aged less than
30 years would generally have a calcium score of zero. As the
atheromatous process develops, that score rises such that
it is generally considered simply a reflection of age rather
than significant disease if a 50-year-old male had a total
calcium score of 100. The score increases with age-related
arterial disease. The total score with normal aging is dis-
tributed over differing areas of each of the main coronary
arteries; hence each area may only have a low score with
summation of all being quoted as the total. If a high score
value is located in one or two places it raises the possibil-
ity that a significant coronary lesion lies beneath it. Once
total scores are above 400  the probability is of significant

K17577_C021.indd 415 18/11/2015 14:14

 416  Cardiovascular disease

underlying disease. Identifying calcium and providing a
score count does not differentiate between calcium deposi-
tion within the walls of the artery or calcium incorporated
within an atheromatous plaque narrowing the vessel lumen.
With the detection of a significant calcium score the CT
study normally progresses to CT angiography imaging,
the patient being given an intravenous contrast agent. The
coronary artery images acquired by CT are of high quality
and provide an accurate depiction of the coronary artery.
However, there are some technical limitations. If there is
a dense area of calcification overlying an area of a coro-
nary artery it may not be possible to visualize the lumen
of the vessel and therefore differentiate between calcifica-
tion solely in the vessel wall and assess the degree of lumi-
nal narrowing. In this situation clarification of the vessel
lumen by coronary angiography is required. Occasionally
early soft fatty atheromas not containing any calcium may
be missed although with progressive interpreter experience
this is becoming less frequent. 3-D reconstructed images
of the heart with overlying coronary arteries are impres-
sive and helpful for presentation and discussion but the
original source images are preferred for diagnostic evalua-
tion. Coronary stenoses detected by CT are graded usually
as vessel occlusion, or severe (70–99  per cent), moderate
(50–70  per cent) or mild (less than 50  per cent) luminal
narrowing (Figures 21.9–21.12).
CT-generated coronary angiography currently provides
excellent image data but does not yet have the resolution of
invasive coronary angiography.
CARDIAC MAGNETIC RESONANCE
IMAGING (CMR OR CARDIAC MRI)
With the benefit of no ionizing radiation and excellent res-
olution, cardiac MRI has become an essential diagnostic
modality.
The excess of a small number of hydrogen nuclei present
in water and therefore within fat align within the system’s

Figure 21.9  Cardiac CT coronary calcification. Four images of a series of different slices imaging the left anterior descend-
ing coronary artery (LAD). Areas of calcium deposition are seen as bright spots, isolated on early slices over the proximal
LAD and at its osteum, but almost confluent and heavy calcification in the proximal and mid LAD with a score in excess
of 400. It is not possible to assess if the calcification is principally in the vessel wall or whether there is encroachment and
narrowing of the vessel lumen. Further information to clarify this may be obtained from progressing to CT angiographic
imaging, although definitive clarification may require coronary angiography.

Figure 21.11  CT angiography of the left anterior descend-

Figure 21.10  CT angiography with contrast, highlighting ing coronary artery with moderate luminal narrowing
the right coronary artery. Multiple flecks of calcium are (arrow), yet no calcium deposits. This is ‘soft’ or fatty
seen although there is no luminal narrowing. atheroma of probable recent onset in a young adult.

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Figure 21.12  Three dimensional CT. A three dimensional
reconstruction of cardiac CT imaging in a young adult
with recent onset chest pains. The image demonstrates
the congenital abnormality of the left coronary artery
arising from the right aortic coronary sinus (instead of the
normal left sinus ) with a long left main stem travelling
anteriorly in front of the pulmonary artery before the left
anterior descending branches over the inter ventricular
septum and descending to the apex. Anomalous origins
of coronary arteries of this type, resulting in stretching or
pressure compression of the artery, resulting in restricted
coronary flow causing anginal symptoms are a well-rec-
ognized cause of sudden cardiac death. Surgical coronary
artery grafting is required.
magnetic field and are excited by radio waves. Following an
excitation pulse, the magnetism decays, releasing an energy
signal. The time to do so for two signals is termed T1 and
T2, the difference reflecting different tissues. Computerized
interpretation of the signals converts them to recognizable
images. The term Tesla describes the magnetic field strength.
Different adjacent tissues require a contrast difference to
differentiate them which comes from the difference in their
magnetic resonance, reflected by their T1 and T2 properties.
Enhancement of the T1 signal is generally used for qualita-
tive signal recognition. Gadolinium based contrast material
is injected intravenously, taking up to 30 seconds for a first
pass through the heart with an equilibrium state reached in a
few minutes. MR angiography and myocardial perfusion are
acquired during the first pass of gadolinium with late gado-
linium images acquired 5–15 minutes following injection.
Assessment of renal function is required before admin-
istering gadolinium. ECG triggering for imaging can be
conducted at the time of acquisition or applied in retro-
spect when analyzing the images. Short breath holding can
reduce artefact although continuous real time imaging can
be undertaken but at the expense of reduced resolution.
Cardiac MRI is a safe technique but with cautions
applied. All metallic objects must be left outside the scan-
ning room and a patient check list required for possible
implanted metallic objects including ocular or cochlear
implants, pacing wires and pacemakers (although current
generation pacemakers are MRI friendly). Coronary artery
stents and chest sternal wires from previous CABG proce-
dures are acceptable.
The clinical application of cardiac MRI scanning is
predominantly to assess variations in myocardial tissue.
K17577_C021.indd 417
Diagnostic coronary angiography  417
A common application therefore is to assess the presence
and extent of fibrous scar tissue following a myocardial
infarction, even identifying small previous sub-endocardial
infarction scars which are generally missed by all other
scanning techniques. Coronary MR angiography can theo-
retically be conducted but currently the resolution is insuffi-
cient for diagnostic purposes although myocardial viability
studies which include scar identification and ventricular
function can produce a comprehensive ischaemic heart
evaluation. Myocardial perfusion can be assessed utilizing
the administration of vasodilator stress (as described under
‘Nuclear myocardial perfusion’) or with the stress agent
dobutamine (as detailed under ‘Stress echocardiography’).
Myocardial tissue abnormalities underlie the pathology
of cardiomyopathies. Cardiac MRI is now accepted as the
investigation of choice should any form of cardiomyopathy
be suspected following an echocardiographic study. The
resolution of cardiac MRI enables it to be the preferred
investigation modality for calculating cardiac mass and
cardiac chamber volumes. Given the basis of MRI being
the magnetic orientation of the hydrogen ions of water, not
surprisingly MRI is a very sensitive technique for identify-
ing inflammation or infection within the myocardium or
pericardium, hence its value in diagnosing myocarditis of
any aetiology (Figures 21.13–21.16).
Myocardial infiltrations by inflammatory or protein-
aceous products are also identified by MRI. Applications
therefore also include identifying cardiac sarcoidosis,
amyloidosis and haemosiderosis to name just some of the
cardiac conditions which may be found within the pilot
population.
DIAGNOSTIC CORONARY ANGIOGRAPHY
The cine angiographic technique to image the lumen of the
coronary arteries has been in routine cardiological practice
since the late 1960s. Vast worldwide experience with ever
improving equipment today provides a detailed, accurate
investigation. It is an invasive procedure in that a small
catheter is passed retrogradely from a peripheral arterial
needle puncture site to the heart under X-ray screening.
The morbidity of the procedure in the form of bruising or
bleeding from the puncture site, perforation or trauma to a
coronary artery or peripheral vessel is low at approximately
1 per cent. Given that many patients undergo the procedure
when acutely ill with serious cardiac problems, the mortal-
ity of coronary angiography is low at around 0.2 per cent.
The approach to the procedure until relatively recently was
either percutaneous puncture of the femoral artery or a
brachial arteriotomy. Currently, the majority of coronary
angiograms are conducted by a percutaneous radial arterial
puncture. This markedly reduces bleeding or bruising and
shortens the hospital stay to a few hours.
Coronary angiography identifies the site, severity and
number of atheromatous lesions which are encroaching
upon the coronary artery lumen. This clarifies whether or
not calcium seen on a CT scan is only within the walls of the
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 418  Cardiovascular disease
Figure 21.13  Cardiac MRI. A four chamber view of a nor-
mal adult heart. All chambers are of normal size (volume )
and the myocardial texture normal.
Figure 21.15  Cardiac MRI image of a hypertrophic cardio-
myopathy. Note the asymmetrical hypertrophy of the inter
ventricular septum compared to its lateral wall, this being
a characteristic feature of the pathology.
vessel or causing obstruction. With no luminal encroach-
ment the phrase ‘angiographically normal coronary arter-
ies’ is used, this finding carrying an excellent prognosis. If
atheromatous plaques are identified, the operator reports
where the lesions are in terms of which artery and whether
proximal, mid-segment or distal and the severity. Luminal
encroachment is assessed visually and estimated by the
operator, expressing for example an 80  per cent mid left
anterior descending (LAD) lesion. Clearly there may be
some variation in estimating severity when the images are
reviewed by a different operator. Narrowings usually have
to be in excess of 80 per cent to be responsible for causing
anginal symptoms or flow-limiting changes on a non-inva-
sive functional test.
A significant management difference exists when con-
sidering the results of coronary angiography in members
of the general population compared to pilots. Both groups,
if found to have angiographically normal coronary arter-
ies, are strongly reassured and given an excellent cardiac
prognosis. Primary preventative medications for elevated
K17577_C021.indd 418
Figure 21.14  A dilated cardiomyopathy imaged by
MRI. The myocardium is thinned, the chambers dilated.
The image definition allows accurate measurement of
chamber volumes.
Figure 21.16  A hypertrophic cardiomyopathy, the patient
having sustained an inferior myocardial infarction. The
infarction is identified on this late gadolinium enhanced
image, seen as a bright scar from the base to the car-
diac apex. MRI identifies the site and extent of the
infarction damage.
risk factors in terms of hypertension, and hyperlipidaemia
together with lifestyle modifications will be advised. The
pilot can continue with unrestricted certification.
Minor irregularities identified on angiography are fre-
quently too small to ascribe a percentage obstruction as
they are not obstructive. Such irregularities may have
been identified by angiography conducted for chest pain
of debatable cause. Minor lesions do not cause symptoms
and should not be associated with abnormal functional
tests. Again, preventative medications will normally be
prescribed if indicated. Knowing that early stage coronary
disease exists, pilots should undergo intermittent review to
include a functional test. The time interval for review is
variable depending on the angiographic findings, age and
other associated risk factors. Diabetic individuals develop
atheromatous disease earlier than the general population,
their review interval usually being annually. Otherwise, for
non-diabetics an alternate-year cardiological review will
be appropriate.
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 Further assessment of coronary lesions by debatable severity  419
The difficulty comes when it is assessed that a coronary
lesion, particularly if sited proximally, e.g. in the left main
stem or soon thereafter in the proximal anterior descend-
ing or circumflex or in the proximal right coronary artery,
is visually assessed to be associated with an approximate
50  per cent luminal narrowing. Generally, such a lesion
would not be associated with symptoms and would not cause
flow limitation on a functional test. These lesions again are
usually incidental findings on a ‘clarification’ angiogram.
If angiography is conducted after a calcium CT scan, there
may be disease. However, although asymptomatic even on
stress, the possibility of unexpected plaque disruption pre-
cipitating an acute coronary event is such that multi crew
restriction must be applied with annual reassessment plus
preventative medication.
Should a pilot present to his GP or AME with symptom-
atic chest pain episodes, then be found to have a positive
exercise ECG or functional test, angiography is required
generally omitting a CT study. Confirmation of a signifi-
cant stenosis, particularly if proximal or bifurcational, has
to result in immediate grounding. Revascularization alter-
natives are then considered.
PERCUTANEOUS CORONARY
INTERVENTION (PCI)
This is a specific form of treatment, an outline of the meth-
odology being appropriate within this text.
Following diagnostic angiography, provided the culprit
lesion is angiographically suitable in terms of site (location),
a PCI procedure may be undertaken. The procedure is ini-
tially similar to coronary angiography commencing with
a percutaneous needle puncture to the radial or femoral
artery. Repeated baseline angiographic images are obtained
through the inserted guiding catheter. A guide wire is
introduced and advanced across the atheromatous narrow-
ing with a balloon catheter advanced over the guide wire
until it lies across the lesion. Balloon inflation dilates the
stenosed area of artery. The balloon is only able to expand
to its manufactured size limitation, e.g. 2.5 or 3.0 mm, the
size chosen by the operator based on a visual assessment
of the vessel size proximal and distal to the lesion. Once
dilated the balloon catheter is withdrawn, being replaced by
another catheter carrying a stent upon a deflated balloon at
the catheter tip. Once the stent is angiographically assessed
to be across the lesion the balloon is inflated, deploying or
expanding the stent, which dilates the artery to its normal
luminal diameter. With the balloon deflated the catheter
is withdrawn and the procedure completed. This is a basic
outline of the procedure. Clearly there are variations and
significant subtleties in the techniques applied. Multiple-
stent deployment can be undertaken in the same session
if required. There have been many developments of the
original fine metal expandable stent, notably the drug-
eluting stents (inhibiting blood coagulation and reducing
K17577_C021.indd 419
subsequent stent occlusion) and more recently biological
stents, which are slowly absorbed, not leaving any long-term
residual metal within the artery.
For a pilot undergoing the procedure there follows a
minimum of six months of medical suspension, similar to
that described elsewhere after an acute PCI procedure for an
acute coronary syndrome. Attendance at a cardiac rehabili-
tation exercise class and modifications to diet and lifestyle
are encouraged together with the continuance of secondary
preventative medications plus anti-platelet drugs. For con-
sideration for re-licensing, after six months a cardiac assess-
ment is required, again with similar requirements as listed
on page 393. The original angiography may be requested by
the medical advisory board to ascertain if there are lesions
in any of the other coronary arteries and if so of what sever-
ity. These may not have been treated by the PCI operator on
the basis of not being of sufficient severity. However, within
the pilot population, if there are one or more lesions of
greater than 50 per cent in other vessels this is usually dis-
barring for recertification, even in the absence of symptoms
and in the presence of normal functional testing. This can
be difficult for a pilot to accept and may result in an appeal
process, requiring repeat angiography and reassessment by
the Medical Advisory Board.
FURTHER ASSESSMENT OF CORONARY
LESIONS BY DEBATABLE SEVERITY
The severity and significance of an atheromatous narrow-
ing within a coronary artery is undertaken visually by the
operator. There are measurement packages available in
current angiographic equipment to place calculated rather
than a visual estimate of the narrowing. However, whatever
that figure and however derived the functional status of the
narrowing is the important factor is the question ‘should
it be treated by intervention or left untreated?’ Stent inser-
tion can only normally be justified if there are indications
that the lesion is of flow-limiting significance. Two methods
of further evaluating a coronary lesion can be undertaken
if required during an angiographic procedure. These are
detailed below.
Intravascular ultrasound
A small phased array ultrasound transducer is incorporated
onto the tip of a guide wire. This is advanced inside the
guiding catheter then down the coronary artery and across
the lesion in question into the distal vessel. Slowly the trans-
ducer is withdrawn with the ultrasound image recorded.
The presence and extent of disease within the coronary
artery distally, at the site of the lesion and then proximally
can be visualized and measured. This is far more accurate
than measuring an angiographic image. Depending on the
results and extent of disease the operator may decide to pro-
ceed with further intervention.
18/11/2015 14:14
 420  Cardiovascular disease
Flow wire
A continuous wave Doppler transducer is mounted on a
guide wire and again passed through the guiding catheter
and into the coronary artery in question. The blood flow
velocity is detected by the system. An injection of a coro-
nary vasodilator medication, usually adenosine, is given
as a bolus. The coronary arteries dilate with consequential
increased coronary flow, this being detected by the trans-
ducer. The increase in flow by vasodilatation is termed ‘the
flow reserve’. The equipment calculates the increase in flow
and expresses it as a fraction. Should there be only a mini-
mal increase in flow despite dilating distal coronary arter-
ies then the atheromatous lesion is preventing an increase
in flow and it is therefore ‘flow limiting’ and as such is sig-
nificant requiring dilatation and stenting to restore nor-
mal flow. Should the converse be found, i.e. that the flow
increases with no limitation caused by the lesion in ques-
tion, even if it appears visually significant it is not function-
ally significant and does not require coronary intervention.
Advances in clinical practice now frequently combine
diagnostic angiography and intervention (PCI) into one
session. A high index of suspicion that significant coro-
nary disease exists and the probability of which vessel(s)
are involved is usually available from the pre-procedural
non-invasive investigations. Hence, angiography proceed-
ing to an intervention is progressively undertaken as a
combined procedure.
SUMMARY
●● Clinical aspects of adult congenital and acquired
cardiac conditions relevant to aviation medical
certification are covered.
●● Guidance is given on full, restricted or rejected
medical licencing for each condition.
●● Clinical treatment and management options are
outlined.
●● Current cardiac diagnostic techniques are
discussed.
●● Image examples of pathological states are
provided.
●● References for further reading are included.
FURTHER READING
Abramson S. The Complete Guide to Cardiac CT.
Maidenhead, UK: McGraw Hill Education, 2011.
K17577_C021.indd 420
Bonow RO, Mann DL, Zipes DP, Libby P. Braunwald’s
Heart Disease: A Textbook of Cardiovascular Medicine,
9th edn. Philadelphia: Saunders, 2011.
Camm AJ, Luscher TF, Serruys PW. The ESC Textbook of
Cardiovascular Medicine, 2nd edn. Oxford: Oxford
University Press, 2009.
Charron P. Clinical genetics in cardiology. Heart 2006; 92:
1172–6.
Dahya V, Spottiswoode BS. Cardiovascular magnetic
resonance imaging – a pictorial review. South African
Journal of Radiology 2010; 40(4): 92–6.
Heller GV, Hendel C. Nuclear Cardiology: Practical
Applications, 9th edn. New York: McGraw Hill, 2011.
Herman A, Bennett MT, Chakrabarti S, Krahn AD. Life
threatening causes of syncope: channelopathies and
cardiomyopathies. Autonomic Neuroscience: Basic and
Clinical 2014; 184: 53–9.
Jankharia B, Raut A. Cardiac imaging: current and emerg-
ing applications. Journal of Postgraduate Medicine
2010; 56(2), 125–130.
Katritsis DG, Camm AJ. Atrioventricular nodal reentrant
tachycardia. Circulation 2010; 122: 831–40.
Knaapen P. Cardiac PET-CT: advanced hybrid imaging for
the detection of coronary artery disease. Netherlands
Heart Journal 2010; 18(2), 90–8.
Lane DA, Lip YH. Use of the CHA2DS2-VASc and HAS-
BLED scores to aid decision making for thrombopro-
phylaxis in nonvalvular atrial fibrillation. Circulation
2012; 126: 860–5.
Lee JC, West MJ, Khafagi FA. Myocardial perfusion scans.
The Royal Australia College of General Practitioners
2013; 42(8): 564–7.
O’Donnell C, Nabel E. Genomics of cardiovascular
disease. New England Journal of Medicine 2011; 365:
2098–109.
Pennell D J. Cardiovascular magnetic resonance.
Circulation 2010; 121: 692–705.
Perloff JK, Child JS, Aboulhosn JA. Congenital Heart
Disease in Adults. Philadelphia: Saunders, 2009.
Rubert M, Zipes DP. Mechanisms of sudden cardiac death.
The Journal of Clinical Investigation 2005; 115(9):
2305–15.
Selby JB, Lin EC. Coronary artery calcification on CT
scanning. Medscape Article 352189 – Overview, 2013.
Available from: http://emedicine.medscape.com/
article/352189-overview.
Thilo C, Auler M. Zwerner P, et al. Coronary CTA. Thoracic
Imaging 2007; 22(1), 35–9.
Wilde AAM, Elijah RB. Genetic testing for inherited
cardiac disease. Nature Reviews Cardiology 2013; 10:
571–83.
18/11/2015 14:14

Hypertension
EDWARD NICOL
Introduction 421
Diagnosis and measurement 421
Cardiovascular risk assessment 423
Aeromedical concerns 423
INTRODUCTION
Hypertension affects over 1 billion individuals globally and
is the most prevalent risk factor for atherosclerosis and atrial
fibrillation. Despite its association with significant morbid-
ity and mortality, it remains challenging both to diagnose
and to manage (Lawes et al. 2008). Hypertension is associ-
ated with an increased risk for ischaemic and haemorrhagic
stroke, myocardial infarction, heart failure, atrial fibrilla-
tion, chronic kidney disease, cognitive decline and prema-
ture death and, if left untreated, usually continues to rise
until it becomes resistant to treatment.
Hypertension may be defined as the level of blood pres-
sure above which excess morbidity and mortality is observed
compared with a control population. This is often consid-
ered to be any blood pressure ≥140/90  mmHg. Although
there are varying degrees of hypertension and many pub-
lished definitions, recent UK National Institute for Health
and Clinical Excellent (NICE) definitions are helpful in
classifying hypertension (Figure 22.1) and may be used as a
basis for decision making in clinical practice both for civil-
ians and the aircrew population.
Hypertension is often just one manifestation of multiple
interrelated cardiovascular risk factors, such as raised lipid
levels, raised glucose levels and increasing body mass index.
Therefore, a whole system approach is required to address
the myriad interrelated risks. Initiating a weight loss and
exercise programme may prevent the need for pharmaco-
logical intervention, even in a healthier population such as
aircrew. In cases of resistant or significantly elevated hyper-
tension, or hypertension in individuals under 40  years of
K17577_C022.indd 421
22
Management 423
Aeromedical disposition and follow up 425
References 425
age, it is imperative to seek and rule out causes of secondary
hypertension. The number of cases of secondary hyperten-
sion amongst newly diagnosed patients with hypertension
is higher than previously thought and a considerable pro-
portion of these are potentially curable or mandate specific
therapy (Musameh et al. 2013).
DIAGNOSIS AND MEASUREMENT
Diagnosing hypertension remains challenging. Both stress
and anxiety are known to elevate blood pressure and con-
tact with the medical profession can be perceived as quite
a threatening experience, particularly when occupational
disposition may be dependent on the outcome. ‘White
coat’ or ‘office’ hypertension is a well-recognized phe-
nomenon and, although thought not to convey any addi-
tional cardiovascular risk compared with normotension
(and so should not be treated), the diagnosis should not be
assumed, even in an otherwise apparently healthy patient,
as missed true hypertension can cause significant target
organ damage if left untreated (Fagard and Cornelissen
2007).
In addition to the stress and anxiety effect of a medical
consultation, diurnal variability, environmental factors and
recent exercise or consumption of caffeine or alcohol can
all have a marked effect on single office-based blood pres-
sure readings. While historically, serial office-based mea-
surements were used in an attempt to mitigate the above
variations by repeating readings in comfortable, relaxed
surroundings, recent evidence would suggest that the use of
ambulatory blood pressure monitoring (ABPM) to confirm
421
17/11/2015 15:56
 422 Hypertension

Care Pathway for Hypertension

Clinic blood pressure

Clinic blood pressure Clinic blood pressure
< 140/90 mmHg
≥ 140/90 mmHg ≥ 180/110 mmHg
Normotensive

If accelerated
hypertension* or
suspected Refer
phaeochromocytoma† same day
for
specialist
care
Consider starting antihypertensive
drug treatment immediately

Offer ABPM‡ (or HBPM¶ if ABPM is declined or not tolerated)

Offer to assess cardiovascular risk and target organ damage

ABPM/HBPM ABPM/HBPM ABPM/HBPM

<135/85 mmHg ≥135/85 mmHg ≥ 150/95 mmHg
Normotensive Stage 1 hypertension Stage 2 hypertension

If target organ damage

present or 10-year
Consider cardiovascular risk > 20% Offer antihypertensive
If evidence of target alternative drug treatment
organ damage causes for
target
organ If younger than
damage 40 years Consider specialist
referral

Offer lifestyle interventions

Offer to check blood pressure at least

every 5 years, more often if blood
pressure is close to 140/90 mmHg Offer patient education and interventions to support adherence to treatment

* Signs of papilloedema or retinal

haemorrhage
Offer annual review of care to monitor blood pressure, provide support and
†
Labile or postural hypotension, headache,
discuss lifestyle, symptoms and medication
palpitations, pallor and diaphoresis
‡ Ambulatory blood pressure monitoring
¶ Home blood pressure monitoring

Figure 22.1  BHS/NICE hypertension care pathway.

Reproduced with permission from NICE (NICE 2011).

the diagnosis of hypertension is both more reliable and
more cost-effective (NICE 2011).
It should be noted, however, that the values used to
determine hypertension using this technique are different
to those used in the office setting. Using NICE guidelines,
any patient with an office-based blood pressure reading of
>140/90 mmHg should be offered a 24-hour ABPM to con-
firm the diagnosis. However, when making the diagnosis of
hypertension with a 24-hour ABPM, an average blood pres-
sure of ≥135/85 mmHg would confirm stage 1 hypertension,
while an average reading of ≥150/95 mmHg confirms stage
2 hypertension. These values correlate with >140/90 mmHg
and >160/100  mmHg, respectively, in the office setting
(Musameh et al. 2013). Stage 3 (severe) hypertension is defined
as a BP >180/110 and should be referred for same day special-
ist opinion. If ABPM is not available or not tolerated, home
blood pressure monitoring (HBPM) is an acceptable alterna-
tive; however, a representative range of readings is necessary
and no assessment of whole day variation or nocturnal dip can
be made. It should be noted that the lack of a nocturnal dip car-
ries a significant and additional cardiovascular risk, above and
beyond that of daytime hypertension (Verdeccia et al. 1994).

K17577_C022.indd 422 17/11/2015 15:56


Additional benefits of 24-hour ABPM readings are that
they mitigate many of the problems of manual or office-
based readings such as digit bias preference, uncertainty
over which Korotkoff sound correlates best with diastolic
blood pressure (Korotkoff V – the disappearance of sound is
now accepted as the correct time point), or poor technique
if mercury-based sphygmomanometers are used. It remains
essential that the correct size cuff is used and, in individuals
whose bicep measurement is in excess of 33 cm, a large cuff
is mandatory to prevent artificially high readings.
CARDIOVASCULAR RISK ASSESSMENT
A finding of hypertension should prompt further assess-
ment and it is crucial to assess the patient’s overall car-
diovascular risk using a validated risk-score calculator
(Q-risk, New Zealand Coronary Event Risk Chart, etc.).
Clinical examination should include the assessment of
end-organ damage, the checking of peripheral pulses (to
exclude radio–radio or radio–femoral delay in coarcta-
tion), fundoscopy, cardiac and renal auscultation. Further
office investigations should include urine dipstick (to check
for haematuria, proteinuria and a spot albumin to creati-
nine ratio [ACR]), a 12-lead electrocardiogram (ECG) and
a fasting blood screen for electrolytes, glucose, lipids and
renal function. While evidence of left ventricular hypertro-
phy (LVH) on the 12-lead ECG is common in aircrew as an
incidental finding, in the context of hypertension, further
cardiovascular assessment with echocardiography should
be performed to assess for both evidence of concentric LVH
or left atrial dilatation, both of which suggest longstanding
hypertension and increased cardiovascular risk (Levy et al.
1990; Pierdomomenico et al. 2008).
Special attention should be given to excluding second-
ary causes of hypertension (especially in younger patients
(<40  years old), severe or resistant cases of hypertension).
Onward referral for specialist evaluation and manage-
ment is recommended in these cases as specialist imaging
(computed tomography (CT)/magnetic resonance imaging
(MRI)/functional renal imaging) or biochemistry (such as
urinary metanephrines and renin activity) may be required
to exclude conditions such as renal parenchymal or reno-
vascular disease, phaeochromocytoma, primary aldoste-
ronism or coarctation of the aorta.
AEROMEDICAL CONCERNS
Hypertension is a major risk factor for stroke and coro-
nary artery disease, with every 10  mmHg rise above nor-
mal (130/80  mmHg) thought to contribute an additional
30 per cent to coronary mortality risk (Prospective Studies
Collaboration 2002). Additionally, the increased likelihood
of arrhythmia, especially atrial fibrillation (AF), is also
a major concern, particularly in patients with a left atrial
dimension of >4.0 cm, and also specifically in patients who
lack a nocturnal dip who appear to be twice as likely to
develop AF as those with a nocturnal dip (Pierdomomenico
K17577_C022.indd 423
Management 423
et  al. 2008). Hypertension in combination with other
risk factors such as hyperlipidaemia, obesity or smoking,
increases cardiovascular risk exponentially and requires an
aggressive approach to lifestyle management if aircrew wish
to retain a license.
In this context, hypertension is clearly pertinent to the
aircrew population where cardiovascular disease is the
most common cause for loss of license and conditions such
as arrhythmia and chest pain are both clear and obvious
candidates for distraction and incapacitation. The UK civil
aviation authority recommends a 24-hour ABPM for all air-
crew who have an office reading of >140/90 mmHg but only
accept HBPM in non-professional aircrew.
MANAGEMENT
Aircrew with hypertension must, as with all clinical
­conditions, be treated as patients with a significant, but
usually modifiable, cardiovascular risk factor. Lifestyle
advice should be offered to all patients with hypertension,
as simple lifestyle changes have been demonstrated to be
effective in treating both pre-hypertension (BP between
120–139/80–89  mmHg) and established hypertension
(Musameh et al. 2013). This advice should include guidance
on smoking cessation (if required), minimizing alcohol
intake, reduction in salt (sodium chloride) on food, weight
loss and increasing levels of exercise.
The optimal level of blood pressure control remains
controversial, however an average BP of <140/90  mmHg
is deemed essential, while many would regard <130/80  as
more optimal, although strong outcome evidence for this
approach is lacking.
One area where caution is advised in aircrew however is
the selection of pharmacologic agents. The current British
Hypertension Society/NICE guidelines provide a useful
starting point for consideration of treatment options in all
comers (Figure  22.2). While most classes of modern anti-
hypertensive agents are deemed compatible with continued
flying, alpha-blockers, loop diuretics, adrenergic blocking
agents (e.g. guanethidine) and other centrally acting agents,
e.g. methyl-dopa should be avoided due to the risk of unpre-
dictable postural and central effects. As a general rule, it is
preferable to initiate multiple agents at sub-maximal doses
than to use a single agent at the top of the therapeutic range
where side effects are more prevalent. All aircrew should be
grounded for a short period to exclude idiosyncratic reac-
tions to new drugs (this is usually two weeks in civilian fly-
ing and 28 days for military aircrew) both at the initiation of
a new agent and following a change in dose regimen.
Thiazide diuretics have a long history of use in aircrew
and, until recently, were often the initial therapy of choice
for treating hypertension, especially in elderly patients.
However, the use of thiazide diuretics has been downgraded
from step 1 in older (age ≥55 years old) and black patients
from African or Caribbean origin to step 3 agents in recent
guidance (NICE 2011). There is a lack of evidence for the
use of bendroflumethazide 2.5  mg, a drug that is widely
17/11/2015 15:56
 424 Hypertension

Summary of Antihypertensive Drug Treatment

Aged over 55 years or

Aged under black person of African
55 years or Caribbean family
origin of any age

Step 1 A C

Step 2 A+C

Step 3 A+C+D

Key
Resistant hypertension A—ACE inhibitor or
A + C + D + consider further angiotensin II receptor
Step 4 diuretic‡, ¶ or alpha- or blocker (ARB)*
beta-blocker§ C—Calcium-channel
blocker (CCB)†
Consider seeking expert advice
D—Thiazide-like diuretic

* Choose a low-cost ARB.

† A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or
the person has oedema, evidence of heart failure or a high risk of heart failure.
¶
‡ Consider a low dose of spironolactone or higher doses of a thiazide-like diuretic.
¶ At the time of publication (August 2011), spironolactone did not have a UK marketing
authorisation for this indication. Informed consent should be obtained and documented.
§ Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated,
or is contraindicated or ineffective.

Figure 22.2  Recommended BHS/NICE treatment summary of antihypertensive treatments.

Reproduced with permission from NICE (NICE 2011).

prescribed, so if this class of agent is introduced, either
indapamide or chlortalidone is now recommended.
In the majority of aircrew (especially if <55  years old
and not black patients of African or Caribbean origin),
angiotensin converting enzyme (ACE) inhibitors or angio-
tensin receptor blocking (ARB) agents (sartans) are con-
sidered acceptable and are positively indicated in patients
with diabetes mellitus. ARB may be preferred to ACE
inhibitors due to the incidence of a bradykinin related,
irritating dry cough associated with the latter. In mili-
tary flying, there was previous concern about the adverse
effect of ACE inhibitors on Gz tolerance; however, both
classes of agent have been shown to be acceptable for unre-
stricted flying duties, even in high performance aircraft
(Rhodes 2003).
Calcium channel blockers (CCBs), which act by induc-
ing arteriolar dilatation and reducing peripheral resistance
(the dihydropyridines), are also usually well tolerated, espe-
cially if moderate doses of longer acting agents are used
(i.e. Amlodipine 5mg). These agents are especially useful in
patients with diabetes or hyperlipidaemia as they exert no
effect on these metabolic pathways and they do not require
routine screening of renal or liver function. The phenyl-
alkylamine agents (such as verapamil) and benzothiapine
agents (such as diltiazem) have both negative inotropic and
chronotropic effects and, while effective antihypertensive
agents, they should be used with caution in aircrew. CCBs,
in addition to reducing hypertension, have also been dem-
onstrated to reduce blood pressure variability and further
reduce the risk of cerebral vascular events (Rothwell et al.
2012). While dihydropyridine CCBs are acceptable in air-
crew, both civil and military, usually without restriction,
the use of the other classes of agent is restricted to aircrew
of non-high-performance aircraft.
Beta-blockers are no longer recommended as first
line agents in hypertension and are poorly tolerated by
younger individuals who often feel profoundly lethargic on
this medication. They are also not ideal for patients with
hyperlipidaemia or glucose intolerance. Cardio-selective
beta-blockers remain acceptable agents for civilian pilots;
however, military aircrew are restricted to non-high perfor-
mance aircraft and multi-crew environments.

K17577_C022.indd 424 17/11/2015 15:56


If patients remain persistently hypertensive despite
three agents, a diagnosis of resistant hypertension should
be considered. One must always consider the potential for
non-compliance and all causes of secondary hypertension
should be actively excluded. It is usually at this point that
beta-blockers are considered in aircrew, with the alterna-
tives, such as alpha-blockers, usually incompatible with the
retention of an aircrew license.
Novel therapies for resistant hypertension are slowly
finding their way into routine clinical practice and may be
brought up by aircrew keen to seek a ‘curative’ solution to
their hypertension. Renal denervation therapy and carotid
baroreceptor stimulation are two new invasive approaches
to the treatment of resistant hypertension. The strategies
may offer an alternative to multiple pharmacological agents
but will clearly require a substantial body of evidence on
both efficacy and complications before they will be con-
templated as suitable for aircrew, in either a civil or mili-
tary context. However, it would appear likely that, at best, a
multi-crew limitation may well be required for future flying.
AEROMEDICAL DISPOSITION AND
FOLLOW UP
Pilots who present with severe hypertension (BP ≥
160/100 mmHg) should be grounded, promptly investigated
and treated. For aircrew with lesser degrees of hypertension,
a subjective assessment of overall cardiovascular risk is
required with full examination and investigation to exclude
end-organ damage. Most aircrew will be able to continue
flying (although with a multi-crew limitation) while under
investigation, with a minimum period of grounding follow-
ing initiation of medication or changes to dosing regimens.
This allows the systemic or idiosyncratic side-effects to be
identified and allows assessment of adequate blood pressure
control prior to the resumption of flying duties.
Once commenced on therapy or having initiated life-
style interventions it is critical that aircrew are regularly
reviewed. First, it is important to reassess the eGFR and
electrolytes of all patients commenced on ACE inhibitors
or ARB, to ensure renal impairment is not precipitated in
those with renal artery stenosis. For all other patients, a
review of electrolytes, glucose and lipids is recommended
four to six weeks after starting treatment. Many patients
require multiple pharmacological agents to control their
hypertension with up to half of patients failing to achieve
target blood pressure despite pharmacological intervention
(Wolf–Maier 2003). To maintain adequate control, regular
follow-up is mandatory with repeat office and ABPM mea-
surements to confirm adequate control. There is some evi-
dence to suggest that the use of regular ABPM may allow
adequate control at lower doses when compared to tradi-
tional office based recordings (Staessen et al. 1999).
Most civilian aircrew can expect to return to unrestricted
flying duties following successful treatment and stable
blood pressure control, unless their 10  year cardiovascu-
lar risk exceeds 10 per cent when they may be restricted to
K17577_C022.indd 425
References 425
multi-crew operations. For military aircrew, however, more
caution is required and certain physiological limitations
may be required depending on the prescribed pharmaco-
logical therapy. Patients must be normotensive for a mini-
mum of four weeks prior to resumption of military flying.
Treatment with beta-blockers or rate slowing calcium chan-
nel blockers will restrict aircrew to lower Gz environments
(maximum +2.5Gz). Treatment with beta-blockers is also
only permitted in multi-crew environments due to concerns
with regards to subtle cognitive and motor retardation.
SUMMARY
●● Hypertension remains a major cause of morbidity
in the general population as well as in aircrew.
●● Early diagnosis of hypertension requires a high
index of suspicion and should warrant the rou-
tine use of ABPM in order to provide a robust,
proactive and preventative occupation service to
this population.
●● Active exclusion of causes of secondary hyper-
tension is imperative in a population who are
otherwise often healthy and a comprehensive
cardiovascular risk assessment is mandatory.
●● Lifestyle advice should be given to all aircrew
with hypertension and, if unsuccessful, indi-
viduals should be treated according to national
guidelines and best practice.
●● Consideration should be given to the aviation
environment prior to the treatment of aircrew;
however, many aircrew members will retain an
unrestricted flying category following success-
ful treatment, as long as regular and thorough
follow-up is undertaken.
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 426 Hypertension
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Respiratory disease
GARY DAVIES
Introduction 427
Passenger travel 427
Asthma 428
Sarcoidosis 431
Pneumothorax 432
Bullous lung diseases and cysts 433
Obstructive sleep apnoea 434
INTRODUCTION
Respiratory disease is the most common cause of emer-
gency hospital attendance and the most common cause of
morbidity and loss of productivity in the workplace, includ-
ing the aviation industry. Consideration should be given not
only to the disease itself but also to its natural history, treat-
ment and possible sequelae. The potential for sudden inca-
pacitation or the requirement for restrictions in the working
environment (i.e. G force or pressure breathing) must be
addressed when assessing fitness to return to work.
In this chapter, a distinction is made between trained air-
crew, in which considerable investment in time and money
has been made, and initial applicants for aircrew training,
in which the potential uncertainty of the natural history of
the disease may preclude acceptance.
The following diseases will be discussed. Although it is
recognized that this is not an exhaustive list, it addresses the
more common conditions that can present to the aviation
medicine specialist:
●● Asthma.
●● Sarcoidosis.
●● Pneumothorax (spontaneous, traumatic).
●● Obstructive sleep apnoea.
●● Chronic obstructive pulmonary disease (COPD).
●● Bullous lung disorders.
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23
Chronic obstructive pulmonary disease 435
Bronchiectasis 436
Pulmonary tuberculosis 436
Atypical mycobacterial disease 437
Interstitial lung disease 438
Pulmonary thromboembolic disease 439
References 440
●● Bronchiectasis.
●● Mycobacterial diseases (tuberculosis [TB], atypical).
●● Interstitial lung disease (ILD).
●● Pulmonary thromboembolic disease.
PASSENGER TRAVEL
It is commonly thought that modern passenger aircraft are
pressurized in order to allow a normal sea-level environ-
ment. However, this is untrue and most are pressurized to
cabin altitudes up to 2438 m (8000 feet), although this max-
imum may be breached in emergencies. At 2438  m cabin
altitude, the partial pressure of oxygen will have dropped to
the equivalent of breathing 15.1 per cent oxygen at sea level,
and a healthy passenger will experience a fall in arterial
oxygen tension (PaO2) to around 8.7 (65 mmHg). This would
rise to about 10.0 kPa (75 mmHg) at 1829 m, arterial oxy-
haemoglobin saturation (SPO2) 89–94 per cent, respectively.
Upon prolonged exposure, this can lead to symptoms of
tiredness, fatigue, headaches and reduction in concentration
in normal passengers, so the concern that altitude exposure
may exacerbate hypoxaemia in patients with lung disease
seems justified in those who are hypoxaemic at sea level.
Patients may experience mild to moderate hyperventilation
(due to acute hypoxaemia) and a moderate tachycardia.
In such patients, the following assessment is recom-
mended:
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 428  Respiratory disease
●● History and examination with particular reference
to cardiorespiratory disease, dyspnoea and previous
flying experience.
●● Spirometric tests.
●● Measurement of O2 saturation by pulse oximetry. Blood
gas tensions are preferred if hypercapnia is known
or suspected.
In those with resting oximetry between 92  and 95  per
cent at sea level, hypoxic challenge testing is recommended.
The hypoxic challenge test consists of breathing 15 per cent
fraction of inspired oxygen (FiO2) for 20 minutes with blood
gas measurements being taken directly after.
The recommendations (1) are as follows:
●● PaO2 > 6.6 kPa (> 50 mmHg): oxygen not required.
●● PaO2 < 6.6 kPa (< 50 mmHg): in-flight oxygen (2 l/min).
Often, the Pao2 will be measured on 2 litres O2 in order to
ascertain whether a satisfactory improvement has occurred.
If the person’s resting oximetry at sea level is less than
92 per cent, then supplementary oxygen will be required. If
the person is on supplementary oxygen at sea level, then the
flow rate will have to be increased during flight.
Patients are usually unable to use their own oxygen cyl-
inders on the flight unless agreed in advance by the airline,
and any oxygen that is required will have to be booked well
in advance with the airline. Oxygen usually can be provided
only in flow rates of 2 L/min or 4 L/min via nasal cannu-
lae and often in a breath-activated manner; therefore, if
higher concentrations are required, the patient’s fitness to
fly should be put in doubt. In an extreme emergency, higher
flow rates are possible but may require a medical escort.
Portable oxygen concentrators are increasingly allowed
on commercial flights. There are a number that have been
tested for air worthiness and it is important to check with
the airline as to allowed devices, as the list is currently
increasing. Note should be made to carry sufficient batter-
ies for the whole flight, and chargers for recharging for the
return flight. Power supply for concentrators may be avail-
able on some airlines if given sufficient prior knowledge.
The price charged for supplying the oxygen inflight var-
ies between airline companies and can be an important fac-
tor in the overall cost of the flight.
Other general considerations for passengers with lung
disease should include:
●● Travelling within the airport and on to the aircraft due
to potential long distances in modern airports.
●● A letter from a doctor may be required if carrying con-
trolled medications, needles, syringes or any trial drugs
that are not specifically labelled.
At the end of each section in this chapter, passenger
travel in patients with that particular respiratory disease
will be discussed. These specific recommendations are a
supplement to those stated above (Ahmedzai et al. 2011).
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ASTHMA
Introduction
Asthma is a chronic inflammatory disease confined to the
airways of the lung and resulting in episodic airflow obstruc-
tion (Figure 23.1), which is reversible (spontaneously or as a
result of treatment), and increased airway responsiveness
to a variety of stimuli. Asthma is extremely common in
many industrialized countries, with a prevalence of three to
seven per cent. For reasons that are not well understood, the
prevalence and severity of asthma appear to be increasing.
Comparison of the prevalence of asthma in different parts
of the world suggests that the high and increasing preva-
lence in the Western world is associated with urbanization
and material prosperity.
Natural history
Over the past 15 years, research has resulted in a paradig-
matic shift in the way we view asthma. Rather than perceiving
asthma as a disease consisting primarily of bronchospasm
with resultant airway obstruction, we understand it to be an
airway disorder resulting from a complex inflammatory pro-
cess involving many cells, cytokines and other mediators.
Appreciation of the inflammatory nature of asthma has
also led to recognition of the associated injury and damage
to the airway wall – airway remodelling – which may lead
to irreversible loss of function and be preventable by the
early institution of anti-inflammatory treatment. Therefore,
optimal medical management of asthma has been changed
from regimens that relied almost exclusively on bronchodi-
lators for control of symptoms to protocols emphasizing the
importance of the use of anti-inflammatory agents.
Diagnosis
Diagnosing asthma can often be difficult, with no one
definitive diagnostic test. The symptoms of asthma can be
associated with a number of other respiratory diseases, and
so it is important to take a good history looking for the typi-
cal symptoms of wheeze, shortness of breath, cough (often
Normal airway Asthmatic airway
Smooth
muscle Inflammation Mucus and
and oedema exudate
Epithelium Contraction of Damage and
smooth muscle shedding of
epithelium
Figure 23.1  Mechanism of airflow obstruction in asthma.
17/11/2015 15:57
 Asthma 429

only nocturnal) and specific triggers of symptoms. A family ●● Exhaled nitric oxide (looking for airway inflammation).
history of asthma or atopy may be helpful. The important ●● Skin-prick testing and radioallergosorbent (RAST)
indicators of asthma to look for are: blood tests looking for specific allergens.

●● Intermittency. The differential diagnosis is large and it is important

●● Variability.
●● Nocturnal worsening of symptoms.
●● Provocation of symptoms by specific triggers.
Lung-function testing and simple home peak-flow dia-
ries are very important in the diagnosis of asthma. In these,
the relevant features are:
●● > 20 per cent diurnal variation in peak expiratory flow (PEF)
on three or more days within a two-week period (home PEF
diary) (use the formula [best - worst]/best × 100).
●● > 15 per cent (or 200 ml, whichever is greater) improve-
ment in forced expiratory volume in one minute (FEV1)
with short acting beta-2 bronchodilator (e.g. 2.5 mg
nebulized salbutamol).
Lung-function testing also determines the degree of
airflow obstruction (FEV1/forced vital capacity [FVC]),
the degree of air trapping (residual volume [RV]/total lung
capacity [TLC]) and the degree of small-airways disease
(maximum expiratory flow at 25 per cent of FVC [MEF25] and
maximum expiratory flow at 50 per cent of FVC [MEF50]).
Gas-transfer measurements will also allow assessment of any
emphysema or pulmonary vascular disease.
Other tests may include:
●● Methacholine provocation test.
●● Exercise testing (> 15 per cent decrease in FEV1 after six
minutes of exercise).
to also undertake chest X-ray (CXR), sputum testing for
microscopy (including acid-fast bacilli [AFB] to exclude TB)
and a detailed history looking for symptoms of bronchiec-
tasis, COPD, ILD, bronchial tumour, foreign body, pulmo-
nary emboli and hyperventilation.
Treatment
NON-PHARMACOLOGICAL TREATMENT
Allergen avoidance
Allergen avoidance can be useful in reducing the severity of
existing disease. This can reduce both chronic disease and
exacerbation rates. Avoidance of house dust mites by using
bed-barrier covering, removing carpets and washing bed
linen at high temperatures may reduce asthma symptoms.
Environmental factors
Smoking should be avoided completely. Environmental
pollutants may also play a role in asthma symptomatology.
Workplace factors should also be investigated.
PHARMACOLOGICAL TREATMENT
The British Thoracic Society and the Scottish Intercollegiate
Guidelines Network (SIGN) have reviewed their guidelines,
which advocate a stepwise approach to treatment (British
Thoracic Society and SIGN 2012) (Figure  23.2). This is an
excellent guide to the treatment of asthma, the goal being to
control symptoms on the lowest possible amount of inhaled

Step 5
Add daily oral steroid or regular
booster courses of oral steroid

Step 4
Add any or all of the following as determined by
empirical trial: increase inhaled steroid up
to ≤2000 µg/day, leukotriene receptor antagonist,
theophylline, cromone

Step 3
Add long-acting β2-agonist

Step 2
Add inhaled steroid: ≤800 µg/day adults; 400 µg/day children

Step 1
Inhaled short-acting β2-agonist (or other bronchodilator)

Figure 23.2  Stepwise approach to asthma treatment.

Adapted from draft British Thoracic Society and Scottish Intercollegiate Guidelines Network (SIGN) asthma guidelines.

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 430  Respiratory disease
steroids. The use of long-acting beta-2  bronchodilators
(LABA) with a lower dose of inhaled steroid is an important
consideration, as is the use of leukotriene receptor antago-
nists (especially exercise-induced asthma).
Aeromedical management problems
The major concern from an aviation medicine point of view
is that of sudden incapacitation, though this is very rarely
the case and incapacitation follows a more prolonged course.
This risk is, however, likely to be exaggerated by the use of
pressure-breathing masks and exposure to high G forces.
Unfortunately, there are few predictors of fatal or near-fatal
asthma, except for a previous attack requiring hospitaliza-
tion and intubation. The inclusion of newer treatments has
led to better asthma control and, thus, reduced the likeli-
hood of an asthma attack. It is also important to take into
consideration any known precipitins and avoid exposure
if possible.
Disposition
ENTRY TO PILOT TRAINING
Military
Candidates with a current or past history of confirmed
asthma are permanently unfit for aircrew duties. Candidates
who have had a single episode of wheeze in association with
a respiratory tract infection should be assessed formally for
bronchial hyper-reactivity; if this is negative, they may be
accepted as medically fit for aircrew selection.
Civilian
The following guidelines should be used in the assessment
of candidates for commercial pilot training:
●● There should be a minimum period of five years
from the last acute attack, and no significant
hospital admissions.
●● Lung function tests should be acceptable: the FEV1/
FVC ratio should be greater than 70 per cent, with no
appreciable drop after exercise.
●● The asthma should be controlled on treatment with
an inhaled steroid, with or without an inhaled bron-
chodilator. Treatment with oral steroids should
be disqualifying.
●● There must be no bronchospasm (wheeze) on
examination.
●● There must be no bronchospasm with a mild respiratory
infection (e.g. common cold).
For private flying, restrictions at selection may be less
stringent:
●● There should be a minimum period of two years
since the last acute attack, and no significant
hospital admissions.
K17577_C023.indd 430
●● Lung function tests should be acceptable: the peak flow
rate, a simple test that can be carried out by a general
practitioner (GP), should be more than 80 per cent of
the predicted normal.
●● The asthma must be controlled well on treatment with
an inhaled steroid, with or without an inhaled broncho-
dilator. Treatment with oral steroids is disqualifying.
●● There must be no bronchospasm (wheeze) on examination.
●● Bronchospasm with mild respiratory infection (e.g.
common cold) should be controlled easily.
The above requirements should be confirmed by the pro-
spective pilot’s consultant physician.
TRAINED AIRCREW
The variability in both severity and prognosis of the disease
demands that a specialist assessment is carried out in order
to avoid unnecessary loss of trained aircrew. The aircrew
member should be grounded while this assessment is tak-
ing place. The recommendation regarding return to flying
duties will depend on the severity of the condition and drug
treatment required.
Military
●● Uncontrolled asthma: grounded.
●● Individuals on treatment no higher than step three of
the British Thoracic Society guidelines (see Figure 23.2)
should initially be grounded then once their asthma is
treated and under control they may be upgraded to ‘as
and with pilot trained on type’.
●● Once stability of the pilot’s asthma has been obtained they
can be upgraded to an unrestricted flying category if:
●● The individual has had no acute episodes over a
period of six months or more.
●● The individual has normal lung function tests
(defined as a normal peak flow diary over a one
month period, a FEV1 ≥ 80 per cent and a PEFR ≥
80 per cent of predicted with no reversibility with
salbutamol and a FEV1/FVC ratio ≥ 75 per cent).
●● The individual has had no exercise-induced symp-
toms and no symptoms whilst wearing a respirator.
●● Asthma Control Test (ACT) score of 25 and Asthma
Control Questionnaire (ACQ) score ≤ 0.5 and at
yearly review.
●● Aircrew regularly undertaking pressure breathing for
G should be referred to RAF CAM for testing prior
to being awarded an unrestricted flying category. In
cases of doubt, individuals are to be referred for service
specialist opinion.
●● Regular follow-up with formal lung-function testing is
required.
Civilian
Existing commercial pilots who develop asthma require
similar evaluation to that described above for entry to train-
ing. They may be restricted to multi-crew duties. Existing
class private pilots who develop asthma require similar
17/11/2015 15:57

evaluation as for entry to training and may need a safety
pilot limitation.
Passenger travel
The theoretical risk is of bronchospasm secondary to bron-
chial mucosal water loss due to relatively low cabin humid-
ity. There are, however, no studies that show increased
physiological risks for asthmatics in flight. Preventive and
relieving inhalers should be carried in the hand luggage.
Portable nebulizers may be used at the discretion of cabin
crew. Some airlines can provide nebulizers for inflight use,
and patients should check with the carrier when booking.
It is important to stress that spacers are as effective as a
nebulizer (Cates et al. 2003). Patients with frequent attacks
or recurrent infections should discuss with their doctor to
consider a rescue pack of prednisolone and antibiotics.
SARCOIDOSIS
Introduction
Sarcoidosis is a multisystem granulomatous disorder of
unknown aetiology that typically affects young adults and is
characterized by the presence of non-caseating granulomas in
involved organs. The exact prevalence is not known for cer-
tain, due to the large numbers of asymptomatic people, but it
is estimated to be in the region of 15 per 100 000 people. There
is a significant difference in incidence between ethnic groups,
with Afro–Caribbean people having about a three-fold higher
incidence than white people. There is also heterogeneity of the
illness, with Afro–Caribbean patients tending to have a more
acute presentation and more severe disease than white people.
There has been substantial research into the cause of sar-
coidosis, but as yet there is no definitive answer.
Clinical manifestations
Between 40 and 60 per cent of cases are asymptomatic and
found incidentally, usually on a routine CXR. The most com-
mon presenting symptoms are respiratory (e.g. dry cough,
dyspnoea, chest pain) or dermatological (e.g. erythema
nodosum, sarcoid papules or plaques). Systemic symptoms
(e.g. malaise, fatigue, night sweats, fever) may be present, but
these are rarely the main presenting feature. Ophthalmologic
(e.g. pain, visual change) and musculoskeletal (e.g. joint
pains, myalgia) problems also occur. Rarely, there is neuro-
logical or cardiac involvement.
Lung involvement occurs in about 90 per cent of patients
with sarcoidosis. CXR classically shows bilateral hilar
lymphadenopathy (BHL). Staging of pulmonary sarcoidosis
is based on the radiological stage of disease:
●● Stage 1 – BHL (50 per cent): regression of BHL within
one to three years occurs in about 75 per cent of
patients. Around ten per cent develop chronic enlarge-
ment, which can persist for ten years or more.
K17577_C023.indd 431
Sarcoidosis 431
●● Stage 2 – BHL and pulmonary infiltrates (25 per cent):
usually, the pulmonary infiltrates occur predominately
in the upper zones. Two-thirds of patients undergo
spontaneous resolution. Stage 2 patients usually have
mild to moderate symptoms.
●● Stage 3 – pulmonary infiltrates only: interstitial
nodules commonly are present, predominately in the
upper zones.
●● Stage 4 – advanced pulmonary fibrosis.
Other pulmonary involvement includes endobronchial
(40 per cent of stage 1, 70 per cent of stages 2 and 3), pleu-
ral sarcoid, superior vena cava obstruction (secondary to
lymph-node compression) and pulmonary hypertension.
Investigations
Histology may show evidence of non-caseating granulomas,
with exclusion of AFB. This can be from any available lesion
(e.g. lymph node, cutaneous lesion) or transbronchial or
endobronchial bronchoscopy biopsy. Pulmonary function
tests may show:
●● Restrictive pattern with preserved flow rates.
●● Reduced gas transfer factor.
Pulmonary function tests may be normal. Serial studies
are useful for assessing treatment and progress.
Other investigations to support the diagnosis include:
●● Serum angiotensin-converting enzyme (ACE) level:
raised in more than 75 per cent of untreated patients
(NB: if the level is very high, consider lymphoma).
●● Bronchoalveolar lavage: lymphocytosis (increased num-
bers of activated T-cells).
Other tests may include electrocardiogram (ECG), echo-
cardiogram, cardiac magnetic resonance imaging (MRI),
urinalysis, full blood count (FBC) and full neurological
examination.
Treatment
Asymptomatic BHL rarely requires any treatment. Patients
who are symptomatic or show signs of disease progres-
sion should be started on corticosteroid treatment, usually
given orally and continued for about 12 months, tailing off
slowly. If an initial rapid benefit is required, then pulses of
methylprednisolone can be given, with the added advantage
of a lower maintenance dose of oral corticosteroids being
required. All patients with organ dysfunction should be
treated. Bone-density studies should be performed on peo-
ple taking long-term corticosteroids.
Steroid-sparing agents can be used to minimize the amount
of oral corticosteroid used in the long term. These include
­azathioprine, hydroxychloroquine and methotrexate.
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 432  Respiratory disease
Aeromedical management problems
The major concern is sudden incapacity due to arrhythmias
and syncope secondary to the presence of cardiac sarcoid.
Cardiological assessment is required for all patients with
sarcoidosis. Pulmonary involvement may lead to symptoms
that interfere with the individual’s ability to perform their
role and complete their mission. Steroid treatment itself has
a variety of metabolic and central nervous system effects
that may be hazardous to flying.
Disposition
ENTRY TO PILOT TRAINING
Because of the possibility of future cardiac involvement, can-
didates are considered unfit for aircrew training if sarcoidosis
is present. This includes the presence of simple uncomplicated
BHL. Candidates will be considered only following complete
resolution and normal full evaluation by a specialist.
TRAINED AIRCREW
Military
The patient should be grounded on diagnosis until they
have been investigated fully. Those being treated with cor-
ticosteroids or immunosuppressants should be grounded
throughout treatment. To return to flying duties, the patient
must show no evidence of active disease over a period of
12 months and have a full cardiac assessment (ECG, echo-
cardiogram, Holter monitor, cardiac MRI) that is negative.
Initially, they should return to multi-crew capacity, being
upgraded to solo flying in a further year if the condition
continues to be inactive.
Patients with chronic sarcoid or myocardial sarcoid
should be considered permanently unfit for flying duties.
Patients with isolated pulmonary fibrosis should be referred
for specialist opinion and regular follow-up.
CIVILIAN
Commercial flying is acceptable only if the patient is inves-
tigated fully with respect to the possibility of systemic
involvement and then none is found. There must be no evi-
dence of cardiac involvement. If lymphadenopathy is pres-
ent, this should be limited to hilar lymphadenopathy only,
and the applicant should be free of medication.
Passenger travel
Because of the risk of pulmonary fibrosis, a hypoxic chal-
lenge test should be performed and the results interpreted
as per the previously stated recommendations.
PNEUMOTHORAX
Introduction
A pneumothorax occurs when air enters the thoracic pleural
space, the space between the visceral pleura and the parietal
pleura. Air entering this space interrupts the usual negative
K17577_C023.indd 432
intrathoracic pressure and causes a degree of lung collapse
on that side. The degree of collapse is proportional to the
size and duration of the leak. This can be either spontaneous
or as the result of trauma.
Spontaneous pneumothorax
NATURAL HISTORY
Spontaneous pneumothorax is caused by a spontaneous
rupture of the lung tissue leading to the escape of air into
the pleural space. There is a bimodal distribution of inci-
dence, with peaks occurring in young adults and in elderly
people. The second peak is, however, becoming more diffuse
and extending to an earlier age, as the age of patients with
COPD decreases (Chen 2003).
In young adults, spontaneous pneumothorax is a conse-
quence of a subpleural bleb rupturing. There is usually no
underlying lung pathology. It occurs most commonly in
tall, thin, fit men. Presentation can be with breathlessness
or chest pain (usually pleuritic in nature). Often, symptoms
are very minor.
In patients with underlying lung disease (usually in the
older age group), i.e. secondary pneumothorax, the cause is
usually due to rupture of a bulla. The most common cause
of this is COPD. Presentation in this group tends to be with
worsening breathlessness and chest pain. These patients
tend to have a reduced respiratory reserve and can be sig-
nificantly breathless, even with a small pneumothorax.
The major concern is a tension pneumothorax, which may
occur when there is a flap valve at the site of the leak. This
leads to a progressive increase in the size of the pneumotho-
rax, which eventually becomes under pressure. The pressure
causes cardiac compression and can lead to cardiorespiratory
arrest. This requires immediate drainage and decompression.
Recurrence is a major problem. The recurrence rate,
without definitive treatment, is very high (30–60 per cent).
The vast majority of cases occur within the first year, and
the risk reduces dramatically with time after this. Risk of
contralateral pneumothorax is about ten per cent.
INVESTIGATION
Tension pneumothorax should be treated immediately on
clinical grounds, without further investigation. To confirm
spontaneous pneumothorax, a CXR is the investigation of
choice. A CT scan of the thorax may be required in cases
where previous pleural adhesions may have occurred, e.g.
previous pleurodesis.
Further investigation of aircrew should always include a
routine CT thorax to exclude any underlying lung pathology.
Full lung-function tests are also important in order to assess
airways obstruction, increased RV and decreased gas trans-
fer factor, which might suggest underlying emphysema.
TREATMENT
Initial treatment may not be required or should be with
simple aspiration according to the British Thoracic Society
17/11/2015 15:57

guidelines (Henry et  al. 2003). Occasionally, a chest
drain may be required, usually in people with secondary
pneumothorax.
In view of the increased risk of recurrence even after
a single episode, it is recommended that aircrew undergo
definitive treatment. Pleurectomy is the treatment of choice
due to its low recurrence rate. This can be as an open opera-
tion or, more commonly, by a thoracoscopic approach.
Chemical pleurodesis is a further option but is not recom-
mended in aircrew because of the higher failure rate.
AEROMEDICAL MANAGEMENT PROBLEMS
During flight, the chances of occurrence of a pneumotho-
rax are increased. Increase in altitude (even cabin pres-
sure) leads to expansion in the volume of air within the
bullae, producing an increased risk of rupture. During
pressure breathing, the higher pressure can lead to air
trapping and increased risk of rupture. Fortunately,
inflight occurrence of pneumothoraces is very rare, even
with pressure breathing. The occurrence of a spontane-
ous pneumothorax during flight may result in incapacita-
tion due to breathlessness and pain. Furthermore, during
flight, the reduction in ambient pressure will cause an
increase in the percentage collapse (at 8000  feet, a pneu-
mothorax will increase by about 30  per cent compared to
sea level).
DISPOSITION
Entry to pilot training
A spontaneous pneumothorax within two years and with-
out definitive treatment is a bar to entry. Potential military
aircrew should undergo pleurectomy, as discussed above. A
single untreated pneumothorax more than two years previ-
ously is acceptable because of the small risk of recurrence
after this time. Investigation for underlying lung pathology
is recommended.
Trained aircrew
Military
Following successful pleurectomy after a single event with
no underlying lung disease, flying duties can resume three
months after surgery. If pleurectomy is not undertaken on
a first episode, then the patient should be grounded for a
minimum of 18  months. Repeat episodes would require a
pleurectomy for the aviator to continue with flying duties.
Civilian
Full certification following a fully recovered, single spon-
taneous pneumothorax may be acceptable after one year
from the event, with full respiratory evaluation (pulmonary
function testing, CT scanning) by a specialist.
Recertification in multi-pilot operations or under safety
pilot conditions may be considered if the applicant recov-
ers fully from a single spontaneous pneumothorax after six
weeks, provided that pulmonary function testing and CT
scanning show no underlying lung disease.
K17577_C023.indd 433
Bullous lung diseases and cysts  433
A recurrent spontaneous pneumothorax is disqualify-
ing. Certification may be considered following surgical
intervention with a satisfactory recovery.
PASSENGER TRAVEL
A patient with a current closed pneumothorax should not
travel on commercial flights. The patient may be able to fly
one week after a definitive surgical intervention and reso-
lution of the pneumothorax. A patient who has not had
surgery must have had a CXR confirming resolution, and
at least one week must have elapsed following resolution
before travel.
Traumatic pneumothorax
Trauma to the chest can cause a leak of air into the pleural
space. This can be due to penetration through the chest wall,
fractured rib(s) or blunt trauma to the lung tissue.
TRAINED AIRCREW
Military and civilian
The risk of recurrence after initial treatment is very small if
no underlying lung pathology is present. No definitive treat-
ment is required, and flying duties can resume three months
after treatment.
PASSENGER TRAVEL
Patient is fit to travel two weeks after resolution on CXR.
BULLOUS LUNG DISEASES AND CYSTS
Introduction
Bullae are thin-walled airspaces greater than 1 cm in size.
They may compress the surrounding lung tissue. They may
be isolated in otherwise normal lungs or be part of gener-
alized emphysema. Cysts may be caused by destruction of
airspaces by respiratory disease.
Natural history
Isolated bullae in otherwise normal lungs in a young adult
are usually stable and unlikely to progress. Presence of
underlying lung disease suggests the likelihood of pro-
gression. The risk from bullae is associated with the risk of
rupture and, therefore, pneumothorax. The other consider-
ations are a ventilation/perfusion (V/Q) mismatch at the site
of the bullae and potential compression of the surrounding
normal lung.
Investigation
CT scanning and lung-function tests are the mainstays of
investigation. CT scanning is used in order to assess the
extent of bullae and to investigate any underlying lung dis-
ease. Lung-function testing is important in order to assess
17/11/2015 15:57
 434  Respiratory disease
lung volumes and to investigate any airflow limitation.
Radioactive assessment of ventilation and perfusion is also
important in order to assess the degree of mismatch.
Treatment
Surgical treatment involves a bullectomy in patients with
single bullae and otherwise normal lungs. Bronchoscopic
reduction of emphysematous bullae has had reasonable suc-
cess and is far less invasive.
Aeromedical management problems
The main hazard is bullous rupture and subsequent pneu-
mothorax. The bullae may not communicate with the air-
way and, therefore, during decompression training may
lead to an increase in size and pneumothorax (possibly ten-
sion pneumothorax; see earlier). Both rupture and pneumo-
thorax would lead to sudden incapacitation.
Disposition
PILOT TRAINING
The presence of bullae makes the potential trainee unfit.
Previous surgery for a single bulla with normal underlying
lung can proceed following a full respiratory assessment.
TRAINED AIRCREW
An aviator with a single bulla but otherwise normal lungs
must be grounded until definitive surgery has been per-
formed. Multiple bullae or the presence of underlying lung
disease are incompatible with flying.
OBSTRUCTIVE SLEEP APNOEA
Natural history
Obstructive sleep apnoea (OSA) is much more common
than is widely thought. It typically affects middle-aged
overweight men. OSA is characterized by:
●● Daytime somnolence.
●● Snoring.
●● Apnoeic attacks during sleep.
●● Morning headaches.
●● Perceived poor quality of sleep.
Collapse of the upper airway during sleep leads to recur-
rent periods of apnoea. These, in turn, lead to sudden
arousals from sleep (usually not remembered by patient),
poor-quality sleep as a consequence and daytime somno-
lence. Arousals from sleep are usually not recollected in the
morning. Long-term effects include increased risk of car-
diac events and nocturnal carbon dioxide retention.
K17577_C023.indd 434
Investigation
Clinically, an Epworth sleepiness score (out of 24) is of use.
A sleep study is the standard investigation and will provide
information on apnoeas and hypoapnoeas as well as noctur-
nal oxygen desaturation. Overnight oximetry can detect the
repetitive desaturations seen in severe OSA and may give a
diagnosis in some patients. However, if the study is negative,
a formal sleep study is needed.
Treatment
Initial treatment of mild cases should involve addressing
possible precipitating factors, such as obesity, excessive
alcohol use, use of sedating drugs and cigarette smoking.
Ear, nose and throat (ENT) problems and endocrine abnor-
malities, e.g. hypothyroidism, should also be corrected. For
moderate to severe disease, and in people in whom simple
measures have failed, the best treatment is with continuous
positive airway pressure (CPAP). Intolerance of this treat-
ment can occur, in which case a mandibular advancement
device or uvulopalatopharyngoplasty can be used, although
the latter is of minimal effectiveness.
Aeromedical management problems
The risk is that of incapacitation due to severe daytime som-
nolence. This may be either sudden, with onset of sleep, or
chronic, with impairment of performance. Treatment cor-
rects this and removes the risk of incapacitation.
Disposition
ENTRY TO PILOT TRAINING
A history of OSA should be disqualifying.
TRAINED AIRCREW
Grounding is required until a response to treatment and
cure of daytime somnolence have been confirmed. Upon
successful treatment, a return to unrestricted flying duties
should be allowed with regular follow up and objective
ongoing evidence of CPAP usage and effectiveness.
Passenger travel
A doctor’s letter is required outlining the medical diagno-
sis and stating that the CPAP machine should travel in the
cabin as extra hand luggage. Long-haul flight passengers
should consider using their CPAP machine. The majority of
patients will not require CPAP during short flights. Battery-
powered CPAP machines can be used during the flight but
must be switched off before landing. Patients should avoid
drinking alcohol before and during the flight.
Patients with significant OSA should use CPAP when
visiting high-altitude destinations.
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CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
Introduction
COPD is a disorder characterized by airflow limitation
that is largely irreversible and progressive in nature. COPD
encompasses chronic bronchitis and emphysema; the
majority of patients have a combination of both. Chronic
bronchitis is clinically a productive cough due to overpro-
duction of bronchial secretions and without significant
reversibility of airway obstruction. Emphysema is defined
as enlarged airspaces distal to the terminal bronchiole, with
destruction of airway walls without fibrosis. The underlying
cause in almost all cases is passive or active cigarette smok-
ing. Other causes of emphysema are rare, e.g. alpha-1-anti-
trypsin deficiency. It has been found that there is a genetic
susceptibility that may be used in the future to predict the
chances of developing COPD. The mortality from COPD is
rising worldwide.
Natural history
As COPD is a heterogeneous disease, there is a variable nat-
ural history. COPD patients tend to present late and often
with an incorrect diagnosis of asthma. Symptoms consist
of breathlessness, daily sputum production, cough and
wheeze. Response to treatment is poor in comparison with
asthma, with airflow obstruction being mainly irreversible
in COPD. Recurrent respiratory infections are common.
If smoking continues, the disease progression is relentless.
Cessation of smoking at any stage will lead to a slowing of
progression and is the only factor that has been shown to
slow progression.
Pathogenesis
Risk factors for COPD include:
●● Smoking habit.
●● Increasing age.
●● Environmental pollution.
●● Chronic childhood respiratory diseases and low birth
weight.
Treatment
The most important factor in the treatment of COPD is to
stop smoking.
Pulmonary rehabilitation programmes have been shown
to be beneficial for the improvement of symptoms and
should be undertaken if possible.
Pharmacological treatment involves the use of both ste-
roid and bronchodilator inhalers to reverse any reversible
obstruction. The combination steroid and LABAs has been
K17577_C023.indd 435
Chronic obstructive pulmonary disease  435
shown to be beneficial, along with antimuscarinic broncho-
dilators. Oral theophyllines are also used, but much less so
in recent years.
In patients with a significant emphysema element, bul-
lectomy of any large bullae can improve lung function. This
can be performed by bronchoscopic volume reduction as
well as thoracotomy or mediastinoscopy
Aeromedical management problems
Unlike asthma, COPD rarely causes sudden incapacitation,
except when bullae are present, in which case the problems
are those of a spontaneous pneumothorax. Patients with
significant air trapping may experience problems with alti-
tude (increase in volume of already trapped air) and with
pressure breathing (an active increase in trapped air/pres-
sure).This can lead to significant discomfort and compro-
mise. Because of the nature of the disease, there is a greater
rate of pulmonary infections, leading to reduction in opera-
tional efficiency and flying time.
In more advanced stages of COPD (passengers), the lower
partial pressures of oxygen at altitude (discussed earlier),
even in pressurized aircraft, can lead to a significant reduc-
tion in the arterial oxygen saturation (SAO2). This reduction
can lead to significant hypoxia. Oxygen requirement should
be assessed as discussed above.
Disposition
PILOT TRAINING
A diagnosis of COPD disqualifies pilot training. However,
due to the nature of the disease, it would be very unusual in
this group. A full specialist assessment is required in order
to confirm the diagnosis.
TRAINED AIRCREW
Military and civilian
In mild disease, with normal lung function and no CT evi-
dence of bullae, unrestricted flying is allowed with regular
respiratory follow-up. Strong advice to stop smoking should
be given due to the disease progression.
Patients with moderate disease will require specialist
assessment. They will be unfit for fast-jet flying, but their
suitability for other flying duties will depend on the amount
of respiratory limitation.
Aircrew with frequent exacerbations, significantly
decreased lung function (FEV1  < 50  per cent predicted),
presence of bullous disease or abnormalities of arterial
blood gases are unfit any flying duties.
Passenger travel
Preventive and relieving inhalers should be carried in
the hand luggage. Portable nebulizers may be used at the
17/11/2015 15:57
 436  Respiratory disease
discretion of the airline. Some airlines can provide nebuliz-
ers for inflight use and patients should check with the car-
rier when booking. It is important to stress that spacers are
as effective as nebulizers.
BRONCHIECTASIS
Introduction
Bronchiectasis is defined as a chronic dilation of one or more
bronchi. Macroscopically, bronchiectatic lung reveals per-
manent dilation of subsegmental airways that are inflamed,
tortuous and often partially or totally obstructed with secre-
tions. The process also includes bronchioles and, at end stage,
there may be marked fibrosis of small airways. The overall
appearance microscopically is of chronic inflammation in
the bronchial wall, with inflammatory cells and mucus in the
lumen. Causes are widespread, with the majority being idio-
pathic, post-infective (usually in childhood) or secondary to
immunodeficiency. Cystic fibrosis is also a significant cause.
Natural history
There is often a history of childhood pulmonary infec-
tions or sinus/ENT problems. A cough is usually present,
and symptoms of fatigue and breathlessness are common.
Patients usually produce an increased amount of purulent
sputum. The frequency of pulmonary infections increases
with time if treatment is not instituted. Chronic rhinosinus-
itis is also often associated in adult life. Haemoptysis can
be present, and worsening of constitutional symptoms also
occurs. Examination classically shows finger-clubbing and
crackles, usually at the bases.
Investigation
A high-resolution CT scan is required in order to assess
the extent of disease. Investigations of the underlying
cause (immune deficiency, cystic fibrosis, connective tis-
sue disease, ciliary dyskinesia, pulmonary aspergillosis) are
very important and can indicate the course of treatment.
Lung-function testing has a significant role in assessing
small-airways disease. Sputum culture to culture infecting
organisms is also important.
Treatment
If a treatable cause, e.g. hypogammaglobulinaemia or aller-
gic bronchopulmonary aspergillosis, has been excluded,
then the mainstay of treatment is sputum clearance.
Recognizing pulmonary infective exacerbations and their
prompt treatment with antibiotics is also very important.
Infective exacerbations are defined by at least two of the fol-
lowing: increased sputum volume, increased sputum colour,
fever and breathlessness.
In some patients, this management fails to prevent fre-
quent infective exacerbations, thus causing morbidity and
K17577_C023.indd 436
disease progression. In these patients, prophylactic treat-
ment is required. This usually involves either nebulized
antibiotics or oral antibiotics.
Surgery for limited disease was used in the past, but this
rarely leads to cure and is performed very infrequently now-
adays and not recommended.
Aeromedical management problems
Although this disease can be severely debilitating, resulting
in significant loss of flying time, the risk of sudden incapaci-
tation is small. The major feature is that of recurrent infec-
tive exacerbations. These can sometimes be controlled with
prophylactic antibiotics, as stated above.
Disposition
PILOT TRAINING
A history of bronchiectasis is a bar to acceptance to pilot
training. Patients with limited disease and who have had
‘curative’ surgery should be referred for specialist opinion
but are unlikely to be fit for pilot training.
TRAINED AIRCREW
Patients with limited disease and who have minimal
infective exacerbations and normal lung function should
be fit for limited flying duties, e.g. unfit fast jets, unfit
solo flying. Those with more severe disease should be
grounded permanently.
PULMONARY TUBERCULOSIS
Introduction
Pulmonary TB is a pneumonic infection caused by the
organism Mycobacterium tuberculosis. TB is one of the most
important diseases in the history of humanity and remains
an extraordinary burden on human health today. Despite
the availability of curative chemotherapy for more than half
a century, however, TB continues to cause an enormous
amount of suffering, disability and mortality. It is still the
leading cause of death from infectious disease worldwide.
Resurgence in the incidence of TB in the West has been
caused by epidemics of human immunodeficiency virus
(HIV)-related TB and multi-drug-resistant disease.
Natural history
After M. tuberculosis infection is acquired, the risk of devel-
oping disease depends on the host immunity. Tubercle
bacilli are transmitted between people by aerosol particles
(diameter < 1  μm), which remain airborne for long peri-
ods. Deposition of tubercle bacilli in the alveoli results in
a series of protective responses by the cellular immune sys-
tem that forestalls the development of disease in the major-
ity of infected people. Alveolar macrophages ingest tubercle
bacilli, which then multiply intracellularly and eventually
17/11/2015 15:57

cause cell lysis, with release of organisms. Additional alve-
olar macrophages engulf progeny bacilli, resulting in fur-
ther intracellular growth and cell death. Over a period of
weeks, as tubercle bacilli proliferate within macrophages
and are released, infection spreads to regional lymph nodes,
elsewhere in the lungs and systemically. The classic immu-
nological response to infection with tubercle bacilli is the
walling off of viable bacilli in granulomas. A calcified gran-
uloma at the initial site of infection in the lung is referred to
as a Ghon focus. For the majority of people acquiring a new
tuberculous infection, the development of cell-mediated
immunity to the organism is protective and holds the bacilli
in check, although viability is usually maintained.
Clinical manifestations
Infection with TB is often asymptomatic. Pulmonary TB
is usually a subacute respiratory infection with prominent
constitutional symptoms. The most frequent symptoms of
pulmonary TB are cough, fever, weight loss, night sweats
and malaise. Cough in pulmonary TB is initially dry but
often progresses to become productive of sputum and, in
some instances, can cause haemoptysis. Occasionally,
pleuritic pain is experienced, but this is usually with
pleural involvement.
Presentation is usually late, with the patient being unwell
for weeks or even months.
Investigations
Plain CXR may show the typical upper lobe infection, with
cavitations. Consolidation or a pleural effusion may also be
present. Enlarged hilar lymphadenopathy may be seen, but
TB is a great mimic and can present in many ways, often
suggesting other diseases.
An interferon gamma (IFN-γ) release assay (IGRA)
should be performed, though this will not discriminate
between active and latent disease. Early-morning sputum
tests on at least three consecutive days, looking for AFB,
should also be performed. If a pleural effusion is present,
then pleural fluid should be examined for AFB. Often, bron-
choscopic washing of the upper lobe is required if no spu-
tum is available or the diagnosis is still suspected despite
negative sputum microscopy. Sputum culture can take
up to eight weeks but is essential for antibiotic sensitivity.
Polymerase chain reaction (PCR) methods are also used
extensively nowadays.
It is important to remember that if testing is negative but
the diagnosis is still suspected, then continued investigation
should proceed.
Treatment
Standard treatment of TB is with a combination of anti-
tuberculous drugs. The usual regimen in the developed
world, until sensitivities are known, is two months of iso-
niazid and rifampicin plus pyrazinamide and ethambutol.
K17577_C023.indd 437
Atypical mycobacterial disease  437
After the initial two months, depending on the sensitivities,
drug treatment is reduced to isoniazid and rifampicin alone
for a further four months, though this can be longer if extra-
pulmonary disease is present. The side effects of these drugs
are extensive, the main significant effects being hepatitis
and jaundice. Ethambutol may cause optic neuritis, which
presents as colour-vision disturbance. For this reason, an
ophthalmic opinion is suggested if ethambutol is to be used.
Aeromedical management problems
General illness caused by the disease and the intensity of the
treatment is likely to mean that the patient is unable to fly.
The risk of a spontaneous pneumothorax secondary to pos-
sible cavitations is also a concern.
Disposition
PILOT TRAINING
Candidates who have had previously fully treated TB and
with no evidence of underlying lung disease and no evi-
dence radiologically or on lung-function testing of residual
lung damage are acceptable for pilot training.
TRAINED AIRCREW
An aviator with active disease and undergoing chemother-
apy treatment should be grounded. Once they have com-
pleted the treatment and have been shown radiologically
and on lung-function testing to have no residual lung dam-
age, they may be upgraded to unrestricted flying duties.
Those who are taking prophylactic treatment should
remain grounded for the length of the treatment.
Patients with evidence of residual lung damage or who
are shown to have underlying lung pathology should be
referred to a specialist for full radiological and lung-func-
tion assessment and judged on an individual basis.
Passenger travel
Patients with infectious TB must not travel by public air
transportation until they have had a minimum of 14 days
treatment and are non-infectious (three smear-negative
sputum examinations on separate days).
ATYPICAL MYCOBACTERIAL DISEASE
Introduction
Atypical mycobacteria are ubiquitous in the environment
and are low-grade pathogens. They include Mycobacterium
kanasii, M. xenopi, M. malmonoense and Mycobacterium
intracellulare complex (MAC), which is also known as MIAS
due to the combination of organisms (M. intracellulare, M.
avium, M. scrofulaceum). There are a number of other pos-
sible organisms, but these are a very rare cause of genuine
infection. Exposure to them is unavoidable but does not
constitute a threat to most people. Person-to-person spread
17/11/2015 15:57
 438  Respiratory disease
is almost unheard of, with only one reported case. About five
per cent of all mycobacterial pulmonary disease is caused
by atypical mycobacteria. Usually, pre-existing lung disease
(over 50 per cent having COPD) or an immunological defect
is required before these organisms can cause genuine infec-
tion. Sometimes, the nature of the immunological defect is
very hard to identify, but in the absence of pre-existing lung
disease it should be sought by a specialist.
Clinical manifestations
The presentation is very similar to TB, with cough, spu-
tum, fever, weight loss and increasing breathlessness. The
symptoms tend to have an insidious onset, with a subacute
or chronic illness picture, rather than an acute presenta-
tion. A significant proportion of patients (10–40 per cent)
are asymptomatic.
Investigations
It is important to ascertain that the infection is genuine. It
is impossible to distinguish TB from atypical infection on a
CXR. Isolation and culture from sputum, bronchial lavage
or lung biopsy are hindered by the same problems as TB (i.e.
slow growth) and can require a number of different media
and up to eight weeks to culture. This can be overcome on
some occasions by the use of DNA probes and amplification
techniques, but at present these are restricted to specialized
reference laboratories.
Treatment
Rifampicin and ethambutol are the mainstays of treatment.
This should be continued for between 15  and 24  months.
The addition of one of isoniazid, clarithromycin, ciprofloxa-
cin and streptomycin may be required, depending on sen-
sitivities and progress of treatment. Lengthy treatment of
many years’ duration may be involved.
Aeromedical management problems
General illness secondary to the disease and the intensity of
the treatment are likely to mean that the patient is unable
to fly.
Disposition
PILOT TRAINING
The presence of active or previous atypical mycobacterial
infection is a bar to acceptance to pilot training. This is
mainly not due to the disease itself but to the almost certain
causative underlying lung disease or immunodeficiency.
TRAINED AIRCREW
The underlying lung disease or immunodeficiency, high
recurrence rates and problems with inadequate treatment
mean that the aviator should be permanently unfit for flying
K17577_C023.indd 438
duties. In a small number of cases where underlying cause is
not found and curative treatment has occurred then a lim-
ited flying category can be considered after specialist avia-
tion respiratory opinion.
INTERSTITIAL LUNG DISEASE
Introduction
Interstitial lung disease (ILD) consists of a wide variety
of lung disorders characterized by a diffuse parenchymal
disease of the lung interstitium. The previous diagnosis
of fibrosing alveolitis has now been superseded by a more
encompassing classification (Figure 23.3). This classification
includes information from radiology and histopathology.
Natural history
The presentation is usually breathlessness or an unsus-
pected abnormality on a CXR. The natural history and
treated course are critically dependent on the nature of the
underlying disease process, which varies widely within this
group of disorders. The diversity of this is beyond the scope
of this chapter and should be investigated by a specialist.
Investigations
General investigations for presumed ILD should include
the following:
●● CXR.
●● High-resolution CT thorax.
●● Full lung-function testing, including transfer factor.
●● Autoimmune screen, including extractable
nuclear antibodies.
●● Precipitins to known environmental factors, known to
cause ILD.
Treatment
The mainstay of treatment of the lung disease is corticoste-
roids and immunosuppressants, but treatment of the under-
lying pathology or removal of exposure to a causative factor
is also very important. The combination of these can be very
complex and should be left to a specialist in this area. Lung
transplantation may be required in end-stage disease.
Aeromedical management problems
Due to the nature of this group of diseases, they make flying
duties impossible while the disease is active. Corticosteroids
and immunosuppressants are associated with a number of
problems of their own, such as increased risk of infection,
neurological complications and blood dyscrasias, and are
incompatible with flying duties. The other possible prob-
lem is hypoxia due to a reduced transfer factor. This may be
present at sea level and should be picked up by investigation
17/11/2015 15:57
 Pulmonary thromboembolic disease  439

DPLD

DPLD of known Idiopathic Granulomatous Other forms of

cause or interstitial interstitial pneumonia,
association pneumonias e.g. LAM, PLCH,
eosinophilic
pneumonia

Idiopathic Interstitial pneumonia

pulmonary other than idiopathic
fibrosis pulmonary fibrosis

Desquamative interstitial Respiratory bronchiolitis

pneumonia Interstitial lung disease

Acute interstitial Cryptogenic organizing

pneumonia pneumonia

Non-specific Lymphocytic interstitial

interstitial pneumonia pneumonia

Figure 23.3  Classification of interstitial lung disease. DPLD, diffuse parenchymal lung disease; LAM, lymphangioleiomyo-
matosis; PLCH, pulmonary Langerhans cell histiocytosis.

but may manifest only at altitude. Specific hypoxia tests can
be performed at varying levels of Po2 to assess this.
Disposition
PILOT TRAINING
A history of ILD is a bar to acceptance to pilot training.
TRAINED AIRCREW
The majority of diseases within this group are likely to lead
to permanent grounding. There are some diseases within
this group that, when treated, may enable a limited flying
category, but this would require specialist recommendation.
Referral to a specialized unit is recommended.
Passenger travel
All those with oxygen saturations below 92  per cent at
sea level should be given supplementary oxygen. All other
patients should have hypoxic challenge testing irrespective
of resting sea level saturations as significant desaturations at
cabin altitude and when mobilizing in this environment, in
particular, is much more likely in ILD patients and cannot
be predicted by resting saturations or FEV1. Consideration
of rescue packs of antibiotics should also be considered and
discussed with their specialist. Consideration for oxygen
supplementation at the patient’s destination should also be
considered if at a high altitude.
PULMONARY THROMBOEMBOLIC DISEASE
Natural history
Pulmonary thromboembolic disease forms a large spec-
trum, from completely asymptomatic or a small amount of
localized chest pain, through dyspnoea, to cardiorespira-
tory collapse and arrest. By definition, there is embolization
from a clot within the vasculature, and so the causes are
widespread but grouped grossly as due to:
●● Haemostasis, e.g. secondary to immobilization.
●● Clotting disorder.
Embolization can occur before identification of the pri-
mary source. The most common source is from a deep vein
thrombosis of the iliac or femoral veins.
Investigation
Investigation for pulmonary embolism is two-fold:
1. Investigation of a suspected pulmonary embolus:
●● Wells score and d-dimer if appropriate.
●● Chest X-ray (often normal).
●● Arterial blood gases: hypoxia.
●● ECG: sinus tachycardia/atrial fibrillation; right bun-
dle branch block; right ventricular strain pattern.

K17577_C023.indd 439 17/11/2015 15:57

 440  Respiratory disease
●● Computed tomography pulmonary angiogram
(CTPA) is the investigation of choice though a
V/Q scan should be considered in young patients,
particularly female.
2 . Investigation of the underlying primary source of the
embolus:
●● Doppler or venogram of iliac and femoral veins.
●● Bloods for clotting disorders.
●● Search for possible underlying malignancy.
Treatment
In severe cases, thrombolysis may be life-saving. In the
vast majority of cases, initial treatment is subcutaneous
low-molecular-weight heparin with oral warfarin or newer
treatment with factor Xa inhibitors. If warfarin is used then
subcutaneous low-molecular-weight heparin is continued
until the international normalized ratio (INR) is greater
than two, at which point only warfarin is continued for six
months. This ongoing treatment with subcutaneous low-
molecular-weight heparin is not required after first dose of
factor Xa inhibitors.
Aeromedical management problems
A risk of recurrence is the main aeromedical problem. As
stated previously, this could manifest as sudden incapacita-
tion due to a large embolus or cause chest pain or dyspnoea,
leading to a decrease in functional capacity. The other pos-
sible problem is that of hypoxia following a previous pul-
monary embolism. This may be present at sea level and
should be picked up by investigation but it may manifest
only at altitude. Specific hypoxia tests can be performed to
assess this.
Disposition
PILOT TRAINING
Recurrent pulmonary embolism, a history of pulmonary
embolism with no predisposing cause or a history of pul-
monary embolism with an irreversible cause (e.g. clotting
abnormality, malignancy) are disqualifying from pilot
training. A history of a single pulmonary embolism with a
reversible cause requires specialist assessment.
TRAINED AIRCREW
The aviator should be grounded for the length of investiga-
tion and treatment. Following treatment, and with a nor-
mal coagulation work-up and a defined cause found, flying
duties can be resumed. Recurrent episodes or pulmonary
embolisms with an irreversible cause mean permanent loss
of flying category.
Passenger travel
All patients with recent pulmonary thromboembolic dis-
ease should seek specialist assessment before flying. Those
K17577_C023.indd 440
with previous pulmonary thromboembolic disease when
flying should avoid alcohol- and caffeine-containing drinks,
take only short periods of sleep unless they can attain their
normal sleeping position and avoid the use of sleeping pills.
Graduating compression stockings are recommended for
those patients not on anticoagulant treatment. Patients with
recurrent pulmonary thromboembolic disease should use
prophylactic subcutaneous low-molecular-weight heparin,
especially if the flight is greater than eight hours.
SUMMARY
●● Cabin altitude will lead to a degree of hypoxia
in all individuals while flying, leading to
increased respiratory rate and resting pulse.
These effects are accentuated in people with
respiratory disease.
●● With the exception of ILD, patients with oxygen
saturations of > 95 per cent on air at sea level will
not require supplementary oxygen during normal
civilian flight.
●● Most respiratory diseases in a mild form are still
compatible with a flying medical category for
pilots to continue. Most respiratory diseases, even
in a mild form, are usually disqualifying from
individuals entering pilot training.
●● Asthma treatment should be aimed at com-
plete control of symptoms. The use of inhalers,
including combination steroid and long acting
beta 2 agonist inhalers, allows excellent control
in the majority of asthmatics and a return to a
flying category.
●● New, more intelligent auto CPAP machines
allow close and accurate monitoring of pilots
with sleep apnoea remotely, thus allowing a
return to flying duties for those compliant with
appropriate treatment.
REFERENCES
Ahmedzai S, Balfour–Lynn IM, Bewick T, et al. Managing
passengers with stable respiratory disease planning
air travel: British Thoracic Society recommendations.
Thorax 2011; 66 (Suppl 1): i1–30.
British Thoracic Society and Scottish Intercollegiate
Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A National Clinical Guideline.
Updated 2012. Available from https://www.brit-
thoracic.org.uk/Guidelines/Asthma-Guidelines.aspx.
Accessed 13 January 2015.
Cates CC, Bara A, Crilly JA, Rowe BH. Holding chambers
versus nebulisers for beta-agonist treatment of acute
asthma. Cochrane Database of Systematic Reviews
2003; 3:CD000052.
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Aviation gastroenterology and hepatology
GARETH D. CORBETT
Introduction 441
Gastrointestinal physiology and aviation 441
Aviation gastroenterology 442
Functional gastrointestinal disorders 444
INTRODUCTION
Diseases of the gastrointestinal (GI) tract are common in
the wider population and are, therefore, encountered by avi-
ators relatively frequently. These diseases do not cause the
extremes of incapacitation related to acute cardiac or neu-
rological events, however, acute GI illnesses can prevent air-
crew from performing their duties. Most acute GI illnesses
will develop over a period of hours and, therefore, before
flight. They are self-limiting and usually resolve spontane-
ously; therefore, a short term restriction from flying until
the symptoms have passed is sufficient. Chronic GI diseases
such as inflammatory bowel disease often have a relapsing/
remitting course and long term medical intervention is
required to alter the natural history of the disease. These
diseases have significant implications for those pursuing
a career in aviation due to the relapsing nature leading to
unpredictable absences from flying, which can be unaccept-
able to an employer. However, with treatment advances,
many GI conditions can now be managed and allow aircrew
to maintain their fitness to fly.
In this chapter, the impact of the aviation environment
on the GI tract is described, followed by a summary of major
GI diseases and their implications for aircrew diagnosed.
GASTROINTESTINAL PHYSIOLOGY AND
AVIATION
Environmental factors experienced in aviation and space
flight such as extremes of acceleration (G) and vibration have
been historically reported to alter gastrointestinal physiol-
ogy. Examples include gastric emptying time and reduction
K17577_C024.indd 441
24
Infectious gastrointestinal disorders 445
Aviation hepatology 445
Conclusion 447
Further reading 447
in gastric secretion following exposure to high G, visceral
displacement and injury secondary to extreme deceleration
and an increased risk of GI haemorrhage and urge to defae-
cate secondary to vibration stress. Although most of the
experiments which demonstrated these findings were based
on animal models, in which extremes of the forces were
imposed, the most relevant is probably the impact of gastric
physiology. Reduction in gastric emptying may increase a
healthy individual’s risk of experiencing abdominal pains,
an obvious impediment when flying.
Gas expansion at altitude may also cause acute gastro-
intestinal symptoms. In simulated exposures to altitude of
35 000  feet around 28  per cent of participants reported a
degree of abdominal discomfort and of these 5.5  per cent
reported severe discomfort. Increased flatulence has also
been reported and is positively associated with age (28–47),
weight (160–200 lbs) and fullness of the stomach.
Hypoxia has been shown to reduce gastric emptying,
reduce hydrochloric acid secretion by the stomach and to
alter patterns of absorption. Sodium chloride and glucose
absorption falls and water absorption increases in hypoxic
environments. In addition, there is an association with gas-
troduodenal ulceration and prolonged exposure to hypoxia.
However, as aircrew work in a pressure-controlled envi-
ronment these physiological consequences should not be
clinically relevant.
Overall, the physiological changes in response to envi-
ronmental factors which have been shown experimentally
are unlikely to pose a risk to healthy aircrew due to the rela-
tively short exposure. They are, however, of interest, par-
ticularly in the context of chronic GI disease where these
changes may be more relevant.
441
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 442  Aviation gastroenterology and hepatology
AVIATION GASTROENTEROLOGY
Gastro-oesophageal reflux disease
Gastro-oesophageal reflux disease (GORD) is a prime
example of a condition in which environmental factors
experienced by aircrew may worsen symptoms. It is a com-
mon complaint, with up to 60  per cent of adults report-
ing symptoms at some time in their life. The prevalence of
GORD, as defined by the presence of oesophageal mucosal
damage, is between 10 per cent and 20 per cent. The symp-
toms are heartburn and regurgitation. They are often exac-
erbated following large meals or changes in posture and are
relieved with antacids. Upper GI endoscopy is not required
to confirm the diagnosis of GORD if they are the only
symptoms. When flying, it is of interest that extremes of G
and pressure breathing have not been shown to aggravate
reflux symptoms.
Patients sometimes present with additional symptoms
such as dysphagia, epigastric pain, weight loss or vomiting.
These could represent more sinister pathology and endo-
scopic investigation of the oesophagus, stomach and duode-
num is appropriate. Due to the age demographic of aircrew,
the majority are low risk for malignant conditions despite
these symptoms; however, some may have peptic ulcers.
In those with a normal endoscopy further assessment of
oesophageal physiology may be appropriate with pH moni-
toring or oesophageal manometry.
Twenty-four-hour pH monitoring is useful in patients
with symptoms which are not resolving and can be used to
demonstrate whether symptoms are secondary to reflux of
acid or functional in nature.
The treatment of GORD involves alterations in life-
style, medical therapy and, occasionally, surgery. Lifestyle
changes include weight loss, raising the head end of the bed
and eating the final meal of the day at least two hours before
going to sleep. Medical therapies are divided into antac-
ids (alginate compounds) and acid suppressants such as
H2 receptor antagonists and proton pump inhibitors (PPIs).
For patients with no endoscopic evidence of oesophageal
mucosal damage, PPIs have been shown to be relatively inef-
fective at alleviating symptoms and alginates should be used
first line in this group. These medical therapies are safe to
use for aircrew without restriction. For patients where life-
style changes and medical therapy have failed, anti-reflux
surgery can be offered.
Flying restrictions are rarely required for GORD, unless
symptoms interfere with normal duties during flight.
Oesophageal dysmotility
Disorders of oesophageal dysmotility such as achalasia, dif-
fuse oesophageal spasm and scleroderma can be diagnosed
using manometry. These conditions are relatively rare in
younger people.
Achalasia is a condition in which the lower oesophageal
sphincter has high tone and fails to relax or increases in
K17577_C024.indd 442
pressure in response to a food bolus. Patients notice inter-
mittent dysphagia which worsens with time. Treatment
involves altering the integrity of the sphincter either by bot-
ulinum toxin injection, balloon dilatation or surgical divi-
sion of the muscle fibres.
Diffuse oesophageal spasm may cause severe central
chest pains and be confused with cardiac chest pain. The
diagnosis should be considered in any patient with chest
pain when swallowing or in those with unexplained chest
pain despite cardiac investigation. Aircrew with this con-
dition should be restricted from flying until satisfactory
symptom control has been established. As this may involve
the use of nitrates or calcium channel blockers, appropriate
restrictions for these drugs in aircrew may be required.
The oesophageal dysmotility seen in scleroderma is part
of a myriad of symptoms in this autoimmune condition.
Patients also experience Raynaud’s phenomenon and this
component may result in flying restrictions.
One oesophageal condition with increasing prominence
and relevance to aircrew due to their demographic is eosino-
philic oesophagitis. This disease is characterized by intermit-
tent symptoms of dysphagia which are usually self-limiting.
Patients are often young, aged between 25 and 50 and there
is often a male predominance. Patients complain of the sen-
sation of food sticking retrosternally. They are often unable
to swallow solids or liquids until the bolus of food passes.
The condition is an oesophageal motility disorder related to
the presence of eosinophils within the oesophageal mucosa.
Endoscopic findings can vary from normality to significant
denudation of the oesophageal mucosa. It is thought to be
secondary to food intolerance of some kind, and food diaries
are sometimes used to identify associations. However, the
unpredictable nature of the condition means this is often
unsatisfactory and treatment with swallowed corticosteroid
spray is often successful at reducing episodes.
Overall, aircrew diagnosed with oesophageal dysmotility
may require restriction, particularly if food bolus obstruc-
tion is occurring frequently.
Peptic ulcer disease
The discovery of Helicobacter pylori in 1982 and the intro-
duction of proton pump inhibitors (PPIs) in 1989  revo-
lutionized the management of peptic ulcer disease. The
prevalence of gastric and duodenal ulcers has fallen due
to eradication of H. pylori and the widespread use of PPIs.
Despite this fall, peptic ulcers remain a concern in aircrew
due to complications such as acute haemorrhage and perfo-
ration which can occur unpredictably. Therefore, all aircrew
with symptoms suggestive of gastroduodenal ulceration
should be referred for upper GI endoscopy. Patients pres-
ent with symptoms such as epigastric pain, nausea, vomit-
ing and weight loss but ulcers can also be asymptomatic. A
physical examination is often unremarkable, but may reveal
epigastric tenderness. Due to the non-specific nature of
the symptoms, a differential diagnosis of other abdominal
diseases such as inflammatory bowel disease, pancreatitis,
17/11/2015 15:57

cholelithiasis and neoplastic disease should be considered.
Risk factors for peptic ulcer disease include H. pylori infec-
tion, aspirin and NSAID use, SSRI anti-depressant use
and bisphosphonates. Stress can also contribute to the risk
of ulceration, but is not an independent aetiological fac-
tor. Chronic ulceration may cause anaemia or gastric out-
flow obstruction, but these complications are less likely to
develop in the younger population.
Endoscopy will confirm the diagnosis and all patients
should be tested for H. pylori. If a patient presents with acute
haemorrhage the ulcer will be treated endoscopically with
adrenaline injection and either cauterisation or ligation of
the bleeding vessel. Emerging therapies for treatment of
acute bleeding also include haemostatic sprays which are
directed at the lesion using the endoscope and provide rapid
cessation of haemorrhage. Any aircrew with peptic ulcer-
ation should be restricted from flying until it has healed,
which would be expected with PPI therapy and Helicobacter
eradication if necessary. It is usual practice to confirm the
healing of a gastric ulcer endoscopically due to the increased
chance of malignancy; however, in aircrew, both gastric and
duodenal ulcers should have healing confirmed before a full
return to flying duties.
Coeliac disease
Coeliac disease is an enteropathy in which exposure of the
intestine to gluten results in villous atrophy. The common
clinical consequences of this include diarrhoea, weight loss,
anaemia and non-specific abdominal symptoms. Diagnosis
is made in two parts, initially by screening for tissue trans-
glutaminase (TTG) antibodies and then by confirmatory
duodenal biopsy. The TTG assay has 85–90  per cent sen-
sitivity, therefore, if the clinical suspicion is high in TTG
negative patients a duodenal biopsy is still recommended.
Duodenal biopsies show a range of changes in coeliac dis-
ease which may vary from an increase in intraepithelial
lymphocytes to total villous atrophy. Knowledge of the
severity of initial biopsy findings is useful when assessing
response to treatment.
Once the diagnosis has been confirmed, the patient
should start a gluten-free diet. International food standards
defined by the Codex Alimentarius Commission state that
gluten-free foods are those with less than 20 parts per mil-
lion of gluten. Some patients with coeliac disease can toler-
ate oats in their diet, and these can be allowed provided they
do not induce a relapse of villous atrophy.
Long term adherence to a gluten-free diet is important
due to the risk of small bowel lymphoma. Other associa-
tions have also been described including an increased risk
of renal failure.
Aircrew should be restricted from flying if they present
with quantifiable consequences of malabsorption such as
anaemia or folate deficiency. Those with symptoms alone
can fly once a gluten-free diet is established. Restricted air-
crew can return to flying once the deficiencies have been cor-
rected. For military aircrew, a guarantee of gluten-free foods
K17577_C024.indd 443
Aviation gastroenterology  443
may be difficult, particularly when deployed. Restriction to
flying from their home base only may need to be considered.
Cholelithiasis
Gallstone disease may present in a number of different ways,
depending on the location of the stone or stones. However,
the only symptom of concern in aircrew is biliary colic, an
incapacitating right upper quadrant pain which occurs in
around 10  per cent of patients with gallstones. Gallstones
are usually diagnosed incidentally. Aircrew diagnosed with
multiple small gallstones should be restricted from flying
until they have had a cholecystectomy and bile duct clear-
ance, if necessary. Following surgery and radiological con-
firmation of a clear bile duct, usually with an intraoperative
cholangiogram, a return to unrestricted flying is expected.
Pancreatitis
Acute pancreatitis causes incapacitating severe abdomi-
nal pain, vomiting and a systemic inflammatory response.
Patients can be acutely unwell with mortality approaching
10  per cent, therefore, careful consideration regarding the
stability of the patient should be considered prior to aero-
medical evacuation. The most common causes of pancre-
atitis are gallstones and alcohol, although there are many
others. Episodes are likely to recur until the aetiological fac-
tor has been identified and removed. Aircrew who develop
gallstone pancreatitis should be restricted from flying until
the common bile duct is clear of stones and a cholecystec-
tomy has been performed. They may be able to return to
unrestricted flying after this. Those with other causes are
likely to require flying restrictions. Recurrent episodes of
pancreatitis or the development of chronic pancreatitis are
likely to result in permanent grounding.
Inflammatory bowel disease
The inflammatory bowel diseases (IBD), Crohn’s disease and
ulcerative colitis, are relapsing/remitting disorders which
have a significant burden on the lifestyle of the patient. They
are both relatively common conditions. Recent data from
the United Kingdom reported that Crohn’s disease affects
around 1  per 1000  population and ulcerative colitis 1  per
500 population. Both conditions are most commonly diag-
nosed between the ages of 10  and 40. Symptoms include
abdominal pain, diarrhoea, rectal bleeding and fatigue.
Both may require urgent surgical intervention. The varied
response to medical therapy makes defining aeromedical
disposition difficult at times, and can frustrate aircrew and
employers. Due to the high probability of relapse these disor-
ders usually prevent entry for recruits into aviation training.
ULCERATIVE COLITIS
Ulcerative colitis is an idiopathic inflammatory bowel
disorder which affects the colon. Aetiological theories
include genetic susceptibility, bacterial triggers and other
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 444  Aviation gastroenterology and hepatology
environmental factors. Inflammation starts in the rectum
and extends proximally. Disease severity is defined by
endoscopic appearance and the extent of colon affected. It
usually presents with increased frequency of defaecation,
bloody diarrhoea and abdominal pains. A small number of
patients present with fulminant colitis requiring surgical
resection, however most can be managed medically.
The diagnosis is confirmed on biopsy of the inflamed
colonic mucosa. The inflammation is generally in the
mucosa. The initial biopsies are not always confirmatory, and
differentials may include infectious colitis, Crohn’s colitis,
radiation colitis, ischaemic colitis and microscopic colitis.
Treatment usually involves oral or topical 5-aminosali-
cylic acid (5-ASA) in mild to moderate disease. In more
severe disease systemic steroid therapy can be used to
induce remission, and if this is unsuccessful immunosup-
pressants are used. Ciclosporin is often given in the acute
phase when the patient is not responding to steroids as a
bridge to longer term azathioprine. Anti-tumour necrosis
factor (TNF) monoclonal antibodies such as infliximab
and adalimumab can also be used to induce and maintain
remission, although cost can be prohibitive.
For those requiring surgery, it is usually performed in
two stages: subtotal colectomy and ileostomy formation,
followed by a completion proctectomy. The formation of
an ileo-anal pouch to allow natural defaecation may also
be discussed with the patient as an alternative to a perma-
nent ileostomy. Patients with ileo-anal pouches tend to open
their bowels between six and eight times per day and this
should be noted when considering medical flying status.
Symptoms produced by ulcerative colitis may also vary.
For example, a patient may have disease limited to the
rectum but be burdened with frequent bowel movements
and blood.
A decision regarding the aeromedical status of a patient
with ulcerative colitis should be based on the long term
aspects of the disease as it is unlikely to result in acute
incapacitation. Patients may require special conditions at
work such as access to toilet facilities that are incompatible
with flying.
In general, a newly diagnosed patient should be restricted
from all flying duties until the acute phase has been treated
and maintenance therapy established. A clinical assess-
ment of disease extent and severity, including colonoscopy,
should then be performed. Patients with mild distal colonic
disease who remain in remission on 5-ASA may be allowed
an unrestricted flying category. Those with extensive dis-
ease and frequent relapses are unlikely to return to flying.
Those maintained in remission on immunosuppressant
therapies such as azathioprine and anti-TNF drugs may
be allowed a limited return to flying. For those who have
undergone panproctocolectomy there may be an opportu-
nity for a restricted category, however, this is dependent on
availability of facilities for managing an ileostomy or toilet
access for those with an ileo-anal pouch. Any patient who
relapses should be grounded until a further clinical assess-
ment has been performed. High dose steroid regimens are
K17577_C024.indd 444
incompatible with flying. Military aircrew maintained
on high levels of immunosuppression may require being
restricted to flying from their home base area only.
CROHN’S DISEASE
Crohn’s disease is an idiopathic inflammatory disorder
which can involve any part of the gastrointestinal tract. It
is characterized by abnormal segments of intestine sepa-
rated by normal areas, known as skip lesions. The most
common site involved is the distal ileum. The histological
findings include transmural inflammation, crypt abscesses,
lymphoid aggregates, goblet cell depletion and granuloma
formation. The disease frequently results in fistulae, abscess
formation, intestinal strictures and perianal disease.
The impact on the gastrointestinal tract usually results
in nutritional difficulties, anaemia and chronic ill health.
Around 70  per cent of patients will require at least one
operation as a result of suffering from Crohn’s disease.
Extra-intestinal manifestations including arthritis, scle-
rosing cholangitis, uveitis and pyoderma gangrenosum are
also seen.
The medical management of Crohn’s disease has been the
subject of increasing research, and a ‘top down’ approach to
treatment involving early introduction of immunosuppres-
sants and anti-TNF drugs has been shown to reduce long
term complications. New molecular targets for monoclonal
antibody therapies are being investigated with varied suc-
cess. Metanalysis has shown that 5-ASA drugs produce no
benefit in Crohn’s disease.
Surgical management may involve exploratory proce-
dures for perianal disease or resection of diseased bowel.
For those who have undergone resection, the recurrence
rate approaches 100  per cent. Introduction of thiopurines
following surgery may extend the period prior to relapse;
however, the use of these drugs long term is associated with
a small increase in the risk of developing lymphoma and
other cancers, so may not be acceptable to all patients. This
risk is balanced by the beneficial effects of these drugs and
their use is recommended by many gastroenterologists.
The clinical consequences of Crohn’s disease and the high
recurrence rates disqualify recruits from entering aviation
training. Trained aircrew newly diagnosed with Crohn’s
disease should be grounded while treatment is established.
A return to limited flying duties may be possible for those
who have full endoscopic remission maintained over a sig-
nificant period of time. Military aircrew in remission are
likely to have the same restrictions as for ulcerative colitis.
FUNCTIONAL GASTROINTESTINAL
DISORDERS
Functional gastrointestinal disorders are common, repre-
senting up to 50 per cent of referrals to general gastroenter-
ology and symptom severity varies widely. The categories
for adults include: functional oesophageal disorders, func-
tional dyspepsia, functional bowel disorders, functional
abdominal pain syndrome, functional gallbladder and
17/11/2015 15:57

sphincter of Oddi disorders and functional anorectal dis-
orders. The Rome III diagnostic criteria are used to define
these disorders which by definition are without detectable
organic pathology.
Targeted therapies based on neurogastroenterology
research for functional gastrointestinal disorders are being
developed; however, dietary manipulation and drugs altering
motility remain the first line treatments for these syndromes.
Professional aviators rarely present with these func-
tional syndromes, and this could, in part, be due to reduced
healthcare seeking behaviour in this population. However,
the symptoms can be debilitating, particularly the altera-
tions in bowel habit and abdominal pains. Generally, air-
crew with these disorders should be able to maintain an
unrestricted flying category. Those with particularly severe
symptoms should be assessed to determine the impact they
have on their duties and flying restrictions may be required.
INFECTIOUS GASTROINTESTINAL
DISORDERS
Acute infectious gastroenteritis is recognized as a common
cause of incapacitation among flight crews. The frequent
travelling leads to exposure to enteropathogens not expe-
rienced at home. Traveller’s diarrhoea is defined as three or
more loose stools during or after travel, which may be asso-
ciated with abdominal pains, vomiting or fever. The most
likely causative organism is dependent upon the geographi-
cal area. Common bacterial infections include enterotoxi-
genic Escherichia coli (ETEC), Shigella spp, Campylobacter
spp and Giardia lamblia. Common causes of viral gastroen-
teritis include adenovirus, rotavirus and norovirus.
Antibiotics courses such as Ciprofloxacin may reduce
the duration of symptoms, and some advocate prophylac-
tic courses for ‘mission critical’ personnel. Prevention of
infection is the optimal option for aircrew, therefore, high
standards of personal hygiene, avoiding at risk foods whilst
travelling and drinking water only from trusted sources are
recommended. Symptomatic aircrew should be isolated, if
possible, until the diarrhoea has passed, particularly if stop-
ping overnight in a particular location. Loperamide can be
used to reduce diarrhoeal symptoms.
AVIATION HEPATOLOGY
Liver disease presents a problem in aviation medicine when
determining flying status as the spectrum of symptoms is
wide. Many patients with liver disease will be completely
asymptomatic, while those with decompensated liver
disease may be encephalopathic. The underlying aetiol-
ogy is also an important consideration when deciding
aeromedical disposition.
Biochemical screening and liver disease
Biochemical screening in the aviation population often leads
to the detection of minor abnormalities in liver function.
K17577_C024.indd 445
Aviation hepatology  445
Probably the most common is Gilbert’s syndrome, in which
an isolated rise in the serum bilirubin is detected and is of no
clinical significance. Unconjugated bilirubin is released into
the serum due to reduced activity of glucuronyltransferase.
Elevated alkaline phosphatase (ALP) and gamma-gluc-
uronyltransferase (GGT) usually indicates cholestasis, and
further investigation is indicated. Isolated elevation of
GGT occurs due to enzyme induction and is an indicator of
increased alcohol consumption, but may be caused by medi-
cations as well.
A persistent rise in the alanine aminotransferase (ALT)
or aspartate aminotransferase (AST) is associated with hep-
atitis and should be investigated. Levels in the thousands
are associated with acute viral hepatitis, drug-induced hep-
atitis and ischaemic hepatitis. It is more common to detect
minor elevations up to three times the upper limit of nor-
mal and this may be associated with steatohepatitis, chronic
viral hepatitis, autoimmune liver disease and metabolic
liver disease.
Investigation of aircrew with persistently elevated liver
function tests should include:
●● Abdominal ultrasound, which may reveal a
dilated biliary system, focal lesions or general
parenchymal changes.
●● Blood screening for viral hepatitis, autoimmune disease
and inherited liver disease.
●● Alcohol screening questionnaire.
Alcoholic liver disease
Alcohol is the most common cause of liver disease in the
developed world. Cirrhosis will develop in around 10–20 per
cent of those who drink heavily for a decade or more. The
lifestyle factors in the aviation community mean they are
an at-risk group. Liver abnormalities caused by alcohol are
usually reversible in the early stages. There should be no
restriction in flying unless secondary consequences of liver
disease are apparent. The largest impediment to aircrew will
be related to the alcoholism, which should be screened for if
suspected and will result in grounding.
Non-alcoholic fatty liver disease
Although aircrew tend to be health conscious individuals
concerned with their body mass, obesity is increasing in the
population of all developed countries. One consequence of
this is increased fat deposition within the liver. Fatty liver
disease is becoming an increasingly common cause of cir-
rhosis. Non-alcoholic fatty liver disease (NAFLD) and
non-alcoholic steatohepatitis (NASH) are terms often used
interchangeably. NAFLD is characterized by elevated liver
enzymes, ultrasound showing steatosis, and the absence of
other causes of chronic liver disease. NASH is considered
the most advanced form of NAFLD in which inflamma-
tion and fibrosis is seen on biopsy. These conditions are
largely asymptomatic, but may be associated with diabetes
17/11/2015 15:57
 446  Aviation gastroenterology and hepatology
mellitus type 2  and elevated serum lipids. Aircrew with
NAFLD should be advised to lose weight. Flying restrictions
are more likely to be as a result of other consequences of
increased body weight rather than the liver disease.
Viral hepatitis
Acute viral hepatitis is usually self-limiting, but a small
number of patients can develop fulminant liver failure. The
most common causes are the Hepatitis A, B and E viruses,
Epstein–Barr virus and cytomegalovirus. Acute hepatitis A
and E have a faeco–oral route of transmission and do not
have a chronic carrier state. Hepatitis E is more dangerous to
third trimester pregnant females, with mortality approach-
ing 20 per cent compared to 2 per cent overall. The acute ill-
ness may result in temporary flying restrictions but aircrew
can expect a full return to flying duties once recovered.
Chronic viral hepatitis is of more concern aeromedi-
cally, due to symptoms of fatigue, risks of infectivity to oth-
ers and time away from work due to associated morbidity.
Hepatitis B is a DNA virus transmitted through infectious
blood and body fluids. Chronic infection is associated with
cirrhosis and hepatocellular carcinoma. Patients may also
experience acute hepatitis flare ups. The carrier status and
level of infectivity is determined using antigen and antibody
assays. Hepatitis B DNA PCR analysis is also used to deter-
mine viral load. There is no cure for hepatitis B, however
anti-viral medications can stop replication and reduce liver
damage. Side effects from anti-viral medications mean that
flying status should be carefully considered in individuals
undergoing treatment.
Hepatitis C is an RNA virus transmitted in the same
modality as hepatitis B. Patients tend to be asymptomatic
for up to 30 years. Modern anti-viral therapies are provid-
ing increasingly successful sustained virological remission
rates. Flying is precluded for the first month during treat-
ment for hepatitis C due to side effects from interferon. If
there are no adverse effects after this time, a dual flying
status can be awarded. A return to unrestricted flying can
occur once treatment has concluded.
Autoimmune liver disease
Primary biliary cirrhosis (PBC) and autoimmune hepa-
titis (AIH) are the major autoimmune liver diseases. PBC
is marked by a progressive destruction of the small bile
ducts, leading to cirrhosis. It is more common in women
and diagnosed by a combination of elevated ALP and the
presence of anti-mitochondrial antibodies. Management
involves monitoring the patient for signs of cirrhosis and
ursodeoxycholic acid, which reduces cholestasis. There is no
known cure, and patients may require liver transplantation.
Asymptomatic aircrew should be able to fly unrestricted.
AIH may present acutely, but is more common as a
chronic disease. Various antibodies can be detected in the
serum of patients with AIH. These include anti-nuclear
antibodies (ANA), anti-smooth muscle antibodies (SMA),
K17577_C024.indd 446
anti-liver-kidney-microsomal antibodies (anti-LKM) and
anti-soluble liver antigen/liver pancreas antibody (SLA/LP).
The International AIH Group criteria are used for deter-
mining the diagnosis based on serology, histology serum
immunoglobulins and absence of viral hepatitis. Treatment
involves a combination of steroids and azathioprine. Initial
steroid doses are usually high and therefore grounding is
mandated on initial therapy. Aircrew stabilized on low-dose
treatment may be able to have a restricted flying status.
Primary sclerosing cholangitis (PSC) is also considered
an autoimmune liver disease. It has an association with
IBD; 50 per cent to 80 per cent of PSC patients have IBD.
There is inflammation of the biliary system which can
result in strictures of any of the bile ducts and progress to
cirrhosis. There is a significant increase in cholangiocarci-
noma and bowel cancer in this group of patients. Regular
colonoscopy screening for bowel cancer is recommended in
patients with PSC and inflammatory bowel disease. Flying
status will depend on presence and activity of IBD and the
burden of liver disease.
Inherited liver diseases
Genetic haemochromatosis is a disorder of iron overload
leading to a variety of consequences of iron deposition
including cirrhosis, diabetes, cardiomyopathy, arthritis,
infertility and bronzing of the skin. It is an autosomal reces-
sive disorder with an estimated prevalence of 1  in 200  in
Caucasian populations. The diagnosis is suspected in those
with elevated serum ferritin and transferrin saturation.
Mutations in the HFE gene are responsible, and genotyp-
ing for C282Y homozygosity confirms the diagnosis. Other
HFE mutations are also seen but are less common. The phe-
notypic penetrance is varied. The initial treatment of those
with biochemical iron overload involves regular venesec-
tion. Early diagnosis and treatment improves long term
outcome. Maintenance venesection can potentially double
as blood donation as some centres are accepting blood from
those with genetic haemochromatosis. Unrestricted flying
is possible for aircrew on maintenance venesection, but they
are advised not to fly for 48 hours following treatment.
Wilson’s disease is an inherited disorder of copper
metabolism. Presentation is varied, but may include hepatic,
neurological and psychiatric disease. Diagnosis is made
by measuring serum caeruloplasmin and urinary copper
excretion, followed by confirmatory liver biopsy. Treatment
is lifelong with chelating agents. Unfortunately, the neu-
ropsychiatric features of the disease and side effects of the
treatment result in permanent grounding.
Alpha-1-antitrypsin deficiency is the most common
genetic cause of liver disease in children, and occasionally
in adults. It more commonly manifests as emphysema in
adults. It should be considered in patients presenting with
unexplained liver enzyme abnormalities or those with cryp-
togenic cirrhosis. There is no effective treatment other than
liver transplantation. Recruits with alpha-1-antitrypsin
deficiency are unlikely to enter aviation training. Trained
17/11/2015 15:57

aircrew without cirrhosis could fly with restrictions under
regular medical follow up.
CONCLUSION
Most gastrointestinal disease is acute, self-limiting and has
no long term implications for aviators. Chronic gastrointes-
tinal and liver diseases can cause long term barriers to the
flying status of aircrew. With improved medical manage-
ment for many of these conditions, some trained aircrew
could potentially continue in their flying role. Assessment
of these patients by a gastroenterologist, who can also
provide an aviation relevant occupational insight into the
implications of their disease, may assist in this and will be
useful to both aircrew and their employers.
SUMMARY
●● Gastrointestinal physiology is affected by the
environmental aspects of aviation and space
flight, in particular extremes of G.
●● Gastro-oesophageal reflux and peptic ulcer dis-
ease are the most common gastrointestinal condi-
tions in the general population and, therefore,
in aviators. Helicobacter pylori infection should
be excluded and endoscopy recommended to
exclude gastroduodenal ulceration, which could
limit flying duties during treatment.
●● Coeliac disease is unlikely to cause any symptoms
once a gluten-free diet is established. The civilian
aviator will have no restrictions. Military aviators
cannot always be guaranteed gluten-free foods
when deployed and medical grading should be
adjusted accordingly.
●● Cholelithiasis may cause incapacitating pain and
a single episode of symptomatic disease should
result in grounding until cholecystectomy is per-
formed and a clear common bile duct confirmed.
Pancreatitis is not compatible with flying until
the aetiological factor is established and removed.
●● Inflammatory bowel diseases such as ulcerative
colitis and Crohn’s disease have an unpredictable
K17577_C024.indd 447
Further reading  447
course, and aggressive early immunosuppression
is becoming more commonplace, particularly for
Crohn’s disease. These diseases are likely to result
in restricted flying status for all aviators.
●● Chronic liver diseases increasingly have satisfac-
tory treatments which may allow unrestricted
flying once the disease is controlled. Established
liver cirrhosis is not compatible with flying.
FURTHER READING
Baumgart DC, Sandborn WJ. Crohn’s disease. Lancet
2012; 380: 1590–605.
Czaja AJ, Manns MP. Advances in the diagnosis, patho-
genesis and management of autoimmune hepatitis.
Gastroenterology 2010; 139: 58–72.
European Association for the Study of the Liver. EASL
Clinical Practice Guidelines: Management of Chronic
Hepatitis B. Geneva: European Association for the
Study of the Liver, 2008.
European Association for the Study of the Liver. EASL
Clinical Practice Guidelines: Management of Hepatitis
C Infection. Geneva: European Association for the
Study of the Liver, 2011.
Evans KE, Sanders DS. Coeliac disease. Gastroenterology
Clinics of North America 2012; 41: 639–50.
Fisichella PM, Carter SR, Robles LY. Presentation, diagno-
sis and treatment of oesophageal motility disorders.
Digestive and Liver Disease 2012; 44: 1–7.
Longstreth GF, Thompson WG, Chey WD, et al. Functional
bowel disorders. Gastroenterology 2006; 130:
1480–91.
National Institute for Health and Care Excellence.
Dyspepsia: Managing Dyspepsia in Adults in Primary
Care. CG17. London: National Institute for Health and
Care Excellence, 2004.
Ordás I, Eckmann L, Talamini M, Baumgart DC,
Sandborn WJ. Ulcerative colitis. Lancet 2012; 380:
1606–19.
Pfeiffer CJ. Space gastroenterology: a review of the physi-
ology and pathology of the gastrointestinal tract as
related to space flight conditions. Medical Times 1965;
93: 963–78.
17/11/2015 15:57
K17577_C024.indd 448 17/11/2015 15:57
 25
Metabolic and endocrine disorders

RAYMOND V. JOHNSTON

Diabetes mellitus 449 References 458

Endocrine disorders 454 Further reading 460
Hypocalcaemia 457

DIABETES MELLITUS
In the mid 1990s diabetes mellitus was found to have affected
approximately three per cent of the population (Bennett
et al. 1995). However, this figure has been increasing steadily
and in 2008 The Centers for Disease Control (CDC) in the
USA estimated that 23.6 million Americans, or 7.8 per cent
of the population (Figure  25.1), had diabetes and another
57 million adults had prediabetes. They have predicted that
as many as 1 in 3 U.S. adults could have diabetes by 2050 if
current trends continue. In the UK the prevalence of diabe-
tes has been estimated (Diabetes UK, 2010) at 4.26 per cent
of the UK population. The prevalence increases with age
and data from the CDC Diabetes Data and Trends (2011)
are shown in Figure 25.2. The current terminology for the
classification of diabetes mellitus is type 1, previously called
insulin-dependent diabetes mellitus (IDDM), and type 2,
formally known as non-insulin-dependent diabetes melli-
tus (NIDDM). This change in terminology is now used to
reflect the earlier and wider use of insulin to improve con-
trol in type 2  diabetes. These individuals are treated with
insulin but are not truly insulin-dependent. Approximately
20  per cent of people with diabetes are type 1  and 80  per
cent type 2.
Type 1 diabetes mellitus usually presents in the younger
age group. The prevalence shows striking geographical

8 25
Percentage with diabetes
7 Number with diabetes
Number with diabetes (millions)

20
Percentage with diabetes

5 15
4

3 10

2
5
1

0 0
1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06 09
Year

Figure 25.1  Number and percentage of US population with diagnosed diabetes, 1958–2010.

449

K17577_C025.indd 449 17/11/2015 15:58

 450  Metabolic and endocrine disorders

20.0

15.0

Percentage
10.0

5.0

0.0 9

9
–2

–3

–3

–4

–4

–5

–5

–6

–6

–7

–7
18

30

35

40

45

50

55

60

65

70

75
Age at diagnosis of diabetes

Figure 25.2  Age at diagnosis of diabetes. Data Source: Centers for Disease Control and Prevention (CDC), National
Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. Data
computed by personnel in CDC’s Division of Diabetes Translation, National Center for Chronic Disease Prevention and
Health Promotion.

variation. It is some 35 times more common in Finland than
in Japan. Within the UK, the highest frequency is found in
Scotland, where, as in several other countries, the incidence
appears to have doubled within a decade. The basic problem
in type 1 diabetes is insulin deficiency due to autoimmune
destruction of the islet beta cells of the pancreas, which is
determined partially by heredity. The genetic component of
type 1, however, is less important than in type 2.
Type 2  diabetes mellitus is common. Its prevalence
increases with age, inactivity and body weight. For example,
in the USA, the prevalence is 4.3 per cent in white women
aged between 45 and 54 years, rising to 8.9 per cent in those
aged between 65 and 74 years. In type 2, raised fasting insu-
lin levels are a response to fasting hyperglycaemia, but are
inappropriately low for the abnormal blood glucose concen-
tration. After eating a meal, the insulin response is poor,
and so glucose concentrations go higher still and continue
to stimulate further insulin secretion long after physiologi-
cal insulin and glucose profiles have returned to basal levels.
Therapeutic options
DIET
The diet currently recommended for type 2  diabetes is
free from refined carbohydrates but complex high-fibre
carbohydrates are encouraged. It is low in fat and energy-
restricted for obese people, but isocaloric with the existing
diet for people of normal weight.
ORAL HYPOGLYCAEMIC AGENTS
If diet fails to control the diabetes despite good compliance,
the next therapeutic option is oral hypoglycaemic agents.
The largest group of oral hypoglycaemic agents in clinical
use are the sulphonylureas, but their use is best reserved for
non-obese patients as they may be associated with weight
gain. The second major group are the biguanides, which are
more appropriate for overweight patients. The main prob-
lem with sulphonylurea drugs is hypoglycaemia, which can
be fairly prolonged with the long-acting preparation chlor-
propamide. The prevalence of hypoglycaemia with sulfo-
nylurea drugs in one study was approximately 20 per cent
(Jennings et al. 1989). These data had resulted in these drugs
being unacceptable in professional flying. However, recent
work by Heller and colleagues in the UK Hypoglycaemia
Study group (2007) has shown that the rate is of the order of
2 per cent per annum and thus this policy has been reviewed
by a number of Authorities including the United Kingdom
Civil Aviation Authority (CAA).
The only biguanide drug currently available is metfor-
min since the withdrawal of phenformin some years ago
due to the high incidence of lactic acidosis. Metformin has
predominantly peripheral actions in lowering blood glucose
and, to some extent, assists weight loss. There is now pow-
erful evidence from meta-analysis (Selvin et al. 2008) for a
risk reduction in both cardiovascular morbidity (Odds ratio
(OR) 0.85) and mortality (OR 0.74). This study also showed
a benefit from metformin in all-cause mortality (OR 0.81).
The risks of lactic acidosis with metformin are minimal, but
the drug should not be prescribed in the presence of hepatic
or renal disease. Many would now feel that metformin
should be the drug of first choice (Bennett et  al. 2011) in
type 2 diabetes and this is the approach incorporated in the
UK National Institute for Health and Clinical Excellence
(NICE) guidelines (2012). An additional therapeutic option
is the alpha-glycosidase inhibitors, e.g. acarbose, which
inhibit digestion of glucose-containing polysaccharides
from the gut. These may have a therapeutic role as an adju-
vant to diet or oral hypoglycaemic therapy.
Recently, a new class of agents, the thiazolidine-diones
(glitazones), were introduced. These were interesting as

K17577_C025.indd 450 17/11/2015 15:58

 Diabetes mellitus  451

they targeted the underlying problem in type 2  diabetes,
i.e. insulin resistance, by enhancing insulin sensitivity.
They were eventually licensed for monotherapy and showed
promise in the aviation environment as they did not cause
hypoglycaemia when used in this way. Unfortunately this
promise was not maintained when concerns were raised
linking them to an enhanced risk of cardiovascular disease
(OR 1.43). The situation has been reviewed in an editorial
in the British Medical Journal (2011) and by the European
Medicines Agency. In addition, evidence from a case con-
trol study (Azoulay 2012) found an enhanced risk (Rate
Ratio 1.83) of bladder cancer which increased with duration
of use. The result of all these concerns has been that their
use has effectively ceased. A somewhat different approach to
the management of type 2 diabetes has now been proposed.
This involves the use of so called incretin therapies. Incretins
are peptides produced by the intestine and are released in
response to meals. The two major incretins are glucagon
like peptide (GLP-1) and glucose-dependent insulinotropic
peptide (GIP). The incretin therapies are GLP-1 agonists and
dipeptidylpeptidase-4 (DPP-4) inhibitors which inhibit the
breakdown of GLP-1. These therapies’ dual action of switch-
ing on insulin by increasing beta cell turnover, inhibiting
beta cell apoptosis and suppressing glucagon help control of
blood glucose and do not cause hypoglycaemia. They may
also have an effect on satiety with a potential weight loss
benefit. These drugs were marketed heavily but recent con-
cerns have been raised (Cohen 2013) on the association of
pancreatitis and perhaps pancreatic cancer. Although this
may be explained by their growth stimulating effects, the
case is as yet ‘not proven’. The UK CAA has included these
drugs in their recent review of certification of pilots with
diabetes mellitus (UK CAA 2013)
of microvascular disease and, possibly, the incidence of
macrovascular complications. In type 2  diabetes, the UK
Prospective Diabetes Study group (UKPDS 1998a) has
shown that among patients allocated intensive blood-glu-
cose control, there was a significant reduction in any dia-
betes-related endpoint, all-cause mortality and stroke. The
effect was greatest in patients treated with metformin. The
main parameter used in the assessment of quality of dia-
betic control is glycosylated haemoglobin. The percentage of
glycosylated haemoglobin averaged over six to eight weeks
is a useful measure of blood glucose control.
The phrase ‘good metabolic control’ encompasses
other parameters in addition to glucose and haemoglobin
A1 (HbA1) (Table 25.1). The units for HbA1 have now been
standardised internationally and are expressed as mmol/mol.
Key comparative values are shown in Table 25.1. There has
been controversy in the literature on targets for haemoglobin
A1 with some emphasis on driving this as low as possible.
However, Currie (2010) in a study of Type 2 diabetics looking
at median HbA1 and outcomes found the decile with lowest
hazard ratio for events had a median HbA1 of 7.5 per cent.
In addition those with lowest median HbA1c (6.4 per cent)
and highest median HbA1c (10.5  per cent) were associated
with increased all-cause mortality and cardiac events. The
concern over driving HbA1 too low and the increased mor-
tality in this paper is congruent with others in the literature.
In order to achieve good metabolic control, it is impor-
tant to set the patient realistic targets; the physician and
other healthcare professionals should support the individ-
ual in the achievement of these goals with practical advice.
The pilot population is particularly well motivated, and
with appropriate guidance and under certain therapeutic
and metabolic circumstances, may continue to fly.

Control and complications Aeromedical implications of diabetes

mellitus
The reports of the Diabetes Control and Complications
Trial research group (1993) in type 1  diabetes have The aim of medical certification is to reduce the medical
shown that tight diabetic control may minimize the risk component of human factors that may contribute to aircraft

Table 25.1  Targets for metabolic control

Parameter Unit Good Acceptable Poor Very poor

BMI kg/m2 <25 25–27 >27 –
HbA1 (normal 5.0–7.5) % <7.5 7.5–8.8 >8.8 >10.0
HbA1c (normal 4.0–6.0) % <6.0 6.0–7.0 >7.0 >8.0
Blood glucose:
Fasting mmol/L <6.7 <8.01 >10.0 –
Random mmol/L 4.0–9.0 <10.0 >10.0 –
Total cholesterol mmol/L <4.5 <5.2 >6.5 –
LDL cholesterol mmol/L <2.5 <3.0 >3.5 –
HDL cholesterol mmol/L >1.1 >0.9 <0.9 –
Triglyceride mmol/L <1.7 <2.0 >2.2 –
Blood pressure mmHg <130/80 <145/95 >160/95 –
BMI, body mass index; HbA1, haemoglobin A1; HbA1c, haemoglobin A1c; HDL, high-density lipoprotein; LDL, high-density lipoprotein.
New Units HbA1c (mmol/mol) 42 (6 per cent), 53 (7 per cent), 64 (8 per cent), 75(9 per cent).

K17577_C025.indd 451 17/11/2015 15:58

 452  Metabolic and endocrine disorders
accidents to an acceptable level of risk. In the UK, the
acceptable level of sudden or subtle incapacitation in pro-
fessional pilots is one per cent per annum. Up to that figure,
a professional pilot with a specific disease process that may
cause incapacitation may return to flying in a multi-crew
situation. This approach is useful in diabetic pilots.
The risks in diabetic pilots may be divided into those
intrinsic to diabetes mellitus itself and those that are iat-
rogenic due to therapeutic intervention in the disease pro-
cess. The main risks intrinsic to the disease process are of
cardiovascular disease, visual problems and nephropathy.
The only important iatrogenic complication with significant
implications in aviation is hypoglycaemia. Having assessed
the risk, how does one develop a certification policy? The
simple approach would be to disqualify all diabetic pilots.
However, a more scientific approach can be developed from
a cautious literature review, which can then be applied to
the diabetic population and audited over time. In this sec-
tion, we summarize the literature and discuss the develop-
ment of certification guidelines based on that literature.
CARDIOVASCULAR DISEASE
Premature vascular disease is one of the most common
and serious complications of diabetes. The Whitehall Study
showed that coronary heart disease mortality was approxi-
mately doubled for people with impaired glucose tolerance
in a standard glucose tolerance test (Fuller et al. 1980). Data
from a number of studies suggest that the risk of cardiovas-
cular disease is two to four times higher in patients with
diabetes compared with those without, and that the annual
rate of fatal and non-fatal cardiovascular disease among
patients with type 2  diabetes is 2.5  per cent (Entmacher
et al. 1964). Data published by Haffner (1998) has suggested
that diabetic patients without previous myocardial infarc-
tion have as high a risk of myocardial infarction as non-
diabetic patients with previous myocardial infarction. The
risk of cardiovascular disease is high, even at the time of
diagnosis, and is independent of the duration of diagnosed
diabetes, because diabetes is present for approximately
7–12 years before formal diagnosis. Perhaps even before that
time, patients would be classified as having impaired glu-
cose tolerance, which is associated with an increased risk of
cardiovascular disease (Fuller et al. 1980).
NEPHROPATHY
Kidney disease is a significant problem in the diabetic
population. Nephropathy affects approximately 35 per cent
of patients with type 1  diabetes and about five to ten per
cent of patients with type 2  diabetes. Despite this lower
prevalence, the impact of renal disease caused by type
2 diabetes is substantially greater, since type 2 is far more
common, and cardiovascular complications are the major
cause of death in these patients. The importance in identi-
fying those at risk of developing nephropathy in potential
or active aircrew lies in the findings that in type 1 patients
with proteinuria, the relative mortality from cardiovascular
disease is almost 40  times that of the general population.
K17577_C025.indd 452
In patients without proteinuria, the relative cardiovascu-
lar mortality is only four times that of non-diabetic people
(Borch-Johnson and Krenier 1987). Thus, the presence of
nephropathy is a marker for cardiovascular disease. There
is evidence that the presence of microalbuminuria (defined
as urinary albumin excretion greater than 30  mg but less
than 300 mg per 24 hours) may predict, with some accuracy,
the development of diabetic nephropathy. There is also evi-
dence that therapeutic intervention in type 1 diabetics with
angiotensin-converting enzyme (ACE) inhibitors may halt
this progression (Viberti et al. 1994). Treatment with ACE
inhibitors in patients with type 2 diabetes with microalbu-
minuria has been shown to reduce cardiovascular events by
25 per cent in both those with normal creatinine levels and
in those with mild renal insufficiency (Mann et al. 2001). The
Type 2 Diabetes, Hypertension, Cardiovascular Events and
Ramipril (DIABHYCAR) study has shown, however, that
the benefit of the ACE inhibitor ramipril in type 2 diabetes
is dose-dependent (Marre et al. 2004). The measurement of
microalbuminuria is a useful adjuvant to risk assessment in
diabetic pilots.
VISUAL PROBLEMS
Approximately 80 per cent of flight information is accrued
visually and, thus, any pathological process that interferes
with visual function may result in human error and may con-
tribute to an accident. Diabetes mellitus is known to affect
all parts of the eye, e.g. cataract, retinal vein occlusion, isch-
aemic optic neuritis and cranial nerve palsies resulting in
diplopia. Diabetic retinopathy, however, is a highly specific
vascular complication of diabetes mellitus and is estimated
to be the most frequent cause of new blindness among adults
between the ages of 20 and 74 years. By 20 years after the
first diagnosis, almost all insulin-dependent patients and
more than 60  per cent of non-insulin-dependent patients
have some degree of retinopathy (Klein et  al. 1984). More
than four-fifths of cases of blindness among type 1 diabe-
tes patients and one-third of cases among type 2  diabetes
patients are due to diabetic retinopathy. Many people forget
that type 2 diabetes is not a benign disease, and it has been
called a ‘wolf in sheep’s clothing’. The major determinants
for the development of retinopathy are the quality of dia-
betic control and the duration of the diabetes.
HYPOGLYCAEMIA
Hypoglycaemia leads to a combination of neuroglycopenia
and autonomic neural stimulation. This is characterized
by faintness, tremor, sweating, hunger and coma. Any of
these symptom complexes may degrade pilot performance.
A study carried out in type 1  diabetes patients subjected
to modest hypoglycaemia of 3.1  mmol/L showed a decre-
ment in performance, which increased with the complex-
ity of the task performed (Holmes et al. 1986). In this and
other studies, researchers have shown that reaction times do
not return to normal until some 20–30 minutes after eugly-
caemia has been restored. The implications in the aviation
environment are self-evident.
17/11/2015 15:58

Having accepted that hypoglycaemia is a significant
concern in the aviation environment, it is vitally impor-
tant for accurate risk assessment to have good data on
the incidence of hypoglycaemia in both insulin- and
non-insulin-dependent patients.
It is very difficult to assess the frequency of hypoglycae-
mia in insulin-treated diabetic populations because of the
wide variation in severity and outcome. Another problem
is the common occurrence of asymptomatic biochemical
hypoglycaemia, which is evident only if blood glucose is
measured frequently, and the failure to recognize or record
many mild episodes, including those that occur during
sleep. Severe hypoglycaemia, defined by the need for exter-
nal assistance to resuscitate the patient, is a more robust
and consistent measure for estimating frequency and is
reliable even in retrospective reporting. Where a similar
definition for severe hypoglycaemia has been applied, the
lowest annual prevalence is nine per cent, but the average
is approximately 20–30 per cent. Despite the difficulties in
assessment, the frequency of mild hypoglycaemia in one
good study was alarmingly high at 1.6 episodes per patient
per week, i.e. approximately 83.6  episodes per patient per
year (Praming et al. 1991). In type 2 diabetes evidence from
the UK Hypoglycaemia Study Group (2007) has shown
that the rate of severe hypoglycaemia in the first five years
from diagnosis is considerably lower than that in those with
type 1  diabetes and in the first five years from diagnosis
(Figure 25.3).
Strict glycaemic control, usually from intensive insulin
therapy, is recognized to be a risk factor for severe hypogly-
caemia. In the Diabetes Control and Complications Trial in
patients with type 1 diabetes, strict glycaemic control was
associated with a three-fold increase in severe hypoglycae-
mia (Diabetes Control and Complications Trial Research
Group 1993). The risk of severe hypoglycaemia increased
continuously with lower monthly glycosylated haemoglobin
values. Other risk factors for severe hypoglycaemia in the
1.0
one severe hypoglycaemic episode
Proportion reporting at least
0.8
0.6
0.4
0.2
0.0
Treated with
sulphonylureas
Type 2 diabetes
Figure 25.3  Proportion of each group experiencing at least one severe self-reported hypoglycaemic episode during
9–12 months of follow-up. Vertical bars, 95 per cent CI. From: British Journal of Diabetes and Vascular Disease 2011;
11(Suppl 1): S6-S9. Original in Diabetologia 2007; 50: 1140–47
K17577_C025.indd 453
Diabetes mellitus  453
study were a longer duration of diabetes and a history of pre-
vious hypoglycaemia. Another worrying finding from this
group was that no warning symptoms were experienced in
36 per cent of severe hypoglycaemic episodes that occurred
while patients were awake. While loss of hypoglycaemic
awareness is associated with strict diabetic control, it is also
a complication acquired with increasing duration of diabe-
tes, which may underline the emergence of age and duration
of diabetes as risk factors for severe hypoglycaemia.
People with Type 2 diabetes can be managed on diet, diet
and oral agents, and increasingly now may be treated with
insulin. The alpha-glycosidase inhibitors may potentiate the
hypoglycaemic effect of a sulphonylurea. Severe hypogly-
caemia associated with sulphonylureas is well documented,
but the frequency of mild hypoglycaemia not requiring
urgent hospital admission is more difficult to assess because
symptoms are often brief and many patients treated with
oral agents have poor knowledge of the symptoms of hypo-
glycaemia. Despite these difficulties, trials have recorded
an incidence of symptomatic hypoglycaemia ranging from
1.9 to seven per cent per annum. The study by Jennings et al.
(1989), as noted previously, found a prevalence of symptom-
atic hypoglycaemia of the order of 20 per cent when using
direct questioning of the patients and the relatives. More
recent data from the UK Prospective Diabetic Study (1998b)
found the incidence of hypoglycaemia in type 2  diabetics
on sulphonylureas to be ten per cent per annum overall,
with that of major episodes being 1.5 per cent per annum.
Recently, Heller (2011), in a review of hypoglycaemia
reported the rate of severe hypoglycaemia to be of the order
of 2 per cent per annum in those with type 2 diabetes for five
years or less (Figure  25.3). Since the withdrawal of phen-
formin in the early 1970s due to the incidence of metabolic
acidosis, the only biguanide in use in the UK is metformin.
Its mechanism of action does not involve the stimulation of
insulin secretion and it does not cause hypoglycaemia. The
incidence of metabolic acidosis is negligible but has been
<2 years >5 years <5 years >15 years
of insulin treatment of insulin treatment
Type 1 diabetes
17/11/2015 15:58
 454  Metabolic and endocrine disorders
recorded as 0.04 cases per 1000 patient-years, with a mor-
tality of 0.024 per 1000 patient-years (Berger 1985).
The new evidence on the hypoglycaemic rate of sul-
phonylureas has allowed the UK Civil Aviation Authority
(CAA) to review their policy and these drugs are now con-
sidered for multipilot operations. Metformin does not cause
hypoglycaemia, and its risk of metabolic acidosis is accept-
able in appropriately selected pilots.
Aeromedical disposal of civil pilots with
diabetes mellitus
The prime determinant in declining certification to type
1  diabetic pilots and type 2  diabetic pilots on insulin had
been the data available on the risk of hypoglycaemia.
Other concerns in this group are the increase in coronary
heart disease and the associated problems of retinopathy
and nephropathy.
Since type 2  diabetes usually presents in the middle
years, the majority of pilots with this type of diabetes are
usually fully trained and may have a command. The airline
is usually supportive of the pilot in this situation, as they do
not wish to lose a trained individual. It is, thus, important
that any aviation authority has a credible and sound certifi-
cation policy to assess risk in this group.
Hypoglycaemia is not an issue in the risk assessment of
pilots with diet-controlled diabetes, the main area of con-
cern being the vascular complications. If a pilot with diet-
controlled diabetes is to be returned to flying and their
fitness status maintained, then it is vitally important that
they are screened for coronary disease. The gold standard
for diagnosing coronary artery disease is coronary angiog-
raphy. However, this is not without risk, and it is not feasible
to repeat on a regular basis. The resting electrocardiogram
(ECG) alone lacks the sensitivity and specificity required in
this group of higher-risk patients, and thus it is logical to use
a non-invasive technique that will predict coronary artery
disease at somewhat greater sensitivity than the resting
tracing. The exercise ECG is a useful screening tool in this
selected group of patients. It is not of value for widespread
screening, as the prevalence of coronary artery disease in
the otherwise healthy pilot population overall is low. If the
exercise ECG is normal, then a diet-only-controlled diabetic
pilot with good-quality control and no overt complications
may return to flying, subject to an annual assessment with
an exercise ECG and a satisfactory report from the treating
diabetic physician. The alpha-glucosidase inhibitor acar-
bose is acceptable as an adjuvant to diet and will not affect
decisions on certification.
A similar certification policy applies in this group to
pilots whose diabetes is controlled by diet alone. However,
those pilots treated with metformin tend to be overweight
and do carry a small but acceptable risk of lactic acidosis
and, thus, their overall risk is slightly greater than diet-only
patients. Their assessment requires exemplary diabetic con-
trol and annual review, including an exercise ECG; if this is
satisfactory, they may be returned to flying. If metformin
K17577_C025.indd 454
is used as monotherapy individual consideration can be
given to unrestricted certification subject to regular fol-
low up. This screening approach is in line with the Scottish
Intercollegiate Guidelines Network (SIGN) guidelines for
the risk assessment of diabetic cardiovascular disease.
Recent data, mentioned above, on the incidence of hypo-
glycaemia in diabetics treated with the sulfonylureas has
allowed some National Authorities to certify pilots for mul-
ticrew operations only. This policy (UK CAA 2013) has also
been applied to pilots managed by metformin and glitazone
though glitazone use is now extremely rare.
Aeromedical disposal of military pilots with
diabetes mellitus
Candidates with either diabetes mellitus or impaired glucose
tolerance are unfit for selection for military service. Those
who subsequently develop disorders of glucose metabolism
are subjected to more stringent certification restriction than
civil airline or private pilots. Impaired glucose tolerance
does not disqualify trained personnel from aircrew duties,
but frequent medical review is required because of the risk
of progression to frank diabetes. Diabetes responsive to diet
or biguanides is compatible with continued aircrew duties,
but with a reduced medical category, unfit solo pilot/naviga-
tor and subject to regular medical review. Diabetes requir-
ing insulin or sulfonylurea therapy renders the individual
permanently unfit for aircrew duties.
Conclusion
The key to certification of this group of aircrew is to base
policy on robust, good-quality scientific data which have
been subjected to peer review. The field of diabetes is rap-
idly changing and thus the available data must be regularly
reviewed. The aviation physician must also liaise closely
with the endocrinologist/diabetologist treating the mem-
ber of aircrew, so that the benefits of both disciplines can be
consolidated, resulting in the fair and objective assessment
of the pilot. Military operations make greater demands
on the individual, both operationally and physiologically,
and criteria for both initial flying training and subsequent
possible return to aviation duties will be more stringent.
All policies for medical certification of aircrew should be
audited in the light of developments in world literature, and
modified accordingly.
ENDOCRINE DISORDERS
The endocrine system is controlled by the hypothalamus,
which is subject to regulatory influences from other parts
of the brain, especially the limbic system. A number of
releasing hormones from the hypothalamus cause stimulat-
ing hormones to be released from the anterior pituitary to
act on specific end organs. The resulting hormone produc-
tion from the end organs acts as a complex system of feed-
back to inhibit further production. In such a finely tuned
17/11/2015 15:58

homeostatic environment, any disturbance of secretion of
the trophic hormone or of the end organ itself may result
in clinical disease. In aircrew, the most important question
the aviation specialist must ask is whether the disease or
its treatment will affect performance. It has been reported
(CAA Human Factors Strategy 2013) that approximately
75 per cent of aviation accidents are still due to human fac-
tors, and it is vitally important that the aviation physician is
familiar with endocrine conditions that may cause sudden
or subtle incapacitation and, thus, cause a problem in flight.
Anterior pituitary hypofunction
Hypopituitarism may be partial or complete and may
result from either pituitary disease or hypothalamic dis-
ease resulting in a failure of the releasing hormone. Clinical
manifestations vary depending on the extent and severity of
the pituitary hormone deficiency. Thus, a patient may pres-
ent in extremis with acute adrenal insufficiency or profound
hypothyroidism, or with rather non-specific symptoms of
fatigue or malaise, which could be labelled ‘jet lag’ or ‘crew
fatigue’.
AEROMEDICAL DISPOSAL
Hypopituitarism is treatable, and the patient should be able
to perform normal activities as long as appropriate hor-
monal therapy is used consistently and properly. Once the
appropriate regimen has been determined, with appropri-
ate laboratory backup, the doses do not need to be changed,
except for an increase in the glucocorticoid dose (which is
generally doubled) during intermittent illness. Even after
the proper regimen has been stabilized, lifelong follow-up
by a specialist in endocrinology is required.
The implications for aviation are self-evident. In the mil-
itary sphere, the requirement for instant transition to war,
with all the adverse demands that makes, precludes these
individuals from service. In commercial aviation, the possi-
bility of not having replacement therapy taken ‘consistently
and properly’ and intermittent illness away from special-
ized help usually would preclude professional medical cer-
tification, as would concerns on the cardiovascular disease
risk. However, individual risk assessment should be carried
out before a final decision is made. Private pilots may be
suitable for certification, endorsed with a safety pilot limi-
tation, subject to satisfactory specialist reports and annual
follow-up.
Anterior pituitary hyperfunction
Most syndromes of hyperfunction are due to pituitary
tumours. The particular syndrome will depend on which
cell type in the pituitary is involved.
ACROMEGALY
This diagnosis is made from the classic clinical features and
confirmed by raised basal growth hormone levels on two
or more occasions (>5 mU/L). Growth hormone stimulates
K17577_C025.indd 455
Endocrine disorders  455
the production of insulin-like growth factor 1 (IGF-1), pre-
dominantly in the liver. IGF-1  can be used to assess dis-
ease activity, since, unlike growth hormone, the levels do
not fluctuate throughout the day. Any pilot with a growth-
hormone-secreting tumour producing symptoms is unfit
for flying duties. The first line treatment for the disease is
microdissection of the tumour by a competent pituitary
surgeon, usually carried out in specialist centres. The surgi-
cal approach is usually by the trans-sphenoidal route and
this procedure does not carry any risk of post-operative sei-
zure. After treatment, the individual must be reviewed care-
fully to assess the efficacy of the treatment. Those with gross
physical changes that do not regress are unlikely to be fit
for professional or private certification. Specialist endocri-
nological and ophthalmic review would be required before
any assessment by the aeromedical authority.
HYPERPROLACTINAEMIA
Prolactinomas are the most common functional pituitary
adenomas and account for approximately 25  per cent of
asymptomatic pituitary adenomas diagnosed at post mor-
tem. The diagnosis is confirmed by raised prolactin levels. A
prolactin level greater than 5000 mU/L is highly suggestive
of a prolactinoma. A level below 2500 mU/L is more likely
to be the result of compression of the pituitary stalk by an
inactive adenoma. Any individual with an active pituitary
tumour or an enlarged fossa is unfit. Many individuals on
long-term treatment (except bromocriptine, because of its
side effects) or post-curative surgery may be considered for
certification after approximately three months. This will
be subject to lifelong follow-up on an annual basis from
endocrine and ophthalmic specialists. These individuals are
unacceptable for military aircrew.
HYPERCORTISOLAEMIA
Cushing’s disease, described by Harvey Cushing in 1932, is
the term applied to Cushing’s syndrome of pituitary origin.
The signs and effects are those of excess cortisol produc-
tion. Screening for Cushing’s disease is performed most
easily by measuring 24-hour urinary cortisol, increased lev-
els above 280 mmol/day being diagnostic. If this is abnor-
mal, then the dexamethasone suppression test may be of
value in differentiating between pituitary disease, primary
adrenal disease and ectopic adrenocorticotropic hormone
(ACTH) production by a tumour, e.g. small-cell broncho-
genic carcinoma. Applicants for flying training with active
Cushing’s disease are unfit. The primary treatment is sur-
gery to remove the ACTH-secreting tumour. Medical treat-
ment may be required when surgery is contraindicated or in
the work up to surgery (Sam 2013). It may also be required
in those with persistent or recurrent hypercorticolism post-
surgery. Medical treatment usually consists of ketoconazole
and metyrapone. After adequate treatment to suppress the
cortisol excess, the patient may be reassessed at one year,
with appropriate reports from the treating endocrinolo-
gist/neurosurgeon. They are not acceptable for military
aircrew duties.
17/11/2015 15:58
 456  Metabolic and endocrine disorders
ANTIDIURETIC-HORMONE-DEFICIENCY DIABETES
INSIPIDUS
The most marked symptoms are polydypsia and poly-
uria of greater than 3 L/day. The urine is of low osmolality
(<300  mosmol/kg). The long-acting vasopressin analogue
desamino-D-arginine vasopressin (DDAVP) acts almost
solely on the type I receptors in the renal tubule and is the
mainstay of treatment. There is wide individual variation in
the dose required to control symptoms. It is usually given by
intranasal spray (5–40 mg/day) as one to three doses daily.
It can also be given orally in divided doses, and is used in a
dose of 50–1200 mg/day. The sulphonylurea chlorpropamide
enhances the renal response to antidiuretic hormone (ADH)
and in the past was given in partial forms of diabetes insipi-
dus, but it carries a risk of hypoglycaemia and, thus, is no
longer used. Aeromedical certification should be on an indi-
vidual basis, subject to satisfactory endocrinology reports
and biochemistry. Military aircrew selection procedures are
rather more stringent due to the role of the military pilot,
and the need for long-term treatment will preclude selection.
Hypothyroidism
Isolated hypothyroidism beginning in adult life is almost
always due to autoimmune thyroid disease or previously
treated hyperthyroidism. It is a common condition, and one
survey has indicated one per cent of the general population
and four per cent of those over 60 years old are on long-term
thyroxine (Parle et al. 1991). It is more common in females,
with a 10–15-fold lower prevalence in males. Frank hypo-
thyroidism requires a temporary unfit aeromedical assess-
ment. Recertification should be possible once the individual
is euthyroid on thyroxine. This should be subject to satis-
factory endocrinology reports, and the follow-up should be
indefinite. This policy is also acceptable in military aircrew.
Hyperthyroidism: thyrotoxicosis
Thyrotoxicosis is common, with a prevalence of one to two
per cent in women and 0.1 per cent in men. The most com-
mon (70–80 per cent) cause is autoimmune thyroid disease
(Grave’s disease), although rarely it is due to a multinodular
goitre or a single autonomously functioning solitary nod-
ule (‘toxic adenoma’). There are three forms of treatment for
hyperthyroidism: medical, radioactive iodine and surgical.
Only Grave’s disease is ‘cured’ by anti-thyroid drugs, and
even then approximately only 50 per cent of patients have a
permanent remission. Remission occurs because the drugs
notably reduce thyroid hormone synthesis by inhibiting
thyroid peroxidase, but they also have an immunomodula-
tory effect. If the condition relapses, patients may be offered
subtotal thyroidectomy. Patients over the age of 40 years are
usually given radioactive iodine (131I).
A thyrotoxic pilot is unfit for flying duties until stable
euthyroidism has been established and a satisfactory report
from the endocrinologist is received. If there have been eye
signs, then an ophthalmic assessment is of value in order to
K17577_C025.indd 456
establish that there is a good range of eye movement with
no diplopia. Anti-thyroid drugs in the absence of side effects
are not disqualifying.
Military aircrew may return to limited flying duties once
euthyroid. It is possible to return to unrestricted flying after
suitable surveillance, but only on the advice of an appropri-
ate specialist. Long term replacement therapy with thyrox-
ine is compatible with unrestricted flying duties. Treatment
with thyroid-suppressant therapy is compatible only with
restricted flying duty. Providing the patient is euthyroid
post radio-iodine therapy, unrestricted flying is permissi-
ble. All patients should remain under lifelong surveillance.
Addison’s disease
After full investigation and stable maintenance treatment
with hydrocortisone in a dose not exceeding 20 mg per day,
an individual with Addison’s disease may be considered for
recertification in a multi-crew situation. It is unlikely that
these individuals would be acceptable for military opera-
tions under normal circumstances, and the advice of a mili-
tary aviation medical specialist should be sought.
Cushing’s syndrome
Cushing’s syndrome may be due to an adenoma or carci-
noma of the adrenal cortex. Excessive alcohol use has also
been associated with Cushing’s syndrome. The aeromedical
disposal needs to be highly individualized on the basis of
the underlying lesion and the post-operative result.
Conn’s syndrome (mineralocorticoid)
This is found in 0.5–3 per cent of the hypertensive popula-
tion and presents with mild hypertension and hypokalae-
mia. It is associated with an adenoma (in approximately
80 per cent of cases) or hyperplasia of the zona glomerulosa
of the adrenal glands due to enhanced sensitivity to angio-
tensin II (Stewart 1999). If an adenoma is demonstrated,
the treatment is surgery. If bilateral hyperplasia is present,
it is treated with the aldosterone antagonist spironolactone.
If an adenoma is diagnosed and removed, this is curative
and, thus, aeromedical recertification should not cause a
problem, with regular follow-up. If the patient is on long
term spironolactone, amiloride or other medical treatment,
then individual assessment is appropriate with full endocri-
nological reports. It is probable that recertification will be
acceptable in a multi-crew situation.
Phaeochromocytoma
This is a rare tumour of the adrenal medulla. The inci-
dence often quoted is 0.1 per cent of cases of hypertension.
Diagnosis is made by measurement of plasma adrena-
line/noradrenaline or their many precursors or metabo-
lites, vanillylmandelic acid (VMA), metanephrines and
normetanephrines. The excretion may be paroxysmal and,
17/11/2015 15:58

thus, repeated sampling is mandatory. Tumours are local-
ized by computed tomography (CT) or magnetic resonance
imaging (MRI) of the abdomen or by scintigraphy.
If the tumour is removed completely, blood-pressure
control is satisfactory, and there is no significant end-organ
damage, then aeromedical certification should be possible
on individual assessment. This may be multi-crew initially.
Long term follow-up is essential.
Calcium metabolism
HYPERCALCAEMIA
Hypercalcaemia may result from a wide range of causes,
including vitamin D intoxication, sarcoidosis and malig-
nancy. Endocrine disorders associated with hypercalcaemia
are uncommon in aviation medical practice but are included
here for the sake of completeness. Hyperparathyroidism
is the most common of the parathyroid disorders, with a
prevalence of about one in 1000 in the USA. Approximately
80 per cent of cases are associated with a single adenoma.
The remaining cases have more than one adenoma or
hyperplasia of all four glands. There may be associated mul-
tiple endocrine neoplasia. Secondary hyperparathyroidism
occurs in chronic renal insufficiency and vitamin D defi-
ciency when the para-thyroid hormone (PTH) level rises
in response to the hypocalcaemia. It can result in changes
in bone mineralization. In some patients, long-standing
hypersecretion (in secondary hyperparathyroidism) trans-
forms to inappropriate autonomy and resultant hypercal-
caemia. This is termed tertiary hyperparathyroidism, and
the parathyroid glands show nodular hyperplasia.
HYPOCALCAEMIA
There are three main conditions that show hypocalcaemia
and elevated phosphate in the presence of normal renal
function. Idiopathic hypoparathyroidism presents in early
adult life and is often associated with antibodies to para-
thyroid tissue. There may be other associated autoimmune
disease, e.g. Addison’s disease and autoimmune thyroiditis.
Post-surgical hypoparathyroidism is the most common
cause of hypocalcaemia, and the prevalence following thy-
roid or parathyroid surgery varies from 0.2 to two per cent.
Pseudo-hypoparathyroidism is a rare condition thought to
be due to a defect in the PTH receptor or to its coupling with
adenylcyclase (Jüppner 1994). It is characterized by skeletal
abnormality and mental deficiency and is unlikely to be
encountered in aviation medicine practice.
The aeromedical certification of a member of aircrew
with hypo- or hypercalcaemia depends on firstly making a
temporarily unfit assessment until the cause is established
and definitive management has been completed. The prob-
lems range from a well individual who has had a parathy-
roid adenoma successfully removed and is eucalcaemic and
being followed up by their endocrinologist, who would be
suitable for certification in all classes, to the individual who
has hypercalcaemia secondary to carcinoma, and is not
K17577_C025.indd 457
Hypocalcaemia 457
suitable for certification. The keys to the certification pro-
cess are good-quality data and close cooperation between
the endocrinologist and the aviation physician.
Disturbances of lipid metabolism
AEROMEDICAL CONCERNS
The major concern with disturbances of lipid metabolism,
whether primary or secondary, is accelerated atherogenesis
and therefore a potential increase in the risk of sudden car-
diovascular incapacity in the aviator.
LIPID METABOLISM
Lipids are not water-soluble and are transported in the
blood in association with apoproteins as a lipoprotein com-
plex. These lipoproteins are usually divided into five groups
characterized by their ultracentrifugation densities. These
are designated chylomicrons, very-low-density lipoproteins
(VLDL), intermediate-density lipoproteins (IDL), low-
density lipoproteins (LDL) and high-density lipoproteins
(HDL). Apoproteins also play an important role in lipo-
protein metabolism, by activation of enzymes and acting as
receptor ligands.
In general terms, HDL and LDL are the major carriers
of cholesterol, while triglycerides are carried on VLDL and
chylomicrons. HDL cholesterol constitutes approximately
20–25  per cent of the total cholesterol. HDL lipoproteins
are regarded as anti-atherogenic, whereas the major con-
tributor to atherogenicity appears to be LDL. Lipoprotein(a)
is a lipoprotein similar to LDL. Its apoprotein, protein(a),
resembles plasminogen, and high levels are also proven to
be atherogenic.
FAMILIAL HYPERCHOLESTEROLAEMIA
This is an inherited disorder of LDL receptors. In the homo-
zygous condition there are virtually no effective receptors,
whereas in the heterozygote only about 50 per cent of the
receptors are active. It is characterized by high levels of
both total and LDL cholesterol. Homozygotes will often
have untreated levels of cholesterol of 15 mmol/L or greater,
while those of heterozygotes may be around 8 mmol/L. Both
groups are at risk of early coronary heart disease, events
characteristically occurring in the second decade in homo-
zygotes and in the fourth to fifth decades in heterozygotes.
AEROMEDICAL DISPOSAL
A diagnosis of familial hypercholesterolaemia should lead
to rejection of candidates for military aircrew training. For
civil aviation certification, candidates are assessed on an
individual basis. If they are on treatment, with well-con-
trolled lipids and no evidence of cardiovascular disease, then
they may be accepted without restriction. However, this will
be subject to continued careful follow-up and assessment.
SECONDARY HYPERLIPIDAEMIA
Secondary hyperlipidaemias are common and are related
to a variety of underlying disorders, the most common
17/11/2015 15:58
 458  Metabolic and endocrine disorders
of which are obesity, diabetes mellitus, hypothyroidism,
renal failure and nephrotic syndrome. Secondary hyper-
lipidaemias are also seen with excess alcohol ingestion,
steroid or sex hormone therapy, and the use of thiazide or
beta-blocker therapy.
The important implications for increased coronary risk
with the secondary hyperlipidaemias in diabetes mellitus
and renal disease are well established. In aviation, the clini-
cal problem is seen most frequently in obese people and
in people who have an excessive intake of ethanol. Both
are associated with a rise in triglycerides, but the fall in
HDL is greater in obese people. The Framingham Study
confirmed the increased coronary risk in both sexes with
raised triglycerides and reduced HDL (Gordon et al. 1981).
A meta-analysis of individual data from 61  prospective
studies showed conclusively the positive association with
IHD mortality of cholesterol, HDL and LDL levels in mid-
dle and old age and at all blood pressure levels (Lewington
et al. 2007).
AEROMEDICAL DISPOSAL
Flying restrictions should be related to the cumulative
risk factors. However, when lipid levels have been brought
within acceptable limits, unrestricted flying may be possible
subject to careful follow-up and a negative exercise ECG.
SCREENING
The arguments for lipid screening in aircrew were discussed
at the first European Workshop in Aviation Cardiology
(Keech and Sleight 1992). These have now been translated
into appropriate programmes for both military and civil-
ian aviators as part of cardiovascular risk assessment. The
screening programme requirements vary from country to
country and it is recommended that the local regulations
are consulted
Treatment of hyperlipidaemia in aviators
The rationale and supporting data for both primary and
secondary prevention of coronary artery disease by treat-
ment are well established.
Causes of secondary hyperlipidaemia, such as those
disorders listed above, should be excluded before initia-
tion of therapy. First-line treatment should, where appro-
priate, be in terms of lifestyle management. Reduction in
alcohol, cessation of smoking and increased exercise should
be associated with commencement of a lipid-lowering diet
and reduction of weight to achieve a BMI of 25 or below. A
lipid-lowering diet may result in a fall of up to 15 per cent
in total cholesterol levels and often a marked decrease in tri-
glycerides. In those whose lipids remain sufficiently elevated
to constitute an increased cardiovascular risk, drug therapy
should be considered. In both civil and military aviation,
hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase
inhibitors are the treatment of choice. The benefit of statin
therapy in both primary and secondary prevention of car-
diovascular morbidity is now well established. In primary
K17577_C025.indd 458
prevention, reductions in all-cause mortality, major vascu-
lar events and revascularisations have been shown with no
excess of adverse events among people without evidence of
CVD treated with statins (Taylor et al. 2013).
Standard therapeutic doses of HMG-CoA reduc-
tase inhibitors may be prescribed for aircrew and, in the
absence of adverse side effects, are acceptable for unre-
stricted civil aviation certification and military flying. The
use of other drugs should be considered carefully on an
individual basis.
SUMMARY
●● Prevalence of diabetes is increasing and therefore
not uncommon in aircrew.
●● Management of diabetes has progressed signifi-
cantly in the last five years with the development
of new drugs which are compatible with the
aviation environment.
●● Robust evidence now shows that good control
decreases complications. This should encompass
blood sugar, body mass index, blood pressure
and lipids.
●● Hypoglycaemia is the rate determining step in
risk assessment. Better evidence now exists for
the rate of severe hypoglycaemia which facilitates
this assessment.
●● Rarer endocrine conditions are best managed on
individual assessment using the complementary
competencies of the endocrinologist and the
aviation physician.
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17/11/2015 15:58

Renal disease
ANDREW TIMPERLEY
Introduction 461
The effects of the aviation environment on the kidneys 461
The effects of kidney disease on the aviator 462
Assessment of kidney disease 462
INTRODUCTION
Chronic kidney disease is common, with a prevalence esti-
mated in England of 14 per cent in males and 13 per cent in
females (Roderick et  al. 2011). Many patients with kidney
disease are asymptomatic and have an excellent prognosis
but others may suffer significant symptoms and complica-
tions, which could be distracting or even incapacitating.
This chapter will discuss the common and important kid-
ney conditions that an aviation medical examiner might
expect to see, focusing on the aeromedical aspects deter-
mining medical certification. For completeness, common
urological conditions will also be discussed.
United Kingdom specific guidance for certification of
military aircrew can be found in Air Publication AP1269A
(Defence Council 2013) and for civilian aircrew on the
Civilian Aviation Authority (CAA) website (CAA 2013).
THE EFFECTS OF THE AVIATION
ENVIRONMENT ON THE KIDNEYS
It is obviously important to protect aircrew, astronauts and
passengers from any physiological complications related to
air and space travel. It is reassuring to note that the kidneys
seem to tolerate these environments well.
The levels of hypobaria and hypoxia aircrew and pas-
sengers are exposed to in modern commercial and military
aircraft do not appear to have any significant detrimental
effects on the kidneys. This is also the case for astronauts.
The effective cabin altitude in the International Space
Station approximates to sea level and the pressure suits
K17577_C026.indd 461
26
Haematuria and proteinuria 463
Specific kidney conditions 463
References 466
worn by astronauts for extravehicular activities protect
them against excessive hypobaria and hypoxia.
Human centrifuge experiments have demonstrated
only transient effects of acceleration on kidney function.
Reduced renal perfusion during +Gz results in a decrease in
glomerular filtration rate (GFR) and an increase in plasma
renin activity (Epstein et al. 1974). In addition, the reduc-
tion in central blood volume causes a decrease in atrial
natriuretic peptide (ANP) and an increase in antidiuretic
hormone (ADH) release (Rogge et al. 1967). The net result
of these physiological responses is compensatory salt-water
retention, which attempts to correct the perceived fall in cir-
culating blood volume. Exposure to +Gz can also result in
transient proteinuria (Lee et al. 1999) and non-visible hae-
maturia (NVH), though the evidence for the latter is less
convincing. Cromarty found NVH in three out of 39 post-
flight urine samples from fast-jet pilots (Cromarty 1984).
However, Froom et al. failed to detect any difference in the
cumulative incidence and point prevalence of haematuria in
jet, transport or rotary pilots, suggesting +Gz had no effect
on the presence of blood in the urine (Froom et al. 1987).
Prior to manned space flight, head-down bed rest and
water immersion studies suggested that microgravity
would result in the opposite of +Gz i.e. cardiac disten-
sion, increased ANP and decreased ADH, with resultant
salt water loss. In these ground-based experiments, a new
equilibrium with a lower circulating volume and a pre-
served renal response to salt water loading was observed.
However, once manned space flight began in the 1960s, it
was evident that these models did not accurately reflect
microgravity. In-space studies revealed that, although
461
17/11/2015 15:58
 462  Renal disease
circulating blood volume did indeed decrease, there was no
associated natriuresis or diuresis, the renal responses to salt
water loading were blunted and sympathetic nervous activ-
ity increased. It was suggested that these in-space observa-
tions were primarily the result of reduced oral intake, fluid
shift to the interstitial compartment and a decrease in red
cell mass (Norsk 2005).
Proteinuria, as assessed by microalbuminuria, decreases
during space missions (Cirillo et  al. 2003). Although
astronauts might be expected to suffer transient NVH as
a result of the acceleration forces during takeoff and re-
entry, there is no evidence of persistent haematuria related
to microgravity.
THE EFFECTS OF KIDNEY DISEASE ON
THE AVIATOR
Kidney disease has the potential to distract or even incapac-
itate aircrew, astronauts and passengers, particularly those
with pre-existing medical conditions. The means by which
this may occur include:
●● Renal colic. Caused by ureteric obstruction, usually due
to calculi. Other causes include pelvi-ureteric junction
obstruction, transitional cell carcinoma and thrombus.
External ureteric compression may also occur as the
result of lymphadenopathy, tumour and retroperito-
neal fibrosis. The development of renal colic may be
unpredictable, of rapid onset and severe, often said to be
‘worse than childbirth’.
●● Declining kidney function. The onset is insidious with
symptoms being uncommon until GFR falls to about
20–30 mL/min/1.73m2. As kidney function deteriorates,
lethargy, pruritus, anorexia and breathlessness develop.
Severe uraemia, particularly if acute, may result in
loss of consciousness and seizure. Platelet dysfunction,
gastritis and pericarditis may result in gastro-intestinal
haemorrhage and cardiac tamponade. Disturbance of
acid-base, calcium-phosphate and potassium balance
become increasingly problematic as kidney failure
progresses. Hyperkalaemia is of particular concern as
it may result in life-threatening arrhythmias including
ventricular fibrillation.
●● Increased cardiovascular disease. This can occur even
with only mild degrees of renal impairment. The urae-
mic environment plus the frequent findings of hyper-
tension, dyslipidaemia and insulin-resistance in kidney
failure, significantly increases the risk of atherosclerosis
and cardiovascular disease. For example, the adjusted
hazard ratios for cardiovascular mortality increases to
1.52 when estimated glomerular filtration rate (eGFR)
falls to 45–59 mL/min/1.73m2, 1.63 when urine albu-
min to creatinine ratio (ACR) increases to 1.1–3.3 mg/
mmol, and 2.38 when these eGFR and ACR changes
occur together (Matsushita et al. 2010).
●● The nephrotic syndrome. Characterized by heavy pro-
teinuria, hypoalbuminaemia and peripheral oedema,
K17577_C026.indd 462
may occur in many kidney diseases but is most com-
monly seen in minimal change nephropathy in the
young and membranous nephropathy in the elderly.
Patients are in a hypercoagulable state and at increased
risk of venous and arterial thromboembolism, includ-
ing deep venous thrombosis, renal vein thrombosis and
pulmonary embolism.
●● Associated conditions. Kidney diseases may be sec-
ondary to systemic diseases such as diabetes mellitus,
vasculitis and multiple myeloma. Any such conditions
could independently compromise the ability of aircrew,
astronauts and passengers to fly safely.
●● The use of medication. Will need to be considered when
determining fitness to fly. Loop diuretics, angiotensin
converting enzyme inhibitors, angiotensin receptor
blocker, steroids and novel immunosuppressants are
just a few examples of drugs commonly used in the
treatment of kidney disease.
ASSESSMENT OF KIDNEY DISEASE
Whenever kidney disease is being considered, it is crucial
that the aeromedical examiner takes a detailed history and
performs a thorough clinical examination. Assessment
should include:
●● Blood pressure. If repeated clinic readings are high,
home and ambulatory recordings may be useful.
National guidelines vary but the upper limit of normal
is generally considered to be around 140/90 mmHg.
Kidney disease, regardless of cause, may result in
hypertension. Uncontrolled hypertension is known to
increase renal damage.
●● Urine analysis. Performed using urine reagent strips
(dipsticks). To avoid contamination, patients should
be instructed on how to perform a clean catch speci-
men of urine. In addition, samples should not be taken
within 24 hours of menstruation, arduous exercise
or high-G exposure, all of which can cause transient
haematuria. Unexpected results should be confirmed
by repeating the test several times with two out of three
positive results being considered confirmatory. Trace
results in isolation are considered negative, i.e. trace
haematuria with no proteinuria or trace proteinuria
with no haematuria. Most reagent strips are highly
sensitive to haem, which can be assumed to be due to
haematuria if there is no history or clinical findings to
suggest red cell fragmentation (haemoglobinuria) or
muscle breakdown (myoglobinuria). The strips are also
highly sensitive to proteinuria, primarily albumin, but
they are not sensitive to non-albumin proteins such as
Bence–Jones proteins.
●● Urine microscopy and culture. Although the presence
of red cells on microscopy is not necessary to confirm
haematuria, the findings of cells, casts or organisms are
all diagnostically important. Urine culture is needed to
exclude occult infection.
17/11/2015 15:58

●● Proteinuria. Traditionally been assessed with 24-hour
urine collections but they are time consuming, expen-
sive and liable to timing errors. Most laboratories
now offer urine protein to creatinine ratio (PCR) or
albumin to creatinine ratio (ACR) estimations, using a
single early morning urine sample. Although random
samples later in the day give a reasonable estimate of
proteinuria and albuminuria, the first morning sample
is more accurate and avoids detecting non-pathological
orthostatic proteinuria. From an aeromedical perspec-
tive, proteinuria greater than 0.5g/day (PCR >50 mg/
mmol, ACR >30 mg/mmol) is considered significant.
Proteinuria greater than 1g/day (PCR >100 mg/mmol,
ACR >70 mg/mmol) usually warrants grounding pend-
ing further review.
●● Renal function. Usually assessed by calculating the
eGFR, which uses the subject’s gender, ethnicity and
serum creatinine (Levey et al. 1999). It is more accurate
than estimates based on creatinine clearance, such as
24-hour urine collections and the Cockcroft–Gault
equation, which overestimate kidney function since a
small proportion of urinary creatinine is derived from
proximal tubular secretion. Renal function must be
stable in order to calculate eGFR and the result must
be interpreted with caution since it is less accurate at
near-normal values. It is also inaccurate in children,
pregnancy and at extremes of weight. Because serum
creatinine is primarily derived from skeletal muscle,
higher levels are seen in those with increased muscle
mass such as athletes. These individuals will have a
higher serum creatinine and consequently lower calcu-
lated eGFR than might otherwise be expected, despite
having normal renal function.
●● Renal imaging. Assesses the number, size and location of
the kidneys as well as the presence of scars, stones and
obstruction. In asymptomatic patients, renal ultraso-
nography (US) is the modality of choice. It offers good
visualization of the kidneys without exposure to ionizing
radiation. Plain abdominal radiographs (AXRs) may be
a useful alternative for monitoring those with renal stone
disease. Non-contrast computed tomography (CT) is the
preferred choice for those with suspected ureteric colic.
Radionucleotide scans are reserved for those requiring
detailed assessment of kidney function and urine flow.
HAEMATURIA AND PROTEINURIA
Both haematuria and proteinuria may be transient. In a
study of students in England, 6.2 per cent out of 3570 ini-
tial urine samples were positive for blood and/or protein on
reagent strip testing; however, only 22.4  per cent of those
retested remained positive (Topham et al. 2004). It is gener-
ally accepted that transient haematuria or proteinuria is not
pathological, particularly in the young, whereas persistent
abnormalities require investigation.
Aircrew with visible haematuria (VH), regardless of age,
should be grounded and referred for urological assessment
K17577_C026.indd 463
Specific kidney conditions  463
in order to exclude underlying malignancy and kidney
stones, both of which can cause ureteric and bladder out-
flow tract obstruction, which could cause pain and poten-
tially syncope. Aircrew over 40 years of age with persistent
isolated NVH need referral to a urologist for the same rea-
sons. However, if they are asymptomatic, normotensive,
have normal kidney function and have no evidence of renal
tract calcification on US or AXR, it would be reasonable to
allow a return to restricted flying duties (unfit solo), pend-
ing expeditious urological assessment. This is on the pre-
sumption that a malignant cause is unlikely and, even if
present, unlikely to cause obstruction of the urinary tract.
The individuals above, who have no demonstrable uro-
logical cause for their haematuria, plus all other aircrew
with persistent haematuria and/or proteinuria, should be
referred for renal assessment. If they are asymptomatic,
normotensive, have proteinuria less than 1g/day, have nor-
mal kidney function and have no evidence of renal tract
calcification on US or AXR, it would be reasonable to allow
a return to unrestricted flying duties, pending expeditious
nephrological assessment.
The final aeromedical disposal of aircrew with kidney
disease will depend on the underlying diagnosis, kidney
function, proteinuria, associated conditions and treatment.
SPECIFIC KIDNEY CONDITIONS
Renal stone disease
Kidney stones are common, with a lifetime risk of up to
15  per cent in Europe rising to 25  per cent in the Middle
East, where the hot sunny climate results in dehydration
and increased vitamin D synthesis. Stones are twice as com-
mon in men as in women. Recurrence is to be expected with
50 per cent of patients suffering a further stone within ten
years and 75 per cent within 20 years. Peak rates of recur-
rence occur at two and between seven and eight years after
an initial stone. Recurrence is more likely with youth, a
positive family history, urinary tract infection and where
there is an identifiable metabolic abnormality. Following a
second stone, the risk and frequency of recurrence increases
(Moe 2006; Coe and Parks 1988). Renal stone disease is
more common in aircrew. In an American study, the inci-
dence of renal calculi in army aviators was twice that of a
control population (Clark 1990). This is probably the result
of dehydration as aircrew often reduce their fluid intake to
avoid the need to urinate in flight. In addition, military air-
crew may also become dehydrated due to excessive sweating
from working in hot climatic conditions and having to wear
bulky flying clothing, which may include body armour. The
astronaut population also appear to have an increased risk
of stone formation. In addition to the risk factors common
to aircrew, astronauts suffer bone demineralization with
associated hypercalciuria ( Pietrzyk et al. 2007).
Stones within the kidney are asymptomatic. Ureteric
stones causing obstruction result in renal colic with severe,
incapacitating pain, radiating from loin to groin, often
17/11/2015 15:58
 464  Renal disease
associated with diaphoresis and vomiting. Bladder stones
may cause urinary frequency, dysuria and interruption of
micturition. All stones within the urinary tract may cause
VH or NVH and predispose to urinary tract infection.
As soon as kidney stones are suspected, aircrew should be
grounded. A return to unrestricted flying is normally possi-
ble once they are clinically and radiographically stone free.
Asymptomatic stones within the kidneys usually require
treatment with lithotripsy or ureteroscopic intervention.
Small, peripheral stones, not in proximity to the urinary
space, may be compatible with unrestricted flying duties
but where there is doubt, restrictions (including unfit solo)
will be necessary. Those with renal colic will require anal-
gesia, often mandating admission to hospital. Non-contrast
CT is the investigation of choice to confirm the diagnosis. If
the stone does not pass, lithotripsy or ureteroscopic inter-
vention may be necessary. Bladder stones can usually be
removed cystoscopically but very large stones may require
open surgery.
An attempt should be made to identify any metabolic
abnormalities predisposing to stone formation, particularly
following a recurrence. Biochemical analysis of a captured
stone or fragments is particularly useful. Most stones are
primarily composed of calcium and oxalate with urate
stones being relatively uncommon, though the incidence
of the latter is higher in the Middle East. Initial investiga-
tions usually include assays of calcium, phosphate and urate
in blood and urine; cystine and citrate in the urine; and
urinary pH.
Those with recurrent stone disease and an identifiable
metabolic abnormality may require specific dietary restric-
tion and/or pharmacological intervention, e.g. sodium and
protein restriction plus hydrochlorothiazide for hypercalci-
uria; protein restriction plus citrate for hypocitraturia; and
purine restriction plus allopurinol for hyperuricosuria. In
addition, all patients should be advised to maintain high
urine output, e.g. no less than two litres per day.
Aircrew with a history of renal stone disease will need
to undergo regular imaging in order to monitor residual
stones and to look for new stones forming within the kid-
neys. Ultrasound and AXR appear to have similar sensitiv-
ity for stone detection, 61  versus 57  per cent respectively
(Fulgham et al. 2013). Ultrasound avoids exposure to ion-
izing radiation but is relatively costly, time consuming and
operator dependent, whereas AXRs can be easily reviewed
and compared to previous films, aiding detection and mon-
itoring of small stones, but may fail to detect radiolucent
stones composed of urate, for example. The modality and
frequency of screening will need to reflect the population
being considered. It would be reasonable to use US for those
with radiolucent stones and for women of childbearing age
and to use AXR for all other aircrew. At the very least, imag-
ing should be performed at two and seven years post first
stone, coinciding with the known peak rates of recurrence.
For recurrent stone-formers and single-seat military pilots,
screening will need to be more frequent, possibly every one
to two years.
K17577_C026.indd 464
Dialysis and transplantation
Haemodialysis and peritoneal dialysis are generally con-
sidered incompatible with flying because of the associated
unacceptably high cardiovascular mortality rates of 8  and
10  per 100  patient-years respectively (Johnson et  al. 2009).
Transplantation, however, carries a much lower cardiovascu-
lar risk at just 0.5 per 100 patients-years (Ojo et al. 2000). Some
civilian aviation authorities now allow restricted certification
(unfit solo) for commercial pilots and unrestricted certifica-
tion for private pilots. Patients must have made a full surgical
recovery and have stable renal function, good blood pressure
control and acceptable cardiovascular risk; assessment of the
latter usually requires an annual exercise ECG. Anti-rejection
medication levels must be within therapeutic range and ste-
roid doses must be kept low e.g. equivalent to less than 10 mg
prednisolone per day. All other co-morbidities and treatment
must be compatible with flying.
Single kidney
The incidence of unilateral renal agenesis (URA) is approxi-
mately 1 in 2000. Compensatory renal hypertrophy is to be
expected. Additional abnormalities of the urinary tract are
identified in one-third of these patients, most commonly
vesico-ureteric reflux. Extra-renal anomalies are also found
in one-third of all patients, including rare genetic disor-
ders associated with hearing impairment (branchio-oto-
renal syndrome) and visual disturbance (renal-coloboma
syndrome). Micro-albuminuria, hypertension and renal
impairment are seen in 21, 16 and 10 per cent respectively
(Westland et al. 2013). Any associated abnormalities must
be considered when assessing aircrew with URA.
A functionally single kidney may be the result of hypo-
plasia, scarring or nephrectomy. Compensatory hypertro-
phy of the remaining kidney usually occurs with time and
renal function is generally preserved, though hypertension
and proteinuria are not uncommon. It is reasonable to pre-
sume a favourable outcome and allow unrestricted flying in
those with no renal scarring, normal kidney function, good
blood pressure control and no proteinuria.
Polycystic kidney disease
Autosomal dominant polycystic kidney disease (ADPKD)
is the commonest form of inherited kidney disease, with
a prevalence between 1  in 400  and 1  in 1000. The major-
ity of cases are due to mutation of the PKD1  gene or less
commonly PKD2, which results in the development of fluid
filled cysts within the kidneys, which increase in size and
number over time, progressively destroying viable renal tis-
sue. Kidney function typically declines more rapidly with
the PKD1 rather than PKD2 mutation, with median age of
death or onset of end-stage renal disease at 53 and 69 years,
respectively (Hateboer et al. 1999).
Renal manifestations of ADPKD include deteriorating
kidney function, hypertension, haematuria, pain related to
17/11/2015 15:58

expanding cysts, urinary tract infections, kidney stones and
renal cell carcinoma. In addition, there are important extra-
renal manifestations. Hepatic and pancreatic cysts are fre-
quently seen but these are rarely problematic. Cardiac valve
abnormalities are commonly found, most often mitral valve
prolapse and aortic regurgitation. Abdominal aortic aneu-
rysms may also occur. However, probably the most important
extra-renal manifestation is that of cerebral aneurysm, which
is found in around 10 per cent of ADPKD patients. Most of
these aneurysms are small, less than 10  mm diameter, and
unlikely to rupture. The risk of rupture increases with size,
location in the posterior circulation and a history of previ-
ous bleed (Mariani et al. 1999). In view of these associations,
before being considered for unrestricted flying duties, aircrew
with ADPKD should undergo assessment of renal function,
an echocardiogram, an abdominal aortic Doppler ultrasound
scan and cerebral magnetic resonance angiography.
Benign prostatic hypertrophy
Benign prostatic hypertrophy (BPH) can result in distract-
ing symptoms such as urinary frequency, nocturia, poor
stream, post-micturition dribbling and urinary retention.
Alpha-blockers (alpha-1-adrenergic antagonists) give
rapid relief of the symptoms of BPH by causing smooth
muscle relaxation of the bladder neck, prostate capsule and
prostatic urethra. Unfortunately, they also act on vascular
smooth muscle, potentially causing postural hypotension
and syncope. Some alpha-blockers, such as tamsulosin and
alfuzosin, are more prostate-selective and may have a less pro-
nounced effect on blood pressure. Before being considered
for unrestricted flying duties, aircrew taking alpha-blockers
for BPH will need to demonstrate that they do not have pos-
tural hypotension, e.g. via lying and standing blood pressure
measurements and ambulatory blood pressure monitoring.
Five-alpha-reductase inhibitors act by inhibiting the
conversion of testosterone to dihydrotestosterone. Unlike
alpha-blockers, they reduce the size of the prostate, though
this takes several months. Side effects include reduced libido
and erectile dysfunction. They are generally considered
compatible with unrestricted flying but when combined
with an alpha-blocker, the guidance relating to postural
hypotension will need to be adhered to.
Malignancy of the urinary tract
From an aeromedical perspective, all malignant tumours of
the urinary tract should be assessed as per the chapter on
malignancies with assessment taking into account the risk
of local recurrence and distal metastasis and the resultant
risk of incapacitation. The effects of treatment including
surgery, chemotherapy and radiotherapy will also need to
be assessed. Finally, the psychological stress of a diagnosis
of cancer should not be underestimated.
Renal cell carcinoma may result in haematuria and
potentially renal colic due to ‘clot colic’. When metasta-
sis occurs, it may involve the brain in up to 10 per cent of
K17577_C026.indd 465
Specific kidney conditions  465
cases. Paraneoplastic symptoms are common including
fever, night sweats and hypercalcaemia. Patients are usually
anaemic but a few may become polycythaemic due to over-
production of erythropoietin. Unfortunately, recurrence is
common, even after surgery.
Bladder cancer is the commonest malignancy of the
urinary tract. It usually presents with painless haematu-
ria or occasionally bladder irritation. Ureteric and urethral
obstruction due to tumour growth has the potential to cause
renal colic and urinary retention, respectively. Patients with
superficial disease may be managed by transurethral resec-
tion and intravesical therapy, but those with more invasive
disease may require cystectomy or radiotherapy, with or
without chemotherapy.
Serum prostate specific antigen (PSA) is frequently used
to screen for prostate cancer, leading to early detection and
the potential for useful intervention. However, there is a
high false positive rate associated with PSA-based screening,
resulting in a significant number of healthy men undergoing
further tests, some of which are associated with significant
morbidity, e.g. trans-rectal biopsy. Symptomatic patients
suffer the same symptoms as those with BPH, described
above. Patients with localized disease may be managed
with anti-androgen therapy, brachytherapy, radiotherapy
or prostatectomy. In advanced disease, metastasis to bone
is common with resultant bone pain, pathological fractures
and hypercalcaemia.
SUMMARY
●● Hypoxia and hypobaria have no clinically sig-
nificant effects on the kidneys; however high +Gz
and microgravity have demonstrable effects on
urinary sediment and salt-water balance.
●● Kidney diseases have the potential to distract
and incapacitate aircrew due to obstructive,
uraemic and nephrotic symptoms and associated
cardiovascular risk.
●● Haematuria and proteinuria are common, often
transient, findings in aircrew and if persistent require
investigation. Those without evidence of malignancy
or vasculitis may be able to return to flying duties.
●● Renal stone disease is twice as common
in aircrew compared to non-aviators and
has the potential to result in unprovoked,
incapacitating pain.
●● Dialysis is incompatible with flying duties due to
high cardiovascular risk; however, this improves
post-transplant giving civilian aircrew the oppor-
tunity to return to restricted flying duties.
●● Kidney diseases may be associated with other con-
ditions including malignancy, which along with
any medication, needs to be taken into account
when considering an aviator’s fitness to fly.
17/11/2015 15:58
 466  Renal disease
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17/11/2015 15:58

Haematology
PAUL L. F. GIANGRANDE
Introduction 467
Anaemia 467
Myeloproliferative disorders 470
Haematological malignancies 470
INTRODUCTION
This chapter focuses on areas of general haematology which
are of particular relevance to the practice of aviation medi-
cine as applied to both medical certification of flight crew as
well as the transport of passengers in commercial aircraft.
Several blood disorders can affect fitness to fly and, at the
same time, flight itself may lead to various problems: an
example of the former is anaemia and an important exam-
ple of the latter is venous thromboembolism. A list of nor-
mal haematological values can be found as an appendix to
this chapter.
ANAEMIA
Haemoglobin in red blood cells (erythrocytes) is necessary
for the uptake of oxygen in the lungs, and its transport and
transfer to peripheral tissues. The normal haemoglobin level
is 13.5–17.5 g/dL for males and 11.5–15.5 g/dL for females.
Anaemia is not in itself a diagnosis but may be a conse-
quence of a wide variety of disorders and it is important to
determine the cause. Whatever the aetiology, cardiovascu-
lar reserve could be impaired and this could pose a problem
in an aircraft cabin with a pressure altitude of up to 8000 ft.
With regard to passengers, subjects with a haemoglobin
level of 7.5 g/dL or more are not likely to experience prob-
lems with commercial air travel. However, the haemoglobin
level alone cannot be relied upon to decide whether a patient
is fit to travel. A distinction must also be made between
chronic and acute anaemia. Patients with long-standing
K17577_C027.indd 467
27
Disorders of haemostasis 471
Blood transfusion 475
Splenectomy 475
References 476
anaemia, such as that associated with renal failure, often
have good cardiovascular compensation and experience few
problems with travel. By contrast, patients with anaemia of
recent onset, such as after surgery, are more likely to expe-
rience problems. Chronic anaemia may precipitate angina
in subjects with an already compromised circulation. The
Canadian Cardiac Society Guidelines recommend a hae-
moglobin level of 9  g/L as a threshold value below which
travel is inadvisable in passengers who have undergone
coronary artery bypass grafting (Ross et al. 2004). Signs of
haemodynamic instability precipitated by exertion include
tachycardia or other arrhythmias, hypotension, chest pain
and changes in the ST segment of the electrocardiogram.
In addition to possible difficulties associated with the jour-
ney, travellers with anaemia should be advised of the pos-
sible hazards of blood transfusion in developing countries
(see below). This is particularly important for patients with
chronic haematological conditions where periodic transfu-
sion is required. When assessing potential passengers for
fitness to fly, it is also important to bear in mind that exami-
nation whilst at rest may prove misleading and exercise tol-
erance should be assessed. As a general guideline, those who
are able to walk about 50 metres and to climb 10–12 stairs
without symptoms should be able to fly without incident.
In the case of flight crew, there are no longer firm rules
with regard to haemoglobin levels and medical certification.
However, a finding of a haemoglobin level of 11 g/dL or less
should prompt appropriate clinical enquiry and investiga-
tions. Final assessment will dependent on the diagnosis and
response to treatment.
467
17/11/2015 15:59
 468 Haematology
Deficiencies of haematinics
Screening for deficiencies of haematinic agents such as iron,
folic acid and vitamin B12 are normally included in the ini-
tial evaluation of a subject with anaemia. Iron deficiency is
the most common cause of anaemia and the typical picture
is a low haemoglobin associated with hypochromia (mean
corpuscular haemoglobin (MCH) <27  pg) and microcy-
tosis (mean corpuscular volume (MCV) <80  fl) of the red
cells. The diagnosis can be confirmed by the finding of a
low serum ferritin level. It is always important to estab-
lish the underlying cause of iron deficiency. It may simply
reflect poor intake (e.g. in vegetarians) or poor absorption
(e.g. coeliac disease), but the most common cause is chronic
blood loss (e.g. heavy menstrual blood loss, peptic ulcers or
other gastrointestinal pathology).
Deficiency of folic acid or vitamin B12  may also cause
anaemia. In this case, the red cells are unusually large
(macrocytosis) with an MCV of 100 fl or more (Kaferle and
Strzoda 2009). Deficiency of folic acid is almost always the
consequence of poor dietary intake: this vitamin is plen-
tiful in fresh fruit and vegetables. However, deficiency of
folic acid may be a manifestation of malabsorption and the
possibility of coeliac disease needs to be considered in the
differential diagnosis. Pernicious anaemia is an autoim-
mune condition characterized by chronic inflammatory
gastritis associated with achlorhydria and the development
of antibodies directed against intrinsic factor and/or gas-
tric parietal cells. This results in malabsorption of vitamin
B12  despite a normal dietary intake. Regular intramuscu-
lar injections – typically every three months – will restore
normal haematopoiesis. The underlying gastritis is not cor-
rected with this treatment and there is a persisting long-
term risk of the order of 2–3 per cent of developing gastric
cancer. It should also be borne in mind that there is also
an association between pernicious anaemia and the subse-
quent development of other autoimmune disorders (in par-
ticular hypothyroidism). Severe vitamin B12 deficiency may
be associated with both peripheral neuropathy and spinal
cord demyelination, but this does not occur in association
with folic acid deficiency.
Isolated macrocytosis associated with a normal haemo-
globin also merits documentation as it may be an indicator
of several conditions including chronic liver disease, sus-
tained high alcohol intake, and hypothyroidism, although
it is a normal finding in pregnancy. Anaemia in associa-
tion with thrombocytopenia and/or an abnormal leukocyte
count deserves specialist investigation and referral to a hae-
matologist should be considered.
Eosinophilia
The print-out from automated full blood count analysers will
usually provide a differential white cell count. Eosinophilia
is defined by an eosinophil count above 0.5  ×  109/L. A
raised eosinophil count is most often seen in association
with certain skin disorders such as eczema and psoriasis as
K17577_C027.indd 468
well as allergic conditions like asthma, hay fever and drug
reactions. It can also be an important indicator of under-
lying parasitic infections, including filariasis, toxocariasis,
schistosomiasis (bilharzia), trichinosis, ancylostomiasis
(hookworms) and ascariasis. Unexplained eosinophilia in a
routine full blood count should therefore prompt enquiry
into travel history and medication, as well as examination
of stool and urine for parasites, cysts and ova.
Haemolytic anaemias
The haemolytic anaemias can be defined as those forms
resulting from an increase in the rate of destruction of eryth-
rocytes, which normally have a life span of around 120 days.
Many of these are hereditary conditions and a classic exam-
ple is hereditary spherocytosis, which is inherited as an
autosomal dominant condition. Deficiency of structural
membrane proteins (such as spectrin or protein 4.1R) result
in premature destructions of the erythrocytes resulting in
anaemia of variable degree which is often accompanied by
mild jaundice and splenomegaly. Diagnosis is easily estab-
lished by examination of the blood film and demonstration
of reticulocytosis as well as a negative direct antiglobulin
(Coombs’) test. Splenectomy is beneficial in patients with
significant anaemia although this does result in increased
susceptibility to certain bacterial infections (see below).
Hereditary elliptocytosis is a similar condition, although
any resulting anaemia is only slight and splenectomy is only
rarely indicated.
Autoimmune haemolytic anaemia is caused by the
destruction of erythrocytes by autoantibodies directed
against red cell antigens, resulting in anaemia of varying
severity often associated with mild splenomegaly (Lechner
and Jäger 2010). It can develop at any age and both sexes are
affected equally and typically run a chronic course, punctu-
ated by intermittent remissions and relapses. Typical hae-
matological findings include spherocytosis in the peripheral
blood and a positive direct antiglobulin (Coombs’) test.
Treatment options include the use of steroids and immu-
nosuppressive agents such as azathioprine or cyclophos-
phamide. Splenectomy may also be of value. Permanent
remission is not common and the requirement for continu-
ous or intermittent therapy is likely to prejudice medical
certification as flight crew.
Glucose 6-phosphate dehydrogenase deficiency (G6PD)
deserves special mention because of the potential for devel-
opment of severe and acute haemolytic anaemia in con-
ditions when the erythrocytes are subjected to oxidative
stress. This form of haemolytic anaemia is inherited as a sex-
linked condition and thus affects males only. It is by far the
most common form of haemolytic anaemia, encountered
particularly frequently in the Mediterranean, West Africa,
Middle East and South East Asia. Whilst it can occasionally
be associated with persistent haemolytic anaemia and mild
jaundice, most patients maintain a normal haemoglobin
level. There will usually be no abnormality noted on rou-
tine laboratory screening. However, viral infections or other
17/11/2015 15:59

acute illnesses can precipitate rapid and sudden intravascu-
lar haemolysis associated with haemoglobinuria. Ingestion
of the fava bean or exposure with certain common drugs
can have the same effect: drugs which can provoke this reac-
tion in susceptible (G6PD-deficient) individuals include
aspirin, sulphonamide antibiotics and the antimalarial
drugs primaquine and chloroquine.
Sickle cell disease
Hemoglobinopathies are inherited disorders of haemo-
globin resulting from synthesis of abnormal haemoglobin
molecules. In general, these conditions are encountered in
people originating from tropical areas and it is believed that
these conditions originally developed to confer protection
against malaria. The HbS gene frequency in people of Afro-
Caribbean origin may be as high as 5 per cent. The gene is
also found with a lower frequency amongst people of the
Mediterranean, Middle East and Indian subcontinent. This
condition is due to a single mutation in the β-globin chain
of the haemoglobin molecule: valine (V) is substituted for
glutamic acid (E) at position 6. The abnormal haemoglobin
is unstable and forms precipitates within the erythrocyte
due to polymerisation when deoxygenated.
It is of fundamental importance to distinguish between
heterozygous carriers of this condition (‘sickle cell trait’)
from homozygous subjects. Sickle cell trait is a benign con-
dition in which 20–40 per cent of the circulating haemoglo-
bin is Hb S and the rest is normal Hb A. Heterozygotes have
no clinical problems and indeed the haemoglobin levels are
typically normal and examination of the blood film shows
no significant abnormality. In vitro tests show that sickling
does not occur in sickle cell trait until the Po2 falls to about
10  mmHg and thus clinical problems will only occur in
conditions of extreme hypoxia. Flight in pressurized com-
mercial aircraft certainly poses no problems and sickle cell
trait is not a bar to a career in commercial, civil aviation.
Similarly, sickle cell trait is no longer a bar to licensing of
military aircrew in the UK and USA. This was a controver-
sial area in the past but is no longer considered to be a bar
to certification of even military aircrew (Voge et al. 1991).
By contrast, homozygote subjects with sickle cell disease
have a persistent anaemia (with a haemoglobin level typi-
cally in the range of 7–10 g/dL) and are prone to recurrent
episodes of painful ‘crises’ due to intramedullary necrosis
following occlusion of small vessels. The most frequently
involved areas are the knee, lumbosacral spine, elbow and
femur but the ribs, sternum, clavicles, calcaneus and facial
bones may also be affected. Often there is no obvious pre-
cipitating cause, but it is recognized that infections, dehy-
dration and exposure to cold or low levels of oxygen can
provoke crises. Joint effusions are commonly seen when
the knees or elbows are involved. Crises can be extremely
painful, and opiate analgesics are usually needed. Extensive
sickling within the lungs can be life-threatening. This can
initially present with cough, fever and pleuritic chest pain,
and a chest X-ray shows extensive infiltration of either one
K17577_C027.indd 469
Anaemia 469
or both lung fields. Other complications of homozygous
sickle cell disease include episodes of painless haematuria,
avascular necrosis of the hip, vaso-occlusive stroke, devel-
opment of gallstones formed from aggregates of bilirubin
and the development of intractable leg ulcers. Patients with
sickle cell disease experience splenic infarction leading to
loss of immune function and are therefore vulnerable to
certain bacterial infections (see section on splenectomy).
Repeated infarction within the hypertonic environment of
the renal medulla often results in recurrent episodes of pain-
less haematuria. The ability to concentrate urine is eventu-
ally impaired, and patients are thus prone to dehydration.
It will be obvious from the above that a diagnosis of
(homozygous) sickle cell disease is incompatible with medi-
cal certification as flight crew. As regards passengers with
sickle cell disease, recent data suggest that sickling crises
and related problems in patients with homozygous sickle
cell disease (Hb SS) flying in pressurized commercial air-
craft are extremely rare. There is thus reassuring evidence
now available which permits a more relaxed attitude to
flight in commercial aircraft. People with sickle cell dis-
ease should certainly be encouraged to drink plenty of
water during the journey as they are particularly prone to
dehydration due to the impaired ability of the kidneys to
concentrate urine. The risk of sickling with other variants,
including combined haemoglobin S/C disease and hae-
moglobin S/β-thalassaemia is significantly higher. In such
cases, it would be sensible to have oxygen available on board
pressurized aircraft although it is not necessary to use it on
a prophylactic basis in flight. By contrast, there are several
case reports describing the development of a sickle cell crisis
in subjects with simple sickle cell trait in flight at altitude in
unpressurized aircraft at altitudes above 8000 feet.
Thalassaemia
The thalassaemias are a group of haematological disorders
in which a defect in the synthesis of one or more of the glo-
bin polypeptide chains is present, resulting in the formation
of unstable aggregates of globin chains within erythrocyte
precursors, which are prematurely destroyed. A full clas-
sification of the thalassaemias is beyond the scope of this
chapter, but the principal division is that between disorders
involving the α and β-chains of the haemoglobin molecule.
The prevalence of the genes for thalassaemia is particularly
high in Mediterranean countries (particularly Greece, Italy,
Cyprus and North Africa), the Middle East, the Indian sub-
continent and South East Asia. Carriers of β-thalassaemia,
the most common form in European countries, have no
clinical problems, apart from a mild and persistent micro-
cytic anaemia with a haemoglobin level typically in the
range of 10–12  g/dL. The condition can thus be mistaken
for iron deficiency anaemia but haemoglobin electrophore-
sis will permit the distinction through the demonstration
of a mildly elevated level of haemoglobin A2. A diagnosis of
heterozygosity (‘thalassaemia trait’) is certainly not a bar-
rier to medical certification for flight duties.
17/11/2015 15:59
 470 Haematology
β-Thalassaemia major is the homozygous form and this
results in very severe anaemia which becomes apparent
3–6  months after birth. This is accompanied by massive
enlargement of the liver and spleen due to both excessive red
cell destruction and extramedullary erythropoiesis. Marked
expansion of the bone marrow leads to thinning of the cor-
tex in the bones, which can result in pathological fractures.
Striking features in untreated children include prominence
of the parietal and frontal bones and protrusion of the max-
illary bones, leading to malocclusion of teeth and orthodon-
tic problems. Somewhat paradoxically, many of the serious
medical complications seen in thalassaemia actually result
from treatment of the condition. A programme of regular
transfusions to maintain a haemoglobin level of 10  g/dL
will lead to regression of hepato-splenomegaly and skeletal
changes. However, regular transfusion eventually results in
iron overload and fibrosis in vital organs which can result in
diabetes mellitus, cirrhosis and cardiac complications such
as arrhythmias or congestive cardiac failure. The admin-
istration of iron-chelating agents such as desferrioxamine
may postpone the onset of iron overload. A diagnosis of
homozygous thalassaemia is clearly not compatible with
medical certification as flight crew.
MYELOPROLIFERATIVE DISORDERS
Polycythaemia and essential thrombocythaemia are
both disorders within the spectrum of myeloprolifera-
tive disorders. These are associated with abnormal clonal
proliferation of haemopoietic stem cells, resulting in
increased red cell mass and abnormally high platelet counts
respectively (Tefferi 2013). There is considerable overlap
between these conditions with regard to symptoms and
potential complications.
Polycythaemia
Polycythaemia is defined by an increase in the red cell mass,
resulting in a haemoglobin level of 17.5  g/dL or more in
males and 15.5 g/dL in females. True polycythaemia rubra
vera (PRV) is a myeloproliferative disease which can run a
long clinical course but which transforms into myelofibrosis
in about one-third of cases. Acute myeloid leukaemia may
also develop in a smaller number of around 5  per cent of
patients. Almost all of these patients have a mutation in the
JAK2 kinase (V617F), which renders the erythroid precur-
sors hypersensitive to erythropoietin. This mutation may be
helpful in making a diagnosis or as a target for future ther-
apy. PRV typically develops in older subjects aged 50 or more.
Many of the clinical features are a consequence of hyper-
viscosity of the blood, hypermetabolism or hypervolaemia.
Symptoms include headaches, dyspnoea, night sweats, pru-
ritus, blurred vision and onset of gout. The typical facial
appearance is plethoric with florid cyanosis. The diagnosis is
based on the finding of an increased haematocrit associated
with increased red cell mass using radio-isotopic studies. A
raised neutrophil and platelet count may also be observed.
K17577_C027.indd 470
The haematocrit can be effectively controlled through regu-
lar venesection alone, although other treatment options
include the use of alkylating agents (e.g. hydroxyurea and
busulphan) or interferon (Passamonti 2012). Aspirin is also
commonly given as antiplatelet therapy. The median survival
time is of the order of 10–16 years from diagnosis, regardless
of the form of treatment used. Thrombosis and haemorrhage
are common and vascular accidents are a frequent cause of
death. Increased viscosity of the blood, vascular stasis and
high platelet counts may all contribute to the development
of thrombosis. Vascular distension, infarcts of small vessels
and defective platelet function may promote haemorrhage.
Although there is some discretion allowed, a diagnosis of
PRV is normally considered to be disqualifying due to the
potential for thromboembolic complications and unpredict-
able progression of the disorder.
Essential thrombocythaemia
The platelet count in this condition exceeds 600  ×  109/L,
often considerably so. The high platelet count may result in
thrombotic problems or, somewhat paradoxically, bleed-
ing if platelet function is abnormal. The spleen may also
be enlarged. The long-term prognosis is significantly bet-
ter than in polycythaemia and the risk of leukaemic trans-
formation is also lower at around 1 per cent over 10 years.
Agents of value in the management of this condition include
hydroxyurea, anagrelide and α-interferon.
HAEMATOLOGICAL MALIGNANCIES
Advances in recent years offer the prospect of a cure for
many haematological malignancies, including acute leu-
kaemias and lymphomas. A description of the acute leukae-
mias falls outside the scope of this book but it should be
borne in mind that treatment of haematological malignan-
cies often involves prolonged courses of chemotherapy and/
or radiotherapy. Long-term immunosuppression may also
be required after bone marrow transplantation. The poten-
tial longer term complications of such treatment do need
to be considered when reviewing candidates for medical
certification as pilots who have a history of previous suc-
cessful treatment for a malignant condition in childhood
(Bhatia 2012). Radiotherapy can result in cataract forma-
tion and pulmonary fibrosis years later. Radiation can also
result in endocrine abnormalities such as hypothyroidism.
Anthracycline cytotoxic agents like doxorubicin can cause
latent cardiomy­opathy. Platinum-containing chemothera-
peutic drugs like cisplatin can cause serious and permanent
bilateral hearing impairment. Osteonecrosis is a well-rec-
ognized complication of prolonged corticosteroid therapy.
Chronic lymphocytic leukaemia
Chronic lymphocytic leukaemia (CLL) is a malignant prolif-
eration of B-lymphocytes and occurs chiefly in the elderly. It
typically runs an indolent course and is often picked up as
17/11/2015 15:59

an incidental finding, e.g. when a routine full blood count is
taken prior to elective surgery. Many patients die of a com-
pletely unrelated condition. Mutations within TP53 are asso-
ciated with an overall poor prognosis and impaired response
to therapy and so screening is recommended as part of the ini-
tial assessment. In advanced stages there may be evidence of
bone marrow failure, with anaemias and thrombocytopenia,
diffuse lymphadenopathy and splenomegaly. Most patients
will not require treatment initially. Treatment may only be
needed as the disease progresses and agents like chloram-
bucil, fludarabine and rituximab are among the most widely
used drugs nowadays (Oscier et al. 2012). Autoimmune hae-
molytic anaemia is also a recognized complication, which
responds well to steroid therapy. Patients with chronic lym-
phocytic leukaemia are prone to bacterial, fungal and her-
pes zoster infections because of hypogammaglobulinaemia,
neutropenia and disturbances of cellular immunity.
Chronic myeloid leukaemia
Chronic myeloid leukaemia (CML) occurs most frequently
in the age range of 40–60 years, although it can rarely affect
children. The natural course of the disease is characterized by
two distinct phases. The initial chronic phase lasts 3–4 years.
There are often signs of hypermetabolism, including weight
loss, fever and night sweats. The condition is associated with
high white cell counts and often marked splenomegaly which
may cause discomfort. There may also be anaemia due to bone
marrow infiltration, as well as thrombocytopenia which can
result in haemorrhagic complications. Hyperuricaemia due
to excessive purine turnover may also precipitate attacks of
gout. Other rarer complications include priapism and visual
disturbances due to the high blood viscosity. Eventually,
transformation into an acute ‘blast’ phase occurs. This can
develop quickly, over a period of days or weeks. The white
cell count rises rapidly and is less responsive to treatment
and the spleen enlarges. The development of imatinib has
transformed the treatment and prognosis in this condition.
This drug specifically inhibits the abnormal bcr-abl fusion
protein which arises in CML as a consequence of a trans-
location involving chromosomes 9 and 22. Long-term oral
treatment is well tolerated and is associated with an excel-
lent prognosis (Marin et al. 2013). Nilotinib and dasatinib
are newer agents which may be used as first line therapy or
as treatment in patients who develop resistance to imatinib.
Allogeneic bone marrow transplantation remains an option
for patients with more advanced disease.
Multiple myeloma
Multiple myeloma is another malignancy affecting lym-
phoid precursor cells. Like CLL, it typically affects older
individuals and often runs an indolent course for several
years. The insidious progression of the condition means that
the disease is often not diagnosed until it is quite advanced.
The characteristic abnormal plasma cells do not appear in
the blood, unlike leukaemic blasts, and so bone marrow
K17577_C027.indd 471
Disorders of haemostasis  471
aspiration is needed to confirm the diagnosis. The accu-
mulation of plasma cells within the marrow results in the
development of discrete osteolytic lesions which are another
important diagnostic feature on X-ray. The malignant cells
also secrete large amounts of non-functional immunoglob-
ulin into the plasmas and serum electrophoresis will usually
reveal the presence of a monoclonal band.
Progressive marrow infiltration can cause bone pain
and progressive pancytopenia. Extensive bony disease may
also be associated with hypercalcaemia, which may become
manifest with polyuria and acute confusion. Hyperviscosity
may also precipitate neurological problems like ataxia, neu-
ropathies and visual disturbances or even impairment of
consciousness. The abnormal monoclonal proteins may
interact with coagulation proteins and platelets, resulting
in haemorrhagic manifestations. Accumulation of Bence–
Jones protein in the kidneys often results in progressive
renal failure. There are thus a number of potentially seri-
ous complications that can arise in myeloma which in turn
could cause sudden incapacitation. These include patho-
logical fractures, spinal cord compression, hypercalcaemia,
hyperviscosity syndrome, renal failure and infections.
It is not possible to offer a definitive cure for multiple
myeloma but the disease may be effectively controlled for
some years with treatment. In recent years, high-dose che-
motherapy followed by autologous hematopoietic stem-cell
transplantation has become the preferred treatment for
patients under the age of 65 (Gentile et al. 2013). This may
not be feasible for older patients or those with significant
concurrent illness. In such cases, chemotherapy with mel-
phalan and prednisone has long been regarded as standard
treatment but newer therapeutic options include bortezo-
mib and lenalidomide.
DISORDERS OF HAEMOSTASIS
Haemorrhagic disorders may be congenital or acquired. Even
in the congenital cases there is a wide spectrum of severity
(as in the case of anaemia) and a diagnosis of a bleeding dis-
order does not necessarily preclude medical certification.
Thrombocytopenia
The normal range for the platelet count is 150–400 × 109/L
but when assessing the risk of the bleeding tendency, it
should be borne in mind that far more platelets are pro-
duced than are actually required to control bleeding. Easy
bruising and persistent bleeding from cuts and scratches
only develop when the platelet count falls below approxi-
mately 80 × 109/L. Serious internal bleeding, such as intra-
cranial haemorrhage, may occur if the platelet count falls
below 20 × 109/L. Many conditions result in thrombocyto-
penia and the nature of the underlying disease needs to be
considered when assessing a pilot for medical certification
or patient for suitability to travel, as will the trend in the
count. The risk of bleeding is not just related to the absolute
platelet count. In autoimmune thrombocytopenia there is
17/11/2015 15:59
 472 Haematology
a rapid turnover of young platelets and serious bleeding is
rarely a problem, even with very low counts.
As a general rule, a platelet count below 75 × 109/L should
be considered the critical threshold for medical certification
of pilots. However, it would be reasonable to permit a pas-
senger to fly in a civil aircraft with a much lower threshold
of 40 × 109/L. Patients with thrombocytopenia should not
be given aspirin or similar non-steroidal drugs as these will
exacerbate the bleeding tendency through their inhibitory
effect on platelet function. Paracetamol (US: acetomino-
phen) is a perfectly safe alternative analgesic. Patients who
have undergone splenectomy for autoimmune thrombocy-
topenia will be permanently vulnerable to certain infec-
tions (see below).
There are various inherited forms of thrombocytopenia
and this may well be picked up as an incidental finding dur-
ing a medical examination. Isolated thrombocytopenia is
accompanied by a normal white cell count and haemoglobin
level. Screening of other family members can help to prove the
hereditary nature. There is often no clinical history sugges-
tive of bleeding tendency and an increased platelet size seems
to compensate for the often modest reduction in the platelet
count, to the extent that the bleeding time may be normal.
Autoimmune thrombocytopenia (ITP) in childhood is a rel-
atively common disorder but complete remission is the most
common outcome and the patient can be assured that relapse
does not occur. For this reason, a history of an isolated episode
of ITP years ago in childhood can be disregarded as being of
no consequence for the purpose of medical certification of
flight crew if the platelet count is normal. By contrast, auto-
immune thrombocytopenia with onset in adult life typically
has a chronic course (Provan et al. 2010). Treatment options
include the use of steroids or infusion of intravenous immu-
noglobulin as first line therapy. Thrombopoietin-receptor
agonists like romiplostim and eltrombopag are also effective
and rituximab is another alternative. Splenectomy may also
be required in cases refractory to pharmacological therapy.
Applicants with a history of chronic ITP but who have stable
platelet counts above the threshold of 75 × 109/L may be con-
sidered for medical certification.
Haemophilia
Haemophilia A is a congenital disorder of coagulation, char-
acterized by hereditary deficiency of factor VIII. Deficiency
of factor IX results in an identical clinical condition known
as haemophilia B (also known as Christmas disease). These
are both sex-linked recessive disorders which only affect
males. Severe haemophilia is defined by a coagulation fac-
tor level of <1 per cent, and a level of 1–5 per cent is classed
as moderately severe. The hallmark of severe haemophilia is
recurrent and spontaneous bleeding into joints, principally
the knees, elbows and ankles. Repeated bleeding into joints
can result in disabling arthritis at an early age. Bleeding into
muscles and soft tissues is also seen frequently and there is
also the potential for intracranial bleeding. About 10  per
cent of patients with haemophilia A develop inhibitory
K17577_C027.indd 472
antibodies to infused factor VIII, which makes treatment
more difficult. Mild cases of haemophilia can be picked up
on routine screening prior to surgery. A factor VIII level
of 15 per cent would represent a mild case, with no prob-
lems whatsoever in day-to-day life and requiring treatment
only in the setting of surgery or other invasive procedures.
While patients with severe haemophilia would generally not
be regarded as suitable for medical certification as pilots, it
must be emphasized that those with mild forms are not at
increased risk of sudden incapacitation and medical certifi-
cation should not necessarily be withheld.
Travel for a person with haemophilia as a passenger
should present no significant problems. People with haemo-
philia should also carry an adequate quantity of coagula-
tion factor concentrate for their stay abroad. The internet
web site of the World Federation of Haemophilia carries a
database of specialist haemophilia centres around the world
(www.wfh.org). It needs to be borne in mind when assess-
ing a patient for fitness to fly that a significant proportion
of older patients have been exposed to hepatitis and/or
HIV through their treatment with blood products. People
with asymptomatic HIV infection and CD4+ lymphocyte
cell counts in the range of 0.2–0.5 109/L have only limited
immunodeficiency and are generally regarded as suitable
for immunization. By contrast, seropositive subjects with
CD4+ lymphocyte counts of less than 0.2 × 109/L should not
receive live-attenuated viral or bacterial vaccines because of
the risk of serious systemic disease and suboptimal response
to vaccination (Smith 2012).
Von Willebrand disease
Von Willebrand disease (VWD) is a congenital bleeding
disorder associated with a deficiency of von Willebrand fac-
tor (VWF) in the plasma, a protein which plays an essential
role in the early phases of the platelet adhesion and acti-
vation. VWD is now recognized to be the most common
inherited bleeding disorder with an estimated prevalence
of at least 1/1000 in the general population. In contrast to
haemophilia, it is transmitted in an autosomal dominant
fashion so that both sexes are affected.
The typical symptoms reflect the underlying defect in
platelet function and include easy bruising and prolonged
bleeding from cuts and scratches, epistaxis, menorrhagia
and bleeding after dental extractions or surgery. The sever-
ity of the bleeding tendency generally parallels the degree
of deficiency of both factor VIII and VWF in the blood.
Haemarthrosis is very unusual in VWD and tends to be
seen only in patients with the severe form.
The diagnosis of VWD is complex as no single blood
test suffices and repeated testing in a specialist laboratory is
warranted in borderline cases (Keeney et al. 2011). A diag-
nosis of VWD certainly does not necessarily preclude medi-
cal certification of flight crew if there is evidence that the
phenotype is mild and there is no significant bleeding his-
tory such that therapy is not required. Bleeding from muco-
sal surfaces such as epistaxis and menorrhagia can often
17/11/2015 15:59

be controlled with tranexamic acid alone. Desmopressin
(DDAVP) is another option for the majority of patients
who have the type 1 subtype. Concentrates of VWF are also
available for intravenous infusion.
Deep vein thrombosis and anticoagulation
The most common indication for anticoagulation is a deep
vein thrombosis (DVT) in the veins of the leg. Pulmonary
embolism has been estimated to occur in approximately
1 per cent of cases of deep vein thrombosis. Clinical prac-
tice in this area is likely to change radically in the next
few years as new drugs are introduced (see below). For the
time being, the conventional approach to the treatment of
venous thromboembolism involves anticoagulation with
heparin and, subsequently, warfarin or similar drug such
as nicoumalone. The primary purpose of anticoagulation is
to prevent extension of the thrombosis and anticoagulation
does not cause dissolution of the thrombus. A typical case
of proximal deep vein thrombosis in the leg will require
treatment for 3–6 months with warfarin, aiming for a target
INR (International Normalised Ratio) of 2.5 (Keeling et al.
2011). Other conditions in which anticoagulation is indi-
cated include atrial fibrillation, transient ischaemic attacks,
peripheral arterial disease, ischaemic heart disease and fol-
lowing insertion of prosthetic heart valves. Obviously, these
underlying conditions may themselves constitute a bar to
medical certification of flight crew.
Anticoagulation is associated with a small, but definite,
risk of bleeding complications such as intracranial haem-
orrhage. In one review, the average annual frequencies of
fatal, major and minor bleeding during warfarin therapy
were 0.6, 3 and 9.6 per cent respectively. The risk of haem-
orrhagic complications, including intracranial bleeding, is
particularly high in older subjects and patients with an INR
of >4. An intravenous injection of vitamin K will reverse the
effect of warfarin. In the case of life- or limb-threatening
bleeds, infusion of a prothrombin complex concentrate such
as Octaplex® or Beriplex P/N® is the best option for prompt
and full reversal of the effect of warfarin.
Anticoagulation with warfarin does not pose any par-
ticular problems for passengers, but patients should ensure
that they take adequate medication with them. If travel-
ling on a long journey, perhaps with connecting flights,
the tablets should be carried in hand-luggage. The risk of
haemorrhagic complications is greatest in patients who
are excessively anticoagulated with an INR greater than
5.0, and this emphasizes the need for continued labora-
tory control whilst away from home. If staying abroad for
an extended period, arrangements should be made to have
the usual periodic blood test to check the INR. Changes in
diet, new medications and an increase in alcohol consump-
tion may affect sensitivity to warfarin, and illnesses such as
diarrhoea or vomiting may impair absorption of the drug.
Permanent anticoagulation with warfarin is no longer con-
sidered an absolute bar to continued flying as a pilot. Some
regulatory authorities will now permit pilots to fly if the
K17577_C027.indd 473
Disorders of haemostasis  473
INR has been checked within the preceding 12 hours and
found to be within the therapeutic range. This can easily be
monitored by individuals with a point of care device like the
CoaguChek® or similar device.
New oral anticoagulants have recently been licensed
which will transform clinical practice in the coming years.
These novel agents include dabigatran (a direct inhibitor of
thrombin) and apixaban and rivaroxaban (which inhibit
activated coagulation factor X). These drugs have proved as
effective as warfarin in the management of thromboembo-
lism but they are associated with a lower risk of significant
bleeding. Other major advantages include fixed daily dosing
and the fact that no ongoing laboratory monitoring (such as
INR tests) is required. However, a disadvantage of these new
anticoagulants is that there is no specific antidote for the
reversal of the anticoagulant effect.
The long-term consequences of venous thromboembo-
lism are not insignificant. Approximately 20  per cent of
subjects will experience a recurrence of a DVT in the sub-
sequent five years. Aspirin is an inhibitor of platelet func-
tion and is used in a number of conditions, quite apart from
its use as a simple analgesic, including prevention of stroke.
Consumption of aspirin per se is not incompatible with fly-
ing duties, although any underlying conditions are likely to
be contraindications. Aspirin has very little antithrombotic
effect in the venous circulation and should not be used as
an alternative to warfarin simply in order to avoid suspen-
sion of a medical certificate. There is often some permanent
damage to the valves in the veins and this can lead to per-
manent circulatory problems with persistent swelling of the
limb or even chronic ulceration (post-phlebitic syndrome).
Approximately 60  per cent of patients will develop post-
phlebitic syndrome within two years despite appropriate
anticoagulant therapy but the risk is significantly reduced
by wearing compression hosiery on the affected leg for
up to two years afterwards. A previous medical history of
thrombosis will also preclude future prescription of hor-
mone replacement therapy (HRT) or oestrogen-containing
oral contraceptives for women and may make it difficult to
secure travel insurance in future because of the higher risk
of recurrence.
Thrombophilia
A haematological abnormality may exist in an individual
which predisposes to the development of venous thrombo-
embolism. Such disorders include the relatively rare con-
genital (inherited) deficiencies of natural anticoagulants,
such as antithrombin, protein C or protein S. By far the
most common genetic abnormality which predisposes to
thrombosis is the factor V Leiden genotype, which is asso-
ciated with resistance to activated protein C. The defect
involves a single mutation in the factor V molecule (R506Q)
which renders the molecule resistant to cleavage by protein
C. This mutation is encountered in approximately 4 per cent
of the European population but is very rare or even absent
in other racial groups. It is associated with an approximately
17/11/2015 15:59
 474 Haematology
eight-fold increased risk of venous thrombosis, but with
a considerably higher risk in women taking oestrogen-
containing oral contraceptives. Elevation of the plasma
prothrombin level in association with a point mutation
(nucleotide G20210A) in the prothrombin gene is another
newly-identified genetic risk factor for venous thrombo-
sis. This is encountered in approximately 2 per cent of the
Caucasian population and is associated with an approxi-
mately three-fold risk of thromboembolism. In addition to
these inherited defects, the development of antiphospholipid
antibodies (‘lupus anticoagulant’) is also associated with an
increased risk of venous thromboembolism. Other acquired
haematological disorders associated with an increased risk
of thrombosis include myeloproliferative disorders such as
polycythaemia and thrombocythaemia.
Screening for thrombophilia may be of value in selected
individuals and indications include thromboembolism at
an unusually early age (<40), recurrent thromboembolism,
thrombosis at an unusual site, or strong family history
(Baglin et al. 2010). The full panel of tests can only be car-
ried out once the subject has been off warfarin for at least
one month. However, thrombophilic defects are increasingly
being found in asymptomatic individuals as a result of family
studies in relatives with a history of thrombosis. There is no
justification for refusing medical certification in asymptom-
atic individuals with no personal history of thromboembo-
lism as the overall risk is still small in absolute terms. Even
the identification of an underlying thrombophilic defect in a
pilot who has experienced a single episode of venous throm-
boembolism does not ipso facto rule out certification once a
course of warfarin therapy has been completed.
Air travel and thrombosis
It is now generally accepted that there is an association
between long-distance travel and venous thromboembolism
although the incidence is low and mainly involves passen-
gers with additional risk factors for venous thromboembo-
lism. The risk is not exclusively associated with air travel and
it has also been documented following long car, bus or even
train journeys. The alternative term of ‘travellers’ throm-
bosis’ has therefore been suggested as an alternative to the
term ‘economy class syndrome.’ It is possible to derive some
general conclusions from published cases of venous throm-
boembolism associated with travel. Thromboembolism is
rarely observed after flights of less than five hours’ duration
and, typically, the flights are of twelve hours’ duration or
more. The risk rises with age; older subjects over the age of
50 are more at risk whilst those under the age of 40 years
are less vulnerable. Symptoms of thromboembolism do not
usually develop during or immediately after the flight, but
tend to appear within three days of arrival when the patient
may present far away from the airport and thus the causal
link may not be immediately apparent. Symptoms of throm-
bosis or pulmonary embolism have been reported up to two
weeks after a long flight. Pulmonary embolism may also be
the first manifestation, without any symptoms in the lower
K17577_C027.indd 474
limbs. Whilst most case reports and studies involve deep
vein thrombosis (DVT) in the lower limbs, there are also
reports of cerebral venous thrombosis and arterial throm-
bosis associated with long flights.
The precise incidence of thromboembolism in relation to
air travel is uncertain, but is of the order of 0.5 per cent for
flights of more than eight hours (Watson and Baglin 2010)
The aetiology of venous thrombosis is usually multifacto-
rial, with a combination of both constitutional and environ-
mental factors responsible for causing a thrombosis in an
individual at a given time. Stasis in the venous circulation
of the lower limbs is undoubtedly the major factor in pro-
moting the development of venous thromboembolism asso-
ciated with travel. It has also recently been suggested that
exposure to mild hypobaric hypoxia in pressurized aircraft
may also result in activation of the coagulation cascade but
the data are conflicting. A number of other risk factors are
now also recognized, primarily through clinical experience
in the setting of surgery, which predispose to venous throm-
boembolism. These are listed in Table 27.1.
A number of general measures may be taken to minimize
the risk of thrombosis associated with long flights. Perhaps
the most important step is to consider at the outset whether
the patient is actually fit to fly in the first place. For example,
it is probably wise to defer long-haul travel after recent major
orthopaedic surgery. Passengers should be encouraged to
carry out leg exercises from time to time whilst seated (e.g.
flexion, extension and rotation of the ankles will help to pro-
mote circulation in the lower limbs). Hand luggage stowed
under seats will also restrict movement. Passengers should
also take advantage of refuelling stops on long-haul flights to
get off the plane and walk around for a while. Perhaps con-
trary to intuition as well as to previous recommendations,
there is no indication that the development of thromboem-
bolism is linked to dehydration during flight (Schreijer et al.
2008). It is not necessary to abstain from alcohol, but exces-
sive consumption should be avoided as this will discourage
Table 27.1  Risk factors for venous thromboembolism
Age: greater than 40 years (but especially the elderly, >65)
Previous thrombotic episode (especially pulmonary
embolism)
Documented thrombophilic abnormality
(e.g. antithrombin deficiency)
Other haematological disorders (polycythaemia &
thrombocythaemia)
Pregnancy and puerperium
Malignancy
Congestive heart failure or recent myocardial infarction
Recent surgery (especially lower limb)
Chronic venous insufficiency
Oestrogen therapy (e.g. oral contraceptive pill, hormone
replacement therapy [HRT])
Obesity
Prolonged recent immobility (e.g. after recent stroke)
Significant dehydration (e.g. diarrhoea)
17/11/2015 15:59

mobility. Similarly, the use of sedatives is best avoided. There
is certainly no value in screening passengers for thrombo-
philic defects prior to long-haul flights.
A number of randomized prospective studies have
shown a clear benefit from the use of compression hosiery
(‘flight socks’) (Clarke et  al. 2006). They apply graduated
pressure to the leg which is maximal at the ankle, thus
encouraging venous return. The use of compression hosiery
is recommended only in subjects considered to be at risk
of thromboembolism who are going on a flight of more
than four hours’ duration: global use in all air passengers
is certainly not warranted. Quite apart from reducing the
risk of thrombosis, compression hosiery helps to prevent
oedema of the legs and feet which can itself cause dis-
comfort after a long flight. Aspirin has been advocated by
some in the general prophylaxis of thrombosis associated
with travel but the beneficial effect is very weak in absolute
terms. Furthermore, there is a potential for side effects such
as allergic reactions or gastrointestinal bleeding: 13 per cent
of subjects taking aspirin in the LONFLIT-3 study reported
mild gastrointestinal symptoms. In short, there is no firm
evidence to support the indiscriminate use of aspirin as a
routine prophylactic measure. The use of heparin may be
considered in the relatively few passengers considered to be
at particularly high risk of thrombosis (e.g. patient flying
home with leg in plaster after fracture).
BLOOD TRANSFUSION
Blood transfusion in many parts of the world still poses
very real risks with regard to transmission of viral and
other infections (Dodd 2012). Systematic screening of blood
donations is not yet feasible in many developing countries
and needles may not even be properly sterilized before re-
use. Infections which may be transmitted by transfusion of
blood or plasma include human immunodeficiency virus
(HIV), hepatitis B and C, malaria, babesiosis, Trypanosoma
cruzi (Chagas’ disease), brucellosis, syphilis, cytomegalovi-
rus (CMV), West Nile virus and human T-cell lymphoma
virus (HTLV-I). Patients with chronic disorders must be
counselled about the possible risks in certain parts of the
world if transfusion might be required. Patients sometimes
enquire about the possibility of taking blood from their
home country with them abroad. This raises a number of
technical as well as logistical problems (e.g. blood has to be
stored at 4°C and has a limited shelf-life of up to six weeks)
which are not easy to resolve. Emergency blood transfusion
is rarely required and is likely to be needed only in the set-
ting of massive haemorrhage after trauma, gastrointestinal
bleeding or obstetric emergencies. A decision to transfuse is
far too often based solely on the haemoglobin level. The deci-
sion should be based on the clinical state and haemodynamic
stability (e.g. pulse, blood pressure, respiratory rate) of the
patient. It is by no means essential, for example, to transfuse
someone just because the haemoglobin has fallen to 8 g/dL.
Even in the case of massive haemorrhage, resuscitation can
often be achieved through the use of colloid or crystalloid
K17577_C027.indd 475
Splenectomy 475
plasma expanders instead of blood. While it is not feasible to
transport packs of blood abroad, plasma expanders may be
transported much more readily as they have a much longer
shelf-life and only require storage at room temperature. In
some cases it might also be advisable to take sterile needles
and other disposable equipment such as giving sets.
Pilots are permitted to donate blood but a period of
24  hours should elapse between donation and resuming
normal duties because of the small risk of delayed fainting
or other adverse reaction (12 hours in the case of air traffic
controllers). The minimum recommended interval before
duty for both aircrew and controllers after bone marrow
donation is 48 hours.
SPLENECTOMY
Splenectomy has already been referred to as a treatment
option for some haematological disorders (including certain
haemolytic anaemias and autoimmune thrombocytopenia)
and discussion of the hazards of splenectomy is therefore
relevant. The most common reason for splenectomy nowa-
days is traumatic rupture following abdominal injury. The
operation also used to be carried out routinely in Hodgkin’s
lymphoma as part of the staging process before starting
treatment but nowadays haematologists are much more
cautious about recommending splenectomy in general.
Patients with sickle cell disease are also effectively asplenic
due to repeated infarction within the organ. Whilst splenec-
tomy may control the underlying haematological condition,
the patient will be left permanently vulnerable to certain
infectious diseases. Asplenic individuals are particularly
susceptible to encapsulated organisms such as Streptococcus
pneumoniae, Haemophilus influenzae and Neisseria men-
ingitidis. Vaccination should be offered where possible,
although the immunological response is better when the
vaccine is given before elective splenectomy. Bacteraemia in
asplenic individuals often has a fulminating course, leading
rapidly to shock and coma accompanied by disseminated
intravascular coagulation. Patients should be treated with
an antibiotic at the first sign of fever or respiratory illness,
however trivial (Davies et al. 2011). Amoxicillin is preferred
to penicillin V because of better absorption following oral
administration, and also because it has a broader antibac-
terial spectrum which includes H. influenzae. Malaria in
asplenic subjects is often fatal, and it is vital that asplenic
subjects take appropriate prophylaxis where indicated. It is
recommended that asplenic subjects either carry a medi-
cal card or wear a bracelet which provides some medical
information about their condition. Although an applicant
for medical certification may appear to be perfectly fit and
healthy after splenectomy, the potential for medical compli-
cations should not be overlooked.
Normal haematological values
Haemoglobin: 13.5–17.5 g/dL (males); 11.5–15.5 g/dL (females)
MCV (mean corpuscular volume): 80–95 fL
17/11/2015 15:59
 476 Haematology
MCH (mean content haemoglobin): 27–34 pg
WBC (white blood count): 4.0–11.0 × 109/L
Neutrophils: 2.5–7.5 × 109/L
Lymphocytes: 1.5–3.5 × 109/L
Monocytes: 0.2–0.8 × 109/L
Eosinophils: 0.04–0.44 × 109/L
Platelets: 150–400 × 109/L
Serum ferritin: 40–340  μg/L (males); 14–150 μg/L (females)
Serum folate: 3.0–15 μg/L
Red cell folate: 160–640 μg/L
Serum vitamin B12: 160–925 ng/L
Normal ranges for coagulation tests cannot be stated, as
these vary according to the method and reagents used. The
normal range for the laboratory which carried out the tests
must therefore be consulted.
SUMMARY
●● ‘Anaemia’ is not a final diagnosis: an underlying
cause always needs to be identified.
●● Sickle cell trait  (Hb AS heterozygosity) is not
associated with any clinical problems and is cer-
tainly not a bar to flying.
●● Although many forms of leukaemia are now emi-
nently treatable, the long term consequences of
therapy need to be borne in mind and looked for.
●● A platelet count of 75 × 109/L or more is not asso-
ciated with an increased risk of bleeding.
●● Several studies have confirmed the value of
compression hosiery (‘flight socks’) in the preven-
tion of deep vein thrombosis in passengers on
long-haul flights. By contrast, aspirin is of little (if
any) value.
●● Eosinophilia may be due to underlying parasitic
infections acquired abroad.
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testing for heritable thrombophilia. British Journal of
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Bhatia S. Long-term complication of therapeutic expo-
sures in childhood: lessons learned from childhood
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Clarke MJ, Hopewell S, Juszczak E, et al. Compression
stockings for preventing deep vein thrombosis in
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Davies JM, Lewis MP, Wimperis J, et al. Review of guide-
lines for the prevention and treatment of infec-
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Dodd RY. Emerging pathogens and their implications
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Kaferle J, Strzoda CE. Evaluation of macrocytosis.
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Keeling D, Baglin T, Tait C, et al. Guidelines on oral anti-
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Marin D, Rotolo A, Milojkovic D, Goldman J. The next
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Oscier D, Dearden C, Erem E, et al. Guidelines on the
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Passamonti F. How I treat polycythemia vera. Blood 2012;
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Schreijer AJM, Cannegieter SC, Caramella M, et al. Fluid
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Malignant disease
Revised by TANIA JAGATHESAN
Introduction 477
Certification after treatment for malignant disease 480
Colorectal carcinoma 482
Lymphoid malignancy 483
Cutaneous malignant melanoma 485
Germ-cell tumours of the testis 487
Carcinoma of the bladder 488
INTRODUCTION
Malignant disease has become an increasingly common
diagnosis in pilots and air traffic controllers (ATCOs). This
reflects the situation in the general population, where there
has been a reduction in all-cause mortality and increased
life expectancy, combined with an increase in cancer inci-
dence, due to changes in lifestyle factors and increased
detection by screening.
There have been many studies examining the incidence
of cancer in pilots; however, none has conclusively estab-
lished an occupational link. One study demonstrated a
lower incidence of cancer in pilots and ATCOs, mainly due
to fewer smoking-related cancers from the lower prevalence
of smoking, whilst skin melanoma rates were increased,
which was thought to be a result of sun-related behaviour
rather than occupational exposure to cosmic radiation (Dos
Santos Silva et al. 2013).
For pilots and ATCOs, a diagnosis of cancer not only has
implications on long-term health, but also on their fitness to
perform the operational role. Licence holders tend to pres-
ent earlier than their peers, which may be due to a combina-
tion of increased awareness of their health, periodic medical
examinations and a professional responsibility to report
symptoms. This is countered by the tendency of tumours
affecting young people to be aggressive and their symptoms
are less likely to be attributed to a cancer than in an older
person. There is currently no evidence that the prognosis for
K17577_C028.indd 477
28
Adenocarcinoma of the prostate 488
Carcinoma of the kidney 488
Carcinoma of the breast 489
Lung cancer 490
Conclusion and summary 490
References 491
a particular type of tumour in a pilot or ATCO is different
to that in the general population.
Prior to the 1990s, it was unusual for an individual
with a history of malignant disease to gain a professional
licence. However, advances in evidence-based medicine and
improved cancer treatments and outcomes have allowed a
more pragmatic approach to certification.
Following treatment for cancer, oncologists encourage
their patients to make an early return to the normality of
working life. Some patients may even manage to continue
to work while receiving chemotherapy or radiotherapy.
However, in view of the safety-critical role of licence hold-
ers, no pilot or ATCO should exercise the privileges of their
licence whilst undergoing or recovering from primary treat-
ment for malignant disease.
Once remission has been achieved and a full recovery has
been made, a specialist medical report should be obtained
from the oncologist or surgeon. Medical information that
should be sought includes the histological diagnosis, the
stage and grade of tumour, the results of blood tests and
radiological imaging, the treatment given with start and
end dates, the follow-up planned and the prognosis.
Most established staging systems are based on clinical and
pathological evaluation. The TNM system is commonly used,
where T is tumour extent, N is extent of local lymph-node
involvement and M is presence of distant metastatic spread.
Curative treatment is given with the intent to cure.
Adjuvant treatment is given after primary treatment to
477
17/11/2015 15:59
 478  Malignant disease
reduce the risk of local recurrence. Neo-adjuvant treatment
is given as preliminary therapy to reduce tumour size before
the primary treatment such as surgery. Palliative treatment
is given for the alleviation of symptoms caused by cancer
rather than with the aim of being curative, and precludes
future certification.
The certificatory assessment should consider both the
physical and mental state of the individual following treat-
ment and the risk of incapacitation secondary to local or
distant metastatic recurrence of the cancer.
Prevalence of malignant disease in
professional licence holders
Most professional licence holders are male and between the
ages of 20  and 65. The cancers that present in this popu-
lation are representative of the types of malignant disease
seen among the general population of working age. Cancer
is the third most common reason for permanent withdrawal
of a pilot’s medical certificate, ranking after cardiovascular
disease and neuropsychiatric disorders. The five most com-
mon malignancies are prostate, colorectal, lymphoid, mela-
nomas and testicular cancers.
Primary treatment for malignant disease
SURGERY
Surgery may be the only primary treatment indicated,
in which case, the time to recertification depends on the
postoperative recovery time, freedom from surgical com-
plications and assessment of future risk of incapacitation
from tumour recurrence. Examples of surgical operations,
together with guidance on minimum postoperative time
periods prior to recertification are shown in Table 28.1.
RADIOTHERAPY
Radiotherapy for malignant disease may be given with cura-
tive intent, such as that given to an isolated group of lymph
nodes proven by biopsy to contain lymphoma. Adjuvant
radiotherapy may be used to reduce the risk of local recur-
rence, for example, when radiotherapy is given to abdomi-
nal lymph nodes following orchiectomy for seminoma of
the testis.
General side effects include fatigue and nausea, which are
very common. Localized side effects such as skin erythema,
Table 28.1  Minimum time to recertification after various
types of surgery
Minimum time
to recertification
Operation Example (weeks)
Minor Excision of naevus 1
Intermediate Prostatectomy 6
Major Hemicolectomy 12
K17577_C028.indd 478
diarrhoea and cystitis may occur as a result of tissue dam-
age within the field of the radiation beam. Prophylactic
cranial irradiation can cause neurotoxicity and cognitive
deficits. Small-vessel coronary artery disease may be a late
effect if radiation has been directed to the left chest area, for
example, in the treatment of Hodgkin’s disease or left breast
carcinoma. As side effects may occur in the post-treatment
period, a minimum interval of four weeks should elapse fol-
lowing completion of radiotherapy before a return to opera-
tional duties can be considered.
CHEMOTHERAPY
Chemotherapeutic agents are toxic to dividing cells. They
have a wide range of side effects as a result of the damage
caused to healthy cells, which inevitably occurs in addi-
tion to the intended toxic effect on malignant cells. These
side effects may occur during the course of treatment or
may persist for many days, weeks or months after treat-
ment has been completed (short-term effects). They may
persist for longer than six months (long-term effects) or
may present many months or years afterwards (delayed
effects).
A minimum interval of two months should elapse before
returning to operational duties after chemotherapy, sub-
ject to haematological indices being within the normal
range and stable. Neutropenia is very common and the
risk of infection can persist for some time after comple-
tion of chemotherapy. Enquiry should be undertaken to
exclude any possible short-term sequelae that may be of
potential flight-safety importance. Table 28.2 lists examples
of systems that may be affected by common chemothera-
peutic agents. Cardiotoxicity from anthracyclines, neu-
ropathies from vinca alkaloids and hepatotoxicity from
methotrexate may persist for a considerable length of time
or remain permanently.
The assessment of future incapacitation risk should con-
sider the possibility of delayed side effects. Anthracycline
cardiotoxicity is related to dose in the short term, but there
is concern that long-term ventricular dysfunction and car-
diac arrhythmias may not have a direct relationship to dose
and may pose an increased risk of incapacitation to licence
holders throughout their lives (Evans and Cooke 2003).
Several drugs, including bleomycin and cyclophosphamide,
may cause pulmonary fibrosis, and busulfan has been asso-
ciated with lenticular changes.
As newer and more aggressive treatments are increas-
ingly used, a larger proportion of patients, including those
treated as children, are surviving for longer, effectively being
‘cured’ of their cancer, and an increased risk of developing
second malignancies is seen. The anthracyclines, especially
epirubicin and etoposide, are known to be leukaemogenic.
Following treatment for Hodgkin’s lymphoma, there is an
increased risk of developing acute myeloid leukaemia, non-
Hodgkin’s lymphoma and lung cancers (Swerdlow et  al.
2011). Considerable caution needs to be exercised with new
chemotherapeutic agents whose long-term side effects have
not yet been evaluated fully. The potential long-term and
17/11/2015 15:59

Table 28.2  Examples of short-term side effects of chemotherapy of potential flight-safety importance
System affected Chemotherapeutic agent
Cardiovascular Anthracyclines
Cyclophosphamide
5-FU
Neurological 5-FU
Vinca alkaloids
Auditory Cisplatin
Renal Cisplatin
Hepatic Methotrexate
Psychological Interferon
5-FU, 5-fluorouracil.
delayed toxicities of all newly introduced treatment regi-
mens require full appraisal, and clinical studies should con-
firm the absence of potentially incapacitating late sequelae
before recertification can be considered. As the periodic
medical examination comprises a general physical assess-
ment, tests of ophthalmic function and hearing, the major-
ity of side effects should be detected routinely. Respiratory
function tests and a full neurological examination can be
included if the applicant is known to have received a drug
that could have affected these systems. Specific cardio-
logical investigations may be required if an anthracycline
formed part of the chemotherapy protocol. Anthracyclines
are used to treat a wide variety of malignancies, including
those of the immune system, breast cancer, osteosarcoma
and lung cancer.
ADJUVANT HORMONE THERAPY
Adjuvant hormone treatment is given after the primary
treatment to reduce the recurrence risk. Adjuvant steroid
treatment precludes operational duties as steroids can
cause euphoria and subtle cognitive changes when given in
large doses and usually are prescribed only for malignant
disease to reduce inflammation around an active tumour.
Tamoxifen, an oestrogen-receptor antagonist, used for
breast cancer, is acceptable, as is goserelin, a gonadorelin
analogue, and bicalutamide, an anti-androgen, both of
which are used in the management of prostatic cancer. The
medication should be tested for a suitable period of time
whilst non-operational, and if there are no adverse effects
once established on a maintenance dose of the medication,
a return to operational duties can be considered.
Serum tumour markers
The measurement of serum tumour markers can be a useful
prognostic factor in some cancers such as colorectal, pros-
tatic, ovarian, breast and germ-cell tumours of the testis,
where they are also used in staging. Serum tumour markers
are a useful surveillance tool for early detection of tumour
recurrence. Depending on the cancer type, tumour marker
levels should be requested before recertification and at each
follow-up review.
K17577_C028.indd 479
Introduction 479
Potential side effect
Arrhythmia, cardiomyopathy
Myocarditis
Angina pectoris
Cerebellar syndrome
Peripheral neuropathy
High-tone hearing loss
Renal failure
Hepatotoxicity
Depression
Psychological effects of cancer
The psychological effects of a diagnosis of cancer and an indi-
vidual’s reaction to illness and to its treatment vary widely
from one licence holder to another and from one month to
the next in the same individual. This is often the first major
illness experienced by a previously fit individual and it can
have devastating effects on self-confidence. Coupled with
anxiety about future employment and financial security for
themselves and their family, it is not uncommon to develop
symptoms of stress, anxiety, lability of mood, anger and
depression. Before a pilot can be returned to flying duties or
an ATCO to the operational environment, it is essential that
they have a normal mental state.
Stem cell transplantation
Stem cell transplants are mostly used for the treatment of
malignant disease involving the bone marrow, for example
leukaemia, lymphoma and myeloma. Stem cell transplants
can use cells from an individual’s own body in autologous
transplants, or from a donor in allogeneic transplants.
High-dose chemotherapy is given prior to autologous
stem cell transplants to destroy cells in the bone marrow.
Following autologous transplantation, recertification can
be considered after a one year relapse-free interval. Graft–
versus–host disease may complicate allogeneic transplants,
and recertification can be considered only after a longer
relapse-free period of two years.
Central nervous system involvement
Both primary and secondary brain tumours are perma-
nently disqualifying for certification, due to the unaccept-
ably high risk of potentially incapacitating side effects. Of
greatest concern is the increased risk of seizures. Other
associated adverse effects include syncope, nausea and
vomiting, paresis, cerebellar, motor or sensory distur-
bance, confusion, headache, cognitive dysfunction and
personality change. Lung and breast cancers can cause
cerebral metastases and melanoma, and renal cell carcino-
mas also have a propensity to spread to the central nervous
17/11/2015 15:59
 480  Malignant disease
system. Both breast cancer and melanoma can result in
the sudden presentation of a solitary brain metastasis after
a 10-  to 20-year disease-free interval. Radiological imag-
ing with computed tomography (CT), magnetic resonance
imaging (MRI) and positron-emission tomography (PET)
of the brain may be used to detect cerebral metastases.
CERTIFICATION AFTER TREATMENT FOR
MALIGNANT DISEASE
Certification after treatment for malignant disease usually
can be considered only if primary treatment (surgery, che-
motherapy, radiotherapy) has been undertaken with cura-
tive intent and there is no residual evidence of tumour. A
few exceptions to this rule exist, including some chronic
lymphoid malignancies and early prostate cancer, for which
no active treatment may be indicated.
The aeromedical concern is whether recurrence or, in the
exceptions mentioned above, progression of disease could
present with symptoms that would jeopardize flight safety.
As with other types of illness, it is the risk of sudden or sub-
tle incapacitation that has to be assessed.
It is important to note that the certificatory assess-
ments described in this chapter refer only to certification
after primary treatment and do not apply after treatment
for recurrence or relapse. For some tumours, certification
after recurrence may be possible. However, it should be
borne in mind that survival after recurrence tends to be
very much worse than after primary treatment and the
shorter the disease-free interval from the completion of
treatment to recurrence, the worse the prognosis is likely
to be.
The certification assessment method described uses pub-
lished population survival rates, as data on recurrence is
not available for most tumours. The use of survival rather
than recurrence data tends to be ‘fail-safe’ in respect of
incapacitation risk.
For each type of tumour, the survival figures vary
according to the presenting features of the disease. The
most important of these prognostic factors is usually the
stage at presentation, but grade, tumour markers, site and
biochemical parameters may also need to be considered. In
addition, the age and gender of the individual may influ-
ence outcome. The certification assessment method takes
into account survival data for homogeneous groups using
the most important prognostic indicator or indicators. It is
possible to vary the level of certification for an individual
according to whether the prognostic factors that exist at
presentation would weigh the overall prognosis towards a
substantially better or worse outcome.
The maximum acceptable annual risk of incapacitation
for a pilot undertaking multicrew operations is one per cent
per annum. This is also the maximum permissible risk for
an ATCO. Unrestricted certification in a pilot is only pos-
sible when the risk of incapacitation is substantially less
than this.
K17577_C028.indd 480
Certification assessment method
There are three main factors to consider when assessing an
individual’s risk of recurrence of malignant disease in any
one year. The first is the actual risk of recurrence, the sec-
ond is the site of that recurrence and the third is the risk of
a recurrence at that site leading to incapacitation (Janvrin
1995).
The annual risk of incapacitation can be calculated as
shown in Figure 28.1.
RISK OF RECURRENCE
The annual recurrence rate can be estimated from survival
curves. Ideally, these should be disease-free survival curves,
but for many tumours these are difficult to find and overall
survival data will need to be used. However, as the progno-
sis after recurrence is often very poor, the overall survival
and disease-free survival curves are usually very similar
in shape, and the annual recurrence rate is similar to the
annual mortality rate.
Overall survival figures do not allow for deaths from other
causes. This is important for cancers that affect mainly older
people. Figures quoted in published studies usually include
patients over the age of 70 years, so they are often artificially
poor for licence holders of working age. This is probably
countered to some extent by the fact that individuals who
develop tumours before the age of 40 years tend to have very
aggressive disease. Also, survival figures will include cases
where curative treatment has not been attempted.
Survival data are, by definition, historical data and
represent the outcome from treatments given years ago.
Improvement in survival from recently introduced treat-
ment regimens will not be reflected in the certification
assessment until published data can confirm the claims
of increased efficacy of more modern treatment protocols.
These factors tend to push the certification assessment in the
fail-safe direction and act to provide a regulatory safeguard.
SITE OF RECURRENCE
Each type of tumour has a propensity to recur at character-
istic sites. However, it is often difficult to determine from
the literature the risk of a first recurrence at a particular site.
When these data do not exist, information may be obtained
from post-mortems. Inevitably, post-mortem data include
tissue that has become affected during the terminal phase of
the disease, and sites that tend to become involved only in
the late stages will be over-represented.
Weighting factor
Risk of type (according to
Risk of of metastasis propensity of
recurrence most likely metastasis
in that year to cause to result in
incapacitation incapacitating
symptoms)
Figure 28.1  Risk of incapacitation from recurrence of a
tumour in any particular year.
17/11/2015 15:59
 Certification after treatment for malignant disease  481

Studies of malignant melanoma have shown that
approximately a quarter of patients with evidence of
cerebral metastases at post-mortem will have presented
with a cerebral secondary as a first recurrence (Moseley
et  al. 1978). A broad assumption can be made that a
similar proportion of patients with post-mortem brain
involvement will be likely to present with a symptomatic
cerebral metastasis.
WEIGHTING FACTOR
Each type of tumour tends to display a similar pattern of
recurrence in specific organs, local to, or more distant from,
the primary site. Studies that quantify the risk of presenta-
tion of recurrence with an incapacitating symptom are not
widely available, as this is not the paramount concern of cli-
nicians. The potential risk of incapacitation has, therefore,
to be estimated for each likely location. The figure varies
from five per cent for recurrence locally or in a regional
lymph node basin to 100  per cent for sudden incapacita-
tion from a cerebral metastasis. The possibility of subtle
incapacitation also has to be considered, as many types of
recurrence could result in a degradation of performance
and, thus, affect the operational ability of a licence holder
to some extent.
Table 28.3 shows the incapacitation risk weighting used
to give a measure of the potential for sudden incapacita-
tion from recurrence at various metastatic sites. The factor
is deliberately weighted towards the upper level of expec-
tation in the interests of flight safety. It may be possible to
assign a more accurate weighting factor that reflects the
incapacitation risk from recurrence at different metastatic
sites if quantitative data can be determined from relevant
clinical studies.
Certification assessment for a theoretical
tumour
In order to calculate the annual risk of incapacitation for
an individual, the three parameters described above have
to be determined. Figure  28.2  demonstrates the likeli-
hood of survival for the five year period after completion of
Table 28.3  Incapacitation risk weighting for recurrence at
different metastatic sites
Incapacitation risk weighting
Site (%)
Local 5
Lymph nodes 5
Liver 5
Lung 5
Bone 5
Bone marrow 20
Brain 100
primary treatment for three stages of a theoretical tumour.
The annual recurrence risk is the probability of developing
a recurrence during each year and is calculated as shown in
Table 28.4. As recurrence figures (in the form of disease-free
survival rates) are often difficult to ascertain, overall sur-
vival figures usually have to be used. The number (or per-
centage) of survivors at the end of the year is divided by the
total number (or percentage) alive at the start of the year in
order to obtain the probability of surviving in any one-year
period. Using a theoretical example that three per cent of
first recurrences will be a cerebral metastasis, with an inca-
pacitation risk weighting of 100 per cent, the incapacitation
risk for any year can be calculated by applying the formula
described previously, i.e. recurrence risk × 3% × 100%, for
each year.
Taking the annual recurrence risks for the theoretical
tumour in Table 28.4, the annual risk of incapacitation for
each stage of tumour is shown in Table 28.5.
For some malignancies, there is only a very small chance
of cerebral spread and an alternative secondary site may
present a greater risk of incapacitation. By knowing the like-
lihood of metastases affecting a particular site and applying
the relevant incapacitation risk weighting, the annual inca-
pacitation risk can be calculated.
As an incapacitation risk above one per cent per
annum is incompatible with professional flying, it is pos-
sible to determine the interval after primary treatment
that should elapse before a licence holder can be given a

Stage I Stage II Stage III

100% 5 100% 100%
3 22
2 1 1
15 50
10
Survival

Survival

Survival

5
2

31

7
5
2
0% 0% 0%
0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5
Years since completion of Years since completion of Years since completion of
primary treatment primary treatment primary treatment

Figure 28.2  Five-year survival curves for three stages of a theoretical tumour. Numbers on the curves reflect the reduction
in survival percentage during each year.

K17577_C028.indd 481 17/11/2015 15:59

 482  Malignant disease

Table 28.4  Annual recurrence risk for three stages of theoretical tumour

Stage Years since completion of primary treatment

1 2 3 4 5
I 5/100 = 5% 3/95 = 3.2% 2/92 = 2.2% 1/90 = 1.1% 1/89 = 1.1%
II 22/100 = 22% 15/78 = 19.2% 10/63 = 15.9% 5/53 = 9.4% 2/48 = 4.2%
III 50/100 = 50% 31/50 = 62% 7/19 = 36.8% 5/12 = 41.7% 2/7 = 28.6%
Recurrence risk is stated as a probability and percentage for each year.

Table 28.5  Annual risk of incapacitation from recurrence of theoretical tumour

Stage Years since completion of primary treatment

1 2 3 4 5
I 0.15% 0.1% 0.07% 0.03% 0.03%
II 0.66% 0.57% 0.48% 0.28% 0.13%
III 1.5% 1.86% 1.1% 1.25% 0.86%
Assumes three per cent of recurrences will present as cerebral metastases.

certificate limited to multicrew operations. A risk of inca- COLORECTAL CARCINOMA

pacitation from tumour recurrence approaching 0.1  per
cent per annum is normally required before unrestricted
professional certification can be granted. This is demon-
strated in Figure 28.3.
If prognostic factors are more favourable than those con-
sidered in the certification assessment, then it is reasonable
to shift the transition point from no certification to multi-
crew certification, or from multicrew certification to unre-
stricted certification, to the left. Conversely, if prognostic
factors are less favourable, then it is reasonable to wait for
a longer period before relaxing the certificatory assessment.
As the major prognostic factors will have been used in the
assessment, this is likely to result in the reduction or addi-
tion of only a few months in either direction. Furthermore,
for some types of malignancies, if more than one recurrence
site is significant, it may be appropriate to consider each
recurrence site and to sum the risks from different sites to
obtain a comprehensive estimate of annual incapacitation
risk. Ideally, published evidence should be sought on the
particular stage of cancer being assessed to give as accurate
a risk estimate as possible.
Similar bar charts can be created for any tumour if sur-
vival or preferably recurrence data are available.
Number of years since completion of treatment
0 1 2 3 4 5
I operative radiotherapy. An alternative staging system is the
Stage
Cancers of the lower gastrointestinal tract are common
tumours seen in aircrew. Survival data are usually based
on whole-population studies. As the risk of colorectal car-
cinoma increases considerably after the age of 60  years, it
may not always be appropriate to use these data to predict
the prognosis in younger licence holders. As with other
tumours, there is some evidence to suggest that they tend to
be more aggressive in younger age groups, and this is likely
to relate to genetic predisposition. Hereditary non-polyposis
colorectal cancer is known to be due to faults in the deoxy-
ribonucleic acid (DNA) mismatch repair genes and 80 per
cent of affected patients will develop colorectal cancer.
The most common site for colorectal cancer is the rec-
tum (27  per cent), followed by the sigmoid colon (20  per
cent) and the caecum (14 per cent). Cancer of the rectum or
rectosigmoid junction tends to have a slightly worse prog-
nosis than colon carcinoma.
The treatment of choice for tumour that has not spread
beyond the bowel wall (Dukes’ stage A or B) is curative
resection. The overall rate of local or distant recurrence
after surgery with curative intent is 33  per cent (Renehan
et  al. 2002). Adjuvant chemotherapy using 5-fluorouracil
after surgery for Dukes’ C colonic tumours, where nodal
involvement has been demonstrated, has improved survival
dramatically. Chemotherapy is also useful for Dukes’ C rec-
tal carcinoma and may be used in combination with pre-
TNM classification used by the American Joint Committee

II on Cancer (AJCC). In this system, stages T1–2 are equiva-

lent to Dukes’ stage A, T3–4 to Dukes’ stage B and N1 or
III more to Dukes’ stage C.
Unrestricted OML No certification The certification assessment chart for colorectal car-
cinoma has been created using the five-year cancer-spe-
Figure 28.3  Certification assessment during the first cific survival figures for men of 93  per cent for stage A,
five years after treatment for a theoretical tumour. OML, 77 per cent for stage B and 48 per cent for stage C (NCIN
operational multicrew limitation. Data Briefing 2009). Women below the age of 65 years have a

K17577_C028.indd 482 17/11/2015 15:59


survival advantage (Majek et al. 2013). The risk of incapaci-
tation from recurrence is low, as clinical follow-up surveil-
lance is well established, and distant spread rarely presents
with symptoms. This is reflected in the assessment, which
permits early recertification, even after treatment for cancer
with nodal involvement (Figure 28.4).
In addition to the stage of tumour at presentation, the
grade and whether there is venous, lymphatic or perineu-
ral invasion influence the risk of local or distant relapse.
The most common site of relapse is the liver, followed by
local spread, pulmonary metastases and other abdominal
sites. The incidence of brain metastases is two per cent and
usually associated with preceding pulmonary metastases
(Mongan et  al. 2009). Adverse prognostic factors include
a short disease-free interval and the presence of multiple
metastases. The presence of distant metastatic disease is
disqualifying for certification. In recent years, surgical
resection of metastatic lesions has become more common
and these cases should be considered on an individual basis.
The 5-year recurrence-free survival following resection of
pulmonary metastases is 54 per cent (Tomohiko et al. 2013)
and following resection of liver metastases is 44  per cent
(Morris et al. 2010), with these survival curves reaching a
plateau after ten years. Following resection of both pulmo-
nary and liver metastases, the 10-year survival is only 18 per
cent (Limmer et al. 2010).
Carcinoembryonic antigen (CEA) levels may be use-
ful as a marker of recurrence, but usually only if the levels
were originally elevated at presentation. Long-term follow-
up with regular CT scans and chest radiographs to detect
hepatic and pulmonary metastases is essential for all licence
holders, as even those with Dukes’ stage A (T1–2) disease
have a distal relapse rate of approximately ten per cent
(Gunderson et al. 2002).
LYMPHOID MALIGNANCY
The number of applicants for initial certification and recer-
tification with a history of malignancy of the immune sys-
tem has increased steadily during the past few years due to
the increased efficacy of treatments available and conse-
quent increase in survival. Lymphoid malignancies are a
heterogeneous group of more than 25 conditions, with very
different clinical features and widely varying treatment
Number of years since completion of treatment
0 1 2 3 4 5
A
Dukes’ stage
B aggressive but potentially curable and those that are indo-
C survival curve that demonstrates a high mortality risk in the
Dukes’ stage A = T1–2 Class 1 unrestricted
Dukes’ stage B = T3–4 Class 1 OML
Figure 28.4  Certification assessment following colorectal
cancer. OML, operational multicrew limitation.
K17577_C028.indd 483
Lymphoid malignancy  483
regimens. They have different patterns of relapse in terms of
type, site and clinical presentation. The relapse-free, event-
free and overall survival patterns follow completely differ-
ent but quite characteristic time curves. The implications
for aeromedical certification are therefore diverse.
The classification of lymphoid malignancies is complex
and several systems have been developed over the years,
including the World Health Organization (WHO) classifi-
cation that uses morphologic, immunophenotypic, genetic
and clinical features to define diagnoses. There are four
broad groups based on cell lineage: myeloid, lymphoid,
mixed and histiocytic/dendritic neoplasms.
In aviation medicine practice, excluding Hodgkin’s dis-
ease, the peripheral B-cell neoplasms make up 85 per cent
of all lymphoid malignancies seen. The most common are
B-cell chronic lymphocytic leukaemia, follicular lymphoma
and diffuse large B-cell lymphoma.
HODGKIN’S LYMPHOMA
Hodgkin’s disease accounts for about 10  per cent of all
lymphomas and exhibits a bimodal age distribution curve
peaking at around 20  and 65  years. A diagnosis is not
uncommon in aircrew, especially in young men apply-
ing for professional certification. The five-year survival
rates for early stage Hodgkin’s disease (Stage I and II) are
90 per cent and for more advanced disease are 80 per cent
(Stage  III) and 59  per cent (Stage IV). These figures have
shown a steady improvement over the past 30  years. The
risk of sudden incapacitation as a presentation of relapse of
Hodgkin’s disease is negligible. As most cases are treated
with anthracyclines, professional aircrew and controllers
should undertake cardiological evaluation before certifica-
tion. Long-term follow-up is required as the risk of a second
malignancy, either as a solid tumour or as leukaemia, fol-
lowing chemotherapy is raised (Swerdlow et al. 2011). Those
who have received mantle field irradiation involving the
neck region are at risk of hypothyroidism. Provided oncol-
ogy and cardiology reports are satisfactory, class 1 medical
certification with a multicrew restriction can be regained
six months after completing treatment. The multicrew limi-
tation can be removed after two years of clinical remission.
Hodgkin’s lymphoma that is refractory to conventional
therapy may be treated with stem-cell transplantation.
Certification is possible if remission is sustained for a mini-
mum of one year after autologous transplantation and two
years after allogeneic transplantation.
OTHER TYPES OF LYMPHOMA
Lymphomas can be divided broadly into those that are
lent and inexorably progressive. The aggressive group has a
first year or two after diagnosis but once this time has elapsed,
the chance of relapse is very slim. The indolent group may
stay in asymptomatic remission for long periods of time and
pose the greater certificatory problem, as relapse, although
inevitable, may be delayed for many years. Chemotherapy is
17/11/2015 15:59
 484  Malignant disease

often used to slow progression in this group, and certification
can be considered even after one or more relapses.
Certification assessment
Lymphoid malignancies are treated separately as distinct
entities for certificatory purposes. For each type of lym-
phoid malignancy, published survival rates allow estimation
of the likelihood of potential cure. They can be categorized
into groups with similar prognoses (Table  28.6). Known
prognostic factors at presentation, such as age, stage, lactate
dehydrogenase level, number of extranodal sites involved
and performance status, related to mobility impairment,
are taken into account on a case-by-case basis. Performance
status is scored according to the Eastern Co-operative
Oncology Group scale, from 0 (fully active), to 1 (ambula-
tory) through to 4 (totally confined to bed).
Consideration should be given to the likelihood of cen-
tral nervous system relapse and the time period to recer-
tification must be weighted accordingly. An assessment of
incapacitation risk can be undertaken when full clinical
details are known. Any central nervous system involve-
ment would be permanently disqualifying for medical cer-
tification. Prerequisites for certification include a minimum
period of time following completion of treatment in order
to ensure that a sustained remission has been achieved and
that there are no ongoing side effects from treatment and
minimum levels for blood parameters, including haemoglo-
bin, platelets and neutrophil count. A full oncology report
should be obtained and a regular follow-up protocol estab-
lished. Any reclassification as a result of transformation to a
higher grade or restaging during treatment should be noted,
as this may influence certification.
Relapse may present with general symptoms, such as
malaise and fatigue, and localized symptoms, such as pres-
sure effects from a lymphoid swelling. Relapse may also
be detected prior to the development of symptoms by sur-
veillance blood testing or regular radiological imaging.
Symptomatic relapse is relatively uncommon and sudden
incapacitation is rare. Potential short-term and long-term
side effects of treatment also need to be considered.
Table 28.7 gives the minimum time to class 1 certification
following completion of primary treatment. Certification is
based on the likelihood of long-term relapse-free survival,
acknowledging that if relapse occurs, then the symptoms
are almost always insidious and detectable at an early stage
by routine clinical follow-up. The malignancies in group D
are weighted because of their propensity for central nervous

Table 28.6  Potential cure rates in patients with lymphoid malignancy

Group Potential cure (%) Diagnosis

A > 80 MZ MALT (stage I/II)
DLBC (stage I/II)
ALCL (stage I/II), including ALK-positive solitary plasmacytoma
B 70 Primary mediastinal lymphoma
C 60 DLBC (stage III/IV)
MZ MALT (stage III/IV)
D 50 Burkitt’s/Burkitt-like lymphoma
Pre-B lymphoblastic lymphoma/leukaemia
B-cell lymphoblastic lymphoma/leukaemia
ALCL (stage III/IV) including ALK negative
E 40 Pre-T ALL
Pre-T LBL
F < 10, moderately Other peripheral T-cell and NK lymphoma/leukaemia
aggressive Adult T-cell lymphoma (HTLV+)
Mantle cell lymphoma
Multiple myeloma
G Considered incurable using SLL
current therapy, but B-cell CLL
indolent Lymphoplasmacytic lymphoma
T-cell prolymphocytic leukaemia
T-cell granular lymphocytic leukaemia
Hairy cell leukaemia
MZ B-cell lymphoma (nodal/splenic)
H Miscellaneous group with a Primary cutaneous lymphoma
generally good prognosis
ALCL, anaplastic large cell lymphoma; ALK, anaplastic lymphoma kinase; CLL, chronic lymphocytic leukaemia; DLBC, diffuse large B-cell
lymphoma; HTLV, human T-cell lymphoma/leukaemia virus 1; MALT, mucosa-associated lymphoid tissue; MZ, marginal zone lymphoma; NK,
natural killer; Pre-T ALL, precursor T-cell lymphoblastic leukaemia; Pre-T LBL, precursor T-cell lymphoblastic lymphoma; SLL, small lympho-
cytic (B-cell) lymphoma.

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 Cutaneous malignant melanoma  485

Table 28.7  Minimum time to class 1 certification after
lymphoid malignancy
Group Class 1 multicrew Class 1 unrestricted
A 3 months 3 months
B 6 months 2 years
C 1 year 2 years
D 2 years 3 years
E 2 years 3 years
F 5 years 10 years
G 3 months 1 year
H 6 weeks 6 weeks
system relapse. The cutaneous lymphomas in group H have
to be assessed on an individual basis due to the heterogeneity
of the group.
Myeloid leukaemias
The myeloid, or myelogenous, leukaemias are seen much
less frequently than those of lymphoid origin in appli-
cants for certification. Acute myeloid leukaemia is rarely
seen and this is mainly due to the poor prognosis, with
a 5-year survival rate of 50  per cent for those aged below
50  and 12  per cent for those aged above 50. Chronic
myeloid leukaemia has a median age of presentation of
50. Treatment options include allogeneic bone marrow
transplant, where relapse rates are about one per cent
per year. Tyrosine kinase inhibitors such as imatinib and
dasanatib are increasingly used as first line therapy in the
chronic phase of the disease. Depending on the individual
disease response achieved, in the absence of side effects
from the drugs and with frequent follow-up surveillance
planned, it may be possible to consider restricted certifi-
cation whilst on these drugs. After an appropriate period
of remission, certificatory assessment for myeloid condi-
tions can be undertaken using the same principles as for
lymphoid malignancies.
CUTANEOUS MALIGNANT MELANOMA
The past few decades have seen an increase in the incidence
of malignant melanoma in many parts of the world, and
flight crew appear to be at particular risk, which is thought
to be due to lifestyle factors rather than cosmic radiation on
the flight deck (Dos Santos Silva et al. 2013).
The prognosis of a primary malignant melanoma depends
on the vertical thickness of the excised lesion, as first
described by Clark et al. (1969) and subsequently confirmed
by Breslow (1970), and whether there is lymph-node involve-
ment or more distant spread (Breslow 1970). Ulceration is
now known to be associated with a poorer prognosis, and
anatomical site also influences outcome. A lesion on the arm
is more favourable than one on the trunk or leg; a lesion on
the head or neck has the worst prognosis. Being male and
over 50 years of age is also associated with a poorer progno-
sis, but the histological category is not of prognostic value.
Treatment is by surgical excision. Sentinel lymph-node
mapping (identification of the lymph node to which the
affected area of skin drains) and biopsy at the time of excision
influences the decision to remove the complete lymph-node
basin, but it has not been established whether this affects
survival. The long-term benefits of immunotherapy and
chemotherapy have yet to be proven, and trials are ongoing
with vaccines containing melanoma-associated antigens to
stimulate antibody production against the tumour.
Melanoma confined to the skin
Certification is possible only if there has been complete
excision of the primary lesion with regular clinical exami-
nation for signs of local recurrence and regional and distant
metastases. Clinical staging uses the TNM classification to
describe the extent of disease. This method assesses tumour
spread after primary excision and pathological staging,
which takes into account microscopic evaluation of both the
primary tumour and locoregional lymph nodes. A compari-
son of pathological and clinical staging, as described by the
AJCC, is shown in Table 28.8 (Balch et al. 2009).
If the primary tumour is ulcerated, then the prognosis
has to be upstaged. For example, a T2 tumour with ulcer-
ation has the prognosis of a T3 tumour that is not ulcerated.
A T4  tumour with ulceration is equivalent in prognostic
terms to a node-positive lesion.
The AJCC Melanoma Database consists of more than
30 000 patients, and complete prognostic factors are known
for 17 600  of them. Survival data demonstrate a marked
reduction in survival with higher stages and, importantly, a

Table 28.8  Comparison of staging classifications for malignant melanoma

Pathological stage Clinical stage Tumour thickness (mm) Nodes Metastases

I T1 £1.00 No No
T2 1.01–2.00 No No
II T3 2.01–4.00 No No
T4 >4.00 No No
III N1 Any 1 No
N2 Any 2–3 No
N3 Any 4+ No
IV M Any Any Yes

K17577_C028.indd 485 17/11/2015 15:59

 486  Malignant disease
continued reduction in survival beyond ten years from pri-
mary treatment for stages I and II. This supports the clini-
cal impression that recurrence of melanoma is notoriously
difficult to predict, even many years after first presentation.
Assessment after excision of a primary cutaneous mela-
noma limited to skin or locoregional lymph nodes is shown
in Figure 28.5. T1 lesions have a good prognosis, and unre-
stricted certification is possible as soon as the wound has
healed sufficiently to permit a return to operational duties.
Nodal involvement
Survival rates for microscopic lymph-node disease appear to
be better than in cases where macroscopic disease has been
demonstrated (Schuchter 2001). Microscopic disease may be
detected on elective or selective lymph-node dissection or
biopsy of the sentinel lymph node. Additionally, melanoma
may be detected only in a lymph node by molecular diag-
nostic techniques such as immunohistological staining or
reverse-transcriptase polymerase chain reaction (RT-PCR)
to detect tyrosinase messenger ribonucleic acid (mRNA).
Certification after macroscopic lymph-node involvement
is more difficult than if only microscopic disease has been
detected. The number of nodes affected – the N staging –
also influences outcome. It may be reasonable to downstage
by one stage, e.g. consider microscopic N2 disease as N1 or
microscopic N1 disease as T4, if there are no lymph nodes
affected on macroscopic examination in a similar way to the
upstaging of disease if the primary lesion is ulcerated.
Metastatic disease
Metastatic disease to the lung and other visceral sites (stages
M1b and M1c) is incompatible with class 1 certification.
Number of years since completion of treatment
0 1 2 3
T1 ≤1 mm
T2 ≤2 mm
T3 ≤4 mm
T4 > 4 mm
N1 (macroscopic)
N2 (2–3 nodes)
N3 (4+ nodes)
M1a (skin,
subcutaneous)
M1b/c (other
metastases)
Unrestricted OML
Figure 28.5  Certification assessment after excision of a primary cutaneous malignant melanoma. OML, operational
multicrew limitation.
K17577_C028.indd 486
Local recurrence
The most common site of recurrence is locally to the skin
(40 per cent), particularly in the scar from the original exci-
sion or in the surrounding skin. Five-year survival rates after
local recurrence vary in the literature from 60 per cent for
in-scar recurrence (Cohn–Cedermark et  al. 1997) to nine
per cent for local skin (Balch et  al. 2000). Recertification
after local recurrence has to be assessed, taking into account
all known prognostic factors at the original presentation, as
these continue to influence survival. The overall prognosis
is similar for local recurrence, satellite disease and in-transit
metastases and these can be grouped together as ‘regional
stage III disease’ and treated as such for certificatory pur-
poses (Schuchter 2001).
Distant recurrence
The most common site of distant spread is to lymph nodes
and less commonly to the lungs (19  per cent), the brain
(17 per cent) and the liver (6 per cent) (Akslen et al. 1987).
The incidence of cerebral metastases presenting as the first
recurrence following treatment of a primary melanoma was
found to be eight per cent in a large US and Australian
series and was also exactly the same figure in a group of US
Air Force personnel (Conrad et  al. 1971). Cerebral spread
often occurs alone, without evidence of regional lymph
node spread or metastases to other sites, unlike spread to
lung, liver or bone (Akslen et  al. 1987). It is particularly
important to identify latent cerebral spread in aircrew; as
the resolution of imaging techniques available continues to
improve, these may become increasingly useful to detect
asymptomatic cerebral secondaries.
4 5 6 7 8 9 10
No certification
17/11/2015 15:59
 Germ-cell tumours of the testis  487

GERM-CELL TUMOURS OF THE TESTIS
Testicular tumours are predominantly of germ-cell origin.
There are two main types, seminoma and non-seminoma-
tous germ-cell tumours (NSGCTs). They account for 15 per
cent of aircrew seeking recertification following treatment
for malignant disease. This is not surprising, as germ-cell
tumours of the testis are the most common malignancy in
males between the ages of 20 and 40 years. Since the intro-
duction of platinum-based chemotherapy in the 1970s,
over 95  per cent of patients can now expect to be cured
(Dearnaley et al. 2001).
Germ-cell tumours arise from primitive germ cells, and
more than 90 per cent arise in the testes. NSGCTs arising
in other primary sites such as the mediastinum, and other
types of testicular cancer, e.g. choriocarcinoma and embry-
onal carcinoma, tend to have a poorer prognosis and should
be considered on an individual basis.
A staging system based on disease site of origin, histol-
ogy, tumour size and level of serum tumour markers has
been developed by the International Germ Cell Cancer
Collaborative Group (IGCCCG 1997). The prognosis for
seminoma and NSGCT is related to metastatic spread to
secondary sites. The prognosis for NSGCT is also related
to the level of serum tumour markers, alpha-fetoprotein
(AFP), human chorionic gonadotrophin (hCG) and lactate
dehydrogenase (LDH) at presentation and to the extent of
disease. If the AFP is raised, then the tumour cannot be a
pure seminoma and is treated as a NSGCT.
Most licence holders present with early stage I disease
confined to the testis. Standard treatment is orchiectomy,
often combined with platinum-based chemotherapy if vas-
cular invasion has occurred for NSGCT and radiotherapy
to para-aortic lymph nodes for seminoma, which is a highly
radiosensitive tumour. Even if salvage treatment for recur-
rence is subsequently required, the cure rate for stage I
tumours approaches 100 per cent.
Figure 28.6 shows the certification assessment following
primary treatment for germ-cell tumours of the testis that
have spread beyond the testis. In more extensive disease, the
progression-free survival curves plateau three to five years
after completion of treatment, irrespective of the initial
stage, and most pilots will be able to achieve unrestricted
certification once this time period has elapsed.
Survival rates for NSGCT and seminoma range from
94 and 86 per cent for good-prognosis tumours, to 83 and
72  per cent for those with an intermediate prognosis, to
71 per cent for poor-prognosis NSGCT (IGCCCG 1997 and
Van Dijk et  al. 2006). Seminoma with pulmonary metas-
tases falls into the group with a good prognosis. The
good-prognosis group accounts for three-quarters of all
germ-cell tumours.
Even with metastatic disease, the prognosis in testicular
cancer is good compared with that of other tumours. The
organs most likely to be affected include the liver, lung, bone,
brain and adrenal gland. Central nervous system metasta-
ses are rare with an incidence of two to three per cent (Doyle
et al. 2008) and cerebral spread usually is preceded by ret-
roperitoneal and systemic metastases (Nyugen et al. 2004).
Isolated cerebral relapses of NSGCT reported in the litera-
ture usually presented within the first two years after the
initial diagnosis (Cohn et al. 2001). For seminoma, the risk
of cerebral relapse is negligible (Fosså et al. 1999).
Asymptomatic relapse in NSGCT can often be detected
by elevated serum tumour markers, which are quantified
routinely at oncology review appointments. Regular clini-
cal follow-up, including chest radiography, is routine for all
germ-cell tumours. Aircrew should be encouraged to report

Number of years since completion of treatment

0 1 2 3 4 5
Good prognosis
IGCCCG

Intermediate prognosis

Poor prognosis

International Germ Cell Cancer Collaborative Group (IGCCCG) prognosis Unrestricted

OML
Good prognosis = All seminoma except non-pulmonary metastases
NSGCT: AFP < 1000 ng/mL No certification
hCG < 5000 IU/L
LDH less than ×1.5 normal
Intermediate prognosis = Seminoma with non-pulmonary metastases
NSGCT: AFP < 10 000 ng/mL
hCG < 50 000 IU/L
LDH up to ×10 normal
Poor prognosis = NSGCT: AFP > 10 000 ng/mL
hCG > 50 000 IU/L
LDH more than ×10 normal

Figure 28.6  Certification assessment after treatment for a germ-cell tumour of the testis (other than stage I). AFP, alpha-
fetoprotein; hCG, human chorionic gonadotrophin; LDH, lactate dehydrogenase; OML, operational multicrew limitation.

K17577_C028.indd 487 17/11/2015 15:59

 488  Malignant disease
symptomatic relapse with pain or detection of a lump as
soon as symptoms occur.
CARCINOMA OF THE BLADDER
Transitional cell carcinoma accounts for 90 per cent of all
bladder cancers. Adenocarcinoma, squamous cell carci-
noma and small-cell carcinoma are much less common.
Bladder cancer is common among the general population
but is seen relatively infrequently in licence holders. This is
partly because it affects mainly men over the age of 60 years
and partly because tobacco use is a major risk factor and a
smaller proportion of licence holders are smokers than in
the general population.
Treatment of an early tumour is by transurethral resec-
tion followed by regular cystoscopic examination. More
invasive tumours may require intravesical chemotherapy or
immunotherapy with bacillus Calmette–Guérin (BCG) and
possibly total cystectomy.
Following removal of an in-situ carcinoma of the blad-
der, a licence holder may be given unrestricted class 1 certi-
fication. Lesions limited to the lamina propria (T1) are also
compatible with unrestricted class 1 certification, however
50  per cent are likely to progress, so close surveillance is
required (Borden et al. 2003). The prognosis is much poorer
for tumours extending to muscle (T2a and T2b) and radi-
cal cystectomy is likely to be the treatment of choice. An
operational multicrew limitation (OML) or unfit assess-
ment may be appropriate in this circumstance. If there is
microscopic or macroscopic extension beyond the bladder
(T3a or higher), then certification is unlikely to be possible.
Metastatic sites include lymph nodes (69  per cent), bone
(47 per cent), lung (37 per cent) and liver (26 per cent). Brain
involvement is rare (5 per cent) and even rarer are isolated
brain metastases (Shinagare et al. 2011).
ADENOCARCINOMA OF THE PROSTATE
The increased uptake of prostate-specific antigen (PSA)
testing has led to earlier diagnosis and more diagnoses of
non-aggressive prostate cancers in the general population
(Moore et  al. 2009). This has also been the experience in
the aircrew population. The certification of licence holders
with adenocarcinoma of the prostate is relatively straight-
forward compared with most other cancers. Progression of
disease can, in the majority of cases, be tracked using the
PSA. However, less than one third of those with a raised
PSA will have prostate cancer and up to 15 per cent of those
with prostate cancer will have a normal PSA.
Prostate cancer is predominantly a disease of elderly men
and is usually seen after the age of 50 years. It is generally
indolent. Conservative management or active surveillance,
known as ‘watchful waiting’ is an acceptable management
protocol for early disease localized to the prostate. Regular
clinical reviews and PSA monitoring is essential. Other treat-
ments include surgical removal of affected tissue, commonly
transurethral resection of prostate (TURP), radiotherapy
K17577_C028.indd 488
(external beam or radioactive implants known as brachy-
therapy) and neoadjuvant hormone therapy; although even
for high-grade tumours the treatment method has little
influence on overall survival (So et al. 2003).
Nomograms are being used increasingly in clinical
practice to predict outcome and are likely to be useful for
aviation medical practice as they become more refined (Di
Blasio et  al. 2003). The main prognostic factors for recur-
rent disease are the pre-treatment PSA levels, the stage and
the Gleason score (determined by adding two gradings of
biopsy tissue each scored from 1 to 5). The five year survival
for prostate cancer is 96  per cent for organ-confined dis-
ease, 76 per cent for disease that has spread to local lymph
nodes and 35 per cent for metastatic disease that has spread
to distant lymph nodes, bone and other organs. Distant
metastatic sites are predominantly to bone (90 per cent) and
much less frequently to lung and liver and rarely to brain.
In aviation medicine, prostate cancer is of certificatory
importance only if it extends beyond the prostatic capsule
(stage T3 or higher), the PSA trend is rising (especially when
> 20 μg/L) and/or the Gleason score is 8–10. These factors
indicate a higher probability of recurrence and a poorer
prognosis. Certification is possible after treatment, as long
as the PSA remains suppressed on hormonal therapy, and
there is no evidence of nodal or bony spread on scanning.
Bony metastases to the vertebra and other skeletal sites can
result in pathological fractures and spinal cord compres-
sion, as well as symptoms of bone pain and hypercalcaemia,
and precludes future certification.
CARCINOMA OF THE KIDNEY
Renal cell cancers comprise 90  per cent of all cancers
affecting the kidney. Of renal cell cancers, three-quarters
are clear-cell carcinomas and 10–15 per cent are papillary
carcinomas. Collecting duct carcinoma, chromophobe and
unclassified tumours are rare. Tumours arising from the
renal pelvis are mainly transitional cell cancers and associ-
ated with a high risk of later bladder cancer.
Treatment is usually radical nephrectomy, often with post-
operative cytokine-based immunotherapy. Partial nephrec-
tomy is sometimes undertaken for small, localized tumours.
The most important prognostic factor is stage at diag-
nosis. T1  tumours measure less than 7  cm and T2  more
than 7 cm; both are limited to the kidney. T3 tumours do
not extend beyond the Gerota fascia (they may involve the
renal vein, vena cava or adrenal gland), but T4 tumours do
extend beyond this layer. Grade 1  tumours are associated
with a relatively good prognosis, but any effect on general
mobility, as reflected by a performance score of more than
zero, is associated with a poorer prognosis. These factors
have been incorporated into the University of California,
Los Angeles (UCLA) integrated staging system, as shown in
Table 28.9 (Zisman et al. 2002).
Metastatic spread is detected in up to 50  per cent of
patients at diagnosis. The most common sites are lung
(42  per cent) and bone (22  per cent), followed by the
17/11/2015 15:59

Table 28.9  University of California, Los Angeles (UCLA) integrated staging system for N0M0 renal cell carcinoma
Risk factor for recurrence
Low
Intermediate 1, 2 or 3
High
Performance status determined according to Eastern Co-operative Oncology Group criteria.
adrenal glands and brain (two per cent) (Janzen et  al.
2003). Approximately half of T3 tumours will recur, usually
within two years of the original presentation. Brain metas-
tases are accompanied by other sites of metastatic disease in
most cases (Schuch et al. 2008) and are usually a late mani-
festation of advanced disease. Late recurrence more than
ten years after treatment is rare, having been reported in
6 per cent of patients and most frequently affecting the lung
(Miyao et al. 2011). The appearance of a late solitary cerebral
metastasis more than ten years after treatment is extremely
rare. Certification after treatment for renal cell carcinoma is
shown in Figure 28.7. The prognosis for tumours that have
spread to nodes or more distantly, or have recurred after
primary treatment, is poor (Patard et al. 2004) and certifi-
cation is not possible for metastatic disease.
CARCINOMA OF THE BREAST
In recent years, there has been an increase in the preva-
lence of breast cancer in female licence holders reflecting
that seen in the general population. Male breast cancer and
histological types other than invasive ductal, ductal carci-
noma in-situ or lobular carcinoma of the breast are rare and
should be considered separately. The most significant indi-
cators of prognosis are tumour grade, stage as indicated by
histological lymph-node involvement, and tumour size. The
Nottingham Prognostic Index (NPI) (Haybittle et al. 1982)
uses these factors to predict outcome on an individual basis
by applying the following formula:
NPI = Lymph Node Stage (I–III) + Grade (1–3) + (0.2 ×
maximum diameter in cm)
●● Stage I: no lymph-node involvement.
●● Stage II: lower axillary or internal mammary nodes positive.
●● Stage III: apex or both axillary and mammary nodes positive.
Number of years since completion of treatment
0 1 2 3
Risk of recurrence based on
UCLA staging system
Low
Intermediate
High
Unrestricted
Figure 28.7  Certification assessment after treat-
ment for renal cell carcinoma. OML, operational
multicrew limitation.
K17577_C028.indd 489
Carcinoma of the breast  489
T stage Grade Performance status 5-year survival (%)
1 1–2 0 93
Any Any 71
4 or 3 Any 1+ 50
This gives a value of NPI from 2.08  to 6.8 which
the prognosis assesses as Excellent, Good, Moderate  I,
Moderate II, Poor and Very Poor in terms of long-term
survival (Table 28.10) (Blamey et al. 2007). Since it was first
described, the NPI has been used to predict survival with
tumours of less than 1  cm in size and in metastatic dis-
ease. Recurrences continue to occur many years after pri-
mary treatment, and survival rates are influenced for many
decades. Figure  28.8  shows the certification assessment
after treatment for carcinoma of the breast.
Mastectomy or lumpectomy, with or without radiotherapy,
is the mainstay of treatment. The use of adjuvant chemotherapy
is determined by the extent of the disease and menopausal and
oestrogen receptor (ER) status. Postmenopausal ER-positive
women may be given tamoxifen, which is compatible with
certification. The aromatase inhibitors, such as anastrozole,
exemestane and letrozole, when used as adjuvant treatment
following surgery may be acceptable for certification, subject
to there being no adverse effects from the medication.
Genetic factors are likely to play an increasing role in
both the therapy and the prognosis of breast cancer. Breast-
cancer susceptibility is known to be increased in the presence
of mutations of BRCA1  and BRCA2  genes. The expression
of the human epidermal growth factor receptor-2 (HER-2)
may influence prognosis and is used to provide a basis for
therapeutic choices if an anthracycline is contra-indicated.
In the Moderate, Poor and Very Poor prognostic groups,
the concern for aeromedical certification is the risk of a sud-
den incapacitation from covert metastatic disease. The most
common sites involved are liver, lungs and bone. Cerebral
metastases occur in 10–30 per cent of those with life-limit-
ing disease and there is some evidence to suggest that this
may be more common in people with ER negativity. As the
course and prognosis of breast cancer is so variable and
there can be a long interval between primary treatment and
the presentation of secondary spread, long-term oncology
follow-up is important for ongoing certification.
4 5 Table 28.10  Ten -year survival for breast cancer using the
Nottingham Prognostic Index (NPI) prognostic groups
10-year
Prognosis NPI survival (%)
Excellent 2.08–2.4 96
Good 2.42 ≤ 3.4 93
OML
Moderate I 3.42 ≤ 4.4 81
Moderate II 4.42 ≤ 5.4 74
Poor 5.42 ≤ 6.4 50
Very Poor 6.5–6.8 38
17/11/2015 15:59
 490  Malignant disease
Nottingham prognostic index
Prognosis based on
Figure 28.8  Certification assessment after treatment for breast cancer. OML, operational multicrew limitation.
LUNG CANCER
Tumours of the lung are seen rarely in professional aircrew,
as these are mainly seen in the elderly. Although lung can-
cer is very common, it is often not diagnosed before it has
become inoperable, and the prognosis is very poor.
This is especially true for small-cell lung cancer, which
has a five-year survival of 15  per cent for limited disease
confined to the lung and 5  per cent for extensive disease
that has spread beyond the lung. It also has a high predilec-
tion for cerebral metastases (Janssen–Heijnen et  al. 1998).
Treatment may include cranial irradiation, as well as che-
motherapy, and paraneoplastic syndromes may complicate
the clinical situation. Future certification is not possible
with this condition.
Non-small cell lung cancer accounts for about 85  per
cent of all lung cancers. The survival figures are better than
for small cell lung carcinoma and using the certification
assessment process described earlier, it may be possible to
recertify a licence holder who has had a non-small-cell lung
cancer (NSCLC) successfully resected and with no evidence
of metastatic spread.
Figure  28.9  shows the certificatory possibilities follow-
ing surgical treatment for the three most common types
of NSCLC: adenocarcinoma, squamous cell carcinoma
and large-cell (undifferentiated) carcinoma. Other types of
NSCLC should be considered separately. Staging is based
on the TNM classification. Stages I and II are described as
‘localized’ tumours and have a much better prognosis than
stage III tumours. Five-year survival figures are 50 per cent
for Stage IA, 43 per cent for stage IB, 36 per cent for stage
IIA and 25  per cent for stage IIB (Goldstraw et  al. 2007).
The prognosis for stage III or IV tumours is too poor to
permit certification.
Number of years since completion of treatment
0 1
I in aviation.
Stage
II
OML No certification
Figure 28.9  Certification assessment after treat-
ment for non-small-cell lung cancer. OML, operational
multicrew limitation.
K17577_C028.indd 490
Number of years since completion of treatment
0 1 2 3 4 5 6 7 8 9 10
Good
Moderate
Poor
Unrestricted OML No certification
For resected stage I and II disease, once a disease-free
interval of five years has been reached, the future risk of
recurrence is less than the risk of developing a second lung
primary. The risk of late recurrence is not related to the initial
stage and has a much poorer outcome than a second primary.
Following resection of the tumour, often endoscopically,
a minimum of three months should elapse prior to recerti-
fication. Lung function tests should be undertaken to evalu-
ate the functional capacity of the remaining lung. A lung
lobectomy may be compatible with recertification, however
total pneumonectomy is disqualifying due to the significant
loss of parenchymal tissue.
CONCLUSION AND SUMMARY
Certificatory guidelines for fitness to fly after treatment for
malignant disease have evolved as more up-to-date evi-
dence has become available from studies on overall and dis-
ease-free survival rates from different types of cancer. This
has allowed the more accurate estimation of future inca-
pacitation risk from recurrence of disease or sequelae from
treatment. Licence holders should be encouraged to report
symptomatic recurrence as soon as they are aware of any
symptoms. Regular follow-up and investigations to detect
recurrence at the earliest possible stage, together with the
use of modern imaging and biochemical techniques, facili-
tates certification with close surveillance.
The survival rates of many cancers are continuing to
improve as new, more diverse treatment regimens are
developed. Treatment of many childhood cancers has
shown particular improvement in the past few decades,
and there have been an increasing number of applicants for
initial certification for professional flying or ATCO train-
ing declaring a history of treatment for cancer as a child.
The certificatory assessment method described enables
consideration of these candidates, who previously would
2 3 4 5 not have been able to embark on a commercial career
As scientists unravel the complexity of the human
genome, our understanding and knowledge of the devel-
opment and progression of many cancers at the molecular
genetic level grows, allowing the development of targeted
therapies at this level. Tumour markers are already in rou-
tine clinical use for some tumours, but new advances in
molecular biology, such as the polymerase chain reaction
17/11/2015 15:59

(PCR), permit the detection of cells that it would not have
been possible to identify using conventional microscopic
techniques. In addition, molecular markers may, in the
future, allow prognostic assessment on an individual basis.
Attempts are being made to correlate markers of cell func-
tion with progression, likelihood of recurrence and survival.
Clinical trials of vaccination using autologous tumour cells
are being undertaken for melanoma and colorectal carci-
noma, and gene therapy using genetically modified viruses
to selectively destroy cancer cells is also under trial.
The evolution of novel therapies to treat malignant disease
may lead to further clinical studies that provide improved
survival data. If data were to become available on the risk of
incapacitation from recurrence, it could also affect certifi-
catory assessments. With continuing advances in medical
treatments and technology for surveillance techniques, the
future outlook for licence holders remains promising.
ACKNOWLEDGEMENT
This is a revision of the chapter originally written by Sally
Evans.
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17/11/2015 15:59

Neurological disease
DAMIAN JENKINS AND RALPH GREGORY
Introduction 493
Static neurological disease – low chance of
recurrence or progression 493
Static neurological insult – moderate to high risk of
recurrence or progression 496
INTRODUCTION
Neurological diseases are often disabling or progressive,
and many present an unpredictable risk of sudden incapaci-
tation. This explains why they are disproportionately cited
as a reason for disqualification from flying. In an analysis
of the United States Air Force, McCrary (McCrary and van
Syoc 2002) found attributable to neurological disease a dis-
qualification rate of 0.26 per 1000 pilot years. Neurological
illness might even be the leading cause for disqualification
within the commercial sector (Arva and Wagstaff 2004).
To assess the impact of a neurological condition on a per-
son’s fitness-to-fly is challenging, as the natural history of
many disorders is not well established. The myriad job roles
and aircraft add to the complexity. For example, a pilot fly-
ing solo represents a much greater risk should he suffer a
migraine than if a member of aircrew has the same problem
aboard a well-staffed flight.
In gauging whether a disease presents an unacceptable
risk in the flight environment a clinician needs to ask:
●● Is the disease static or might it recur?
●● If static, does it disable the sufferer? If so, is the disabil-
ity compatible with flight safety?
●● Where a disease recurs or progresses is there a risk of
sudden incapacitation?
●● If there is a risk of sudden incapacitation, is the risk low?
If so, could the person continue to fly with restrictions?
Static insults that result in limited functional impairment
are not disqualifying if the air crewman remains competent
K17577_C029.indd 493
29
Infectious diseases 499
Episodic disease 499
Progressive disease 503
References 505
to perform their safety drills. For example, a pilot is not
debarred from flying if she suffers a head injury that does
not induce seizures, or post-traumatic amnesia (PTA) last-
ing more than 30  minutes. Contrast this to a head injury
resulting in persistently reduced cognition where the sufferer
is disqualified from flying. Where uncertainty exists about
the impact on flight safety of a static illness, response times
can be measured objectively by means of flight simulation.
Diseases that recur present an ongoing risk to flight
safety, but the magnitude of that risk varies greatly between
diseases. In the case of stroke there is the potential for rapid
incapacitation and, with a cumulative annual risk of recur-
rence of five per cent, it poses an unacceptable risk to flight
safety. For these reasons, stroke precludes further flying.
Compare this with multiple sclerosis (MS), which rarely
causes catastrophic or sudden incapacitation. As such MS
poses a much lower risk to flight safety and can be compat-
ible with future flying.
STATIC NEUROLOGICAL DISEASE –
LOW CHANCE OF RECURRENCE OR
PROGRESSION
Head injury
Traumatic brain injury (TBI) encompasses a spectrum of
parenchymal damage, ranging from mild TBI (e.g. concus-
sion) to severe TBI (new focal deficits). Evidence of injury
may be found clinically or radiologically: MRI hallmarks of
TBI include contusions, haematomata and axonal shearing.
493
17/11/2015 16:00
 494  Neurological disease
The assessment of aircrew with TBI starts with a thorough
history, which may contain important prognostic markers.
For example what was the duration of PTA, or how long was
the individual unconscious? Answers to these, and similar
questions, helps determine the risk of cognitive sequelae and
post-traumatic epilepsy (PTE) amongst other future conse-
quences. The physical examination seeks to identify new
focal deficits. These will then be assessed to determine what
impact, if any, they have on the execution of emergency drills.
COGNITIVE OUTCOME FOLLOWING TBI
PTA, or a reduced level of consciousness, denotes new neu-
rological damage. PTA correlates well with the severity of
Head injury
With: normal imaging
Without: PTA, LOC,
focal neurological deficit
PTA or LOC <30 min
Without: neurological deficit, brain
injury on scanning, skull fracture
PTA or LOC >30 min <24 hr
Without: neurological deficit, brain
contusion on imaging, seizure
With/without: skull fracture
PTA or LOC >24 hr <7 d
With: neurological deficit, brain
contusion or intracranial bleed on
imaging, or depressed skull fracture
Without: seizure
PTA or LOC >7 d
With: penetrating brain injury,
significant parenchymal damage, or
disabling neurological deficit
Very severe TBI
Unfit flying
Figure 29.1  Head injury assessment flowchart.
K17577_C029.indd 494
TBI and is useful for predicting long term changes in cogni-
tion. Furthermore, PTA is both well-validated and simple
to use. TBI can be categorized as mild, moderate or severe
depending on the duration of PTA. Mild TBI, where PTA
does not exceed 30 minutes, is rarely associated with ongo-
ing cognitive impairment. Compare severe TBI, where
PTA lasts between one and seven days, where cognition is
invariably, and durably, affected. PTA is incorporated into
guidance on TBI and fitness-to-fly in Figure 29.1. Long term
follow up of TBI patients is prudent to permit repeated cog-
nitive assessments. Performance reports from family mem-
bers and colleagues will be invaluable when seeking subtle
cognitive impairment.
Concussion
Ground until symptoms
resolve + 7 days
Mild TBI
Ground for 6 weeks and dual flying
for 1 year if professional aircrew
Assessment of cognition before
removing restrictions
Moderate TBI
Ground for 6 months then
restrictions for 2 years if professional
or
Ground for 3 months then
restrictions for 3 months
Assessment of cognition before
removing restrictions
Severe TBI
Ground for 3 years then long term
restricted flying if professional aircrews
or
Ground 2 years then restricted
flying for 1 year
Assessments of cognition before
removing restrictions
Ongoing cognitive assessments
with witness reports
17/11/2015 16:00
 Static neurological disease – low chance of recurrence or progression  495

PREDICTING POST-TRAUMATIC EPILEPSY Can risk be measured objectively? An electroencephalo-

PTE is a serious concern following TBI. Since the work of gram (EEG) does not sufficiently predict the risk of epilepsy
Jennett in the 1970s, it has been appreciated that TBI sig- after TBI to warrant its incorporation into risk stratifica-
nificantly increases the risk of epilepsy above the recorded tion. However, MRI scanning may help. Imaging can iden-
2–5  per cent lifetime prevalence. This is especially true tify deposits of haemosiderin in the brain parenchyma.
where the mechanism of injury is complicated. For exam- Formed from ferritin, haemosiderin promotes gliosis and
ple, penetrating brain injury increases the risk of PTE to epileptogenesis. Messori et  al. found that sufferers of TBI
40 per cent, a new focal neurological deficit to 35 per cent, with MRI evidence of haemosiderin had an increased risk
and a depressed skull fracture with dural tear to 30 per cent. of epilepsy when compared with TBI sufferers without such
Annegers et al. demonstrated that the risk of PTE was also deposits (6 per cent versus 4 per cent at five years) (Messori
increased by intracerebral haematoma formation and PTA et al. 2005). This risk rises to 24 per cent of patients where
lasting >24 hours (Table 29.1) (Annegers et al. 1988). gliosis accompanies haemosiderin deposition.
The likelihood of developing epilepsy after TBI dimin- In all, failure to develop seizures with time, combined
ishes with time. For example, the risk falls by >75 per cent with a low-risk MRI, is reassuring. Aircrew falling into
if seizures do not develop within two years of injury. By five this category are often safe to fly after an extended period
years, the risk returns to baseline - even when the initial TBI of observation. If the TBI occurred during childhood or
was severe. This may not be true of TBI in children and ado- adolescence, a longer period of observation is warranted: in
lescents who are at greater risk of post-traumatic epilepsy. one study, 45 per cent of TBI sufferers aged 8–16 developed
Interrogation of a Danish registry suggests that the risk is seizures more than 5  years after their injury (Asikainen
increased for more than 10 years (Christensen et al. 2009). et al. 1999). Figure 29.1 incorporates the risks of cognitive
impairment and post-traumatic epilepsy into workable
clinical guidance.
Table 29.1  Head injury and observation periods in adult
traumatic brain injury (TBI)
Spinal cord injury
Period of
Severity Symptoms grounding
Recovery from spinal cord injury is dependent on the type
of disease. Acute compression with early surgical release
Mild <30 minutes post- 1 week
may cause little durable disability. Predicting outcome is
traumatic amnesia difficult, with recovery often occurring spontaneously. The
(PTA) likelihood of this depends on the degree of motor strength
No loss of at time of injury, extent of spinal shock, and the spinal level
consciousness affected. Lesions of the cervical cord foretell greater impair-
No neurological deficit ment than those of the lumbar cord. Static cord injuries are
<30 minutes PTA 2 months incompatible with commercial flying but private licenses
Fleeting loss of may be awarded. An assessment will need to be made by
consciousness a trainer of both the aircrew and, where used, the person’s
No neurological deficit specially adjusted aircraft. Although rare, ejection seat usage
Moderate PTA >30mins <24hours 2 years can lead to spinal cord injury. A review of Royal Air Force
Neurological deficit accident logs and medical records suggests up to a third of
Non-depressed fracture those ejected suffer a vertebral fracture. Following ejection,
of skull base pilots should be assessed by a neurologist and undergo MR
MRI evidence of imaging before recommencing flying.
haemosiderin
Severe PTA >24hours <7 days 5 years Nerve injury
Neurological deficit
Depressed skull CRANIAL NERVES
fracture The cranial nerves subserve our special senses. Damage can
Traumatic dural have an impact in the aviation setting:
penetration
MRI evidence of I The olfactory bulb is located at the base of the skull. It
haemosiderin and is commonly damaged as a result of blunt trauma to the
gliosis head, and the prognosis for recovery is poor (less than
Very severe PTA >7 days Disqualifying 10 per cent of cases) (Reden et al. 2006). Fortunately,
Debilitating anosmia does not prevent the sensation of noxious
neurological deficit fumes as the trigeminal nerve detects acrid and pungent
Penetration of brain scents, e.g. those from a burning cockpit. As such, olfac-
parenchyma tory nerve damage does not prevent further flying.

K17577_C029.indd 495 17/11/2015 16:00

 496  Neurological disease
II Loss of stereopsis occurs when visual acuity falls
below 6/18 in one or both eyes, and precludes fly-
ing. Monocular vision is a bar to commercial and
military flying but not private flying, subject to
satisfactory assessment.
III, IV, VI  Weakness or paralysis of the extra-ocular
muscles displaces the visual axes and can cause double
vision. Diplopia is a contraindication to flying. As most
cases resolve, a license may be granted after a period of
grounding if the risk of recurrence is low.
VII  Facial nerve palsies must be reviewed case-by-case to
assess the effect on tasks performed in-flight. Exposure
to dusts and gases makes the ability to blink a require-
ment of certain jobs, whilst the ability to use an oxygen
mask is necessary for military flying.
VIII  Hearing loss is a bar to unrestricted professional
flying, especially in the military setting. Similarly, a
propensity to vestibular disorders resulting in vertigo is
incompatible with solo-flying (see below).
PERIPHERAL NERVES
The outcome following peripheral nerve injury depends on
the extent of damage and the response to treatment: options
include surgical repair and physiotherapy. Following injury,
aircrew should be reviewed and their new functional abili-
ties documented. The assessment should include a global
assessment of musculoskeletal function and a flight simula-
tion. Personnel with minimal functional impairment may
resume flying.
Peripheral nerves may also be affected in Guillain–Barré
syndrome (GBS) and peripheral neuropathy. GBS is an
autoimmune attack on peripheral nerves mediated by anti-
bodies produced in response to an antecedent infection.
Most sufferers make a good recovery, and recurrence is rare.
Patients should be assessed once the autoimmune condition
has stopped. Where peripheral neuropathy is concerned,
there is the question of progression, as well as functional
impairment. In some instances, such as vitamin B12  defi-
ciency, correcting the deficiency prompts recovery. In other
cases, no treatment will be possible. Regular assessments of
function are mandatory.
STATIC NEUROLOGICAL INSULT
– MODERATE TO HIGH RISK OF
RECURRENCE OR PROGRESSION
Ischaemic stroke and transient ischaemic
attacks
In the past two decades the incidence of stroke, and its asso-
ciated mortality, has fallen (Feigin et al. 2003). Nonetheless,
it remains the most disabling of cardiovascular diseases. It
also carries a high risk of recurrence with some 25–40 per
cent of survivors suffering a further event within five years
(Table  29.2). As such, stroke is incompatible with flying.
Transient ischaemic attacks (TIAs) are equally significant.
K17577_C029.indd 496
Table 29.2  Risk of further stroke after first ischemic stroke
Time Further stroke (per cent patients)
30 days 3–10
1 year 10–14
5 years 25–40
Whilst they provide a window for the early use of second-
ary prevention, they, like stroke, can rapidly incapacitate the
sufferer. Furthermore, TIAs are associated with an 18.5 per
cent risk of stroke at three months. For this reason, aircrew
suffering a TIA must also be grounded.
One of the leading causes of stroke is atherosclero-
sis. Plaque rupture can give rise to thrombus formation
or embolism of atherosclerotic material. Cerebral artery
occlusion follows, causing infarction of downstream brain
tissue. Lacunar infarcts inflict similar damage on deep
brain matter. Such infarcts are thought to be the result of
a vasculopathy of the small, penetrating arteries and they
are associated with hypertension, diabetes mellitus and
smoking. Ischaemic stroke can also be the result of cardio-
embolic disease arising from arrhythmias (notably atrial
fibrillation), valve disease and myocardial infarction.
Atherosclerosis, lacunar disease and embolic phenomena
are most common in the older population, although all are
seen in cases of young-onset stroke. Aircrew suffering cere-
brovascular accidents may have a different, and potentially
remediable, aetiology. Herein lies a problem: there is scant data
about the risk of disease recurrence in such a population and
so prognosis is guarded. What is known is that certain causes
of stroke have a favourable outcome. An example is cervical
arterial dissection (CAD). This commonly affects a younger
population and is associated with a low risk of recurrence.
Touzé et al. report a one per cent recurrence of CAD at three
years and the risk is greatest where a predisposition exists to
arterial dissection, e.g. Marfan’s syndrome or arteritis (Touzé
et al. 2003.) Where no such illness is identified, a return to fly-
ing will be contingent on there being no lasting disability.
WHITE MATTER HYPERINTENSITIES
The increasing use of MRI has revealed changes to the brain
that are of uncertain significance. White matter hyperin-
tensities (WHTs) are non-specific findings and can relate
to previous trauma, infection or vascular insults. The lat-
ter are more likely with increasing numbers of WHTs on
serial scans. Approximately 11–21  per cent of people aged
64  are found to have WHTs, and this rises to 94  per cent
of 82  year olds. In the aeronautical world, they raise con-
cern about future stroke, cognitive decline and dementia.
Debette and Markus demonstrated a trebling in the risk of
stroke when WHTs were found in otherwise well individu-
als (Debette and Markus 2010). When discovered in people
with vascular risk factors, e.g. hypertension, diabetes mel-
litus and raised cholesterol, that risk rises to 7.4 times the
background stroke risk.
If found in aircrew, WHTs are likely to be an inciden-
tal finding. However, they should prompt investigation and
17/11/2015 16:00
 Static neurological insult – moderate to high risk of recurrence or progression  497
treatment of cardiovascular risk factors. To determine the
annual risk of stroke, one needs to determine the back-
ground risk of stroke. That figure is then multiplied by the
risk attributable to WHTs. A decision can then be made
about flight safety. Where a crewmember has a significant
number of WHTs they should be assessed for declining cog-
nition. Serial MRI scans, cognitive tests and reports about
performance should be sought.
Haemorrhagic stroke
Between 10  and 20  per cent of strokes are haemorrhagic
in origin. They are frequently devastating, causing direct
parenchymal damage and conferring a risk of secondary
complications such as epilepsy and hydrocephalus. The
most common cause of bleeding is aberrant vasculature, e.g.
berry aneurysms, arterio-venous malformations (AVMs)
and cavernous haemangiomata.
SUBARACHNOID HAEMORRHAGE (SAH) AND BERRY
ANEURYSMS
Berry aneurysms are saccular out-pouchings of arterial
walls. They present throughout the cerebral circulation but
are more frequently found along the Circle of Willis. They
have a predilection for junctures and bifurcations where the
thin aneurysmal wall is exposed to turbulent blood flow.
The annual risk of aneurysm rupture is approximately one
per cent, although the threat rises with age, aneurysmal
size and anatomical location (Wermer et al. 2007). Systemic
hypertension, smoking and an association with other dis-
eases (such as polycystic kidney disease and Ehlers Danlos)
confer a greater risk of rupture.
Ruptured aneurysms
Disqualification from further flying is likely where an aneu-
rysm ruptures and causes SAH. In highly selected cases,
where treatment has been undertaken and shown to be
effective, and where no epilepsy has developed, a return to
flying may be considered (see ‘Treated aneurysms’).
Unruptured aneurysms
Unruptured intracranial aneurysms (UIAs) are increas-
ingly discovered incidentally, particularly as a consequence
of MRI brain scanning undertaken for another reason.
The impact on flying is related to the risk of rupture with
single, small aneurysms (less than 5mm) in the ante-
rior circulation displaying a low risk of rupture (less than
0.55  per cent per annum) (Sonobe et  al. 2010). Aircrew
found to have such an aneurysm might continue to fly
although professional pilots should be restricted to multi-
crew flights for one year. This allows for repeated imaging
to ensure that no enlargement of the aneurysm occurs. The
multicrew flight restriction may be lifted if the aneurysm
remains unchanged at one year. Annual neurovascular
assessment is required thereafter.
Aircrew with high-risk aneurysms (multiple aneu-
rysms; diameter greater than 5mm; posterior circulation;
K17577_C029.indd 497
more than 60 years of age; previous SAH; enlargement on
serial scanning; associated with hypertension) must be
reviewed on a case-by-case basis, but routinely preclude
unrestricted flying.
Treated aneurysms
Aneurysms can be treated by means of neurosurgical clip-
ping or endovascular coiling. Both offer long term oblit-
eration of the aneurysmal sac, although repeated coiling
may be required. Serial imaging is required to provide
evidence of aneurysm occlusion before treatment can be
considered successful. Both treatment modalities can be
used emergently and treatment is mandated to dimin-
ish the risk of rebleeding. The decision to treat an UIA is
more nuanced: the risk of iatrogenic bleeding and epilepsy
needing to be weighed against the lifetime risk of rupture.
Following successful treatment there is an extant risk of
seizure development. Risk is determined by anatomical
location, treatment modality and iatrogenic complications.
A middle cerebral artery (MCA) aneurysm treated by clip-
ping confers a 10.5 per cent risk of seizures at one year and
3.5 per cent at two years (Hart et al. 2011). Treatment that
is complicated by thrombo-embolism increases the risk of
epilepsy fivefold.
Despite these figures, many people undergo treatment
without complication and do not develop epilepsy. The
risk of seizures is less than 2 per cent at one year where a
non-MCA aneurysm is treated (by either clipping or coil-
ing) as long as the patient encounters no complications
within the first two months. Aircrew in this low risk group
can be grounded for two years to permit observation and
serial scanning before returning to multicrew restricted fly-
ing. Following a further event-free year, restrictions may
be lifted. Private pilots in the low risk group may return to
unrestricted flying at one year, following further imaging.
Patients not considered to be low risk must be assessed on a
case-by-case basis (Figure 29.2).
Family history of aneurysmal disease
A history of a first-degree relative with an SAH confers a
fourfold increase in the incidence of aneurysmal disease
in those over 30 years of age. Whilst the evidence suggests
little survival benefit from screening, there is a role for such
assessment in aircrew, as their individual risk extends to
passengers and colleagues. A family history of SAH in two
or more first-degree relatives mandates MR angiography,
repeated at five years to ensure that no aneurysm exists
or develops.
SAH without evidence of aneurysm
The remainder of non-traumatic SAH is explained by peri-
mesencephalic haemorrhage, the aetiology of which is not
well understood. However, where no aneurysm is found
at repeated, formal catheter angiography, the chance of
rebleeding is low (less than 1 per cent per annum). Aircrew
may return to unrestricted flying after one year if normo-
tensive without evidence of rebleeding.
17/11/2015 16:00
 498  Neurological disease

Aneurysm

<5mm
Single
No enlargement on
1 year follow-up scan

Repeat imaging at 1 year

>5mm and treated If no enlargement risk of
or rupture low
ruptured and treated return to
flying permitted

MCA aneurysm
Non-MCA aneurysm
Complication within
No complications
2 months of
at 2 months
treatment

Yes No Yes
Ground Private licence holders: Profession aircrew:
Review on ground for 1 year ground 2 years and
case-by-case basis and rescan rescan
Unfit professional, Unrestricted Permit to fly with
solo flying flying therein restrictions for 1 year
before upgrading
Annual review

Figure 29.2  Flight restrictions based on intracranial aneurysms.

Arterio-venous malformations 10 per cent. This ought to preclude fitness-to-fly. However,

The risk of haemorrhage attributable to intracranial AVMs
is between two and four per cent per year. In addition to
bleeding, AVMs can give rise to headache, epilepsy, focal
deficits attributable to flow phenomena, or may be discov-
ered incidentally. AVMs can be treated by surgical resec-
tion, endovascular embolization, or radio-ablation: some
require all three. Each treatment modality may obliter-
ate an AVM, so treatment choice is determined by loca-
tion (e.g. eloquent cortex, which precludes surgery), size,
mode of drainage and the required speed of treatment. For
example, stereotactic radio-ablation induces luminal scar-
ring, obliterating the aberrant vessels. However, scarring
takes approximately two years to develop, in which time the
bleeding risk remains.
Therein the decision about fitness-to-fly is dictated by
any ensuing disability and the risk of epilepsy. Treatment
does not reduce the risk of epilepsy compared with conser-
vative management regardless of whether or not the AVM
has bled (Josephson et  al. 2012). The risk of epilepsy in
people incidentally found to have an AVM is greater than
carefully selected individuals, in whom no seizures have
developed after several years, may return to dual seat flying
after extended periods of observation.
Cavernous haemangioma
Cavernoma are formed from abnormal clusters of capillar-
ies. They distribute throughout the central nervous system
and may provoke seizures, focal neurological deficits or
haemorrhage. Up to half of cavernomas are discovered inci-
dentally and the risk of developing epilepsy in these cases is
low (approximately 1–2 per cent at 5 years) (Josephson et al.
2011). A quarter of people with cavernoma are diagnosed
following a seizure and upwards of 90 per cent of these will
develop epilepsy. Where the diagnosis is made in light of an
intracerebral haemorrhage, 15 per cent of patients go on to
develop epilepsy within five years. Putting this together, a
presentation with seizures, bleeding or focal deficit is not
compatible with flying. Although the risk of epilepsy attrib-
utable to cavernoma discovered incidentally is low, it is not
negligible. Such aircrew should permanently be restricted to

K17577_C029.indd 498 17/11/2015 16:00

 Episodic disease  499

dual-flight capability. Unfortunately, stereotactic radiother- Is it epilepsy?

apy is ineffective for such lesions and they are not amenable
to endovascular repair.
INFECTIOUS DISEASES
Meningitis and encephalitis
Infection of the central nervous system (CNS) can lead to
behavioural and cognitive changes and to epilepsy. The
epilepsy risk depends on the type of pathogen and on
the presence of seizures early in the course of infection.
Uncomplicated viral/aseptic meningitis (i.e. that not associ-
ated with early seizures) does not increase the risk of epi-
lepsy. Uncomplicated bacterial meningitis confers a small
risk (2.4 per cent), whereas complicated bacterial meningi-
tis increases the risk to 13  per cent at 20  years (Annegers
et  al. 1988). Encephalitis, probably through cortical dam-
age, bestows a high risk: 10 per cent of those who are ini-
tially seizure free, and 22 per cent of those suffering early
seizures, go on to develop epilepsy. Finally, the risk follow-
ing a cerebral abscess, malaria or neurocysticercosis is also
sufficiently high to preclude flying (Table 29.3).
HUMAN IMMUNODEFICIENCY VIRUS
Human immunodeficiency virus (HIV) causes neurologi-
cal disease in approximately 40 per cent of suffers. This is
covered in Chapter 38. However, it is important to state that
HIV may affect memory and cognition and the examiner
should seek reports from colleagues which may identify
Cumulative probability of subsequent
Not all seizures represent epilepsy and many neurological or
systemic insults can provoke seizures in otherwise healthy
people. To avoid mislabelling such individuals as suffering
from epilepsy, the term acute symptomatic seizure is used to
describe a fit occurring within one week of a neurological or
systemic insult. Acute symptomatic seizures may arise from
metabolic disturbances (e.g. renal failure, glucose or elec-
trolyte abnormalities), febrile infections or withdrawal from
drugs or alcohol. Equally they can be precipitated by strokes
or TBI. The pathological process driving acute symptomatic
seizures determines the risk of developing epilepsy. A diag-
nosis of epilepsy requires two or more unprovoked seizures
to occur more than 24 hours apart.
The aircrew member has had an acute
symptomatic seizure. What are the risks of
developing epilepsy?
The risk of developing epilepsy following an acute symptom-
atic seizure is 18.7 per cent at 10 years and, in large part, is
determined by the cause of the seizure (Hesdorffer et al. 2009).
Based on the findings of Hesdorffer (Figure  29.3) an acute
symptomatic seizure should attract a period of grounding of
at least 4 years. At this point, the risk of developing epilepsy has
peaked. If an individual has remained seizure free off medica-
tion, and has both a normal EEG and MRI, a return to dual
flying may be considered on an individual basis.
1.00

Log rank p <0.001

deteriorating mental status.
0.75
unprovoked seizure

EPISODIC DISEASE First unprovoked

Disorders of consciousness 0.50

SEIZURES AND EPILEPSY

0.25
Epilepsy can lead to an unheralded loss of consciousness
and presents one of the greatest medical threats to flight Acute symptomatic
safety. To compound matters, some forms of focal epilepsy 0.0
are not readily detectable to untrained individuals but can, 0 2 4 6 8 10
Time (years)
nonetheless, impair a crew member’s judgment or ability to
carry out flight tasks. Loss of consciousness is not the only
Figure 29.3  Cumulative probability of further unprovoked
concerning feature of epilepsy: a pilot having a seizure may seizures following acute symptomatic seizures and first,
inadvertently disrupt the flight-control panel with poten- unprovoked seizures.
tially devastating consequences. As such, epilepsy renders
aircrew unfit further duties. From Hesdorffer 2009.

Table 29.3  Flight restrictions after neurological infection

Type Period of Grounding Restriction on Flying

Viral or aseptic meningitis 6 months Nil
Bacterial meningitis without early seizures 1 year Nil
Bacterial meningitis with early seizures 2 years Dual, 5 years
Viral encephalitis without early seizures 5 years Dual 5 years
Viral encephalitis with early seizures Ground permanently
Cerebral abscess, cerebral malaria, neurocysticercosis Ground permanently

K17577_C029.indd 499 17/11/2015 16:00

 500  Neurological disease
The aircrew member has suffered a first
and unprovoked seizure. How should he be
managed?
The risk of developing epilepsy after an unprovoked seizure
is much greater: 64.8 per cent of those having a first fit will
develop epilepsy. The risk may be lower in certain individu-
als. For example, seizures occurring before the age of five
and seizures attributed to a benign epilepsy phenotype (e.g.
benign rolandic epilepsy), do not appreciably increase the
risk of epilepsy above background prevalence. In such cases,
a new applicant may be permitted to fly without restrictions
if they have been seizure free for ten years without medica-
tion and have a normal MRI brain scan.
Where a first unprovoked seizure is not of a benign phe-
notype, and does not occur before the age of five, greater
precaution is warranted. Aircrew should be grounded for
ten years and should then only fly dual seated aircraft if the
EEG and MRI scanning prove normal. The occurrence of a
first fit is disqualifying for military flying.
Does the EEG predict the development of
epilepsy?
The EEG can be used to support a diagnosis of epilepsy
and helps to predict seizure recurrence in individuals suf-
fering a first fit. Interictal epileptiform discharges (IEDs)
are recorded in 0.5–1.0  per cent of healthy adults but this
figure increases dramatically with cerebral pathologies.
Approximately 50 per cent of individuals with epilepsy have
an abnormal initial EEG, and the yield rises to 80 per cent
with sleep-deprived or repeated EEG recordings. The pres-
ence of IEDs (e.g. focal or generalized spike or spike-wave
phenomena) suggests a predilection for further seizures.
Those showing benign waveforms, such as 4–6Hz spike and
wave and 14Hz spikes, are acceptable.
Whilst the demonstration of IEDs in aircrew presenting
with a first seizure is sufficient to preclude further flying, the
converse is not true. Given that the EEG is normal in at least
20  per cent of people with a single epileptic seizure, even
after repeated recordings, the test is not sufficient to predict
flight safety. However, it is useful combined with a period of
clinical observation.
Should aircrew undergo EEG screening?
The false-positive rate of EEG is high – sufficiently high
to preclude its use in routine medical screening. However,
EEG with photic stimulation can be considered in screening
helicopter aircrew. These people undergo prolonged expo-
sure to a powerful epileptogenic stimulus: the rapid rota-
tion of the blades. Gregory et  al. have demonstrated that
the risk of epilepsy is between 2–3  per cent in those with
a positive EEG on photic stimulation and these individu-
als must be disqualified from flying (Gregory et  al. 1993).
The disqualification is not necessarily lifelong as photo-
sensitivity diminishes with time (Harding et  al. 1997). A
potential helicopter crewman who has remained seizure
free for five years after a positive EEG may be fit to fly but
K17577_C029.indd 500
only if there is no ongoing photosensitivity on photic or
sleep-deprived EEG.
SYNCOPE
Syncope is a sudden, transient loss of consciousness and is
the physical manifestation of cerebral hypoperfusion. The
vast majority of cases can be accounted for by postural hypo-
tension or neurally mediated syncope (e.g. simple vasovagal
faints, carotid sinus hypersensitivity or situational syncope).
However, it may portend an underlying disease such as a
cardiac arrhythmia, structural heart disease or cerebrovas-
cular disease and it is incumbent on the medical examiner
to rule out these more serious ailments. The history is key
to understanding the events leading up to a syncopal event,
and a witness statement will provide clues to the underlying
diagnosis. It is crucial that the correct diagnosis be reached
as an incorrect diagnosis of epilepsy has major career impli-
cations. Attention should be paid to anoxic seizures (or con-
vulsive syncope) and concussive seizures. Both entail fitting
but the cause (reduced cerebral perfusion and concussion
respectively) is benign and not linked to epilepsy.
Was it syncope?
The first diagnostic challenge is to decide whether the event
was syncope or an alternative diagnosis. A definite diag-
nosis can be made from the medical history alone, with
tests used to screen for alternate diagnoses. Features of
syncope include:
●● Pre-syncopal triggers, e.g. prolonged standing, episodes
that occur after eating, following an unpleasant smell,
sight or sound, or episodes that occur after pain or after
standing or exertion: ‘What was the last thing you were
doing, prior to the collapse?’
●● Pre-syncopal symptoms such as nausea or epigastric
discomfort, sweating, light-headedness, or visual symp-
toms (such as the world greying out or the visual fields
closing in).
●● A short-lived event.
●● A full recovery being made without post-ictal con-
fusion: ‘What was the first thing you remember on
regaining consciousness?’
Some features of the history should raise the suspicion of
an underlying medical problem. For example:
●● A collapse during exertion or arm exercise.
●● The sensation of chest pain or palpitations prior to the
event.
●● The development of focal neurological signs or headache
prior to collapse.
●● Syncope whilst in the supine position.
Finally, some elements of the history may give rise to con-
fusion about the underlying aetiology. Convulsive move-
ments do not readily aid in the diagnosis as they can occur
in response to all causes of cerebral hypoxia.
17/11/2015 16:00

Which investigations should be ordered?
All aircrew presenting with syncope should be clinically
assessed and undergo investigation where appropriate.
Personal interview of a first-hand witness can be rewarding.
Blood tests, an electrocardiogram, echocardiogram and
lying and standing blood pressure measurements should be
performed. Some aviation authorities also mandate Holter
testing and exercise ECG recording. If the tests are normal,
and the clinician has a high suspicion of neurally mediated
syncope or postural hypotension, no further investigations
are required. Specialist tests are indicated when the history
or clinical examination suggests an underlying abnormality.
The effect on flying
●● Single episode of syncope – classic history, baseline
tests normal.
●● No further tests are required. The aircrew should
be grounded for a period of six months and may
return to dual flying therein. It is reasonable to lift
all restrictions after a period of five years.
●● Episode of collapse – diagnosis uncertain.
●● Ground and investigate further. The period of
grounding will depend on the likely diagnosis. For
example, if the aircrew is being investigated for
epilepsy the restrictions pertaining to that illness
should be used.
●● Recurrent syncope.
●● Recurrence occurs in approximately 16 per cent
of sufferers and episodes may cluster (Ungar et al.
2010). Whilst the medical significance to the patient
is not great, the risk in the flight environment is
marked. Such individuals must be considered unfit
to fly.
NARCOLEPSY AND CATAPLEXY
Narcolepsy is a chronic disorder of arousal linked to altered
sleep–wake cycles. It is associated with cataplexy, a condi-
tion that results in the sudden loss of tone of the voluntary
muscles, especially in response to emotional stimuli. Both
conditions reduce performance, as do their treatments, and
sufferers must be considered unfit to fly.
TRANSIENT GLOBAL AMNESIA
This enigmatic phenomenon is a temporary disturbance of
anterograde, and partial retrograde, memory. It may be a
migrainous phenomenon, but what seems clear is that tran-
sient global amnesia (TGA) is not due to cerebrovascular
disease. During an episode of TGA sufferers are seemingly
able to perform demanding tasks, which may even include
the ability to fly without mishap. However, they are disori-
ented, repetitive and their immediate recall is impaired.
This leads to repeated questions even though the sufferer
may otherwise appear appropriate to colleagues. Up to
20 per cent of sufferers have a second attack within a five-
year window, and these may be prompted by emotional or
physical exertion. For safety, aircrew are best grounded for
K17577_C029.indd 501
Episodic disease  501
at least one year following an episode. A multicrew restric-
tion should be considered for a further four years.
Disorders of balance
VERTIGO
Vertigo may be caused by peripheral diseases of the ear or
vestibular nerve, or may represent a brainstem lesion. An
acute attack associated with vomiting, which improves over
the course of a few days, is likely to be vestibular neuronitis.
Recurrent, positional vertigo might represent benign posi-
tional paroxysmal vertigo (BPPV). This is caused by oto-
liths in the inner ear endolymph. These stimulate the nerve
hair cells, causing a sense of motion. BPPV can be demon-
strated using the Dix–Hallpike test and, if positive, an Epley
manoeuvre can be curative. However, symptoms may recur,
so vertiginous crewmembers require grounding for six
months to ensure no recrudescence in symptoms. Chronic
vertigo, even when paroxysmal, is incompatible with flying.
Migraine is often implicated as a cause for recurrent vertigo
and requires assessment of risk on a case-by-case basis.
Headache and neuralgia
MIGRAINE
Migraine affects many people: it has a prevalence of 17 per
cent amongst women and 6 per cent amongst men. Symptoms
are driven by a sterile inflammatory response which drives
oedema and vasodilation of cerebral blood vessels. In classic
migraine, this gives rise to aura followed by headache, whilst
in common migraine there is headache alone. The diagnosis
is made from the history. Typically, the patient reports a uni-
lateral, throbbing headache accompanied by nausea, vomit-
ing, photophobia and/or phonophobia. Some sufferers also
experience stroke-like symptoms such as weakness, dyspha-
sia or sensory symptoms. In over 50 per cent of migraines, the
sufferer is rendered prostrate, taking to bed for hours to days.
Flight safety can be jeopardized by prostration or visual
aura and the medical assessment must determine how likely
the migraneur is to be able to carry out their inflight drills.
The type of symptoms, speed of onset and the frequency
with which they are suffered determine the likely safety
implication of migraine:
●● Aura – significant aura that obscures a significant
portion of the visual field debars medical certification,
whereas minor scintillations in the far periphery of
vision are manageable. For military aircrew the onset of
aura whilst on the ground precludes being able to fly.
●● Speed of onset – where a migraine develops over hours,
sufficient time is given to avoid flying. The converse is
true of rapidly evolving migraines which can render
aircrew useless midflight.
●● Frequency – up to a third of sufferers have monthly
attacks. The number of episodes will determine the abil-
ity of the aircrew to carry on working in aviation.
17/11/2015 16:00
 502  Neurological disease

Finally, one should enquire about triggers and treatment.
In reality, the role of triggers (hunger, food types, lack of
sleep) is overstated, and the medical examiner should be
wary of aircrew seeking to play down the impact of their
migraines by suggesting they are always avoidable. The
role of treatment is equally important: if effective, it may
make migraines manageable. However, certain drugs (anti-
depressants, narcotics and anti-epileptics) have a sedative
effect and are not appropriate for use by aircrew.
The overall effect of migraine depends on the aircrew
role. It precludes military flying and requires that other
commercial aircrew be grounded or restricted in their work.
Johnston and O’Brien incorporated these factors into a flow
chart. This is adapted and included in Figure 29.4.
CLUSTER HEADACHE AND OTHER TRIGEMINAL
AUTONOMIC CEPHALGIAS (TACS)
Cluster headache is a rare entity characterized by unilateral,
side-locked severe pain in or around an eye. Attacks are
abrupt, often occur at night and may be accompanied by
­autonomic features. Sufferers may report miosis, ptosis, eye
redness, tearing, nasal stuffiness or watering. Most attacks
last between 15 and 180 minutes (average of 90 minutes) before
abating. The pain then recurs several times per day over the
days or weeks of a cluster period (2–3 months). The symptom
Migraine attack
—significant aura, rapid onset
(<2 hours), severe incapacitation,
more than 2 per year
—anti-depressant, anti-epileptic or
narcotic analgesia
severity is such that patients pace around, agitated, unable to
sleep: a feature that renders cluster headaches incompatible
with flight certification. All crew should be grounded dur-
ing the period of a cluster and whilst on treatment. An ongo-
ing multicrew restriction is likely to be required thereafter
as the average sufferer has a cluster every year (Bahra et al.).
However, restrictions should be individualized as the peri-
odicity of the headaches is not uniform. There are reports of
remission periods lasting longer than 20 years, so a return
to flying could be considered in a non-military environment.
Cluster headache is only one of several types of TAC, all
of which are headaches accompanied by autonomic features.
Other examples include paroxysmal hemicrania and short-
lasting unilateral neuralgiform headaches with conjuncti-
val injection and tearing (SUNCT syndrome). In assessing
the impact of these TACs the examiner can approximate the
suggestions made for cluster headache. Additional guiding
information includes the exquisite sensitivity of paroxysmal
hemicranias to indomethacin, which may make that head-
ache controllable, and the erratic recurrence of SUNCT
syndrome, which makes prognostication more difficult.
NEURALGIA
Trigeminal neuralgia and similar entities are readily inca-
pacitating. True trigeminal neuralgia usually occurs in the

YES
Ground indefinitely
Reconsider if migraine features NO
change pattern and Ground for 3 months
aircrew remains migraine
free for 1 year

Migraines remain low frequency

(<2 per year), slow onset
(<2 hours), mild and
without significant aura
or
avoidable trigger identified and
migraines successfully averted
or
medically managed with
acceptable medication

YES
Return to multicrew restriction
(incl flight controllers) for 1 year
If remains attack free at 1 year
consider lifting restriction
NO
Ground indefinitely
Reconsider if migraine features
change pattern and aircrew
remains migraine free for 1 year

Figure 29.4  Non-military flight restrictions following migraine.

Adapted from Johnston and O’Brien 2004.

K17577_C029.indd 502 17/11/2015 16:00


elderly, so is rarely a problem for aircrew. Severe pain with
many occurrences in a single day reduces the performance
of the sufferer and thus serves as a bar to flying. Successful
medical management is unlikely to alter this situation as
most neuralgiform illnesses respond best to antiepilep-
tic medication which itself debars flying. Where neuralgia
enters remission, and no underlying disease is identified (for
example an aberrant vessel near the trigeminal ganglion, or
demyelination plaques in multiple sclerosis), certification
may be reconsidered.
PROGRESSIVE DISEASE
Degenerative diseases
Assessing the impact of a degenerative disease on fitness-
to-fly requires knowledge of the rate of progression and
the types of disability that the disease confers. Wherever
degeneration affects the brain rather than the spinal cord
or nerves (e.g. Parkinson’s disease) the medical examiner
needs to look carefully for evidence of cognitive decline.
Physicians should be familiar with clinic-based memory
tests (e.g. Addenbrooke’s Cognitive Evaluation). Reports
from colleagues and family members may help when assess-
ing an individual’s performance.
DEMENTIA
Dementia is predominantly a disease of the older popula-
tion and is relatively rare amongst aircrew. Should aircrew
present with cognitive impairment, they must be grounded
and investigated for reversible causes (vitamin deficien-
cies, endocrinopathies, medication or alcohol use, space
occupying lesions and normal pressure hydrocephalus) or
alternative diagnoses including partial epilepsy, infectious
diseases, autoimmune conditions, and the pseudodementia
of depression. Unless a reversible cause for cognitive impair-
ment is found, aircrew will require permanent grounding.
Table 29.4  Central nervous system (CNS) tumours
Location Examples
Supratentorial, parenchymal Glioma
Ependymoma
Supratentorial, extra-axial Meningiomas
Infratentorial, parenchymal Cerebellar glioma
or extra-axial Acoustic neuroma
Pituitary tumour
Meningioma
Metastases Especially:
Lung
Breast
Bone
Malignant melanoma
K17577_C029.indd 503
Progressive disease  503
PARKINSON’S DISEASE AND PARKINSONISM
Parkinson’s disease (PD) results from the loss of dopaminer-
gic neurons in the basal ganglia, promoting tremor, rigidity
and bradykinesia. Dopaminergic signalling affects more
than just motor pathways: it has a role in arousal, executive
function, memory and mood. For this reason PD is almost
always incompatible with flying. Aircrew permitted to fly
with early PD require frequent cognitive tests and witness
reports about job performance. When aircrew present with
tremor but no bradykinesia, a diagnosis of essential tremor
should be considered: a dopamine transporter scan can help
make the diagnosis.
TUMOURS
Tumours may develop in the CNS de novo or may be the
result of metastatic spread. Most sufferers will not be con-
sidered fit-to-fly owing to the risk of epilepsy, cognitive or
mood effects or sudden, intratumoral haemorrhage. Some
tumours may be compatible with flying. A guide is provided
at Table 29.4.
Autoimmune and inflammatory conditions
MULTIPLE SCLEROSIS
Multiple sclerosis (MS) is one of the most prevalent neu-
rological diseases in the developed world. A likely auto-
immune disease, MS has historically been thought of as a
disease of the white matter. However, grey matter damage
is also prevalent and gives rise to altered executive function
and arousal. Several variants of MS exist, each described
by the temporal pattern in which disability is acquired. In
relapsing–remitting MS (RRMS) the disease smoulders for
years and the time course is punctuated by relapses during
which new neurological deficits appear. After a variable,
but usually lengthy period, disability progresses with-
out relapses. At this point, RRMS is considered to have
Risks Effect of flying
Cognitive impairment, Unfit
epilepsy, recurrence
Recurrence, epilepsy Multicrew restriction two years after
surgical excision if favourable
imaging and seizure free
Unrestricted flying if seizure free
following treatment
Cognitive impairment, If present, ground
bleeding, seizures Retain high index of suspicion for
cerebral metastases in aircrew
‘cured’ of non-CNS cancer: screen
with MRI before certification and
institute repeated surveillance
scans
17/11/2015 16:00
 504  Neurological disease
progressed to secondary progressive MS (SPMS). Primary
progressive MS (PPMS) describes a phenotype in which dis-
ability progresses from the outset and in which relapses do
not feature (although a variety of PPMS with minor relapses
is seen). Finally, there are rare cases of benign MS in which
disability is not major feature.
A diagnosis of MS is a bar to initial licensing. However,
established aircrew may fly unless diagnosed with SPMS
or PPMS as both are invariably associated with cognitive
deficits. Sufferers with epilepsy, trigeminal neuralgia, mood
disorders or significant physical disability are also prohib-
ited from flying. Finally, many MS sufferers are significantly
affected by treatment-resistant fatigue. None of the drugs
able to improve arousal are compatible with flying.
Established aircrew in the early stages of RRMS can con-
tinue to fly with a multicrew restriction. This reflects the
nature of relapses, which are often slow to develop. This pro-
vides sufficient time for aircrew to recuse themselves from
flying. Flying can resume when remission is sustained for
more than six months following a relapse. Commercial air-
crew should be reviewed by a neurologist every six months
and, if indicated, by an ophthalmologist. Flight simulator
reports should form part of the assessment. As cognitive
dysfunction is only weakly correlated with physical disabil-
ity it will not be possible for the assessor to gauge one from
the other, thus they must remain vigilant against mental
decline. Two-yearly cognitive assessments should be evalu-
ated alongside reports from co-workers.
Private license-holders spend less time flying, therefore
the risk is also smaller. If a private pilot remains relapse
free for two years, and has a low degree of disability (e.g.
less than 2 Kurtze Expanded Disability Status Scale), unre-
stricted flying may resume with ongoing surveillance.
CLINICALLY ISOLATED SYNDROME, E.G. OPTIC
NEURITIS
MS requires evidence of neurological disease disseminated
in space and time, with more than one anatomical loca-
tion affected on more than one occasion. Where symptoms
compatible with MS develop (e.g. optic neuritis, transverse
myelitis, brainstem syndrome) without evidence of such
dissemination, a diagnosis of clinically isolated syndrome
(CIS) is made. CIS may progress to MS. If the sufferer has a
normal brain scan that risk is 20 per cent at five years. If the
scan uncovers lesions in keeping with demyelination, the
risk rises to 80 per cent.
Established aircrew with CIS should be assessed accord-
ing to the symptom they develop. Thus, optic neuritis debars
flying until visual acuity is stable and above 6/18  in both
eyes; a cord syndrome will attract restrictions based on the
ability of the individual to carry out emergency drills; whilst
vertigo bars further flying until completely settled. Once
resolved, CIS sufferers may be assessed in a similar way to
those with RRMS. But what of new applicants? The likeli-
hood of converting from the CIS to MS is high. Only 45 of
220 (20 per cent) individuals recruited to the Gothenburg
database of CIS sufferers did not subsequently develop MS
K17577_C029.indd 504
within 25 years (Eriksson et al. 2003). It may be possible to
license aircrew for private flying if the findings on MRI, CSF
and electrophysiology are negative – both at the time of CIS
and again five years later – but CIS prohibits initial licensing
for commercial purposes.
MYASTHENIA GRAVIS
Any disease that significantly affects muscle strength pre-
cludes flying, and myasthenia gravis (MG), a disease of the
neuromuscular junction, is no exception. Flying may resume
if MG is successfully treated by thymectomy and minimal
drug treatment. Otherwise, the patient will require immu-
nosuppression and has the potential for relapse. This is
especially true during intercurrent illness. Restrictions may
be less onerous in the case of ocular MG. Approximately
10–15  per cent of such patients enter into full remission
without weakness spreading to other muscle groups.
If MG spreads to other muscle groups it does within two
years of onset of ocular symptoms in the majority of suffer-
ers older than 50. Thus, ocular MG is compatible with flying
two years from diagnosis if remission has occurred.
SUMMARY
●● Neurological disease accounts for about one third
of cases of loss of professional medical certifica-
tion in the United Kingdom.
●● There are many rare neurological diseases. As
a consequence, affected aircrew may need to be
assessed on a case-by-case basis.
●● A detailed history is crucial for aircrew expe-
riencing an episode of loss of consciousness, as
investigations including the electrocardiogram
and electroencephalogram have low sensitivity
and poor sensitivity.
●● All aircrew sustaining even momentary post
traumatic amnesia following a head injury should
be grounded pending careful clinical assessment.
●● In the assessment of a one-off, static illness such
as a head injury, the physician should focus on the
accrued disability and its effect on flying. Flight
simulation is an invaluable tool in this instance.
●● Witness statements from colleagues and fam-
ily members, coupled with neuropsychological
assessment, is crucial in deciding the fitness to fly
of an individual suffering a neurological disease
which has the potential to alter cognition.
●● Risk factors for neurological disease are increas-
ingly identified while performing tests for unre-
lated conditions. Such findings should prompt
a full clinical assessment to calculate the indi-
vidual’s risk of subsequent illness or injury, for
example, the likelihood of future TIA or stroke
after white matter hyperintensities are found on
MR imaging.
17/11/2015 16:00

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Ophthalmology
ROBERT A. H. SCOTT AND PAUL WRIGHT
Introduction 507
Visual requirements for aviation 507
Refractive error in aviation 507
Management of refractive errors in aircrew 510
INTRODUCTION
Sight is the most important sense used in aviation; more
than 80 per cent of all information acquired by pilots from
cockpit instruments and through the canopy is visual.
Contact lenses are the most popular form of refractive cor-
rection among aircrew, though big advances have been
made in cataract and corneal refractive surgery. Colour
vision is an important issue in aviation as methods of mea-
suring it have developed.
With millions of pounds spent training Royal Air Force
(RAF) pilots, any new ophthalmic interventions in air-
crew must be carefully evaluated. In this chapter, we will
describe and explain some of the visual characteristics of
the eye relevant to aviation, describe how to measure them
and discuss relevant ocular diseases in relation to the
aviation environment.
VISUAL REQUIREMENTS FOR AVIATION
Aviators require two eyes that see distant and near objects
clearly. The ocular muscle balance must be within nor-
mal limits and colour vision must be normal. The visual
fields must be full and stereopsis must be present to the
required standard.
RAF visual standards
The standards at selection for RAF aircrew are summarised
in Table 30.1.
K17577_C030.indd 507
30
Ophthalmic history and examination 514
Ophthalmic conditions encountered in aviators 519
Ophthalmic drugs 526
Further reading 526
Poor vision in one eye
An individual with a single or a single seeing eye can fly an
aircraft safely with certain restrictions. Uniocular subjects
have a slightly reduced field of vision and no stereoscopic
vision. The sensory loss and increased risk of complete visual
incapacitation if the good eye is damaged pose a flight safety
issue. An experienced private pilot is likely to be permitted
to fly with a safety lookout if wearing appropriate eye pro-
tection, after a successful flight test. Professional pilots who
become uniocular are normally restricted to fly as or with a
qualified co-pilot. These restrictions appear to be adequate
as the US Federal Aviation Authority (FAA) report no sig-
nificant difference in accident rates between uniocular and
binocular pilots.
REFRACTIVE ERROR IN AVIATION
Variation of refraction with age
The majority of neonates are hypermetropic. The magni-
tude increases until the age of 8 years, when the refraction
becomes relatively myopic, until the end of the third decade
when refractive stability is attained. Increasing hypermetro-
pia characterizes middle age as accommodation decreases.
After the seventh decade there is a myopic shift, due to the
higher refractive index of the nucleosclerotic crystalline lens.
It is impossible to give an accurate prognosis of the prog-
ress of an individual’s refractive error as any single case will
507
17/11/2015 16:01
K17577_C030.indd 508
508 Ophthalmology

Table 30.1  Aircrew eyesight standards at selection.

Refraction range
VA VA Near Muscle balance Accommodation Convergence
Branch (uncorrected) (corrected) (33 cm) Sph Cyl (max ‘phoria) (minimum) (cm) CP
Pilot (includes 6/6 6/6 N5 Plano to +1.75 (RN/ +0.75 DV 6ESO to 8EXO Age 17–20 9D To 10 cm or 2
UAS flying) (RN/AAC 6/12) AAC -0.75 to +1.75 1 Hyperphoria Age 20–25 7D better 4
WSO 6/24 -1.25 to +3.00 +1.25 NV 6ESO to 16EXO
ALM 1 (SAR) 6/9 -0.25 to +3.00 1 Hyperphoria
ALM 2 6/24 -1.50 to +3.00
AEng 6/60 -2.00 to +3.00 No standard laid No standard laid
WSOp down down
WSOpL 44

17/11/2015 16:01

not necessarily adhere to population norms. Myopes tend
to demonstrate an earlier and more rapid myopic progres-
sion than hypermetropes. Care should be taken in assessing
and accepting a young candidate for aviation training with
low myopia as the need for visual correction at an early age
is likely.
Hypermetropia
In hypermetropia, light is focused behind the retina, mak-
ing both distance and near objects blurred. When young,
the eye can accommodate to compensate for this. As the
amplitude of accommodation declines with age, reading
glasses are required at a younger age than normal and dis-
tance glasses will often be required later. Axial hyperme-
tropia is the commonest type and occurs if the eye is short
relative to its focal power. If the refractive power of a nor-
mal sized eye is inadequate then refractive hypermetropia
occurs. Aphakia (no lens) is an extreme example of acquired
refractive hypermetropia.
Hypermetropia can be manifest or latent. Manifest
hypermetropia is the strongest convex lens correction
accepted for clear distance vision. Latent hypermetropia
is the remainder of the hypermetropia, masked by ciliary
tone and involuntary accommodation. Latent hypermetro-
pia is often significant in children, and cycloplegic refrac-
tion, where accommodation is paralysed, is necessary to
measure it.
Hypermetropia that is overcome by accommodation is
called facultative hypermetropia, while hypermetropia in
excess of the amplitude of accommodation is called absolute
hypermetropia. Hypermetropia is corrected with a convex
(plus) lens.
Myopia
In a myopic eye parallel rays of light are focused in front
of the retina. Distant objects are blurred, but near objects
are seen clearly (near sightedness, short sightedness). This
is often because the eye is abnormally long; axial myopia.
In high myopia there may be out-pouching of the posterior
segment of the eye called a posterior staphyloma.
The eye may be of normal length but the dioptric power
may be increased; refractive or index myopia. Examples of
acquired index myopia are keratoconus, where the corneal
refractive power is increased, and nucleosclerosis, where
the refractive power of the lens increases as the nucleus
becomes denser.
Low myopia, the most common type, can be defined
as less than –4.00  dioptres, moderate myopia –4.00  to
–7.75  dioptres, high myopia –8.00  to –12.00  dioptres and
extreme myopia more than –12.00  dioptres. High and
extreme myopia are associated with myopic macular degen-
eration and peripheral retinal degeneration, with at least a
four per cent lifetime risk of retinal detachment.
Myopia is treated with concave (minus) lenses to correct
the distance vision. Axial myopia most commonly becomes
K17577_C030.indd 509
Refractive error in aviation  509
manifest in the early teens progressing until the age of
around 24 years. There is evidence that the reading associ-
ated with higher education induces progression of myopia.
Aviators are usually selected under the age of 24 and often
develop low myopia by the time they have finished their
flying training.
Figure  30.1  demonstrates emmetropia, hypermetropia
and myopia.
Astigmatism
The refractive power of the astigmatic (literally, lacking a
point) eye varies in different meridians. A point focus of
light cannot be formed on the retina. The types of regular
astigmatism are as follows:
Compound hypermetropic astigmatism: rays in all merid-
ians come to focus behind the retina.
Simple hypermetropic astigmatism: rays in one merid-
ian focus on the retina and the other focus lies behind
the retina.
Mixed astigmatism: one line focus lies in front of the
retina, the other behind the retina.
Simple myopic astigmatism: one line focus lies on the
retina, and the other lies in front of the retina (Figure
30.2).
Compound myopic astigmatism: rays in all meridians
come to a focus in front of the retina.
Astigmatism is corrected with a lens that is stronger in
one meridian than the other. There are 2  types of astig-
matic lenses, cylindrical and toric. Cylindrical lenses have
one plain surface and form part of a cylinder. Thus, in one
meridian the lens has no vergence power and is the axis
of the cylinder at right angles to this; the cylinder acts as
a spherical lens. The total effect is the formation of a line
image of a point object, the focal line that is projected paral-
lel to the axis of the cylinder.
H E M
Figure 30.1  Emmetropia (E), hypermetropia (H) and myo-
pia (M). In emmetropia, parallel rays of light are focused
on the retina. In hypermetropia, the eye is relatively short
and the rays of light are focused behind the retina. In
myopia, the eye is relatively too long and the rays of light
are focused in front of the retina.
17/11/2015 16:01
 510 Ophthalmology
Toric lenses can be thought of as a spherical lens with a
cylindrical lens superimposed upon it. Toric lenses may be
defined numerically as a fraction, the spherical power being
the numerator and the cylindrical power of the denominator.
For example a toric lens with the power of +2.00 dioptres in
one principle meridian and +4 dioptres in the other principle
meridian can be regarded as a +2.00 dioptre sphere (DS) with
a +2.00 dioptre cylinder (DC) superimposed and is written
as +2.00/+2.00 DC. The cylindrical correction will be at an
angle which is added to the prescription; if it were at 90° the
prescription would be written as +2.00 DS/+2.00 DC × 90°.
Anisometropia
When the refraction of the two eyes differs, the condition
is known as anisometropia. Small degrees of anisometropia
are commonplace and of no significance; larger degrees in
early childhood are a significant cause of refractive amblyo-
pia. A disparity of more than 1 dioptre in a hypermetrope
is enough to cause amblyopia of the more hypermetropic
eye as accommodation is a binocular function and the
more hypermetropic eye remains out of focus. Myopes with
anisometropia are less likely to develop amblyopia because
both eyes have clear vision. However, when one eye is highly
myopic it usually becomes amblyopic. If anisometropia
occurs in adulthood it causes eye strain and diplopia as the
images from each eye are different sizes and are not resolved
into one image by the brain.
Older individuals with nuclear sclerosis causing index
myopia that affects one eye more than the other may not
tolerate full spectacle correction of the more myopic eye as
they are not accustomed to coping with the anisometropia.
Myopic patients who have been anisometropic for all their
lives tolerate higher degree of anisometropia and achieve
binocular vision with more than 2  dioptres difference
between the two eyes.
Presbyopia
lens fibres and lens capsule that reduce spontaneous steepen-
ing of its surfaces on ciliary muscle contraction. The ciliary
muscle itself may become less efficient with advancing age.
In infancy, the eye is capable of 14  dioptres of accom-
modation; by the age of 45 this has fallen to approximately
4 dioptres. There is an inexorable decline after that. In order
to focus on an object at a reading distance of 25 centimetres
(cm), the emmetropic eye must accommodate by 4 dioptres.
However, one third of the available accommodation must be
kept in reserve for comfortable near vision. A normal indi-
vidual will begin to experience difficulty or discomfort with
near vision at 25 cm when the accommodation has decayed
to 6 dioptres between the ages of 40 and 45 years. Such indi-
viduals are presbyopic. The onset of presbyopia occurs ear-
lier with uncorrected hypermetropia than in emmetropia
because the individual with hypermetropia must accom-
modate more to achieve near vision.
MANAGEMENT OF REFRACTIVE ERRORS
IN AIRCREW
Refractive problems in aviators have more implications than
in the general population, as a relatively minor disability
can have catastrophic effects. Refractive correction in air-
crew historically has been with corrective flying spectacles
(CFS). Over the past 20 years high water content soft contact
lenses (CL) have been increasingly introduced to RAF air-
crew groups and the majority of aircrew who require refrac-
tive correction currently use them for flying.
Corrective flying spectacles
Aircrew who require refractive correction are not permit-
ted to use their own civilian spectacles for flying duties.
Defence-issue corrective flying spectacles (CFS) are suitable

$FFRPPRGDWLRQGLRSWUHV

The amplitude of accommodation declines steadily with age

(Figure  30.3). This is related to sclerosis of the crystalline


V H´ C´ C

H V´
Anterior Posterior 
focal line focal line 0 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72
Figure 30.2  Appearance of an image in simple myopic
astigmatism. A cross with a vertical (VV ′) and horizontal
(HH ′) limb is the object. Corneal astigmatism, in which
the vertical diameter (C ′) is more curved than the horizon-
tal diameter (C). The appearance of the image in simple
myopic astigmatism is shown, where a focus in only one
meridian is possible.
K17577_C030.indd 510
$JH\HDUV
Figure 30.3  Change in accommodation with age. The
upper and lower lines represent the maximum and mini-
mum accommodation, respectively. The middle line repre-
sents the mean. The figures are based on the observation
of 4200 eyes and represent the greatest accommodative
power of each individual.
17/11/2015 16:01

for the working environment both in terms of visual perfor-
mance and robustness. A spare pair of CFS must be carried
in an accessible place while flying, in case of mechanical
failure of the pair that is worn.
CFS are made to high specifications and are issued
after a thorough eye examination by an approved optom-
etrist. The two CFS designs both have the characteristic
aviator shape and matt black coated metal frames. One is
a general-purpose frame (9021A), the other has a wrap-
around shape to the front for use with aircrew respirators
and the AR5 hood (9013A). Low powers have CR39 acrylic
lenses; higher powers have polycarbonate lenses to reduce
the weight and thickness of the lenses. They all have anti-
scratch and anti-reflection coatings. A full range of lenses
are available in single-vision, multifocal and progressive
forms. Half-eye reading designs are available for presbyopic
aircrew who have good unaided distance vision, or who
wear contact lenses.
Multifocal lenses available to RAF aircrew include bifo-
cal lenses, trifocal lenses and progressive power lenses.
Executive bifocals, where the whole lower portion of a
lens is dedicated to near vision are useful for people who
perform a lot of reading. They were the first type of bifo-
cal, as invented by Benjamin Franklin. D-segment bifo-
cals have a small reading segment allowing the greatest
area of the lens to be devoted to distance vision. The
D-segment bifocal is most popular with aircrew and allows
a pilot to see the runway landing flare out of the side of
the distance portion of the lens, in focus. Trifocal lenses
incorporate a further segment of intermediate power for
mid-distance vision. These are often used when an indi-
vidual has to read information from a computer screen or
monitor. Progressive power lenses are designed so the lens
power gradually changes from top to bottom with no vis-
ible interface between the distance and near portions. This
leaves an area of peripheral distortion outside the transi-
tion zone of increasing power that reduces the field of clear
view through the lenses. Varifocal progressive lenses are
increasingly popular among aviators.
CFS have been associated with significant problems in
terms of comfort and safety. In a recent survey, flight safety
incidents attributed to CFS were noted in five per cent of air-
crew per year. The incidents were, for the most part, attrib-
uted to mechanical failure of the CFS and lens obscuration
due to misting or sweat accumulation.
LENS PRESCRIPTIONS
When prescribing a spectacle lens the spherical and cylin-
drical components of the lens are specified in the following
way. The power of the spherical lens is written (e.g. +2.50 DS
(dioptre sphere) or –4.25  DS) followed by the cylindrical
component that specifies the cylindrical power and axis. The
axis of the cylinder is marked on each trial frame according
to a standard international convention. Thus, a cylinder of
–2.50 dioptres placed with its axis vertically in the frame is
written as –2.50  DC (dioptres cylinder) × 90°. Astigmatic
lens prescriptions may be transposed from either a plus DS
K17577_C030.indd 511
Management of refractive errors in aircrew  511
to a minus DS and vice versa. This is often required when
the examiner needs to compare the present refraction with
a previous prescription. This can be accomplished in three
steps as follows:
1. The algebraic sum of DS and DC generates new spheri-
cal power.
2. Change the sign of cylinder retaining the numerical
power.
3. Rotate the axis through 90°.
For example:
+5.5/–1.25 × 125° becomes +4.25/+1.25 × 35°
–1.75/+2.50 × 20° becomes +0.75/–2.50 × 110°
Aircrew contact lenses
Contact lenses (CL) are the preferred option for visual
correction across the whole spectrum of aircrew tasks
(Figure 30.4). The aviation environment is generally dry and
hypoxic and aircrew often work unsociable hours and are
detached at short notice to a range of physical environments.
These factors must be taken into account when prescribing
CL. Most aircrew contact lens wearers use daily disposable
CL. These offer good visual performance, they are hygienic
and convenient. Daily disposable lenses are available in a
wide range of spherical and cylindrical powers.
Different methods are used to stabilize CL to maintain
the correct orientation to correct astigmatism; some are
prism-ballasted whilst others have thin zones that use the
eyelid pressure on blinking to stabilize the lens. In addition
to these, some lenses have the toric surface worked on the
front surface and some have it on the back. For some eyes,
several types are tried before a lens is found that sits at the
correct orientation on the eye.
Silicone hydrogel CLs are made of low water content,
highly oxygen permeable material. They are used for exces-
sively dry eyes or in eyes with high corneal oxygen demands.
These CL can be used for 30 day extended wear, though this
use has not been approved for general aircrew use. The lens
type remains a useful option for problem cases.
Aircrew problems with CL are usually related to dehy-
dration from individual or environmental factors. As a CL
dehydrates, the surface deteriorates causing poor vision,
reduced comfort and reduced oxygen transmission. Aircrew
have a reduced blink rate due to concentration on the tasks
in the aircraft; the air-conditioning systems of aircraft cre-
ate a dry, hypoxic atmosphere that dehydrates individuals
and their CL. If ‘on-eye’ dehydration is a problem, aircrew
are advised to ensure adequate water intake, made aware
of the need to blink (at least once every four seconds), and
may be given a written sheet detailing blinking exercises;
rewetting drops can also be used. If there is a problem with
blocked meibomian glands, which results in a poor lipid
layer and excessive tear evaporation, the advice is to use hot
compresses and lid massage. CL movement is a problem
occasionally reported and has a number of causes. The usual
17/11/2015 16:01
 512 Ophthalmology
reason is that the CL has dried to become uncomfortable
and immobile. This initiates a strong ‘squeeze-blink’ reflex,
which, in turn, can dislocate a lens. Sometimes, a toric lens
is reported to rotate under high G conditions; a blink usu-
ally corrects this.
Corneal hypoxia is occasionally seen, though usually
only in cases where the lenses are persistently worn for too
long or regularly left in overnight. The standard advice is to
wear lenses for a maximum of 12 hours in a day for six days
in a week and not to sleep in them. Chronic hypoxic changes
include new vessels growing into the cornea from the lim-
bus and corneal stromal swelling that causes a change in
refraction and topography. Acute hypoxia is rare and causes
painful corneal oedema.
Microbial keratitis is a serious complication of soft CL
use. It is greatest in hot, dusty environments. Aircrew are
made aware of the signs and symptoms of this and advised
to seek immediate medical help should they suspect that
they have an infection.
Presbyopia is a problem, as there is no really success-
ful soft bifocal CL. Some aircrew revert to bifocal CFS,
though many pilots find that the cockpit instruments are far
enough away and of large enough detail to manage without
a reading correction. Reading glasses are reserved for use
with maps, charts and checklists. A small number of rear
crew, whose work is almost entirely VDU based, are suc-
cessful with ‘enhanced monovision’ (a bifocal lens for the
non-dominant eye and a distance vision lens for the domi-
nant eye) or monovision, (one eye distance, one eye near).
Refractive surgery
Radial keratotomy (RK) was the first large volume surgical
treatment for myopia. A series of corneal cuts are fashioned
in a spoke-shaped pattern around the pupil, penetrating
85–95  per cent of the depth of the cornea. The incisions
cause the perimeter of the cornea to bulge out, flattening the
centre to correct myopia. Some of the problems associated
with the technique were from the permanently weakened
Figure 30.4  Contact lens on finger.
K17577_C030.indd 512
cornea and healing of the incisions that caused regression
of the myopic correction. The refraction changes during the
day and at altitude after RK. These are not desirable char-
acteristics in aviation. RK has largely fallen out of favour as
newer laser techniques have been developed.
The first laser corneal refractive surgery (CRS) for myo-
pia, developed in the latter half of the 1980s, was pho-
torefractive keratotomy (PRK). Here, the anterior corneal
surface is reshaped by photoablation using an ultraviolet
excimer laser. The corneal epithelium is removed prior to
treatment and grows back over the treated zone after four to
six days (Figure 30.5).
Night vision abnormalities may occur after PRK, but are
minimized if a sufficient optical zone is reshaped. Corneal
tissue healing after PRK may lead to haze and regression of
the refractive correction over the first two to three months.
This problem has been virtually abolished with improve-
ments in laser technology, the use of preoperative anti-
fibrotic agents and by restricting the use of PRK to low and
intermediate orders of myopia. The integrity of the globe
is unaffected by PRK and refractive stability is achieved
within three to six months of surgery. No significant diur-
nal or altitude-related variations in refractive error or vision
have been reported.
A variant of PRK, called laser epithelial keratomileusis
(LASEK, not to be confused with LASIK) also displaces a
flap of epithelium, which is replaced after the laser proce-
dure and acts as a bandage (Figure 30.6). Recovery is faster
and less painful with this modification than with standard
PRK. The visual outcome is very similar to PRK and LASIK
but the pain of PRK is minimized.
Laser in situ keratomileusis (LASIK) is a popu-
lar refractive surgical technique. It involves the cutting
of a 100–160  micron flap of corneal tissue and ablating
the underlying stromal bed, before replacing the flap
(Figure 30.7). Disruption of the epithelial layer is kept to a
minimum and avoids an aggressive healing response and
corneal haze. Pain is also minimized and the visual recov-
ery is within one to two days.
Cornea
Laser Laser
Stroma
Epithelium
(a) (b) (c)
Figure 30.5  Main types of corneal refractive surgical tech-
niques. Diagrammatic representation of (a) normal cornea,
(b) photorefractive keratotomy (PRK) and (c) laser in-situ
keratomileusis (LASIK). The corneal epithelium must be
removed before PRK but remains intact during LASIK.
17/11/2015 16:01

Figure 30.6  Temporary removal of corneal epithelium
during laser epithelial keratomileusis (LASEK).
Figure 30.7  Partial-thickness corneal laser in-situ ker-
atomileusis (LASIK) flap before excimer laser treatment.
LASIK is a more predictable and safer method of cor-
recting higher levels of myopia and hypermetropia than
surface treatments. It has similar results for the lower levels
of myopia encountered in aircrew. Night vision abnormali-
ties, including a loss of contrast sensitivity with haloes and
starbursts around light sources can be a problem. Between
1–3 per cent of patients lose two or more lines of their best
vision on a test chart after LASIK. Corneal nerve damage
sustained during the formation of the flap can cause dry
eye and requires lubricants for up to six months postop-
eratively. The corneal flap can become inflamed and melt,
be displaced, or cells may grow under it which need to be
removed by lifting and scraping the flap clean. Corneal
ectasia is where the cornea thins and bulges out in a similar
manner to keratoconus. This occurs when too little residual
corneal bed is left after the laser treatment. It distorts vision
and may require a hard contact lens or even a corneal graft
to treat it.
For low to moderate myopia of around –6.00 dioptres or
less; virtually all patients will achieve 6/12 or better vision
after both LASIK and PRK. Approximately 95  per cent of
patients will achieve 6/6 or better. Aviators start with a low
level of myopia and generally have excellent results from
laser CRS. The glare and haze of PRK is roughly as debili-
tating as the haloes and starbursts of LASIK. After PRK at
–8.00 dioptres approximately 10 per cent of cases will lose a
K17577_C030.indd 513
Management of refractive errors in aircrew  513
line of Snellen acuity postoperatively. Visual results and side
effects are worse as more myopia is corrected.
Wavefront aberrometry allows very accurate correction
of not only the basic sphere and cylindrical errors that are
corrected by spectacles but also the higher orders of ametro-
pia responsible for poor night vision after CRS. It was origi-
nally conceived to correct higher orders of aberration in
the atmosphere and allow better resolution of the stars and
planets in astronomy. Wavefront guided surgery increases
the proportion of patients who achieve excellent vision after
treatment and is the most suitable for aircrew as it reduces
postoperative night vision abnormalities.
Wavefront aberrometry is a useful measure of refrac-
tive error that helps plan refractive surgical treatments. It
allows correction of not only the basic sphere and cylindri-
cal errors that are normally corrected with spectacles, but
also the higher orders of ametropia responsible for poor
night vision. It was originally conceived to correct higher
orders of aberration in the atmosphere for astronomical
telescopes. It is a useful option to maximize night vision
after CRS in aircrew.
Femtosecond laser is a new type that can cleave the lay-
ers of the cornea. It fashions thin flaps that sit well on the
cornea and is commonly used in LASIK. The technique
is popular and is developing into a standard method of
delivering LASIK.
Several surgical techniques are under investigation for
the surgical reversal of presbyopia, but none have been
proved safe and effective. Current approaches to correc-
tion of presbyopia include multifocal or accommodative
intraocular lens (IOL) implantation, scleral expansion, laser
presbyopia reversal and intrascleral segment surgery. If a
patient is over the age of 45 and has had full correction of
a refractive error it is likely that some form of reading cor-
rection will be required. Reading glasses remain the most
effective form of near-vision correction.
Other refractive techniques include implantable contact
lenses (ICL). These lenses are implanted inside the eye. They
are used for eyes that cannot be corrected by CRS (more
than +6.00  dioptres of hyperopia or -10.00  dioptres myo-
pia). The refractive correction is highly predictable and the
lens can be removed if required. The technique provides a
high quality of vision.
Intacs are intrastromal corneal ring implants that are
placed at the edge of the cornea avoiding the line of sight.
They are only effective for relatively low refractive errors
and are useful to treat keratoconus (bulging cornea). They
are easily and safely removed if local deposits develop or
glare makes vision uncomfortable. Intacs do not dislodge
under the G forces encountered in fast jet flight.
Diode lasers are low powered lasers that gently heat spots
near the edge of the cornea to correct hypermetropia and
astigmatism. No tissue is removed. It avoids the line of sight,
helping to preserve night vision. Generally, this is a treat-
ment for the over 40 age group. Laser thermal keratoplasty
(LTK) is similar to diode laser and also avoids the visual
axis. Less energy reaches the deeper layers than with a diode
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 514 Ophthalmology
laser so there is a higher rate of regression of the treatment
effect. As the laser system does not control the position of
the eye, severe astigmatism can be induced if the eye moves
suddenly or is treated off-target.
The USAF and US Navy experiences of CRS is that PRK
enhances flight performance in fast jet pilots and does not
cause a functionally significant loss of vision. Simulated
cockpit studies after PRK found that while appreciation
of low-contrast targets decreased, the operation did not
decrease head up display readability. The reduced contrast
sensitivity did not appear to be clinically or operationally
significant. Further treatment was required in 6–20 per cent
of eyes to render them spectacle independent. For LASIK,
USAF has found that there was little to no effect on treated
eyes when subjected to high G forces of combat fighter air-
craft, the wind blast experienced during aircraft ejection,
or exposure to high altitude. Wavefront guided PRK and
LASIK are considered safe for USAF aircrew with a return
to flying duties after three to six months once refractive sta-
bility has been proved.
If a civilian aviator has had successful refractive surgery,
the Civil Aviation Authority (CAA) sanction that a return
to flying is considered after 6  months following success-
ful surface treatments for myopia, 12  months for hyper-
metropia. Following LASIK, the patient is examined at
2 months and certification is granted after 3 months if it has
been successful.
The RAF policy is that, for existing aircrew, CRS in the
form of PRK, LASEK and LASIK is acceptable. A return
to flying duties is considered after 6–12  months following
successful examination by the RAF Consultant Adviser in
Ophthalmology. At this appointment, a full ophthalmic
examination will be performed with measurement of any
residual refractive error, the best spectacle corrected Snellen
visual acuity and contrast sensitivity testing in photopic
and mesopic conditions using the Pelli–Robson chart. If
required, contrast acuity assessment to assess functional
visual performance and pupillometry in mesopic and sco-
topic conditions will be performed.
As aircrew are normally recruited at an age before ocular
maturity when CRS may not provide long term refractive
stability, CRS is not recommended below age 21 and a mini-
mum of one year must have elapsed since surgery, making
the minimum age at application 22  years. The refraction
should be stable for at least 6 months. The recorded pre-oper-
ative visual defect must not exceed –5.00 to +2.00 dioptres.
The post-operative visual acuity should lie within current
aircrew visual recruitment limits. The subject will also be
assessed by the RAF Consultant Adviser in Ophthalmology.
OPHTHALMIC HISTORY AND
EXAMINATION
Visual abnormalities and ophthalmic conditions are major
causes of rejection from flying training as stringent visual
standards are set for aircrew entry. Prospective candidates
are required to complete a detailed questionnaire relating
K17577_C030.indd 514
to past ophthalmic disease, including the need for or use of
refractive correction and any relevant family history.
Visual acuity
The uniocular distance visual acuities are assessed with a
backlit Snellen chart at six metres. The subject should attend
with recently updated spectacles, a written copy of the cur-
rent spectacle prescription and CL should not be worn for at
least two weeks. The visual acuity is recorded as the lowest
line that is correctly and completely read. The test is first
performed unaided and repeated with spectacle correction.
Common errors include facing the chart at the wrong
distance and shining too much light on the chart, causing
glare and surface reflection; these affect the recorded visual
acuity. Occasionally, the candidate will memorize the let-
ters before the test commences so a different chart face
should be used for each eye. The occluded eye should not
be accidentally pressed by the examiner or candidate, as
this will change its shape and reduce its acuity. The subject
should not be allowed to narrow the palpable fissures as this
minimizes the effects of a refractive error.
The uniocular and binocular near acuity are tested with
the normal reading correction, using standard test types at
33 cm. If the visual acuity is normal at distance, the reading
correction is incorrect if N5 is not attained.
Testing for hypermetropia
It is important to identify any individuals who may be mani-
festly hypermetropic who overcome their refractive error by
accommodating to achieve a normal unaided visual acuity.
These individuals will become presbyopic and then hyper-
opic towards middle age. Manifest hypermetropia can be
diagnosed with a convex lens (usually +2.5 D) and recording
the visual acuity unaided and with the lens. An emmetropic
individual who achieves 6/6 vision without correction will
not be able to achieve that with a +2.5 dioptre lens. If they
can read the line then their manifest hypermetropia is at
least +2.5 dioptres. The highest power of ‘plus’ lens through
which the 6/6 Snellen line can be read quickly and correctly
is the manifest hypermetropia. If the 6/6 Snellen line cannot
be discerned, the amount of ‘plus’ lens is gradually reduced
until it can be read correctly. It is important to ensure the
subject does not try to remember or guess the Snellen letters
and is given sufficient time to read the chart.
It is sometimes necessary to measure the total degree of
hypermetropia by refraction using a topical cycloplegic. The
most commonly used drug is cyclopentolate one per cent
(mydrilate) which acts by paralysing the ciliary muscle to
abolish accommodation (cycloplegia) and the sphincter
pupillae muscle to cause pupillary dilation (mydriasis).
Testing accommodation
If the unaided near acuity is reduced, the accommoda-
tion may be quantified uniocularly and binocularly with
17/11/2015 16:01

and without correction using the RAF near point rule. The
drum with the near test-type is selected. The candidate
places the shaped face piece of the rule on their cheekbones
and holds the handle at the end of the rule. The drum is
moved towards the subjective and the near point is when the
N5 print becomes blurred.
When testing the uniocular accommodation, the right
eye is made to focus on the last word of the N5  line and
the left eye on the first word of that line. The amplitude of
accommodation is measured in centimetres and is indicated
by the end of the slide that carries the drum. Near correc-
tion should be worn during this test where appropriate. The
accommodation is assessed for each eye separately and for
both eyes together. Convergence weakness occurs when the
binocular near is less than the uniocular near visual acuity.
Testing convergence
The line and dot test on the RAF near point rule is used.
The drum is moved towards the subject who is instructed
to declare when the single vertical line becomes double
(not blurred). The distance in centimetres is the subjective
convergence. One eye may be observed to hesitate, stop or
diverge suddenly as the drum advances. This represents the
point of objective convergence and is also measured in centi-
metres. Objective and subjective convergent measurements
may differ in the same individual who may not perceive
the doubled vertical line. Subjective convergence should be
measured initially; if this is unattainable the objective con-
vergence should be measured and recorded.
Convergence weakness will often cause eyestrain (asthe-
nopia). If problematic, orthoptic exercises will usually greatly
improve convergence and visual comfort. Symptomatic con-
vergence weakness is often the result of ageing rather than
significant pathology and is associated with presbyopia.
Stereopsis
Stereopsis is the ability to obtain an impression of depth
by the superimposition of two images, one from each eye.
Stereoscopic vision results from normal visual pathways
that have developed optimally. Stereopsis may only be per-
ceived by a subject possessing fully developed and inte-
grated vision and eye movement control.
An individual’s visual system reaches full maturity at
7 to 10 years. It may not realize its full stereoscopic poten-
tial due to ocular abnormalities, usually uncorrected refrac-
tive error or strabismus (squint). Subsequent stimulation to
the visual system will have no significant effect enhanc-
ing stereoscopic vision in a similar fashion to amblyopia.
Psychological 3D vision is depth perception independent
of stereopsis; gained by knowledge and experience of the
known environment. It relies in the subject interpreting
visual clues that include relative image size, light intensity,
shadows and the movement of objects relative to each other
(parallax). Stereopsis is a requirement for pilots and is desir-
able in all aircrew trades.
K17577_C030.indd 515
Ophthalmic history and examination  515
Stereopsis in aircrew is assessed with the Toegepast
Natuurwetenschap Onderzoek (TNO) random dot stereo-
gram stereo test. The TNO test insists of seven plates each of
which contains various shapes (squares, dots, crosses) cre-
ated by random dots in complimentary colours which are
viewed with red–green spectacles. The plates contain both
visible features, which can be seen with and without specta-
cles, as well as hidden shapes which are only apparent when
the spectacles are worn and stereopsis is present. The first
three plates enable the examiner to establish the presence of
stereoscopic vision quickly and the other plates are used to
determine its level. The TNO test provides a true measure-
ment of stereopsis as there are no monocular clues.
The Frisby test is a simpler test of stereovision that can
be used for aircrew. It consists of three clear plastic plates,
each containing four squares of small, random shapes. One
of the squares contains a hidden circle painted on the other
side of the plate. The test does not require special spectacles
because the disparity is created by the thickness of the plate.
Testing ocular muscle balance
Normally when the eyes are regarding a distant object,
the visual axes are parallel. A state of ocular balance with
image fusion without effort is termed orthophoria. Ocular
imbalance results in varying degrees of squint or strabismus
where the deviation can be manifest (tropia) or latent (pho-
ria). Latent ocular misalignment, where the ocular balance
is maintained with effort, is phoric. When image fusion
is absent and the eyes are misaligned, there is a manifest
squint, or tropia. Diplopia (double vision) is rare in a congen-
ital squint due to central cortical suppression of the image
of one eye (strabismic amblyopia). If the manifest squint is
associated with diplopia it is likely to be an acquired dis-
order of extraocular muscle function. Squints are assessed
initially using the cover and alternate cover tests.
Cover–uncover test
The cover–uncover test is a monocular test designed to
diagnose manifest squints. It should be performed for both
near and distance. If the left eye shows a displacement of the
corneal light reflex the examiner should cover the opposite
right eye in search for any movement of that eye. A nasal
movement to take up fixation indicates exotropia, a tempo-
ral movement esotropia, a downward movement hypertro-
pia and an upward one hypotropia. If there is no movement
of the left eye, the test is repeated on the right eye. An eye
may also fail to move on the cover–uncover test if there is
eccentric fixation or if it is blind.
Alternate cover test
The alternate cover test is for latent squints and is performed
only if the cover–uncover test is normal. One eye is cov-
ered for approximately 2 seconds; the cover is then quickly
shifted to the opposite eye. At this moment the examiner
17/11/2015 16:01
 516 Ophthalmology
notes any movement of the uncovered eye as it assumes fixa-
tion. If no movement occurs the patient is orthophoric. A
nasal movement indicates exophoria, a temporal one eso-
phoria and a downward one hyperphoria. The patient with
a heterophoria will, therefore, have straight eyes both before
and after the alternate cover test has been performed, but
during the test a deviation will be induced as a result of dis-
sociation of the visual fusion mechanisms of the eyes.
Prism cover test
The prism and alternate cover test measures the total devia-
tion (latent plus manifest), but does not separate heterotro-
pia from heterophoria. Hand-held prisms are placed in front
of one eye with the base of the prism placed in the direction
that is opposite to the deviation. In a convergent squint, the
prism is held base out. The alternate cover test is then per-
formed and the endpoint reached when the prism negates
eye movement. The angle of deviation, in dioptres, is read
from the strength of the prism. This test is the gold standard
in the measurement of ocular deviations.
Maddox rod
The Maddox rod consists of a series of fused cylindrical red
glass rods which convert the appearance of a white spot of
light into a red streak. The optical properties of the rods
cause the streak of light to be at an angle of 90 degrees with
the long axis of the rods. When the glass rods are held hori-
zontally, the streak will be vertical and vice versa.
The (red) rods are placed, by convention, in front of
the right eye. This dissociates the two eyes because the red
streak seen by the right eye cannot be fused with the unal-
tered white spot seen by the left. The amount of dissociation
is measured by the superimposition of the two images using
prisms. The base of the prism is placed in the position oppo-
site to the direction of the deviation. Both vertical and hori-
zontal deviations can be measured in this fashion. When
the white dot crosses to the right of the vertical line there is
an esophoria. When it remains on the left it is an exophoria.
Vertical deviations are measured by rotating the rods to a
vertical position.
Maddox wing
The Maddox wing dissociates the two eyes for near fixation
at 33  cm and measures the amount of heterophoria. The
instrument is constructed in such a way that the right eye
sees only a white vertical arrow and a red horizontal arrow
and the left eye sees only a horizontal and a vertical row of
numbers. The horizontal deviation is measured by asking
the patient which number the white arrow points to. The
vertical deviation is measured by asking the patient which
number the red arrow intersects. A cyclophoria (rotation)
can be measured by asking the patient to move the red
arrow so that it is parallel with the horizontal row of num-
bers (Figure 30.8).
K17577_C030.indd 516
Left hyperphoria
22
20
18
16
14
12
10
22-20-18-16-14-12-10-08-06-04-02-01-03-05-07-09-11-13-15
Exophoria 6
Esophoria
4
2 incy
0
1 excy
3
5
7
9
11
13
Right hyperphoria
Figure 30.8  Maddox wing test.
Colour vision
In the early days of aviation, very few colours were used in
the cockpit apart from red to signify stop and green to sig-
nify go. Today, colour is used in the cockpits of civil and
military aircraft, as well as air traffic control radar screens.
This increases the demands on the visual system to recog-
nize this coded information. There is a body of evidence
that suggests that colour defective pilots have significantly
reduced target acquisition and lower reaction times to
coloured visual stimuli than colour normals.
Three classes of cones with separate absorption spectra
are responsible for colour vision in the human eye. These
are blue, green and red cones. These are concentrated in the
macular region and react to produce an electrical output in
response to light of different hues. This output is modified
in the retina, the visual pathway and the visual cortex to
balance the relative input of colour information and give the
sensation of colour perception.
Colour deficiency may be congenital or acquired.
Congenital red/green deficiency is a sex linked character-
istic and occurs in 8 per cent of males and 0.4 per cent of
females. Normal trichromats have normal amounts of all
three cones types with normal colour vision. Anomalous
trichromats are colour weak and are slightly deficient in
one of the cone types. Protanomaly is a deficiency in the
red cone type (red weak) and affects 1  per cent of males.
In deuteranomaly, there is a slight deficiency in the green
cone type (green weak) that occurs in 5–6 per cent of males.
Tritanomaly, a slight deficiency in the blue cone type (blue/
yellow weak), occurs in 0.002–0.007 per cent of the popula-
tion. A dichromat is completely colour blind and has two
cone types; a protonope lacks the red cone (1  per cent);
deuteranope lacks the green cone (1  per cent); and tritan-
opes, the rarest of congenital colour defectives, lack blue
cones (0.002–0.007 per cent). Red/green deficiencies are all
x-linked characteristics whereas blue/yellow deficiency is an
allelic characteristic with an equal sex ratio.
Acquired colour defects occur in 5–15 per cent of the pop-
ulation. They affect both sexes equally and typically cause a
17/11/2015 16:01

blue/yellow defect, but red/green discrimination may also
be affected. They are associated with ageing, ocular disease,
medications and drug ingestion. They may be insidious and
precede any other visual loss. Drugs that commonly cause
acquired colour vision deficits include oral contraceptives,
oral diabetic agents, tetracyclines, anti-malarial drugs,
digoxin, ethanol, tobacco, Viagra and thiazide diuretics;
several of these will commonly be used in aircrew. The use
of Sildenafil citrate (Viagra) to boost sexual performance is
associated with a particularly marked effect on blue/yellow
colour discrimination and is associated with a bluish tinge
visually. These effects have been reported in 30–50 per cent
of users in a dose-dependent fashion and last for between
one and six hours. An aviator who uses this drug must not
fly for 24 hours after ingestion.
Electronic flight instrumentation systems
Electronic flight instrumentation systems (EFIS) allow
colour-coded alphanumerical and analogue data for flight
management and control. This is polychromatic data using
more than eight colours, each of which can be displayed at
different light intensities with graphics ranging from very
small areas to entire backgrounds.
The conditions governing the use of colour have changed
from previous cockpit designs and the pilot observes these
colour screens for long periods of time. The colour does not
just have safety connotations but is used to save time read-
ing information; for example, the colour yellow is reserved
for power information and magenta for track or trajectory
processing. Cockpit control images may have several jux-
taposed or superimposed colours. The intensity of contrast
between a colour and a black background is no longer valid
as colour contrast against other colours is utilized.
Measuring and grading colour perception
At present, congenital red/green colour deficiency is tested
in aircrew. A test for acquired defects may be required in the
future. The tests used in British Aviation are the Ishihara
pseudo-isochromatic plate test for colour confusion in
protanopes (confused greens and red) and deuteranopes
(confused greens and purple) (Figure  30.9). The standard
24 plate test is used under suitable lighting conditions. If the
correct numbers are identified, the individual is declared
CP2 colour normal and no further testing is performed.
If the Ishihara plate test is failed, the Holmes–Wright
lantern (type A) is the approved occupational colour vision
test for military aviators; it is also approved for European
commercial pilots. The test requires an individual to tell the
difference between red, green and white lights at different
brightness and is a sensitive screen test for red/green colour
deficiency. The lantern is used at 6 metres in a darkened room
and two lights, one above the other, are presented to the sub-
ject wearing normal spectacle correction. The colours are
named and the test is repeated with various colour combina-
tions. If no mistakes are made in the first run, the individual
K17577_C030.indd 517
Ophthalmic history and examination  517
Figure 30.9  Ishihara plate test card. The number ‘5’ is
read by red/green colour-normal people. (See Colour
Plates section for Ishihara interpretation.)
passes and is declared CP3 colour safe. If there is any red/
green confusion, the subject is automatically failed and is
declared CP4 colour unsafe. If there are any other mistakes in
round one, two extra runs are performed and, if no mistakes
are made in these, the individual is passed as CP3. If there are
any mistakes in the second or third run other than red/green
confusion the individual is dark adapted for 20 minutes and
a dark adapted run performed. If the individual passes this
run he is passed CP3. Any mistake in the dark adapted run
and individual fails and is classed CP4 colour unsafe.
CP1  is the situation where an individual passes the
Holmes–Wright Lantern test in a light room with a device
set on low brightness and is an entry standard for Royal
Naval Aviation. The colour vision grading system CP1–4 is
not continuous, but occupational. The Farnsworth lantern
(Falant) is a similar functional lantern test for aviation,
though the Holmes–Wright lantern has a superior correla-
tion with other colour vision tests.
Lantern testing is rapidly becoming outdated as it does
not assess the amount of colour vision loss and is not related
to the colour vision tasks required in aviation. The Ishihara
plate test is not perfect, as 15 per cent of normal trichromats
will fail and a small number of deuteranopes will pass. All the
trichromats will then pass the Holmes–Wright lantern test.
The CAA developed the colour vision assessment and
diagnosis (CAD) system to accurately measure the thresh-
old for perception of red/green and yellow/blue colour sig-
nals. This test uses a continuously changing background to
mask luminance cues (dynamic luminance contrast noise)
to determine the threshold for perception of pure colour
signal. This gives a range of normal measurement of colour
vision that has been linked to visual tasks required in avia-
tion. From this a broader standard of colour vision is used
for civil aircrew. It is likely that the CAD system will be
incorporated into RAF colour vision testing in the future.
17/11/2015 16:01
 518 Ophthalmology

Visual fields
The visual field is an island of vision surrounded by a sea of
darkness. It is not a flat plain but a three-dimensional struc-
ture. The outer aspect of the visual field extends approxi-
mately 60° nasally, 90° temporally, 50° superiorly and 70°
inferiorly. The visual acuity is sharpest at the very top of the
island and then declines progressively towards the periph-
ery; the nasal slope is steeper than the temporal. The blind
spot, where the optic nerve leaves the eye, is located tem-
porally between 10° and 20°. Visual field estimation can be
static, where points within the visual field are tested using
lights of various dimness until a threshold of perception can
be determined, or kinetic, where a target of a set size and
brightness is moved into the visual field until it is perceived.
A scotoma is either an absolute or relative defect in the
visual field. An absolute scotoma represents total loss of
vision. A relative scotoma is an area of partial visual loss
within which some targets can and others cannot be seen. A
scotoma may have sloping edges so that an absolute scotoma
is surrounded by a relative scotoma. There is no set mini-
mum visual field for aviation; any visual field loss is assessed
on an individual basis. Homonymous or bitemporal defects,
whether hemianopic or quadrantanopic, are not accepted as
safe (Figure 30.10a,b).
Amsler grid
The Amsler grid is used to test macular function and to
detect central or paracentral scotomata by projecting a grid
pattern onto the macula (Figure  30.11). The subject wears
their usual reading correction and occludes one eye while
the Amsler grid is held 33 cm in front of the open eye. The
subject is asked what is in the centre of the page; failure to
see the central dot indicates a central scotoma. The subject
fixates on the central dot, or in the centre of the page if the
dot cannot be seen, and is asked if all four corners of the
diagram are visible or if any of the boxes are missing. The

Right visual field

Grayscale Right visual field
Grayscale (6 mth)

30
30

Left visual field Left visual field

Grayscale Grayscale (6 mth)

30 30

(a) (b)

Figure 30.10  Visual fields of a helicopter pilot. (a) This visual field, demonstrating a bitemporal hemianopia, was from a
pilot who flew his own helicopter to the ophthalmic appointment to complain of vague visual disturbances. He had a pitu-
itary prolactin-secreting adenoma diagnosed on magnetic resonance scanning and was treated successfully with cabergo-
line. Another pilot had to be dispatched to collect the helicopter and gave the individual a lift home. Post-treatment, the
visual field returned to normal by six months. (b) The pilot was returned to full flying duties but subsequently always drove
to follow-up appointments.

K17577_C030.indd 518 17/11/2015 16:01

 Ophthalmic conditions encountered in aviators  519

doxycycline 100 mg daily for at least 1 month. This is contra-

indicated in pregnant or lactating women and children under
the age of 12 years when erythromycin is substituted. Warm
compresses are placed on the eyelids to melt solidified sebum.

CHALAZION (MEIBOMIAN CYST)

The meibomian glands lie within the lid tarsal plates and
secrete lipid onto the eye surface. A chalazion is a chronic
inflammatory lesion caused by blockage of one of these
gland orifices with stagnation of the sebaceous secretion
(Figure 30.13). They are painless, roundish, firm lesions in
the tarsal plate. They may mechanically press on the cornea
to cause astigmatism and blurred vision. They are treated
by incision or curettage, through the tarsal plate, under
local anaesthesia.

EPIPHORA
Epiphora is excessive tearing and can be a cause of poor
Figure 30.11  Amsler grid test. vision. It is caused by reflex overproduction of tears by cor-
neal or conjunctival irritation often due to irritation from
subject is then asked if all the lines are straight and con- misdirected eye lashes (trichiasis) or foreign bodies under
tinuous or if some are distorted and broken. Any missing or the eye lid. Obstructive epiphora is caused by mechanical
distorted areas on the grid are outlined with a pencil. The obstruction to tear drainage. Here the excessive watering is
procedure is repeated on the other eye. It is important to exacerbated by cold and windy atmosphere. The causes of
monitor any eye movement away from the central dot. A red the epiphora are usually managed with appropriate surgi-
Amsler grid may define more subtle defects. cal manoeuvres. Occasionally, lacrimal pump failure causes
epiphora secondary to lower lid laxity or weakness of the
OPHTHALMIC CONDITIONS orbicularis muscle (e.g. facial nerve palsy).
ENCOUNTERED IN AVIATORS
Ocular adnexae
BLEPHARITIS
Chronic blepharitis is an inflammation of the eyelid mar-
gins. It is a very common external eye disorder and, as well
as causing annoying symptoms, it may interfere with contact
lens wear and aggravate the treatment of patients with dry
eyes. There are two main types of chronic blepharitis: ante-
rior and posterior blepharitis, though they are often mixed.
The symptoms include a foreign body sensation, mild
photophobia and lid crusting, frequently worse in the morn-
ings and characterized by remission and exacerbation. In
anterior blepharitis, examination of the anterior lid mar- Figure 30.12  Anterior blepharitis.
gin demonstrates hyperaemia telangiectasia and scaling
(Figure 30.12). In posterior blepharitis, there is lid thicken-
ing, an excessively oily and foamy tear film, a reddened poste-
rior lid margin. The treatment of anterior blepharitis is with
lid hygiene using a cotton bud dipped in a cup of warm water
that has been mixed with a few drops of baby shampoo or a
pinch of sodium bicarbonate. The eyelids are scrubbed twice
daily to remove the crusts. This will usually bring the disease
under control. Alternatively, disposable lid care wipes can be
purchased and used in a similar manner. Artificial tears for
the associated tear film instability will often be required.
If these simple measures do not work, onward referral
to an ophthalmic unit is recommended. Posterior blepha-
ritis (meibomitis) can be treated with systemic antibiotics, Figure 30.13  Meibomian cyst (chalazion).

K17577_C030.indd 519 17/11/2015 16:01

 520 Ophthalmology
ORBITAL BLOW-OUT FRACTURE
A blow-out fracture of the orbit does not involve the orbital
rim and is caused by a sudden increase in the orbital pres-
sure by a striking object that is greater than 5 cm in diameter
such as a fist or a tennis ball. The fracture most frequently
involves the orbital floor, though the medial orbital wall
may also be involved.
Signs of an acute blow-out fracture are ecchymosis,
oedema and occasionally subcutaneous emphysema. The
emphysema is worse on nose blowing and this should be
discouraged. There is likely to be infraorbital nerve anaes-
thesia involving the lower lid cheek side of nose, upper teeth
and gums, though this is usually transient. Enophthalmos,
where the eye sinks back into the socket, may occur later
and diplopia may be caused by mechanical entrapment of
the inferior rectus muscle within the fracture, or restric-
tion of extraocular muscle movements due to haemorrhage
and oedema.
Initial treatment is conservative, with prophylactic
antibiotics if the fracture involves the maxillary sinus. The
fracture needs to be confirmed with a computed tomogra-
phy (CT) scan of the facial bones, along with an orthoptic
examination of the extraocular muscle balance. Fractures
involving more than half of the orbital floor with entrap-
ment of the orbital contents associated with persistent
diplopia should be repaired within two weeks by plac-
ing a plate of synthetic material over the orbital floor.
The diplopia is usually a restriction of upgaze and an
aviator’s flight category will be determined by the results
of surgery.
Ocular anterior segment
EPISCLERITIS
Episcleritis presents with mild uniocular discomfort, ten-
derness and watering of the eye. It is an idiopathic inflam-
mation of the episcleral layer of the conjunctiva. It is a
common, benign, recurrent but self-limiting disorder which
typically affects young adults. It is not associated with
systemic disorders.
The two types of episcleritis are simple or nodular.
Simple episcleritis demonstrates sectorial or diffuse red-
ness. In contrast, nodular episcleritis is localized to one area
of the globe, forming a nodule with surrounding injection.
Simple episcleritis usually resolves spontaneously within
one to two weeks, although the nodular type may take lon-
ger. If discomfort is annoying, topical steroids or topical
non-steroidal anti-inflammatory drugs may be helpful. In
the rare unresponsive, recurrent cases, systemic flurbipro-
fen (100 mg three times daily) taken at the first symptom of
recurrence may be successful in aborting the attack.
RECURRENT EROSION SYNDROME
This is a condition where the corneal epithelial basement
membrane complex is damaged by an initial episode of
superficial corneal trauma, especially from a scratch. Its
K17577_C030.indd 520
features are typically recurrent pain on waking with lac-
rimation, photophobia and blurred vision. In mild cases,
these symptoms resolve spontaneously within a few hours.
It is recurrent and may cause problems for months or even
years. After the initial episode has been treated with either
pressure patching or debridement of the loose corneal epi-
thelium, prophylactic ocular lubricants should be given
using artificial tears four times daily and a simple lubricat-
ing ointment at night. Occasionally, further measures, such
as bandage contact lenses, anti-stromal puncture and pho-
totherapeutic keratectomy may be performed to cure the
worst cases. In bilateral cases, there is a good chance that
the erosion is related to an underlying corneal basement
membrane dystrophy rather that trauma.
KERATOCONJUNCTIVITIS SICCA
Keratoconjunctivitis sicca, or dry eye, in aircrew is usually
the result of meibomian gland dysfunction which destabi-
lizes the tear film. It may be secondary to autoimmune dis-
eases including Sjögren’s syndrome where lacrimal salivary
and salivary gland dysfunction is associated with rheuma-
toid arthritis and hypergammaglobulinaemia. The treat-
ment is with topical ocular lubricants. If severe, temporary
punctal occlusion may be performed using punctal plugs;
occasionally, permanent punctal occlusion is required.
MICROBIAL KERATITIS
The only microbial pathogens that are able to produce
corneal infection in the presence of an intact corneal
epithelium are Neisseria gonorrhoea, Corynebacterium
diphtheriae, Listeria subcuratevia and Haemophilus sub-
curatevia (Figure 30.14). Other bacteria are only capable of
producing keratitis after loss of corneal epithelial integrity,
especially associated with extended wear soft contact lens.
Other causes are from ocular surface disease such as post-
herpetic corneal disease, trauma, bullous keratopathy, cor-
neal exposure or dry eye.
A bacterial corneal ulcer is associated with severe ocular
pain and loss of vision in the affected eye. It is a sight-threat-
ening condition demanding urgent identification and erad-
ication of the causative organism. This is best performed
with the patient hospitalized. A corneal scrape is taken for
culture and sensitivity and broad spectrum topical antibiot-
ics are administered intensively. Aviators may be susceptible
to this condition, especially when wearing contact lenses in
hot and dry countries.
ADENOVIRAL KERATOCONJUNCTIVITIS
This highly contagious, viral keratoconjunctivitis is com-
mon in the crowded conditions of military camps and
presents with an acute onset of watering, redness, discom-
fort and photophobia. Both eyes are affected in approxi-
mately 60  per cent of cases. Examination demonstrates
follicular conjunctivitis and lid oedema associated with a
preauricular lymphadenopathy. In severe cases, subcon-
junctival haemorrhages, chemosis and pseudomembranes
can develop.
17/11/2015 16:01

Figure 30.14  Microbial keratitis in a wearer of soft
contact lenses. The white precipitate is from the topical
ofloxacin treatment.
Treatment is generally avoided unless the symptoms are
severe, when topical steroids are instilled and spontaneous
resolution occurs within two weeks. A sufferer must be iso-
lated in case of disease spread, often through shared towels.
The cornea can also be affected with diffuse punctate epithe-
lial keratitis that spontaneously resolves or focal white subepi-
thelial opacities that may persist for several months and may
affect the visual axis. Topical steroids suppress corneal inflam-
mation to improve vision but do not shorten the natural course
of the disease and may need to be used for several months.
HERPETIC KERATITIS
Herpes simplex virus 1  predominantly causes infection
above the waist (face, lips and eyes) and is usually acquired
by coming into close contact with a person who either has a
cold sore or asymptomatic shedding of herpes labialis virus.
Keratitis follows an attack of blepharoconjunctivitis and is
characterized by a dendritic ulcer that stains with fluores-
cein dye (Figure 30.15). Treatment is initially with acyclo-
guanosine (Acyclovir) three per cent ointment five times
daily for one week. Neurotrophic ulcers may occur after
the primary infection. These are sterile ulcers with smooth
margins in an area of stromal disease that persist despite
anti-viral therapy and are associated with stromal melting
and corneal perforation.
Corneal stromal disease may occur with disciform kera-
titis where disc-shaped stromal oedema with an intact epi-
thelium occurs. A mild iritis with localized granulomatous
keratic precipitates is typical the intraocular pressure may
be raised. Necrotizing interstitial keratitis with multiple
or defuse whitish grey corneal stromal infiltrates may also
occur, associated with corneal thinning and neovascular-
ization. Treatment of disciform keratitis is with a combi-
nation of topical steroids combined with anti-viral cover.
This treatment is slowly tapered off over a period of weeks.
Occasionally a patient will require continuous therapy.
K17577_C030.indd 521
Ophthalmic conditions encountered in aviators  521
Figure 30.15  Dendritic corneal ulcer.
KERATOCONUS
Keratoconus (conical cornea) is a disorder in which the
cornea thins and assumes an irregular, conical shape
(Figure 30.16). The hallmarks of keratoconus are paracen-
tral stromal thinning, corneal protrusion and irregular
astigmatism. The condition starts at around puberty and
progresses slowly thereafter, although it may become sta-
tionary at any time. Both eyes are affected in about 85 per
cent of cases, although the disease is asymmetrical. The
aetiology of keratoconus is obscure, there is a hereditary
component as the offspring of keratoconics have a ten per
cent chance of being affected. Keratoconus is often associ-
ated with atopy and eczema. The wearing of hard contact
lenses and constant eye rubbing have also been proposed as
predisposing factors.
The diagnosis is made using retinoscopy, keratometry,
photokeratoscopy and slit lamp biomicroscopy. Management
is with spectacle correction in early cases followed by hard
contact lenses to provide a regular refractive surface over
the cone. When contact lenses cannot be worn any further,
a partial- or full-thickness penetrating keratoplasty is per-
formed. Potential aircrew are screened for keratoconus.
Early signs are seen in forme fruste keratoconus diagnosed
in eyes that are otherwise refractively normal. A diagnosis
of keratoconus or forme fruste keratoconus precludes an
individual from aircrew selection as there is a chance that
the disease will progress and prevent the individual from
completing a career in aviation.
UVEITIS
Uveitis is an inflammation of the uveal tract. It may be
subdivided into anterior uveitis, in which the iris and,
occasionally, the anterior part of the ancillary body are
inflamed; intermediate uveitis, in which the posterior part
of the ciliary body is affected; posterior uveitis, in which
the inflammation is located behind the posterior border of
the ciliary body; and pan uveitis, in which the entire uveal
tract is involved. Intermediate, posterior and pan uveitis
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 522 Ophthalmology

48.0
Power: 43.5D
47.0 Radius: 7.76 mm 105 90 75
46.0 From vertex: 120 60
45.0 Distance 0.00 mm 135 45
S-merid 0°
44.0 From pupil: 150 30
43.0 Distance 0.33 mm
S-merid 216°
42.0 165 15

41.0
Simulated Keratometer: 180 0
40.0 44.75D (7.54 mm) @92
42.75D (7.89 mm) @2
39.0
195 345
38.0 Astigmatism: 2.00D

37.0 CIM: 2.27 210 330

Shape Factor: 0.75
Diopter 225 315
Standard Pupil Size: 2.93 mm
240 300
AutoSize OS 255 285
270
Custom 08/23/03
11:25 AM
Options

Figure 30.16  Corneal topographic appearance of keratoconus.

are associated with progressive and severe visual loss. These
diseases require systemic immunosuppression and will usu-
ally lead to a severely restricted flying category.
Anterior uveitis is the most common type, followed by
intermediate posterior and pan uveitis. Anterior uveitis may
be acute or chronic. The main symptoms of acute anterior
uveitis are photophobia, pain, redness, decreased vision
and lacrimation. In chronic anterior uveitis, the eye may
be white and the symptoms minimal, even in the presence
of severe inflammation. The signs are a purplish reddish
hue to the eye, associated with keratic precipitates, cellular
deposits on the corneal epithelium. The anterior chamber
has flare and cells and the iris may be stuck to the lens by
posterior synechiae.
Anterior uveitis may be associated with arthritis and
ankylosing spondylitis, especially in the presence of HLA
B27. Reiter’s syndrome consists of a combination of non-
specific urethritis, conjunctivitis and seronegative arthritis
with iritis. The disease affects men more frequently than
women and approximately 75 per cent of patients are posi-
tive for HLA B27. The most common association is conjunc-
tivitis, which follows the urethritis by approximately two
weeks and precedes the onset of arthritis. This disease is
rare in the general population but more common amongst
the aircrew population who will often be deployed to foreign
countries and be exposed to sources of non-specific urethri-
tis. The disease can also be triggered by gastroenteritis.
Treatment of anterior uveitis is with topical steroids and
cycloplegia. Often, the disease is recurrent, though inter-
mittent. Common sense should be employed when dealing
with aircrew with recurrent anterior uveitis and it is pos-
sible for them to attain a full flying career; they should not
fly if the disease is active.
OCULAR HYPERTENSION AND GLAUCOMA
Aqueous humour is produced by active secretion from the
ciliary body that lies behind the pupil. The aqueous humour
passes through the pupil into the anterior chamber where it
drains under resistance through the trabecular meshwork
that lies at the iridocorneal angle. Approximately 10 per cent
of the aqueous humour drains across the ciliary body and
iris. The normal intraocular pressure (IOP) varies between
10 mmHg and 21 mmHg (mean 16 mmHg) and increases
with age as the trabecular resistance increases.
Glaucoma is a term used to describe a collection of
syndromes demonstrating a characteristic form of optic
neuropathy usually associated with a raised intraocular
pressure. The many types of glaucoma can be classified
as having open iridocorneal angles or the angle closure
type according to the manner by which aqueous outflow
is impaired. The disorder may be primary or secondary
depending on the presence of associated factors contribut-
ing to the rise in intraocular pressure.
Ocular hypertension is diagnosed when an individual
has a raised intraocular pressure without any clinical signs
of glaucoma. Such individuals have an increased risk of
developing glaucoma. Aircrew with intraocular hyperten-
sion require annual monitoring with visual field analysis
and are likely to receive treatment if there are significant
risk factors.

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 Ophthalmic conditions encountered in aviators  523

Primary open angle glaucoma (POAG) has an insidi-
ous onset and is only symptomatic if the intraocular pres-
sure is extremely high. It is a common disease occurring in
approximately one per cent of the population. If there is a
positive family history of the disease in a first degree rela-
tive, the lifetime chance for developing POAG is 10 per cent.
Other associated factors include myopia, diabetes, increas-
ing age and ocular hypertension. A cupped optic disc is a
cardinal sign of open angle glaucoma. Visual fields are then
performed looking for the characteristic arcuate scotoma
(Figure  30.17). Aircrew usually present with adult type
POAG in the final stages of their flying careers.
When POAG is diagnosed, the initial treatment is
medical using topical ocular antihypertensives. Where
this fails, surgical treatments are used. The most com-
mon surgical intervention for POAG is a trabeculectomy,
in which a guarded sclerostomy is fashioned to bypass the
trabecular meshwork of the iridocorneal angle and allow
aqueous to directly drain to the episcleral vessels at a
lower pressure. Topical preparations for the treatment of
POAG have increased in number over recent years. They
Fixation Monitor: Gaze/Blindspot
Fixation Target: Central
Fixation Losses: 0/22
False POS Errors: 1/15
False NEG Errors: 0/14
Test Duration: 13:47
act to suppress aqueous production by the ciliary body or
increase uveoscleral outflow. The majority of aviators with
glaucoma will continue to fly under medical surveillance,
according to the nature of the glaucoma and the state
of the visual fields. Specialist supervision of glaucoma
patients is lifelong.
CATARACTS
Cataracts are congenital or acquired opacities of the crystal-
line lens. They are classified according to their morphology,
the age of onset and their causation. The vast majority of
cataracts in the general population are age-related. In the
younger aircrew population, cataracts are more commonly
due to progression of congenital lens opacities or secondary
to trauma, ocular inflammation, diabetes mellitus, steroid
use or previous intraocular surgery. A cataract that does not
cause visual symptoms need not impose limitations to fly-
ing in established aircrew but would be a bar to entry to fly-
ing training, as it might progress. The visual symptoms of
cataracts include blurred and reduced visual acuity, reduced
contrast sensitivity, significant glare that is worse when
Stimulus: III, White Pupil Diameter: 3.5 mm Date: 07-29-96
Background: 31.5 ASB Visual Acuity: 20/25 Time: 8:38 a.m.
Strategy: Full Threshold RX: +4.50 DS DC X Age: 67

Fovea: OFF 10 8 2 2
(10)
15 10 14 <0 0 6
(12) (4) (<0) ( 4)
13 7 25 16 14 0 2 18
(11) (3) (19) (12) (18) (<0) (14)
14 16 22 25 29 28 4 25
28
30 (29) (28) Δ (25) 30
22 26 28 30 29 29 <0 20
29
(30) (29) (29) (26)
24 30 31 29 24 23 26 26
(31) (23)
24 27 26 27 27 28
(24) (26)
28 25 26 26

–13 –15 –21 –21

–15 –16 –23 –22
–12 –16 –19 –29 –28 –21 –10 –15 –17 –27 –26 –19

–14–23 –8 –16 –13 –29 –25 –11 –13 –22 –6 –14 –11 –23 –24 –9
GHT
–11 –11 –7 –6 –3 –2 –2 –3 –9 –9 –5 –4 –1 0 0 –1
Outside normal limits
–3 –2 –2 –2 –1 –2 –1 –5 –1 0 0 0 0 0 0 –4
–3 0 0 –2 –6 –7 –3 –2 –1 3 2 0 –5 –5 –1 0
–4 –2 –3 –2 –2 –2 –2 0 –2 0 0 0
MD: –6.89 dB P < 0.5%
1 –3 –2 –2 3 0 0 0
PSD: 8.68 dB P < 0.5%
Total Pattern SF: 1.75 dB
Deviation Deviation CPSD: 8.48 dB P < 0.5%

P < 5%
P < 2%
P < 1%
P < 0.5%

Figure 30.17  Glaucomatous visual field, demonstrating an arcuate scotoma.

K17577_C030.indd 523 17/11/2015 16:01

 524 Ophthalmology
above the cloud canopy and at night, multiple uniocular
images and progressive myopia.
The management of cataracts is surgical (Figure 30.18).
The most common procedure is phacoemulsification with
intraocular lens implant through a small (less than 3 mm)
corneal incision. The intraocular lenses are foldable and usu-
ally made of silicone or acrylic material. These are implanted
into the capsular bag following the cataract extraction and
focus light to the retina. A unifocal lens is used in aircrew
and the lens selected to give minimal post-operative refrac-
tive error with maximal distance vision. In prepresby-
opic aircrew with unilateral cataracts, the unaffected lens
accommodates for near vision and no reading correction
is required. Multifocal intraocular lenses are not recom-
mended as they reduce contrast sensitivity and increase
glare. The intraocular lens selected for aircrew is designed
to minimize visual aberrations that might cause glare.
Post-operative posterior lens capsule opacification may
occur in up to 10  per cent of cases. Subjects complain of
symptoms similar to those caused by the cataract. It is easily
managed using an yttrium–aluminium–garnet (YAG) laser
to make a hole in the opaque capsule over the visual axis to
restore vision. There is sufficient remaining capsule to sup-
port the intraocular lens.
The specific gravity of the intraocular lens is approxi-
mately the same as the fluids of the eye. This makes the
effect of high G force and ejection negligible. No movement
of an intraocular lens has ever been reported in pseudopha-
kic ejectees. A full return to flying duties can be expected
between six and 12 weeks after uncomplicated cataract sur-
gery, if the visual function is adequate.
Retinal disease
RETINAL DETACHMENT
This is where fluid passes from the vitreous cavity under the
retina causing it to separate from its retinal pigment epithe-
lium. Individuals notice flashes of light, floaters, a ‘curtain’
or shadow moving across the field of vision and periph-
eral or central visual loss. On ophthalmoscopy, the retina
will appear mobile, opaque and sometimes folded. In  the
Figure 30.18  Postoperative appearance of an eye after
cataract surgery. The intraocular lens is visible in the cen-
tre of the eye.
K17577_C030.indd 524
aircrew population, trauma is the most common cause.
Patients with an acute retinal detachment that threatens the
macula should be operated on at the earliest opportunity
to preserve the macular vision. The surgical repair is either
with an external procedure where the retinal break is closed
by indenting the sclera with a silicone explant or a vitrec-
tomy with internal tamponade with silicone oil or gas. The
break is sealed in both cases by the creation of a chorioreti-
nal scar using laser retinopexy or cryopexy.
Air travel is contraindicated in an eye with intraocu-
lar gas. If more than approximately 1  ml of the bubble
remains, it will expand at altitude, according to Boyle’s
law, causing an acute rise in IOP that may be painful.
Patients recovering from retinal detachment surgery with
intraocular gas and wishing to fly should only do so after
being examined by their ophthalmologist. Silicone oil
is also used as an intraocular tamponade agent and will
not expand at altitude. This allows air travel soon after
the operation, though the oil is removed at a later date.
Visual recovery after retinal detachment surgery depends
on whether the macula has been affected and whether the
visual field recovers after surgery.
CENTROSEROUS CHORIORETINOPATHY
Centroserous chorioretinopathy (CSC) is an idiopathic
macular exudative disease that typically affects young to
middle aged men. The characteristic localized neurosen-
sory detachment of the macular region is caused by leakage
of fluid at the level of the retinal pigment epithelium that
underlies the retina and normally removes fluid from the
subretinal space. It presents with unilateral, sudden onset,
blurred vision associated with a greenish-brown positive
scotoma, micropsia and metamorphopsia with impaired
dark adaptation. The diagnosis is made on careful clinical
examination and confirmed by fluorescein angiography,
where characteristic patterns of leakage are observed.
Approximately 80  per cent of eyes with CSC undergo
spontaneous resolution of subretinal fluid with a return
to normal or near-normal visual acuity between six weeks
and six months. Even if the visual acuity returns to nor-
mal, some detgree of subjective visual impairment, such as
micropsia, can persist. This seldom causes any significant
disability. When there are recurrent and prolonged attacks,
progressive disturbance of the retinal pigment epithelium
associated with permanent central visual loss can occur.
Focal argon laser photocoagulation to the site of retinal
pigment epithelial leakage reduces the time to resolution
of the serous detachment but does not reduce the recur-
rence rate of CSC or prevent visual loss associated with
chronic progressive retinal pigment epithelial changes.
Photodynamic therapy using indocyanine green dye and
an infrared laser is a recent and less destructive form
of phototherapeutic treatment, with promising results.
Aviators with CSC are often unfit aircrew duties while they
have significant visual disturbances. They will often opt for
laser treatment of the problem rather than wait for sponta-
neous resolution.
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CENTRAL RETINAL VEIN OCCLUSION
Central retinal venous occlusion is associated with increas-
ing age, systemic hypertension and blood dyscrasias. A
subset of younger patients will develop central retinal vein
occlusions and this may be encountered in the aircrew pop-
ulation. It typically affects one eye of a healthy adult under
the age of 40 years and it probably represents a different dis-
ease process to that seen in older patients. It has been pos-
tulated that it may be caused by a congenital abnormality in
the central retinal vein at the level of the lamina cribrosa,
which gives rise to turbulent flow and thrombus formation.
Presentation is with visual impairment, which is charac-
teristically worse in the mornings. Ophthalmoscopy during
the acute stage demonstrates disc oedema and a moderate
amount of retinal haemorrhage. Systemic causes of central
retinal vein occlusions including sarcoidosis and Behçet’s
disease, autoimmune collagen vascular diseases and the
anti-cardiolipin antibody syndrome. The prognosis is usu-
ally good if the retina does not become ischaemic. A poor
outcome occurs occasionally, especially when ischaemia
and exudative retinal detachment occur. If severe retinal
ischaemia occurs, rubeosis iridis may develop with associ-
ated secondary glaucoma. Panretinal argon laser photoco-
agulation is performed to prevent this.
Neurophthalmology
AMBLYOPIA AND SQUINT
Potential aircrew with a manifest squint and amblyopia will
for the most part be screened out on selection. Amblyopia,
(lazy eye) is caused by suppression of central vision from
suboptimal retinal stimulation during visual develop-
ment in the first six to eight years of life. Amblyopia will
occur in children with strabismus, (strabismic amblyopia)
unequal refractive error (anisometropic amblyopia) or as
a result of uniocular visual occlusion often from cataracts,
ptosis or eyelid tumours (stimulus deprivation amblyopia).
Amblyopia is rarely bilateral and the amount of reduced
vision varies. Occasionally, individuals will be fit for air-
crew duties with mild forms of amblyopia. The treatment of
amblyopia is with adequate spectacle correction and patch-
ing of the good eye before visual maturation is completed
at around seven years of age. After this, no treatment can
improve the vision of the amblyopic eye.
Acquired squints may arise from extraocular muscle
paralysis (III, IV and VI cranial nerve palsies) and will often
cause diplopia. Systemic, intracranial, vascular and trau-
matic causes of these palsies should be excluded and treated
if present. Where diplopia persists, prisms can be incor-
porated into the patient’s glasses to give single vision. It is
unlikely that a flying category will be awarded to aircrew
with diplopia while looking straight ahead, even if it can be
corrected with prisms. Occasionally, individuals with mini-
mal diplopia in the far extremes of gaze and who do not
require a great fusional effort to control it in the primary
position may be awarded a flying category.
K17577_C030.indd 525
Ophthalmic conditions encountered in aviators  525
OPTIC NEUROPATHY
This describes inflammatory or demyelinating disorders
of the optic nerve. The most common type is retrobulbar
neuritis where the optic nerve is inflamed behind the optic
disc. It is associated with multiple sclerosis in approximately
75 per cent of women and 35 per cent of men over 15 years
of age. Presentation is typically with an acute onset on mon-
ocular visual loss associated with periocular discomfort
made worse on moving the eye. There may also be frontal
headache with tenderness of the globe. Ophthalmoscopy is
usually normal, although a few have papillitis. The visual
acuity is markedly diminished and colour vision is typi-
cally decreased, with a washed-out appearance to red tar-
gets compared to the other eye. There is usually an afferent
pupillary defect and electrodiagnostic tests of optic nerve
function are abnormal.
Seventy-five per cent of patients will recover their visual
acuity over the ensuing four to six weeks. Colour vision and
contrast sensitivity often remain abnormal. Optic atrophy
may be observed after recovery. In the acute phase, intrave-
nous and oral steroids may be used; though the treatment
does not improve the final visual outcome, it reduces the
recovery period by approximately two weeks. An avia-
tor with optic neuritis will only regain a flying category
when the visual acuity, colour vision and visual fields have
returned to a satisfactory level.
ABNORMAL PUPILLARY REACTIONS
Aircrew will occasionally present with abnormal pupils,
usually complaining that one pupil is larger than the other.
This is termed anisocoria and is either episodic or constant.
Episodic anisocoria can be due to migrainous episodes,
ocular inflammation or benign pupillary dilation where
the papillary asymmetry may change. In the absence of any
other medical abnormalities and normal pupillary light
reactions, it is likely to be physiological anisocoria.
In constant anisocoria, with sluggish pupil reactions to
light and if iris trauma, pharmacological dilation or a third
cranial nerve palsy have been excluded, it is likely to be a
Holmes–Adie pupil. This is caused by idiopathic denerva-
tion of the post-ganglionic parasympathetic nerve supply
to the sphincter pupillae and ciliary muscles, occasion-
ally following a viral illness. The affected pupil is typically
large and irregular with an absent or very slow light reflex.
Constriction on accommodation is very slow and is associ-
ated with vermiform movements of the iris; re-dilation is
also sluggish. It typically affects healthy young adults and
is unilateral in 80 per cent of cases. If there is a diminished
Achilles tendons reflex it is termed Holmes–Adie syn-
drome. Patients with a Holmes–Adie pupil may have dif-
ficulty with glare and accommodation and can require a
tint to their glasses, as well as reading correction, especially
where both pupils are affected. Diagnosis is confirmed using
0.1 per cent pilocarpine instilled to both eyes. The normal
pupil will not constrict, as the concentration is too low to
affect it, but the Holmes–Adie pupil constricts because of
denervation hypersensitivity.
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If there is constant anisocoria with good light reac-

tions in both eyes that is greater in dim light, Horner’s
syndrome should be suspected. This is due to congenital
or acquired disruption of the sympathetic pathways inner-
vating the eye and adnexal tissues. The lesion is usually
unilateral and is characterized by mild ptosis as a result of
a weakness of the sympathetically innervated component
of the levator muscle, miosis from the unopposed action
of the sphincter pupillae muscle, and apparent enophthal-
mos caused by the ptosis. There may be reduced ipsilateral
facial sweating if the lesion is below the superior cervi-
cal ganglion and heterochromia iridis (different coloured
irises) if the lesion is congenital. It is an important diag-
nosis to make, as it may be associated with tumours of
the lung, carotid and aortic aneurysms, neck lesions that
include malignant cervical lymph nodes, trauma or sur-
gery, brain stem vascular disease, demyelination, syringo-
myelia and cluster headaches.
MIGRAINE
Migraine is characterized by recurrent attacks of headache
that are widely variable in intensity, frequency and dura-
tion, often with a familial tendency. The attacks are com-
monly unilateral and associated with anorexia, nausea and
vomiting. Occasionally, they are preceded by neurological
and mood disturbances.
Classic migraines and retinal migraines will often pres-
ent to ophthalmologists. A classic migraine is often associ-
ated with a visual aura consisting of bright or dark spots,
zigzag lines and scintillating scotomata, in the shape of a
nineteenth century fortification, as well as various visual
field defects. After several minutes, the fortification spec-
trum expands with an associated negative scotoma that
progresses across the visual field and then breaks up. A
headache is usually present and is similar to that found in
common migraine. Retinal migraine is a rare variant with
acute, transient, unilateral visual loss identical to that seen
in patients with amaurosis fugax. Cardiac and carotid artery
diseases must be excluded before making the diagnosis.
Aircrew who suffer from attacks of migraine are unlikely to
retain their full flying category because of the intermittent
and unpredictable loss of visual function.
OPHTHALMIC DRUGS
Aircrew will usually be able to fly while using the majority
of ocular topical medications, as long as they do not affect
their visual function. Allergy to the active component or
the preservatives within the drops should be looked out
for, and the drops changed as required. Cycloplegic drops,
including atropine and cyclopentolate will cause mydriasis
and cycloplegia associated with abnormal glare and visual
aberrations. Aircrew should not fly while using such drops.
Mydriasis is also caused by alpha sympathetic agonists such
as phenylephrine and adrenaline; these drops should be
avoided in aircrew. Miotic drops such as pilocarpine, used
in glaucoma, cause a reduction of visual field due to pupil-
lary constriction and should be avoided in aircrew. Topical
beta-blockers are often used to treat glaucoma; systemic
absorption may cause bradycardia and bronchoconstriction
in susceptible individuals. Topical beta-blockers are contra-
indicated in patients with asthma or heart block. For the
most part, they are well tolerated in aircrew.
Contact lens wear is usually discontinued when topical
treatment is prescribed as some drugs and preservatives in
eye preparations accumulate in the contact lens and induce
toxic reactions. When selecting a treatment for an avia-
tor, the pharmacological vehicle should be considered. In
general, drops and gels cause less visual disturbance than
ointment which blurs vision for up to half an hour after
installation. It is prudent to tailor the medication to suit the
needs of the aviator.
SUMMARY
●● Vision is the most important sense in aviation.
●● The aviation environment is dry and
visually demanding.
●● Small refractive errors that are often insignificant
on the ground should be corrected for flying.
●● Contact lenses are the most popular refractive
devices for flying.
●● Corneal refractive surgery is allowed for air-
crew and is a good option for correcting
refractive errors.
FURTHER READING
Kanski JJ. Clinical Ophthalmology, 6th edn. Oxford:
Butterworth Heinemann, 2007.
Scott RA, Mushtaq B, Shaw P, Coker WJ. Survey of refrac-
tive correction in Royal Air Force aircrew. Optometry
in Practice 2004; 5: 88–104.
Tredici TJ, Ivan DJ. Ophthalmology in Aerospace
Medicine. In: Davis JR, Johnson R, Stepanek J, Fogarty
JA (eds). Fundamentals of Aerospace Medicine, 4th
edn. Philadelphia: Lippincott Williams & Wilkins, 2008.

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Otorhinolaryngology
Revised by SALIYA CALDERA
Introduction 527
The external ear 527
The middle ear 527
The nose 530
Hearing loss in flight 531
INTRODUCTION
Flying produces a variety of challenges to the ears, nose
and throat both in terms of the environmental impact
and variety of equipment used by aviators and other flight
staff. Equally, some common otolaryngological conditions
impact on the ability of flight personnel to perform in the
flight environment. This chapter considers these aspects of
otolaryngology relating to aviation.
THE EXTERNAL EAR
The external ear is seldom a major problem in the flight
environment. Flying helmets, which are sometimes difficult
to don and doff, can cause some trauma to the pinna. This
requires careful attention to the fit of the helmet and some
care to avoid repeatedly traumatizing the skin and under-
lying cartilage of the pinna. Of note is the junction of the
root of the helix with the skin of the temporal region where
some minor tears have been noted with frequent doffing and
donning of tight helmets. If this area becomes chronically
inflamed then a period of rest from repeated trauma with
the helmet is required and the use of some mild steroid oint-
ment to allow this chronic inflammation to settle.
Communication ear plugs have been noted to cause some
discomfort to the cartilage of the external ear. Attention
to the fit of the plugs is required and the discomfort will
usually settle.
Wax build up can be an issue, in which case, this will
need to be treated. Recommended treatment would include
K17577_C031.indd 527
31
Flying after surgery 532
Vertigo 532
Ménière’s disease 532
Throat problems in flight 532
References 533
both initial use of wax softeners and, if further wax is per-
sistent, then mechanical removal with either irrigation or
microsuction would be recommended. If left to build up
further, problems may ensue and may require further man-
agement (Clegg et al. 2010).
THE MIDDLE EAR
The upper aero-digestive tract is particularly at risk from
pressure changes encountered during flight. The inverse
relationship between the pressure of a gas and the volume it
occupies is described by Boyle’s Law; therefore, the air con-
taining cavities of the middle ear cleft are potentially vul-
nerable to pressure changes.
Barotrauma is defined as an injury produced by
mechanical forces caused by change of pressure on a gas-
filled space. Otitic barotrauma is the term that describes
any damage to the ear resulting from such changes in pres-
sure (Bove 1997).
To understand this further, the anatomy of the middle
ear cleft will need to be considered. The middle ear is a bony
cavity, housed within the petrous temple bone. Part of the
lateral wall of the middle ear is the tympanic membrane and,
anteroinferiorly, the eustachian tube extends from the mid-
dle ear to the lateral wall of the nasopharynx. The function
of the eustachian tube is to maintain the equality of pres-
sure around the tympanic membrane, which maximizes the
tympanic membrane compliance and consequently results
in optimum hearing when air pressure on either side of the
tympanic membrane is equal (Farmer 1985).
527
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 528 Otorhinolaryngology
In the normal state, gasses are absorbed from the middle
ear through the mucous membranes resulting in a tendency
towards negative pressure. This negative pressure is offset
by opening of the eustachian tube. In the resting state, the
eustachian tube remains closed. It is opened involuntarily
by actions such as swallowing and yawning. The palatal
muscles, principally the tensor veli palatini attach to the
tubal cartilage and, on contraction, pull on the tubal car-
tilage to facilitate temporary opening of the lumen of the
eustachian tube. The other palatal muscles involved in this
are the levator palati, the salpingopharyngeus and the ten-
sor tympani muscles. With such intermittent opening of the
eustachian tube, the middle ear pressure is maintained by
air passing from the nasopharynx and on the pressure gra-
dient into the middle ear.
Within the flight environment, the volume of air within
the middle ear cleft varies considerably in response to the
pressure changes involved. It has been reported that the vol-
ume can be 5 cm at sea level increasing to nearly 7 cm at a
cabin altitude of 8000 feet (Moser 1990). During ascent, the
expansion of gas within the middle ear initially will push
the tympanic membrane laterally to offset some of the pres-
sure changes. As the gas expands further, the eustachian
tube will be forced open by the increasing pressure of the
gas within the middle ear. This is enhanced by the rela-
tively low pressure across the structures of the eustachian
tube due to the low atmospheric pressure. As the eustachian
tube opens air will escape along the eustachian tube into the
nasopharynx offsetting the pressure changes within the ear.
The reverse is true during descent from altitude. An
increase in the atmospheric pressure during descent causes
a decrease of the volume of gas within the middle ear. This
will cause a relative negative pressure within the middle ear.
The natural absorption of gasses through the mucosal mem-
branes of the middle ear also tends towards creating a nega-
tive pressure within the middle ear and this is exacerbated
during descent from altitude. This negative pressure needs
to be offset by passage of air from the nasopharynx into the
middle ear cavity. In order to achieve this, the eustachian
tube must open. This requires an active process such as
swallowing or yawning. If the pressure differential is noted,
then an active procedure such as the Valsalva manoeuvre
can be employed to enhance the opening of the eustachian
tube. This process is made somewhat more difficult due to
the increase in pressure differential around the eustachian
tube itself caused by the increasing pressure of the sur-
rounding atmosphere during descent (King 1979).
Initial changes of negative pressure within the middle
ear cause medialization of the tympanic membrane in order
to offset some of the pressure gradient. If the negative pres-
sure is not relieved, for example, by passage of gas through
the eustachian tube due to the fact that the middle ear is
within a bony cavity, no further movement of the walls of
the ear canal is possible.
The vasculature within the wall of the middle ear is in
continuity with that of the rest of the body and, therefore,
the intraluminal vascular pressures reflect the ambient
K17577_C031.indd 528
pressure. If the relative negative pressure differential con-
tinues to increase, there will be an increasing difference of
pressure between the intraluminal vascular pressure and
the middle ear pressure. If sufficient gradient exists then
oedema or even rupture of those vessels within the mucosal
lining will occur.
If further pressure changes occur, then damage to the
tympanic membrane can also occur with haemorrhage of
the tympanic membrane vessels and even rupture of the
tympanic membrane.
These features are exacerbated by ‘eustachian locking.’
This occurs at a pressure differential of around 90 mm Hg.
At this pressure, the power of the levator palatine muscles
is insufficient to voluntarily overcome the external closing
pressures of the ambient pressure around the eustachian
tube. Further attempts at Valsalva manoeuvre are fruitless
due to this eustachian tube locking.
Clinical features of middle ear barotrauma
Initially, the patient observes a sensation of blockage in the
ear with the desire to equalize the pressure. With continued
pressure changes, otalgia is the next symptom. The otalgia
typically worsens with increasing pressure changes and fail-
ure to equalize pressure. Further severe pain can be sudden,
possibly indicating perforation.
Examination of the tympanic membrane reveals a vari-
ety of changes depending on the degree of barotrauma sus-
tained as described by Edmonds et  al. (1973): Grade 0  is
symptoms of pressure within the ear with no signs, Grade
1  is redness and retraction of the tympanic membrane,
Grade II is intratympanic membrane haemorrhage, Grade
III is gross tympanic membrane haemorrhage, Grade IV is
haemotympanum and Grade V is perforation. It is difficult
to predict who may be at risk of barotrauma during flight.
Clinical examination is usually unhelpful. The failure to see
movement of the ear drum on Valsalva manoeuvre does not
correlate well with instance of barotrauma. Physiologically
however anything that may impede the ability of the tym-
panic membrane or eustachian tube to normalize pressure
changes will predispose to barotrauma. The most common
predisposing cause for this is an upper respiratory tract
infection causing oedema of the eustachian tube.
Other factors that may cause similar problems are allergy
and rhinitis. Equally, problems of the palate affecting the
palatal muscle pull on the eustachian tube will also con-
tribute to the likelihood of barotrauma. Examination of the
post nasal space is important as any post nasal space masses
which may obstruct the eustachian tube orifice such as ade-
noidal hypertrophy will exacerbate the risk of barotrauma.
Inner ear barotrauma
The fluids of the inner ear in the perilymphatic space are
separated from the middle ear cavity by oval and round
windows. Alterations in intracranial and cerebrospinal
fluid pressure may be transmitted to the inner ear fluid
17/11/2015 16:01

compartments via the cochlear and vestibular aqueducts.
During rise in atmospheric pressure the round window
membrane bulges into the middle ear space. The pressure
gradient is also increased by the ambient positive pressure
acting on the spinal fluids transmitted through the aque-
ducts into the inner ear fluids, this pressure being relatively
positive compared to the relative negative pressure within
the middle ear.
A forced Valsalva manoeuvre, especially in the situation
where the eustachian tube may be locked, causes further
increase in the intracranial and, therefore, cerebrospinal
fluid pressures. Further pressure rises such as this can result
in rupture of the round window membrane or, in severe
cases, even rupture of the oval window. This leads to a con-
dition known as a perilymph fistula.
Typical clinical presentation of a perilymph fistula is one
where there is difficulty equalizing the middle ear pressure
during descent. Performance of a rigorous Valsalva manoeu-
vre is attempted and there is sudden onset of vertigo with an
accompanying hearing loss and tinnitus. These symptoms
can be sudden and incapacitating. These acute symptoms
often resolve rapidly over several days. Clinical examination
may reveal some signs of middle ear barotrauma, Romberg’s
test may be normal, but Unterberger’s test may be positive.
Various investigations for perilymph fistula have been
described, the most well-known of which is a fistula test
involving improvement in pure tone audiometry when lying
for 30  minutes when compared to sitting. However, these
tests are not necessarily positive in surgically proven fistu-
lae. Recent investigations by magnetic resonance imaging
(MRI) and computed tomography (CT) scans have shown
that they may benefit the diagnosis, but often the diagno-
sis is made by clinical history and examination (McGhee
and Dornhoffer 2000; Veillon et  al. 2001). Treatment is
often based on the certainty of diagnosis on clinical history,
examination and investigations. Various approaches for
treatment of a perilymph fistula have been described, but a
pragmatic approach would seem sensible given the difficulty
in diagnosis. Referral to an ear, nose and throat (ENT) spe-
cialist is recommended. Often, a conservative approach will
be initially taken including bed rest with daily audiometry.
Exploration for potential perilymph fistula and surgery
is reserved for those with progressive hearing deterioration
and failure of improvement of vestibular symptoms.
Alternobaric vertigo
Alternobaric vertigo is a condition caused by asymmetrical
middle ear overpressure stimulation resulting in temporary
vertigo. It usually occurs in patients who describe difficulty
equalizing the pressure in one or other ear. This is followed
by temporary vertigo, which tends to resolve spontaneously.
When the pressure in both ears reaches ambient levels, the
stimulus for the dizziness is no longer present and symptoms
tend to resolve. Susceptibility towards vertigo is as a con-
sequence of individual variations in the pressure required
for the middle ear to passively open the eustachian tube.
K17577_C031.indd 529
The middle ear  529
Conditions that alter eustachian tube function as described
previously also contribute to the likelihood of alternobaric
symptoms. The condition often resolves spontaneously and
no specific treatment is required (Wicks 1989).
Delayed otitic barotrauma
Delayed otitic barotrauma is a clinical entity consisting of
ear discomfort and hearing loss noted some hours after
flight. It usually occurs after long flights when breathing
high oxygen concentrations. This results in a high partial
pressure of oxygen within the middle ear. Following the
long flight, often during sleep with decreased swallow-
ing and consequently decreased eustachian tube opening
absorption of oxygen through the mucous membranes with
the middle ear results in significant middle ear negative
pressure. Following this, the reduction in pressure within
the middle ear causes some middle ear pain. This is gener-
ally moderate and usually settles spontaneously.
Management of otitic barotrauma
With minor levels of barotrauma, no specific treatment
is required. Avoidance of further pressure changes until
symptoms have settled is usually all that is required. With
significant problems of pain and other changes within the
middle ear, then further treatment, usually conservative,
is required.
The main symptom of otitic barotrauma is pain. Initial
treatment is with analgesics to relieve this symptom. The
problem of barotrauma is failure of equalisation of pressure,
so treatments to try and improve eustachian tube function
are required such as the use of topical decongestants to help
reduce any oedema of the eustachian tube orifice mucosa.
Oral decongestants may also be employed. If the tympanic
membrane is perforated, then initial treatment should
include the use of antibiotics. This is because the cause of
the perforation is a result of negative pressure, which can
lead to debris from the external ear passing into the middle
ear cavity at the moment of perforation.
The risk of infection of the middle ear is higher in these
cases and prophylactic treatment with antibiotics is recom-
mended. With such conservative measures, the vast major-
ity of cases of acute otitic barotrauma will resolve. Even
perforations have a high spontaneous resolution rate.
If however, perforations fail to heal, then surgical treat-
ment with myringoplasty can be considered. The majority
of cases of otitic barotrauma will therefore heal with this
management plan.
With regards to further flying, it is important that the
original predisposing factor to barotrauma is settled or
treated. Return to flying duties will depend on the degree of
the original barotrauma and resolution of underlying prob-
lems and appearances.
Individuals vary in the recovery from barotrauma.
However, it would seem sensible that following barotrauma
the tympanic membrane should appear normal with no
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 530 Otorhinolaryngology
evidence of middle ear effusion or disease and the eusta-
chian tube function should be demonstrated by auto infla-
tion during otoscopy. Cases of recurrent or chronic otitic
barotrauma need to be investigated for any underlying
nasal or otological causes and referral to an ENT specialist
is recommended.
In certain circumstances, surgery to abnormalities
within the nasal cavity may help. In some cases, insertion of
short term ventilation tubes (grommets) are helpful in order
to aerate the middle ear.
THE NOSE
The nose performs three main functions: humidification,
heat transfer and filtration. The air inhaled through the
nose, by the time it reaches the larynx, has been humidified
and warmed to a constant level irrespective of the external
humidity and temperature. Also gasses contain pollutants
and dust, inspired particles and pollen have been somewhat
filtered by the time they reach the lower respiratory tract.
The physiological role of the paranasal sinuses is somewhat
uncertain, but they are air containing cavities within the
facial skeleton. They are a continuation of the respiratory
cavity and are lined by respiratory mucosa consisting of
pseudo-stratified columnar ciliated epithelium with numer-
ous goblet cells. Mucous secreted by the goblet cells within
the sinuses is cleared by ciliary activity towards the sinus
ostia and into the nasal cavity towards the nasopharynx.
This drainage of mucous together with adequate ventilation
of the sinuses is required for normal sinus function.
Conditions of the nose
Prolonged exposure to excessively dry air either through an
oxygen mask or within the air conditioned cabin can lead
to excessive drying of the nasal mucosa, especially in the
front of the nose known as the nasal vestibule. This can lead
to soreness, inflammation and crusting. This is often easily
treated with moisturization. If acutely inflamed, some topi-
cal antibiotic cream will usually settle down any vestibulitis,
which is noted. Drying of the mucosa can lead to recurrent
epistaxis, which should be treated in the usual manner.
Often, conservative measures such as moisturization and
treatment with antibiotic cream will settle this down, as the
cause is due to inflammation of the nasal mucosa, but if per-
sistent then nasal cautery may be required.
Sinus barotrauma
The sinuses are connected to the nasal cavity through nar-
row channels via the sinus ostium. These channels are lined
by the same respiratory mucosa lining the rest of the upper
respiratory tract. The air within the sinuses themselves is
subject to ambient pressure changes in a similar manner to
other air-filled body cavities.
Unlike the middle ear, the sinuses do not have any active
voluntary control of opening in the same way that there is
K17577_C031.indd 530
voluntary control over the eustachian tube. The air in the
sinuses behaves as described in Boyle’s Law.
During ascent a decrease in the ambient pressure leads
to an expansion of gas within the sinus cavity. Generally,
this air will passively move from the area of high pres-
sure within the sinus cavity to the lower air pressure of the
nasal cavity through the sinus ostium and the clefts lead-
ing to the nasal cavity. The opposite situation occurs dur-
ing  descent. The air-filled cavity of the sinuses is subject
to the ambient positive pressure changes, which results
in negative pressure within the sinus cavity. This is offset
by air passively venting from the relatively high pressured
nasal cavity to the relatively low pressured sinus cavity.
If there are problems with the ventilation of the sinuses
through the sinus channels, then this passive movement of
air may be compromised. Sinus barotrauma is due to the
inability to equalize the pressure within some or all of the
paranasal sinuses in response to changes in the ambient
air pressure.
The commonest cause of obstruction of the sinus ostia
and channels is mucosal oedema, most often associated
with upper respiratory tract infections. Other conditions
such as nasal polyps or masses can also cause obstruction
to these channels. Given that the movement of the air from
the nasal cavity into the sinuses is more likely to be compro-
mised by the obstruction, symptoms of sinus barotrauma
are more likely to occur during descent.
As in the middle ear, the increasing negative pressure
within the sinuses, if it is not offset by passage of air from
the nasal cavity, results in a pressure differential between
the sinus cavity itself and the vessels of the sinus mucosa,
which are subject to the external ambient pressure changes
leading to exudation and oedema, rupture of the mucosal
vessels leading to haematoma within the sinus mucosa and
even frank haemorrhaging within the sinuses themselves.
The frontal sinus is the most commonly affected sinus,
which is mainly due to the circulatory patterns of mucus
drainage within the sinuses.
CLINICAL FEATURES OF SINUS BAROTRAUMA
The main presenting feature of sinus barotrauma is pain
over the affected sinuses and in severe cases this can be
associated with epistaxis. The main predisposing factor for
sinus barotrauma is upper respiratory tract infection, which
contributes to obstruction of the sinus ventilation and
drainage pathways. Other factors that may predispose to
sinus barotrauma include anatomical variations within the
nose, problems of the nasal septum and turbinates, nasal
polyps and chronic rhinosinusitis. Predicting who may suf-
fer from sinus barotrauma is difficult, but a past history of
nasal or sinus symptoms is relevant. Specifically a previous
history of nasal allergy, recurrent acute or chronic sinusitis
or nasal polyps may all indicate a higher predisposition to
sinus barotrauma.
Examination of the nose may show an anatomical abnor-
mality or disease within the nasal cavity itself.
17/11/2015 16:01

MANAGEMENT OF SINUS BAROTRAUMA
In most cases, management can be conservative. Treatment
of pain with analgesia may be necessary and ventilation of
the sinuses by the use of topical nasal decongestants may
improve the patency of the sinus ostium, thus allowing ven-
tilation of the affected sinus together with drainage of the
mucous, resulting in resolution of the inflammation of the
sinus mucosa.
Return to flying can be considered depending on the
degree of barotrauma of the sinuses and will be acceptable if
there is a healthy-looking nasal cavity and all the symptoms
of sinus barotrauma have resolved.
Some patients may continue to get further prob-
lems with sinus barotrauma on a chronic or recurrent
basis. This presents further challenges as this condition
rarely settles spontaneously and does not respond well to
conservative management.
Investigation of the sinuses is best done with CT scans
to show any anatomical abnormalities and evidence of
obstruction to the sinus drainage and ventilation pathways.
Endoscopic sinus surgery to re-establish the natural ventila-
tion and drainage pathways has shown some improvement
in the management of chronic sinus barotrauma (O’Reilly
et al. 1996). The frontal sinus, which is the most commonly
affected sinus, can be difficult to access surgically and recent
use of computer assisted image guided surgery can be ben-
eficial in these circumstances.
Correction of any other anatomical abnormalities in the
nose may also be required. Following treatment of chronic
sinus barotrauma, it is important to establish the ability of
the sinuses to withstand pressure changes that may be expe-
rienced in the flight environment and it is recommended
that this be performed by decompression chamber testing
in hypobaric chambers prior to return to flying duties.
HEARING LOSS IN FLIGHT
Sound describes the mechanical radiant energy transmit-
ted by longitudinal pressure waves. Ambient sound waves
are collected by the external ear, conducted through the
middle ear, causing pressure waves along the fluid inside
the cochlear which stimulate hair cells. This results in neu-
ral discharges through the auditory nerve to the brain and
it is these signals which we perceive as noise, allowing us
to hear.
Noise refers to sound which lacks agreeable quality,
is either unpleasant or is too loud. The aviation environ-
ment is characterized by multiple sources of noise: from
aircraft equipment, transmission systems, jet efflux, pro-
pellers, rotors, hydraulic and electrical actuators, cabin air
conditioning and pressurization systems, cockpit advisory
and alert systems and communications equipment. Noise
is also produced by the aerodynamic interaction between
ambient air and the surface of the aircraft, fuselage wings
and control surfaces and landing gear. Many of these audi-
tory inputs allow flight personnel to assess and monitor the
operational status of the aircraft. It is important to be able to
K17577_C031.indd 531
Hearing loss in flight  531
assess these important noises over and above the unwanted
noises present in the flight environment.
It is also necessary to communicate with other crew and
ground staff in the flight environment. Therefore, hearing
loss in flight personnel does require close assessment so that
advice can be given regarding management of these issues.
There are two main types of hearing loss: conductive
and sensorineural. Conductive hearing loss implies any
hearing loss due to failure of transmission of sound waves
through the external ear and middle ear to the footplate of
the stapes. Sensorineural hearing loss implies a defect in
the central pathways of hearing from the cochlear to the
auditory cortex.
Diagnosing the type of hearing loss can be important in
terms of management of the conditions.
Sensorineural hearing loss
PRESBYACUSIS
The commonest type of sensorineural hearing loss is pres-
byacusis, which describes the bilateral symmetrical deterio-
ration of hearing thresholds associated with ageing of the
cellular elements of the cochlear. Typically, the hearing loss
is at the higher frequencies.
NOISE-INDUCED HEARING LOSS
Excessive noise damages the hair cells of the organ of Corti.
Noise-induced hearing loss may follow either brief high
intensity exposure to noise or exposure to noise over longer
periods of time. Typical hearing thresholds show a dip at
4  kHz. Noise exposure is common in aviation, due to the
many sources of noise as described above.
Management of sensorineural hearing loss depends on
the degree of hearing loss. Hearing losses that are severe
enough can benefit from the use of hearing aids. If it is
found that the underlying cause of hearing loss is due to
noise exposure, further protection from noise exposure
is desirable.
Within the flight environment, ear defenders designed
to shield the ear from surrounding noise are useful. The use
of helmets with ear muffs together with built in transduc-
ers produces good attenuation. The use of communication
earplugs is a further benefit to protecting the ear from noise
whilst allowing good radio communication.
Active noise reduction can also be of benefit to attenuate
surrounding noise while maintaining high signal intensity.
This has been shown to be an effective method of reducing
noise levels at the ear of air crew to acceptable levels.
Conductive hearing loss
Conductive hearing loss can be due to problems of the
external ear, the tympanic membrane or the ossicular chain
within the middle ear. An audiogram of conductive hear-
ing loss demonstrates loss of air conduction thresholds with
preservation of bone conduction thresholds.
17/11/2015 16:01
 532 Otorhinolaryngology
Management of conductive hearing loss can vary from
simple treatments such as removing obstructing wax from
the ear canals, either by using wax softeners, syringing the
ears or the use of an operating microscope and suction
of the wax. Sometimes, conditions such as otitis externa
require medical treatment.
A perforation of the tympanic membrane can require
surgery. This operation, known as a myringoplasty, has a
high success rate at closing the perforation. A particular
condition called otosclerosis involves fixation of the sta-
pes footplate. This can be corrected surgically with a sta-
pedectomy to produce good improvement in hearing. This
requires a fenestration to be made in the stapes footplate,
which is closed with a prosthesis and tissue graft. This par-
ticular procedure, known as stapedotomy with fine fenestra
technique with vein graft, has a risk of a recurrent peri-
lymph fistula. This risk is greater in patients exposed to
high pressure changes, which may involve fast jet pilots. In
general, we would advise against such surgery in air crew,
so long as reasonable speech discrimination can be achieved
through their headset.
Other conductive hearing problems such as persistent
secretory otitis media can be managed by myringotomy and
ventilation tube insertion to allow aeration of the middle
ear whilst awaiting improvement in eustachian tube func-
tion. A difficulty for air crew with grommet insertions is
that it may preclude them from various underwater drills.
Chronic middle ear disease spreading from the middle
ear into the mastoid segment may require mastoidectomy.
Even with newer techniques such as small cavity mastoidec-
tomy and combined approach tympanoplasty, careful con-
sideration must be given to the ability of these patients to
perform flying duties, as often these patients will have long-
standing eustachian tube dysfunction. The risk of further
otitic barotrauma is difficult to predict in these patients.
FLYING AFTER SURGERY
Patients who have recently undergone middle ear surgery
are more likely to have problems with barotrauma. These
patients often have a very suboptimal eustachian tube and
for a period of time after the surgery, the middle ear itself
may have haematoma or effusion within it. Each patient
must be individually advised following middle ear surgery,
but it may require up to six weeks before flying is permitted.
Flying after sinus surgery
Patients who have recently undergone nasal or sinus surgery
are at a greater risk of barotrauma due to mucosal oedema as
a consequence of the surgery together with potential blood
clots and crusting, which may obstruct the sinus ventilation
and drainage pathways.
This can predispose to sinus barotrauma and again res-
olution of the health of the nasal cavity following surgery
should be achieved prior to flying.
K17577_C031.indd 532
VERTIGO
Vertigo consists of an illusion of movement where the person
falsely believes that he or she or the environment is moving.
Vertigo and spatial disorientation contribute to 15  per
cent of flight accidents. Therefore, any symptoms of vertigo
need careful assessment and management. Full assessment
of vestibular function should be undertaken before return-
ing to flying duties.
Some causes of vertigo can be well managed. These
include benign paroxysmal positional vertigo, which is
thought to be due to detachment of calcium carbonate
crystals from otoconia within the posterior semi-circular
canal, often exacerbated by injury, viral infection or ageing.
This condition is often well treated by particle reposition-
ing manoeuvres such as the Epley manoeuvre (Epley 1992).
Management of this usually has a satisfactory outcome and,
with resolution, these people will be fit to fly.
Sudden vestibular failure may occur when there is sudden
hypofunction of one labyrinth. The common causes of this
are head injury, viral infection and vascular problems of the
cochlear. This condition usually improves as a result of cen-
tral compensation, which can often be aided by graded ves-
tibular rehabilitation exercises such as Cawthorne Cooksey
exercises. Sudden vestibular failure usually recovers with
good restoration of balance. With resolution of these symp-
toms, patients may often be fit to fly.
MÉNIÈRE’S DISEASE
Ménière’s disease is a disease of unknown aetiology consist-
ing of a triad of symptoms of vertigo, hearing loss and tinni-
tus. There is usually also the associated symptom of fullness
within the affected ear. The condition presents with exacer-
bations and remissions. The vertigo is usually severe, last-
ing for several hours. There is associated hearing loss and
increasing tinnitus. Over time the hearing deteriorates and
the hearing loss can become permanent.
Ménière’s disease is a somewhat unpredictable condi-
tion. Although it can be treated with either conservative
measures such as the use of bendrofluazide, low salt diet
and betahistine, or surgical approaches such as endolym-
phatic sac decompression or vestibular neuronectomy, it is
difficult to recommend return to flying with this diagnosis
(Gyot 1996).
THROAT PROBLEMS IN FLIGHT
There are few problems caused to the throat in the flight
environment, apart from the inspiration of cold, dry air
which predisposes to chronic pharyngitis and irritation of
the larynx leading to voice disturbances. These symptoms
are often easily treated with rehydration.
Symptoms of a sore throat in air crew can be an indica-
tion of either existing or impending upper respiratory tract
infection and should be resolved prior to flying.
17/11/2015 16:01

ACKNOWLEDGEMENT
Revised and updated from the corresponding contribution
to the Fourth Edition written by Saliya Caldera and John
Skipper.
REFERENCES
Bove AA. A Short History of Diving and Diving Medicine.
In: Bove AA (ed). Bove and Davis’ Diving Medicine.
Philadelphia: WB Saunders, 1997: pp 3–6.
Clegg AJ, Loveman E, Gospodareveskaya E, et al. The
safety and effectiveness of different methods of ear
wax removal: a systematic review and economic evalu-
ation. Health Technology Assessment 2010; 14: 1–192.
Edmonds C, Freeman P, Thomas R, Tonkin J,
Blackwood FA. Otological Aspects of Diving. Sydney:
Australian Medical Publishing, 1973.
Epley JM. The canalith repositioning procedure for the
treatment of benign paroxysmal positional vertigo.
Otolaryngology, Head and Neck Surgery 1992; 107:
399–404.
K17577_C031.indd 533
References 533
Farmer JC. Eustachian tube function: physiology and its
role in otitis media. Annals of Otology, Rhinology and
Laryngology 1985; 94: 1–6.
Gyot JP. Should a pilot suffering from Ménière’s disease
be grounded or lifted off to the moon? Journal of Oto-
Rhino-Laryngology 1996; 58: 304–5.
King PF. The Eustachian tube and its significance in flight.
Journal of Laryngology and Otology 1979; 93: 659–78.
McGhee MA, Dornhoffer JL. A case of barotrauma
induced pneumolabyrinth secondary to perilymph
fistula. Ear, Nose and Throat Journal 2000; 79: 456–9.
Moser M. Fitness of civil aviation passengers to fly after
ear surgery. Aviation, Space, and Environmental
Medicine 1990; 61: 735–7.
O’Reilly BJ, Lupa H, McRae A. The application of endo-
scopic sinus surgery to the treatment of recurrent
sinus barotrauma. Clinical Otolaryngology 1996; 21:
528–32.
Veillon F, Reihm S, Emachescu B, et al. Imaging of the win-
dows of the temporal bone. Seminars in Ultrasound,
CT and MRI 2001; 22: 271–80.
Wicks RE. Alternobaric vertigo: an aeromedical review.
Aviation, Space, and Environmental Medicine 1989; 60:
67–72.
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K17577_C031.indd 534 17/11/2015 16:01

Aviation psychiatry
GEOFFREY EWING REID
Introduction 535
Clinical psychiatric syndromes 537
Specific issues in aviation psychiatry 545
INTRODUCTION
Knowledge of mental health issues is essential to the practise
of aviation medicine. Psychiatric symptoms, especially in
the area of the stress related disorders, are common and are
part of everyday medical practise. The intended audience for
this book is not expected to have an in-depth knowledge of
psychiatry and the scope of this chapter is, therefore, neces-
sarily limited; it is the intent to provide a concise source on
those aspects of mental health that are particularly relevant
to the occupational issues of aviation medicine, setting cur-
rent views in the historical context where this remains rel-
evant to understanding. Descriptions of selected psychiatric
disorders of particular relevance to aviation are provided
with comment on the associated occupational issues and
occupational disposal. A second section is devoted to spe-
cific issues in aviation psychiatry. For those in need of more
detailed psychiatric knowledge, a recommended concise
approach can be found in Essential Psychiatry (Murray et al.
2008) and the New Oxford Textbook of Psychiatry (Gelder
et  al. 2009). The latter is scheduled to have regular online
updates from the next edition.
Psychiatry is in a constant state of evolution, as is all
medicine. However, psychiatry deals rather more closely
than other branches of medicine with issues that relate to
our view of the intrinsic nature of mankind and to the asso-
ciated moral and legal issues. In 1851, Samuel Cartwright
described in the New Orleans Medical and Surgical Journal
a putative disorder of drapetomania, ‘an unexplained
tendency to run away in slaves’, noting that the condi-
tion was ‘practically confined to the Negro’. Our contem-
porary understanding of such behaviour would perhaps
K17577_C032.indd 535
32
Operational aviation psychiatry 548
Suggested readings 554
take a different view of the balance of social, psychologi-
cal and biological factors involved and indeed there was
no wider recognition of this ‘disorder’ at the time. But this
example does illustrate the issues of psychiatric classifica-
tion. Views and values shift in line with cultural changes.
Homosexuality was seen as a classifiable psychiatric disor-
der until 1973 when it was removed from DSM III, reflecting
the view that preferential homosexuality was a normal sex-
ual variant rather than invariably a mental disorder. With
developing knowledge these thresholds continue to change.
Although the development of pharmacological techniques
has shown little advance over the past decade, the advent
of PET (positron emission tomography) brain scanning
has demonstrated, for example, the presence of previously
unknown structural changes in the frontal cortex of the
adolescent brain (often not completed until the age of 24)
and a reduction in grey matter in the prefrontal cortex of
individuals with a lifelong history of anti-social behaviour,
areas associated with executive functions and decision mak-
ing. Observable behaviour is associated with characteristic
biological stigmata. These developments in understand-
ing can be expected to impact considerably on our under-
standing of adolescent behaviour and of criminality. In the
USA, the Brain Research through Advancing Innovative
Technologies (BRAIN) initiative has been launched, seek-
ing to accelerate the development of new tools to map the
activity of the human brain. A European initiative, the
Human Brain Project, seeks to model the human brain on a
supercomputer. The neuroscience field continues to develop;
however, it is already clear from identical twins studies that
a blind biological determinism is not implied but that there
is a complex interaction between biology and environment,
535
17/11/2015 16:02
 536  Aviation psychiatry
both social and physical, and that the biological changes are
not necessarily pathognomonic of observed behaviour. The
complexities are going to be considerable but there is likely
to be a developing understanding of the nature of the bio-
logical underpinnings of anthropology, ethology, history,
economics, sociology, psychology, etc.
The development of psychiatric classification systems,
which remain clinically based and have the aim of achieving
consistency and reflecting the developing state of knowledge,
has been dependent upon the operationalization of defini-
tions. It is important to distinguish between psychiatric
symptoms and psychiatric disorders. Mild to moderate anxi-
ety symptoms (e.g. intrusive worrying thoughts, irritability,
insomnia, physical and autonomic symptoms) are part of
the common human experience in association with stress-
ful events when, if associated with dysfunction, they may be
described as adjustment disorder. But they may also reflect
the presence of one of the other disorders of anxiety (e.g.
panic disorder with or without agoraphobia, social phobia,
post-traumatic stress disorder (PTSD), generalized anxi-
ety disorder and specific phobia) and may also occur in the
context of another disorder. Similarly, a single panic attack,
rather than a symptom of panic disorder, might be an exam-
ple of a specific situational anxiety. Symptoms may not neces-
sarily be associated with the presence of any specific current
external stressor. Symptoms are non-specific indicators that,
as with medicine generally, should lead to a differential diag-
nosis. This is of particular relevance in considering the issues
of fear of flying, this being most usefully seen as a symptom
rather than a specific condition in its own right.
It is also important to be clear on the difference between
form and content. Although the content of a mental phe-
nomenon may change, in response to psychosocial and his-
torical influences, the form remains a constant. Thus, the
diagnosis of post-traumatic stress disorder does not rely
upon the presence of any specific thought content, but on the
presence of a specific form of disturbance, with the charac-
teristics of intrusive recollections, avoidance behaviour, and
chronic anxiety. The diagnosis rests upon the identification
of the form of the disorder and not upon its specific content.
In the past, delusionary experiences of outside influences, a
symptom characteristic of schizophrenia, often had a reli-
gious content, whilst today they tend to feature the televi-
sion or computer.
The development of psychiatric classification systems
continues. There are two major classification systems in cur-
rent use in psychiatry: the American Psychiatric Association
(APA) Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) and the World Health Organization
(WHO) International Classification of Diseases (ICD-10).
Although the UK and Europe make predominant use of the
ICD, the DSM has considerable influence outside the bound-
aries of the USA. Both classifications are highly influential
in determining how treatment is practised and funded, the
delivery of training, the direction of further research and
in defining legal responsibility. The contemporary develop-
ment and introduction (May 2013) of DSM-5 has been highly
K17577_C032.indd 536
contentious, with arguments again centring on borders
between normality and disorder and the associated risks.
These issues are considered to be particularly relevant in the
USA, reflecting the model of healthcare. Some authorities
consider that there is considerable pharmacological over-
treatment, with an overuse of psychotropic drugs. One out
of five US adults is using at least one drug for a psychiatric
problem and it is reported that 11 per cent of all adults took an
antidepressant in 2010. Psychiatric medication has become a
major source of income for pharmaceutical companies, gen-
erating $11 billion per year from antidepressants and nearly
$8  billion from ADHD drugs. Antidepressant usage qua-
drupled from 1988 to 2008; 80 per cent of prescriptions were
written by primary care physicians. These are arguments
that are not only likely to continue but to increase. ‘Illness’
is a social construct and human behaviour is strongly influ-
enced by ideas, expectations, individual values, motivations
and meanings. Treatment decisions are necessarily subject
to economic constraints. However the purpose of classifi-
cation is not primarily to define professional boundaries,
although this will be an important consequence, but to
provide a descriptive map, representing the current stage of
knowledge. The clarification of an area does not necessar-
ily mean that it becomes a subject for formal mental health
care and management; this is an area for secondary consid-
eration and may more appropriately lie elsewhere. Whilst
the clarification of the mechanisms involved in disorder is
the business of science, the development and exploration of
the nature of humanity has more often been the business of
literature and drama which, in turn, is informed by develop-
ing knowledge. Although psychiatry has powerful scientific
tools available in molecular genetics and neuroimaging, at
the present state of knowledge a detailed knowledge of the
mind remains elusive and those worlds arguably still offer
a more comprehensive understanding of normal human
nature than can be provided by psychiatry.
The introduction of DSM-5 in 2013 is to be followed by
the introduction of ICD-11, scheduled for approval in 2015.
The WHO has stated that there will be important differences
between the proposals for ICD-11  and DSM-5, deriving
from a proposed emphasis on simpler definitions to facili-
tate clinical usefulness. Classification systems should not be
seen as prescriptive but as professional guidelines on current
thought and understanding, facilitating professional com-
munication and consistency. They remain works in progress.
Occupational psychiatry
Aviation medicine is an occupational medicine with the
associated issues of appropriate boundaries. Any occupa-
tional health system runs the risk that it will become more
closely identified with the needs of the employer rather than
those of the employee. Mental health issues are readily stig-
matized; the identification and management of significant
mental health problems are essential to any safety critical
task. The tension between these and the evaluation of risk
requires not only an understanding of the mental health
17/11/2015 16:02

aspects but also an understanding of the characteristics,
expectations and demands of the individual’s social and
working environment. Moreover, the credibility of occu-
pational mental health must be critically dependent on the
perception of its effectiveness by those who use its services,
either as patients or as managers. Stigma and lack of trust/
confidence in mental health providers can be barriers to
help-seeking in service personnel (Sareen 2007). Factors
may include embarrassment, fear of rejection, and the desire
to solve problems by themselves. For example, over a third
of Vietnam veterans who still suffered from PTSD 15 years
after the end of the war had never sought help (Kadushin
1981). Solomon (1989) was surprised to find that 16 per cent
of an untreated group of veterans still had PTSD one year
after their participation in the 1982 Lebanon War, despite
the ready availability of psychiatric services. That study
showed that these were mainly the casualties with less severe
symptoms and more inner resources for coping with them
(e.g. perceived self-efficacy in combat). It was thought that
if symptomatology became sufficiently severe the effects of
stigma, shame and embarrassment would be outweighed.
However, Iverson (2011) has identified the continuing issues
of stigma and the continued need to target stigmatizing
beliefs with outreach and formal educational programmes.
A seven year retrospective review of 214  United States
Air Force (USAF) active aircrew admitted to psychiatric
facilities showed that 64.5  per cent had returned to flying
within two years of admission (Flynn 1996). More than half
of this cohort (56.5 per cent) had been referred for alcohol
related problems. However, the study did indicate a good
short term occupational recovery in USAF aircrew follow-
ing psychiatric hospitalization.
CLINICAL PSYCHIATRIC SYNDROMES
Adjustment disorder
OCCUPATIONAL ISSUES
●● Impaired attention and concentration in safety-critical
tasks.
●● Risk of impulsive self-harm and suicide.
●● Differentiated from the mood disorders and not merit-
ing treatment with antidepressant medication.
In DSM-5, adjustment disorder is grouped together with
acute stress disorder and PTSD in a group of stress-related
disorders. Similar arrangements are currently proposed for
DSM-11.
Adjustment disorder arises as an emotional disturbance
associated with a significant life event; low mood and anxi-
ety are the predominant features. Behavioural and con-
duct problems may be associated. It corresponds to what is
often understood by the term ‘stress’. Prior to 1968, when
the term entered DSM-II, it was known as transient situ-
ational disturbance. Other synonyms have included reac-
tive depression and non-endogenous depression. It has a
K17577_C032.indd 537
Clinical psychiatric syndromes  537
generally good prognosis in the absence of continued stress-
ors. Adjustment issues may be perpetuated by the presence
of enduring psychosocial problems.
The concept has been criticized on the grounds that there
is an uncertain separation between the disorder and nor-
mal adaptive reactions, that there is an uncertain overlap
with other conditions such as the mood disorders and that
it is diagnostically unstable, its main utility being to serve
as a justification for diagnosis-based reimbursement in the
US healthcare system (Casey 2011). The initial criticism
is countered by the requirement that there must be some
functional impairment. The diagnosis has been shown to
have predictive validity, the symptoms generally resolving
rapidly. In the military environment adjustment disorder is
a common cause of presentation to mental health services,
possibly reflecting the structured service environment.
Problem solving activity may be impeded by an inability to
make environmental changes; the close supervision of per-
sonnel and involvement in safety critical tasks may lower
the threshold for presentation to medical services. It would
be expected that management and primary care would pro-
vide much of the support for these disorders.
Adjustment disorder may be aggravated by the use of
psychoactive substances, particularly alcohol, these being
associated with self-harmful behaviour, the aggravation of
anxiety and the impairment of problem solving. Substance
misuse, personality disorder and mood disorder are the chief
differential diagnoses; initial episodes of mood disorder
may be difficult to differentiate from adjustment disorder.
Despite the frequency of adjustment disorder, treatments
are under-investigated. A brief, problem-solving approach
to management is often advocated, the aim being to guide
the patient in the use of such techniques, rather than solv-
ing the patient’s problems for them (D’Zurilla 1986). Within
the Armed Forces environment, environmental change may
need to be considered. Psycho-educational strategies have
been reported to be of benefit. Pharmacological manage-
ment has little role other than in short term symptom relief.
The use of benzodiazepines may impair the habituation of
anxiety and situational learning, and they have potential
for dependence. The Royal College of Psychiatrists and the
Royal College of General Practitioners advise that benzodi-
azepines should not be prescribed for more than two weeks.
Such medication is not compatible with flying duties.
OCCUPATIONAL DISPOSAL
Temporarily unfit to fly. Full recovery and return to flying
with resolution of the precipitating issues.
Acute stress disorder
OCCUPATIONAL ISSUES
●● Of particular importance in the context of military
operations.
●● Acute incapacitation.
●● A differential diagnosis of fear of flying.
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 538  Aviation psychiatry
Acute stress disorder (ASD) is a transient disorder,
developing in an individual without any other apparent
mental disorder, in response to exceptional physical and
mental stress. It usually subsides within hours or days.
The symptoms show a typically mixed and changing
pattern and include an initial state of ‘daze’ with some
constriction of the field of consciousness and narrow-
ing of attention, an inability to comprehend stimuli and
disorientation. It may be followed by further withdrawal
from the surrounding situation (even to the extent of
a dissociative stupor) or by agitation and overactiv-
ity. Autonomic signs of anxiety are commonly present.
The symptoms usually disappear within 2–3  days and
often within hours. There may be complete or partial
amnesia for the episode. ASD is more severe than the
adjustment symptomatology.
ASD is associated with an increased risk of the later
development of PTSD.
Management is in accord with the well-established prin-
ciples of PIES:
Proximity: The patient is managed as close to the operating
area as is safe. They should not be isolated from their
peers. Evacuation is avoided.
Immediacy: Assistance is provided as soon as it is recog-
nized that an individual is incapacitated.
Expectation: There is an expectation that the individual is
temporarily overwhelmed but will recover and continue
with their duties.
Simplicity: Normal psychological support (explana-
tion and reassurance) is provided together with rest
and rehydration.
An 80  per cent recovery rate within 72  hours is to be
expected. Delayed recovery should prompt re-evaluation of
the diagnosis.
Although the main risk factor for the development of
an acute stress disorder is the degree of threat, secondary
factors include unexpectedness, sleep deprivation, poor
motivation and morale, poor hydration and nutrition,
hypothermia, intercurrent illness, poor leadership, lack of
training, home psychosocial problems and poor social sup-
port. The converse is protective.
OCCUPATIONAL DISPOSAL
Recovery permits a full return to duty. Evidence from the
Israel–Lebanon War was that personnel recovered from
ASD had a risk of further acute problems no more than
of the general service population. Personnel managed by
PIES had lower rates of PTSD than evacuated personnel
(Solomon 1986). Royal Air Force (RAF) policy requires
further post-operational psychiatric assessment, reflect-
ing the increased risk of PTSD. Specific aircrew data is
not published; the RAF had four instances of ASD in
the first Gulf War. All made a full recovery, returning to
operational flying.
K17577_C032.indd 538
Post-traumatic stress disorder
OCCUPATIONAL ISSUES
●● Impaired attention and concentration in safety-critical
tasks.
●● Development of avoidance of flying. A differential diag-
nosis of fear of flying.
●● Associated vulnerability to alcohol misuse, social dif-
ficulties, conduct problems.
Post-traumatic stress disorder (PTSD) arises as a delayed or
protracted response to a stressful event or situation of an
exceptionally threatening or catastrophic nature. Typical
features include episodes of repeated reliving of the precipi-
tating event in intrusive memories, flashbacks, dreams or
nightmares. These occur against the background of a per-
sisting sense of ‘numbness’ and emotional blunting, detach-
ment from other people, unresponsiveness to surroundings,
anhedonia and avoidance of activities and situations rem-
iniscent of the trauma. There is usually a state of chronic
autonomic arousal, with hypervigilance, an enhanced star-
tle response, irritability and insomnia. Depressive symp-
toms are commonly present and suicidal ideation is not
infrequent. The condition may follow a chronic course over
many years.
Patients may come to medical attention as a result of the
associated features of alcohol abuse, marital disharmony
and disciplinary problems. NICE have produced guidelines
on the management of PTSD in adults and children in pri-
mary and secondary care (March 2005).
OCCUPATIONAL DISPOSAL
Aircrew with a diagnosis of PTSD are unfit to fly. Full recov-
ery and maintained motivation to flying is compatible with
a return to full flying duties. However, residual phobic anxi-
ety for flying may prevent a return to active flying duties.
Mood disorders
OCCUPATIONAL ISSUES
●● Impaired attention and concentration in safety-critical
tasks.
●● Increased risk of suicide.
●● A differential diagnosis of fear of flying.
Mood disorders are those in which the fundamental distur-
bance is a morbid change of affect or mood to either depres-
sion or elation. Most of these disorders tend to be recurrent
and the onset of individual episodes can often be related to
stressful events or situations. Hypomanic illness is charac-
terized by a persisting mild elevation of mood, increased
energy and activity, and often marked feelings of wellbeing
and both physical and mental efficiency. Increased sociabil-
ity, talkativeness, over-familiarity, increased sexual energy
and a decreased need for sleep are often present. Irritability
may be present. In mania there are grandiose ideas and
17/11/2015 16:02

overconfidence. Behaviour may be reckless, foolhardy or
inappropriate to the circumstances. In mania with psy-
chotic symptoms there are also delusions (usually grandi-
ose) or hallucinations (usually of voices speaking directly
to the patient). Bipolar affective disorder is characterized
by the development of an episode of hypomanic or manic
illness. Mixed manic-depressive conditions are recognized
clinically. ICD-10  classifies depressive episodes into mild,
moderate or severe, without psychotic symptoms and severe
with psychotic symptoms. ICD-10  also recognizes that
some depressive symptoms are widely regarded as having
special clinical significance and defines these as a somatic
syndrome, synonymous with the terms biological, vital,
melancholic or endogenomorphic used historically and in
other classifications. There is a marked loss of interest or
pleasure in activities that are normally enjoyable, a lack
of emotional reactivity, awakening in the morning two or
more hours early, depressive mood worse in the morning
(diurnal variation), marked psychomotor retardation or
agitation, marked loss of appetite, weight loss and marked
loss of libido. The presence of the somatic syndrome is par-
ticularly associated with a therapeutic response to antide-
pressant medication. The classification presumes that the
somatic syndrome is present in most cases of severe depres-
sion. DSM-5 does not accept the evidence for a separate cat-
egory of melancholic depression.
Unipolar depressive disorder describes depressive epi-
sodes without any evidence of hypomanic or manic states;
recurrent unipolar depressive illness (more than one epi-
sode of depressive illness) will require consideration of
maintenance treatment with antidepressant medication.
Dysthymia is a chronic, persisting low-grade depression,
often responsive to antidepressant medication but requiring
maintenance treatment.
It is essential that all patients thought to be suffering
from any form of mood disorder should be assessed for the
risk of suicide, employing direct questions.
The development of a depressive illness, which may be
of gradual or insidious onset, is sometimes preceded by a
period of symptomatology that may resemble generalized
anxiety disorder; aircrew may present during this time with
flying-related anxiety. It has been suggested that anyone
presenting in middle age with anxiety symptoms, without
a previous history of anxiety disorder and in the absence of
a definite exceptional major stressor should be regarded as
suffering from a depressive illness until proved otherwise.
The aviation physician should also be aware of the ‘smiling
depressive’, whose overt presentation may not suggest the
presence of depressive illness, but where further enquiry
reveals the presence of depressive symptomatology.
Selective serotonin reuptake inhibitors (SSRIs) act by
increasing serotonin neurotransmitter levels. Previously
the ‘serotonin hypothesis’ proposed that the alleviation of
depressive symptoms was directly related to the improve-
ment in mood. It has now become evident that the increase
in serotonin causes neurones to synthesize a neurotrophic
protein, brain derived neurotrophic factor (BDNF),
K17577_C032.indd 539
Clinical psychiatric syndromes  539
encouraging cell growth and the formation of new syn-
apses. This knowledge has led to an understanding of the
delay (typically 7–10 days) in the appearance of therapeutic
effects after commencing SSRI medication, despite the rapid
pharmacological action. Similar mechanisms have been
demonstrated in repetitive transcranial magnetic stimula-
tion (rTMS) and ECT, both effective treatments for depres-
sive illness. Ketamine, the anaesthetic agent, has been
demonstrated to have a very rapid antidepressant effect,
possibly through similar actions. Cognitive behavioural
therapy (CBT) has a good evidence base for treatment of
depressive illness, but the comparative advantages of CBT
and antidepressant medication remain uncertain. The effect
of psychotherapy on BDNF is unknown.
The National Institute for Health and Care Excellence
(NICE) have produced guidelines on the treatment and
management of depression in adults, including adults with a
chronic physical health problem (Oct 2009) and guidelines
on transcranial magnetic stimulation for severe depression
(Nov 2007, considered for reassessment in Jan 2011).
OCCUPATIONAL DISPOSAL
Aircrew with a diagnosable mood disorder are unfit to fly.
A diagnosis of bipolar disorder, a highly recurrent disor-
der, would lead to permanent loss of license. The Federal
Aviation Administration (FAA) allows pilots who have been
treated with antidepressants to be recertified after 90 days
free from medication with no significant symptoms. The
Joint Aviation Authority (JAA) considers that if an SSRI is
being discontinued the earliest return to fitness is two weeks
after ceasing medication.
See below for a review of the issues regarding fitness to fly
of aircrew taking maintenance antidepressant medication.
Specific phobia
OCCUPATIONAL ISSUES
●● Avoidance of flying. Differential diagnosis of fear of
flying.
The diagnosis of specific phobia is restricted to dispropor-
tionate anxiety specifically associated with certain situ-
ations; contact with the triggering situation can provoke
severe situational anxiety. The development of phobias may
be related to some traumatic event (classical conditioning)
and is subsequently maintained by avoidance of triggering
stimuli. The clinical range of phobic situations is limited and
has led to the concept of ‘preparedness’. Animal phobias have
a mean age of onset of four years of age but with the exception
of snakes, usually subside. Most phobic conditions are more
common in females. Genetic factors play a significant part in
the vulnerability to many specific phobias (‘preparedness’)
but environmental factors (which may include vicarious and
verbal mechanisms in addition to aversive experiences) are
also important in determining the severity of the phobic
response (Torgerson 1979; Rachman 1991). Interestingly, it
appears that the genetic vulnerability component for specific
17/11/2015 16:02
 540  Aviation psychiatry
phobias does not increase the risk of other anxiety disorders
(Fyer 1990) and there are low rates of co-morbidity. Flying
phobia shares factors with the situational phobias (light-
ning, enclosed spaces, darkness and heights), forming a sep-
arate group to the animal phobias and mutilation phobias
(Fredrikson 1996). One member of this group, claustropho-
bia, has a later date of onset, typically appearing between the
ages of 18 and 25. It is associated with fears of suffocation,
entrapment and restriction; avoidance of such situations is
common and fear of flying may be a secondary feature.
A specific phobia may develop in adult life as a conse-
quence of an adverse event, such as an accident, and will
need to be differentiated from PTSD (see below).
There are no effective psychopharmacological treat-
ments. The management of these disorders is best under-
taken by graduated, in vivo, exposure to the phobic stimulus
(Gros 2006; Magee 2009).
OCCUPATIONAL DISPOSAL
Dependent upon the successful treatment of the phobia.
Panic disorder
OCCUPATIONAL ISSUES
●● Impaired attention and concentration in safety-critical
tasks.
●● Acute incapacitation.
●● Avoidance of flying. Differential diagnosis of fear
of flying.
The symptoms of panic disorder include recurrent, unex-
pected panic attacks, persistent concerns about additional
attacks and worries about the implications of the attack
or its consequences. It is distinct from severe situational
anxiety; single panic attacks are common with a lifetime
prevalence of 22.7 per cent in the US. It tends to run a vari-
able course and comorbidity is common. It may be compli-
cated by avoidance of situations in which an unexpected
panic attack would be embarrassing, escape impossible or
help unavailable. Clinical experience suggests that it is an
uncommon condition in aircrew; Marsh (2010) reported
a negligible prevalence in USAF pilots and navigators of
0.002 per cent.
OCCUPATIONAL DISPOSAL
The disorder is not compatible with flying duties until
treated and the individual has been free from panic attacks
for a substantial time (USAF policy requires the patient
to have been asymptomatic and free of medication for six
months).
Obsessive-compulsive disorder
OCCUPATIONAL ISSUES
●● Impaired attention and concentration in safety-critical
tasks.
K17577_C032.indd 540
Obsessive-compulsive disorder (OCD) is a heterogeneous
disorder with a variety of expressions, including hoarding,
Tourette syndrome and chronic tics. It is a neurodevelop-
mental disorder, characterized by recurrent or persistent
unwanted thoughts, images or impulses, and/or repetitive
rituals or mental acts (compulsions) that cause substantial
distress and functional impairment. With prevalence in
the general population of 2–3 per cent, it is the fourth most
common psychiatric disorder. It is frequently comorbid with
other psychiatric disorders, in particular depressive illness.
SSRIs are considered the most effective treatment,
although 40–60  per cent of patients do not respond ade-
quately. Medication may usefully be combined with cogni-
tive behavioural therapy.
Over-conscientious behaviours, orderliness and rigidity,
commonly described as ‘obsessionality’ are seen in anan-
kastic personality disorder (see ‘Personality disorders’).
Such mild traits are not uncommon in professionals and
aircrew.
NICE have produced guidelines on core interventions in
the treatment of obsessive-compulsive disorder (Nov 2005).
OCCUPATIONAL DISPOSAL
Aircrew with diagnosed OCD are unfit to fly. Fitness to
return to flying must be assessed individually.
Personality disorder
OCCUPATIONAL ISSUES
●● Impulsivity, impaired judgement and inappropriate risk
taking.
Psychiatry makes use of personality trait theory in its
description of personality disorders, although it is rec-
ognized that there is considerable comorbidity between
categories and that a dimensional approach is more appro-
priate. ICD-10  describes personality disorders as deeply
ingrained and enduring behaviour patterns, manifesting as
inflexible responses to a broad range of personal and social
situations. They are developmental conditions, which may
have biological foundations, appearing by late childhood
or adolescence and continuing into and throughout adult-
hood. They are not secondary to another mental disorder
or to brain disease. They represent extreme or significant
deviations from the cultural norms and tend to be stable.
They are frequently, but not always, associated with vari-
ous degrees of subjective distress and problems of social
performance. Paranoid personality disorder is character-
ized by an excessive sensitivity to setbacks and rebuffs, a
tendency to bear grudges persistently, suspiciousness, a
combative sense of personal rights out of keeping with the
actual situation, recurrent suspicions (without justifica-
tion) regarding the sexual fidelity of the spouse or sexual
partner, a persistent self-referential attitude, and a preoccu-
pation with unsubstantiated ‘conspiratorial’ explanations
of events. Schizoid personality disorder is characterized
17/11/2015 16:02

by a withdrawal from affectional, social and other con-
tacts, with a preference for fantasy, solitary activities, and
introspection. There is a limited capacity to express feel-
ings and to experience pleasure. Antisocial personality dis-
order is characterized by a disregard for social obligations
and callous unconcern for the feelings of others. There is
a low tolerance to frustration and a low threshold for dis-
charge of aggression, including violence. Emotionally
unstable personality disorder is characterized by a definite
tendency to act impulsively and without consideration of
the consequences. There is a tendency towards outbursts of
emotion and an inability to control the behavioural explo-
sions. There is a tendency towards quarrelsome behaviour
and towards conflicts with others. The disorder is further
divided into an impulsive type in which lack of impulse
control predominates, and a borderline type in which
there are additional features of disturbances of self-image,
chronic feelings of emptiness, intense and unstable inter-
personal relationships and a tendency towards self-harmful
behaviour. In histrionic personality disorder there is shal-
low and labile affectivity, self-dramatization, theatricality,
an exaggerated expression of emotions, suggestibility, ego-
centricity, self-indulgence, lack of consideration for others,
easily hurt feelings and a continuous seeking for apprecia-
tion, excitement and attention. Anankastic personality dis-
order is characterized by feelings of doubt, perfectionism,
excessive conscientiousness, checking, and preoccupation
with details, stubbornness, caution and rigidity. Anxious
(avoidant) personality disorder features feelings of tension
and apprehension, insecurity and inferiority. There is a
continuous yearning to be liked and accepted, a hypersen-
sitivity to rejection and criticism and a tendency to avoid
certain activities by a habitual exaggeration of the poten-
tial dangers or risks in everyday situations. Dependent per-
sonality disorder is characterized by a pervasive reliance
on other people to make decisions, fears of abandonment,
feelings of helplessness and incompetence. ICD-10  also
recognizes personality changes and describes an endur-
ing personality change after catastrophic experience, char-
acterized by a hostile or distrustful attitude towards the
world, social withdrawal, feelings of emptiness or hopeless-
ness, a chronic feeling of being ‘on-edge’, as if constantly
threatened, and estrangement. PTSD may precede this
personality change.
The prevalence of formal personality disorder in the
military and civilian professional aircrew population is
unknown but may be expected to be low, by virtue of the
selection procedures. These disorders are ‘deeply ingrained
and enduring’; there are no satisfactory treatments cur-
rently available. Personality disorders are distinguished
from personality traits by severity.
Fear of flying in the general population may be a feature
of avoidant personality disorder.
OCCUPATIONAL DISPOSAL
A confirmed diagnosis of personality disorder is incompat-
ible with flying duties.
K17577_C032.indd 541
Clinical psychiatric syndromes  541
Schizophrenia and other delusional
disorders
OCCUPATIONAL ISSUES
●● Impaired attention and concentration in safety-critical
tasks.
●● Impaired judgement.
Schizophrenia, the most important member of this group
of disorders, is characterized by fundamental and charac-
teristic distortions of thinking and perception, with affects
that are inappropriate or blunted. Whist consciousness and
intellectual capacity is maintained, cognitive deficits may
become apparent during the course of the disorder. The psy-
chopathological phenomena include thought echo, thought
insertion or withdrawal, thought broadcasting, delusional
perceptions and delusions of control, influence and pas-
sivity. Hallucinatory voices may comment upon or discuss
the person in the third person. Thought disorder and nega-
tive symptoms may be present. The course of the disorder
can be either continuous or episodic and there can be one
or more episodes with complete or incomplete remission.
Schizotypal disorder is characterized by eccentric behav-
iour and anomalies of thinking and affect, which resemble
those found in schizophrenia. These include a cold or inap-
propriate affect, anhedonia, odd and eccentric behaviour,
a tendency to social withdrawal, paranoid or bizarre ideas
not amounting to true delusions, obsessive ruminations,
thought disorder and perceptual disturbances, occasional
transient quasi-psychotic episodes with intense illusions,
auditory or other hallucinations and delusion-like ideas.
Persistent delusional disorders are characterized by the
development of either a single delusion or a set of related
delusions that may be lifelong. These disorders are uncom-
mon in professional aircrew.
NICE have produced guidelines on the management
of schizophrenia: Core interventions in the treatment and
management of schizophrenia in adults in primary and sec-
ondary care (Mar 2009).
OCCUPATIONAL DISPOSAL
A confirmed diagnosis of schizophrenia or another delu-
sional disorder is not compatible with flying, except in the
rare circumstances where there is a toxic origin (e.g. hyper-
thyroidism) that can be removed and not recur.
Substance misuse, including alcohol
OCCUPATIONAL ISSUES
●● Impaired attention and concentration in safety-critical
tasks.
●● Impaired judgement.
Recent research has established levels of alcohol consump-
tion and hazardous drinking in British Armed Forces per-
sonnel that are up to three times the UK civilian population
17/11/2015 16:02
 542  Aviation psychiatry
norm, particularly post-operationally. The Royal Navy and
Army have significantly higher mean Alcohol Use Disorders
Identification Test (AUDIT) scores than the RAF (Fear et al.
2007). Specific data for aircrew is not available.
Regulating the excessive or inappropriate consumption
of alcohol is primarily an executive issue. Humans have
made use of psychotropic drugs at least since Neolithic
times, but, hopefully, not generally whilst flying. Or at least
not whilst flying in reality. A variety of disorders may be
associated with the use of such substances. They may be used
harmfully, causing physical or mental damage, and they
may cause the development of dependence syndrome and
withdrawal states. Acute intoxication may result from the
use of alcohol, opioids, cannabinoids, sedatives and hypnot-
ics, cocaine, stimulants (including caffeine), hallucinogens,
tobacco and volatile solvents. Delusional and schizophrenia-
like symptoms may occur in association with or following
psychoactive substance use or abuse. Psychoactive drugs
reduce performance, disinhibit and impair judgement; the
abuse of such substances whilst responsible for an aircraft
cannot be compatible with air safety. A particular problem
with LSD is the phenomenon of ‘flashbacks’, in which the
user experiences unpredictable recurrences of the original
drug induced state.
Acute intoxication due to the use of alcohol is charac-
terized by disinhibition, argumentativeness, aggression and
lability of mood, impaired attention and judgement. When
severe, it is accompanied by hypotension, hypothermia and
depression of the gag reflex. Acute intoxication due to opioids
is characterized by apathy and sedation, disinhibition, psy-
chomotor retardation, impaired attention and judgement.
Acute intoxication due to cannabinoids is characterized
by euphoria and disinhibition, anxiety or agitation, suspi-
ciousness or paranoid ideation, temporal slowing, impaired
judgement, impaired reaction time, auditory, visual or tactile
illusions, hallucinations with preserved orientation, deper-
sonalization and derealization. Acute intoxication due to
stimulants, including caffeine, is characterized by euphoria
and a sensation of increased energy, hypervigilance, grandi-
ose beliefs or actions, abusiveness or aggression, lability of
mood, repetitive stereotyped behaviours, auditory, visual or
tactile illusions, hallucinations (usually with intact orienta-
tion) and paranoid ideation. Harmful use of psychoactive
substances requires clear evidence of physical or psychologi-
cal harm, including impaired judgement or dysfunctional
behaviour. The dependence syndrome develops after repeated
substance use and includes a strong desire to take the drug,
difficulties in controlling its use, persisting in its use despite
harmful consequences, a higher priority given to drug use
than to other activities, increased tolerance and sometimes
a physical withdrawal state. Withdrawal states are described
with features characteristic of the particular drug, but typi-
cally including marked anxiety. Alcohol withdrawal shows
tremor of the tongue, eyelids or outstretched hands, sweat-
ing, nausea, tachycardia, psychomotor agitation, headache,
insomnia, transient visual, tactile or auditory hallucinations
or illusions and grand mal convulsions.
K17577_C032.indd 542
The effects of alcohol on performance are well known.
Euphoria is evident with blood alcohol concentrations of
25 mg per cent, lack of coordination occurs at 50–100 mg
per cent, unsteadiness at 100–200 mg per cent and stupor at
200–400 mg per cent, with subsequent respiratory depres-
sion and death. Billings (1972) demonstrated impairment
of pilots’ ability to fly a single-engine, high winged, piston
aircraft down a glide slope with blood alcohol concentra-
tions from 40 mg per cent upwards. Smith and Harris (1994)
demonstrated impaired performance at 20 mg per cent in
a pilot’s radio communication tasks whilst flying a cross-
country route in a flight simulator, using radio navigation.
Alcohol reduces processing capacity, disrupting the ability
to divide attention between competing tasks, the secondary
task suffering more than the primary. The degree of impair-
ment increases with the complexity or difficulty of the task.
Moreover, the detrimental effects persist after the drug has
been eliminated from the blood stream. Yesavage (1986)
demonstrated impaired performance on complex tasks in a
simulator 14 hours after drinking enough alcohol to attain
a blood alcohol concentration of 100  mg per cent. Other
work has suggested individual differences in the suscepti-
bility to impairment. Age effects have not been conclusively
demonstrated. Taylor (1996) did not demonstrate any gen-
der differences in impairment either acutely or chronically.
An abnormality of vestibular function (positional alcohol
nystagmus, PAN) has been demonstrated up to 34  hours
after alcohol ingestion and, under the effects of +3  G, at
up to 48 hours post ingestion of only three units of alcohol
(Oosterveld 1970). The symptoms of a hangover are worse
when almost all ethanol and its metabolite acetaldehyde
have been cleared and peak blood ethanol or acetaldehyde
levels are not related to the severity of hangover (Chapman
1970). It is thought that complex organic molecules such
as polyphenols, higher alcohols including methanol, and
histamine, collectively known as congeners, are the main
causes of this phenomenon. Methanol is metabolized to
formaldehyde and formic acid. Jones (1986) suggested that it
was methanol that was one of the main causes of hangover.
The types of drink (brandy, red wine, rum, whisky) contain-
ing higher quantities of methanol are associated with more
severe hangovers, the time course of methanol metabo-
lism corresponded to the appearance of symptoms, and a
small dose of ethanol (blocking the formation of formalde-
hyde and formic acid) may provide an effective treatment.
Pathophysiological disturbances following alcohol inges-
tion include dehydration, metabolic acidosis, hypoglycae-
mia, disturbed prostaglandin synthesis, abnormal secretion
of vasopressin, cortisol, aldosterone, renin and testosterone;
cardiac output is increased, vasodilatation and tachycardia
occur. Rehydration and anti-inflammatory analgesics are
useful for the subjective discomforts, particularly if taken
before bedtime (Bargiota 1997).
The disinhibiting effects of alcohol may be a factor in
abusive behaviour in aircraft passengers (Pontell 1983).
Cook (1997) provided a full review of alcohol in aviation.
It remains entirely relevant.
17/11/2015 16:02

Excessive use of alcohol may exacerbate an existing psy-
chiatric disorder; individuals may drink as a result of psy-
chiatric disorder. However, alcohol misuse itself is often the
primary condition and the main cause of any psychologi-
cal disturbance. Patients drinking excessively may present
with depressive symptomatology, e.g. dysphoria, agitation,
apathy, suicidal ideation, loss of libido, loss of appetite and
weight loss. Alcohol, whilst inducing sleep, also decreases
both rapid eye movement (REM) sleep and slow wave sleep.
Rebound of REM sleep may follow withdrawal after regu-
lar use, with vivid dreams, nightmares, and frequent awak-
enings. Alcohol, being rapidly metabolized, may result in
rebound occurring early in the morning, giving rise to early
morning awakening. There may be diagnostic confusion
with depressive disorders. Clinical experience has resulted
in the advice that clinical treatment for a possible co-mor-
bid mood disorder should be withheld until the patient has
been abstinent for 4–6 weeks.
The many physical consequences of excessive alcohol
consumption include alcoholic liver disease, acute and
chronic pancreatitis, gastritis, peptic ulcer and cancers of
the oral cavity, pharynx, oesophagus, liver, rectum and
colon. Alcohol is an established risk factor for hypertension
and 30  per cent of ‘essential’ hypertension may be related
to alcohol abuse. Gout, osteoporosis, avascular necrosis,
gonadal atrophy, hypoglycaemia and acute and chronic
myopathy and cardiomyopathy are also associated.
Alcohol related problems are the result of a wide range
of factors and an individual’s drinking behaviour is a con-
sequence of their age, role, gender, social group and peer
pressures, the family, marital, community and occupational
environments, together with the effects of greater cultural
values and controls. High-risk groups include the armed
forces and medical practitioners.
The CAGE questionnaire (Ewing 1984) and the Severity
of Alcohol Dependence Scale (SADQ) (Stockwell et al. 1979)
are useful instruments for the identification and measure-
ment of the harmful use of alcohol. The CAGE question-
naire asks four questions:
Have you tried or felt you should cut down your drinking?
Have you ever felt annoyed by criticisms about your
drinking?
Have you ever felt bad or guilty about your drinking?
Have you had a drink first thing in the morning (‘eye-
opener’) or before lunch to steady your nerves or get rid
of a hangover?
Any single positive answer is significant. Two positive
answers raise serious suspicions of problem drinking.
Biological indicators include gamma glutamyl-transfer-
ase (GTT). Raised GGT is one of the most sensitive tests
for early liver disorder; whilst the precise mechanism for
its elevation is unknown, it is assumed to reflect enzyme
induction. It can be elevated by factors other than alco-
hol, including other drugs (anti-convulsants, steroids,
allopurinol), diabetes and pancreatic, cardiac and renal
K17577_C032.indd 543
Clinical psychiatric syndromes  543
disorders. Abnormalities of GGT begin to return to nor-
mal within two days of alcohol abstinence. A raised MCV
is also common in excessive alcohol drinkers and the
combination of a raised MCV with raised GGT results in
sensitivity of 80  per cent. The MCV takes several weeks
to return to normal with abstention. The use of such bio-
chemical and haematological measures is, however, not
enough by themselves to determine the presence of exces-
sive alcohol use and they should always be combined with
the use of questionnaires, a full history and a clinical
examination. Where diagnostic uncertainty exists, a trial
of alcohol abstention is an appropriate step to establish
the role of alcohol.
There are three particular aspects of alcohol misuse
management: withdrawal may need inpatient admission for
detoxification; relapse prevention and the management of
any comorbid psychiatric disorder. Benzodiazepines are the
main drug for the management of withdrawal, the longer
acting drugs (diazepam and chlordiazepoxide) being pre-
ferred. Research into the duration and intensity of treat-
ment aimed at relapse prevention continues to favour early
recognition and brief, educative management.
There is a well-established positive relationship between
per capita alcohol consumption and alcohol misuse
(Kendell 1979). Edwards (1994) suggested a separation of
alcohol dependence from the other alcohol related physi-
cal, social and psychological problems, emphasizing that a
mix of social and medical policies was necessary. A com-
prehensive policy for the prevention and control of alcohol
related problems should consist of a number of components,
including controls on the price, the availability, the use and
marketing of alcohol and educational measures. Contextual
policy aims to concentrate on specific hazardous situations,
e.g. drinking and driving policy, where initiatives have
been highly effective. In the field of aviation, Cook (1997)
described two fundamental principles:
Aircrew should not fly unless their blood alcohol concen-
tration (BAC) is ‘zero’ (i.e. <5 mg per cent).
Post alcohol impairment (PAI) suggests that aircrew should
not fly until well after their BAC has reduced to zero.
Regulations reflect these principles by either imposing a
legal limit for BAC, a safe interval between drinking and
flying (‘bottle to throttle time’), or prohibiting flying whilst
‘under the influence’ of alcohol. The US FAA imposes an
8-hour rule. The civil aviation regulations require that
crewmembers shall not consume alcohol less than 8 hours
prior to the specified reporting time for flight duty or the
commencement of standby and shall not commence a
flight duty period with a blood alcohol level in excess of
20 mg per cent. Modell and Mountz (1990) recommended
that at least 12 hours should be imposed and have further
suggested that flying should be prohibited for 24  hours
after five or more ‘standard drinks’ or in the presence of
any after effects. Cook (1997) has provided a full review of
these issues.
17/11/2015 16:02
 544  Aviation psychiatry
RAF aircrew that are identified as misusing alcohol are
managed in accord with the RAF’s Alcohol Policy, integrat-
ing the medical and disciplinary aspects of alcohol misuse.
Return to flying duties is dependent upon compliance with
the requirements of the Policy, which applies to all RAF ser-
vicemen equally. The UK Civil Aviation Authority (CAA)
regulations state that alcohol dependence should be diag-
nosed if the individual’s consumption regularly exceeds
the ‘amount culturally permitted’. Such an individual is
assessed as medically unfit and resumption of flying sta-
tus is permitted only after a course of treatment, complete
abstention is achieved and only if the prognosis for continu-
ing abstinence is good. Recertification at an earlier point
for multi-pilot operations or safety pilot restrictions may be
considered providing that there is:
A minimum of four weeks inpatient treatment;
Review by an approved psychiatric specialist; and
Ongoing review including blood testing and peer reports
for a period of three years.
Following discharge from inpatient treatment there
should be immediate review with the Aeromedical Section
of the Authority. Further review is undertaken at two, four,
six and twelve weeks following discharge and, if absten-
tion is secure, the pilot may be allowed to resume his flying
role but only in the multi-crew role. There is a requirement
for continued attendance at Alcoholics Anonymous or an
equivalent organization and a peer on the same aircraft fleet
is required to supervise and report to the relevant author-
ity. Medical follow-up is continued at three monthly inter-
vals for a recommended period of three years. Multi-pilot
or safety pilot restrictions may be reviewed after eighteen
months from recertification. Relapse may lead to perma-
nent withdrawal of the aviation license.
NICE has produced guidance on alcohol-use disorders:
physical complications and preventing harmful drinking
(Jun 2010) and on alcohol dependence and harmful alcohol
use (Feb 2011).
OCCUPATIONAL DISPOSAL
RAF aircrew identified as misusing alcohol are managed in
accord with the RAF Alcohol Policy, integrating disciplin-
ary and medical management. They are unfit to fly. Failure
to comply with the policy requirements will result in either
medical or executive discharge. CAA regulations require an
individual regularly exceeding alcohol limits to be assessed
as medically unfit to fly.
Eating disorders
OCCUPATIONAL ISSUES
●● Metabolic and associated cognitive impairment.
OCCUPATIONAL DISPOSAL
The risk of metabolic impairment precludes flying duties.
K17577_C032.indd 544
Somatic illness
It should be remembered that many systemic diseases are
associated with psychiatric effects. For example, in sys-
temic lupus erythematosus (SLE) antibrain antibodies are
manufactured and the development of allergic, autoim-
mune encephalitis can result in the appearance of psychi-
atric symptoms. HIV disease is associated with psychiatric
disorder. Initial diagnosis of the illness can precipitate an
adjustment disorder and after a long relatively symptom
free period mental function may become impaired.
Miscellaneous conditions
Fear of physical illness (hypochondriasis) is sometimes
encountered in aircrew. It can be an overvalued idea, a delu-
sion, an auditory hallucination or an anxious or depressive
intrusive thought and it is commonly a symptom of some
other primary psychiatric diagnosis. There is thought to be
a small group of patients who have hypochondriacal disor-
der without other disorder.
Head injury is associated with psychiatric disability.
Severe head injury is associated with intellectual impair-
ment, memory deficits and personality changes. Minor head
injury is associated with post-concussional syndrome with
headache, dizziness, hearing difficulties, fatigue, impaired
concentration, memory problems, irritability, emotional
lability, intolerance of alcohol, anxiety and depressive
symptoms. Most head injury patients have such symptoms
during the first 48 hours post injury, but at six weeks, 50 per
cent still report symptoms although the prognosis for a full
recovery is good. Post-mortem studies have shown that dif-
fuse microscopic lesions (capillary haemorrhages and sev-
ered nerve fibres) are present in a high proportion of human
brains following minor head injury. Slowing of cerebral
circulation has been shown and neurophysiological stud-
ies have demonstrated impairment. The persistence of these
symptoms had previously been attributed to compensation
issues, but this view has been discredited. A more extensive
consideration of traumatic brain injury and aeromedical
licensing can be found in Nicholson (2011).
Minimal traumatic brain injury (mTBI) has been identi-
fied as a distinct disorder in the US. The UK view is that
the issues are considered to be covered by post-concussional
syndrome and PTSD.
Conversion phenomena (dissociative disorders of move-
ment and sensation), in which there is a limitation of motor
or sensory function (often gross) developing in association
with some stressor, were common during the First World
War, particularly in association with gas attacks. Many
cases were treated in the special advanced hospitals and a
‘large proportion’ of cases treated within the first 48 hours
of onset recovered sufficiently to be able to return to their
duties and ‘showed no tendency to relapse’ (Hurst 1940).
The incidence of conversion disorder was much lower in the
Second World War and is now unusual; it is a diagnosis that
should be made with great caution.
17/11/2015 16:02

SPECIFIC ISSUES IN AVIATION PSYCHIATRY
Selection to fly
The presence of a formal psychiatric disorder is likely to
exclude from aircrew training. However, selection for fly-
ing training, selection for employment and fitness to fly are
separate issues and should not be conflated. RAF aircrew
selection assesses both suitability for flying training and
suitability for officer training. Use is made of psychomet-
ric aptitude tests, combined with an interview board for
the assessment of personality factors. During the period
between the two World Wars the RAF had developed the
Sensori-Motor Apparatus No. 3 (SMA 3), requiring aircrew
candidates to carry out coordinated movements of one arm
and both legs, whilst being distracted by visual or audi-
tory stimuli that had to be cancelled using the other arm.
Although this had been shown to provide a good indication
of flying ability, the Air Ministry did not accept it. It was
not until 1944 that the Aircrew Aptitude Test Battery, which
included the SMA 3, was approved. Current psychometric
tests, now computerized, continue to assess ability at com-
plex sensori-motor tasks.
Personality testing (not including personality disorder)
has been used in selection. In the Second World War, the
US Navy used Kelly’s Biographical Inventory as a selection
test (Fiske 1947). Combined with another instrument, the
Mechanical Comprehension Test, a correlation with fly-
ing training success of 0.43  was obtained. However, Ellis
and Conrad (1948) rejected biographical and other per-
sonality inventories (including the Minnesota Multiphasic
Personality Inventory and the Maudsley Personality
Schedule) on the grounds of lack of validity. In 1971 a range
of eight personality tests were trialled in RAF pilot selection.
Of these, one, Eysenck’s Personality Inventory (EPI), showed
some promise. The RAF sample was found to be extraverted
and with low scores on the neuroticism scale; those more
likely to succeed at flying training tended to have relatively
lower neuroticism scores. These tests were subsequently
trialled in Army Air Corps candidates (Feggetter and
Hammond 1976), achieving similar results, but not reach-
ing statistical significance. However, as noted by Bartram
and Dale (1982) the questions on the neuroticism scale tend
to have an obvious significance and the possibility of ‘faking
good’ must be taken into account. Moreover, neuroticism or
‘emotional instability’ as measured using the EPI also iden-
tifies features associated with psychiatric disorder and may
simply reflect trait anxiety. Considerable interest has also
been shown in a Scandinavian psychometric test known as
the Defence Mechanism Test, purporting to identify abnor-
mal psychological ‘defence mechanisms’. Again, prospective
study did not demonstrate adequate validity and reliability
(Cooper 1986; Kline 1987). The available evidence has not
demonstrated adequate reliability and predictive value for
such tests and they are not routinely used in service aircrew
selection. Although there is continuing interest in the use
of such measures, current selection procedures for the RAF
K17577_C032.indd 545
Specific issues in aviation psychiatry  545
do not include any specific psychiatric tests other than what
may be admitted to or detected on clinical examination in
the initial medical assessment. The use of psychological (e.g.
personality) tests for selection for training or employment
should be differentiated from tests for fitness to fly and they
must always be adequately and properly tested for both reli-
ability and predictive value.
Fitness to fly
Psychiatric disorder is a potent element in the assessment
of fitness to fly. Normal behaviour in normal circum-
stances has a significant risk of error; such errors may have
devastating consequences in the unforgiving environment
of the air. Most psychiatric disorders are associated with
impaired concentration and attention. Although aircrew
may frequently claim that flying distances them from
everyday worries and concerns, the presence of a diag-
nosable psychiatric disorder should not be classed simi-
larly. These issues have been considered above under the
various conditions.
Motivation to fly
The motivation to fly will affect both the vulnerability to
mental health issues and the prospects for successful treat-
ment. Flying has intrinsic pleasures. Both the exhilaration
and the romance of flying are well described in the poem
‘High Flight’:
Oh! I have slipped the surly bonds of earth and
danced the skies on laughter-slipped wings…
Pilot Officer Gillespie Magee Jr, d. December 1941
Mastery and control are powerful sensations and have
led to considerable psychoanalytically based speculation.
Aircrew do indeed often describe ‘always having wanted
to fly’ and the temptation to equate this symbolically with
childhood issues of mastery and control in relation to
parents is strong. However, it would seem likely that such
desires are very common; some go on to experience them in
the context of flying.
Many experienced aviators will describe their enjoy-
ment of their sense of control in the air. There is also the
sense of escape from more mundane concerns, a distanc-
ing from other, perhaps not so easily controllable, issues. It
certainly is, for most, a highly enjoyable activity and one
that many of them relinquish reluctantly. However, other
issues do intrude, and the factors motivating a young per-
son may change when they are older. The cost/benefit ratio
of a flying career may not have been realistically assessed
or new factors may change the assessment. A partner in a
close relationship may, perhaps as a result of developmen-
tal or social changes, be no longer ready to accept the fre-
quent absences from home commonly associated with the
flying profession or the risks associated with military flying.
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 546  Aviation psychiatry
An aviator’s priorities and values may change and they may,
for example, come to regret the associated absences from
their family. These factors, and others, may result in a re-
evaluation of their aims and result in a decision or a wish to
leave flying. However, they may find themselves unable to
resolve conflicts between the domestic and other demands
(perhaps financial) upon them and aircrew may present with
a complaint of ‘having become anxious about flying’. Such
anxiety is not ego-dystonic and not part of an anxiety dis-
order; it is important to evaluate the motivation to fly before
embarking on treatment aimed at resolving an anxiety dis-
order. Unrecognized motivational issues may confound
attempts at treatment and should be explicitly recognized
before treatment is commenced. Recognition of these issues
may result in limited treatment aims although motivation
may change following effective relief of symptomatology. A
good source for a psychoanalytically orientated discussion
of these issues can be found in Jones (1986) and Adams and
Jones (1987).
Personality issues
As a discrete, contained, social group, the personality traits
of aircrew have always attracted both attention and the cre-
ation of myths (e.g. Wolf 1980, The Right Stuff ). Whilst indi-
vidual personality vulnerabilities should not be discounted,
there is no evidence of there being any specific personality
vulnerability in aircrew.
The psychiatric concept of personality disorder (a deeply
ingrained maladaptive pattern of behaviour) needs to be
distinguished from wider personality issues. Flack (1919)
in discussing the ‘flying temperament’ considered that
‘the really successful aviator is still possessed of the tem-
perament characteristics of the pioneers. He is endowed
with absolute fearlessness, a love of adventure and sport
and a dogged determination to overcome every difficulty,
no matter how insuperable it may appear’. Similarly, Birley
(1920) commented on the attempts to define and isolate
‘this quality, the flying temperament’. More in line with
thought today, he considered that the most promising line
of approach lay in the use of psychometric tests, reporting
that the work of Camus and Nepper had achieved consider-
able fame in the French flying service. This work was based
on the assumption that aviation required a special quality
of rapid decision, measurable by psychomotor reactions. He
distinguished, however, between the aptitude to fly and the
need for a ‘fighting temperament’.
The fascination with aircrew personality continued, par-
ticularly in the USA where psychoanalytical concepts held
sway. In The Love and Fear of Flying, Bond (1952) developed
the theme of the symbolic meaning of flying. He considered
that the gratification of unconscious desires (chiefly relating
to unresolved oedipal issues) obtained through flying were
very important in understanding the success and failure
of flyers. The gratification was a defence against the devel-
opment of anxiety and the motivation to fly was ‘neuroti-
cally determined’, i.e. as a result of unresolved unconscious
K17577_C032.indd 546
childhood conflicts. These men were accidents waiting
to happen and when they eventually decompensated,
the defence mechanism having failed, they could only be
helped by long term psychotherapy. The concept was devel-
oped further in the idea of the ‘counter-phobic personality’,
(Morgenstern 1966), in which intense childhood fears were
followed in adolescence and adult years by ‘counterphobic
fearlessness’ as a defensive posture. The final penetration of
the defences by a stressor resulted in their collapse. It was
suggested that a flier’s objection to psychiatric examination
resulted from a fear that previously hidden pathology would
be detected and that counter-phobic men should be disqual-
ified from training. However, the idea that some aircrew
were intrinsically psychologically flawed was not substanti-
ated when studies of personality factors in aircrew began
to establish normative data. Reinhardt (1970) reported that
in 105  ‘outstanding jet pilots’, the majority were firstborn
children with unusually close father–son relationships.
They were self-confident, showed a great desire for challenge
and success, were not introspective and tended towards
interpersonal and emotional distance. Goorney (1970) in a
population of 50 RAF aircrew found them to have a mean
neuroticism score on the Maudsley Personality Inventory
one standard deviation below the British general population
mean. In 1974, Novello and Youssef published the results
of a battery of tests on 170 male and 87 female US general
aviation pilots. The results found that the males’ personal-
ity profile generally fell between that of the US Navy pilots
reported by Reinhardt and the means for US adult males.
It was concluded that there was an impressive similar-
ity between the two pilot groups and that there seemed to
be a core ‘aviation profile’. This was summarized as a man
who expressed a higher manifest need for achievement,
exhibition, dominance, change and heterosexuality than
the national norms for adult males. The females showed
similar results, deviating from the US adult female norms
in the same pattern as the males, but to a greater degree.
The authors commented that the results of their study gave
credence to the personality myth: a person who was coura-
geous and adventuresome, one who was orientated towards
demonstrating competency, skill and achievement, one who
found pleasure in mastering complex tasks and one whose
manifest sexual orientation was decidedly heterosexual. A
study in 1987 (Retzlaff and Gibertini) of 350 US Air Force
pilots undergoing undergraduate pilot training used dif-
ferent measurement instruments. They concluded that the
pilots were dissimilar to the general population of male
college students, being more concerned about presenting
themselves in a favourable light, seeking social recogni-
tion, more dominant and achieving, more exhibitionistic,
more confident and self-possessed and with a need for nov-
elty and stimulation. The authors acknowledged that selec-
tion effects might be expected to produce such a profile.
The study also suggested that there might be three dis-
tinct subtypes. A further study in 1991 (Picano) confirmed
these subtypes in experienced military pilots. The largest
subtype (48  per cent) closely resembled the typical ‘pilot
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personality’, being ‘affiliative’, outgoing, and distinguished
by a structured approach to problem solving, emphasizing
planning, logical analysis and attention to detail. The sec-
ond subtype (36 per cent) comprised individuals who were
emotionally controlled, inhibited, apprehensive and socially
retiring. They preferred stability, security, and predictability
and were reserved, somewhat uncomfortable in social situ-
ations and rather pessimistic in outlook. The third group
(16 per cent) was highly independent, competitive and deci-
sive. They tended to be least concerned with making a good
impression and were the least emotionally sensitive and
empathic. It seemed that there was not one ‘right stuff’, but
at least three main variants. Whilst none of these studies
used criteria for personality disorder from modern psychi-
atric classification systems, there is little support for the
presence of any general personality vulnerability.
Prevalence of psychiatric disorder in the
aviation community
Little information is available on the prevalence of psychi-
atric disorder in aircrew. In the Second World War, RAF
Bomber Command sustained an average of 5 per cent psy-
chiatric casualties (Stafford–Clark 1949), although this fig-
ure does conceal considerable variation. Psychiatric illness
has been noted to be the second most common cause of loss
of flying license in UK civilian professional pilots, anxi-
ety disorder being the largest component (Bennet 1983). A
quantitative cross-sectional study of 807 Brazilian working
pilots (Feijo 2012) showed an overall 6.7 per cent prevalence
of common mental disorders, rising to 23.7 per cent in those
characterized as having a heavy workload.
Psychotropic medication and fitness to fly
The issue of fitness to fly and psychotropic medication has
become a significant issue of the past decade; past psycho-
tropic medications had considerable side effects and their
use precluded aircrew duties. Some contemporary medica-
tions (SSRIs, SNRIs, SMRIs) are comparatively free from
side effects, raising the issue of fitness to fly whilst on medi-
cation. It has been suggested that the prospect of grounding
may result in aircrew not seeking appropriate treatment or
that aircrew are encouraged to conceal treatment. Evidence
from a 2003 study (Akin 2003) showed that SSRIs were pres-
ent in 61 of 4184 pilot fatalities in US civil aviation accidents
during 1990–2001. Sen (2007) reported that examination of
the medical records (59 were available) showed that 88 per
cent had not reported any psychological issues or admitted
to antidepressant use.
Potential side effects have been divided into initial
moderate transient effects, persistent effects and effects
due to interaction with alcohol, beverages, other medica-
tions, herbal products and smoking; delayed effects due
to accumulation of medication, diminished metabolism
or idiopathic reactions and effects due to missing doses
or rapid discontinuation of medication (Ireland 2002).
K17577_C032.indd 547
Specific issues in aviation psychiatry  547
In considering the potential use of psychotropic medication
in aircrew, these issues have been addressed with careful
medication choice, patient education, appropriate dosage
regimes, long term monitoring and an adequate period of
mood stability.
Beginning in the early years of this century there has
been a progressive relaxation of the restrictions on flying
with SSRIs, led by Australia and Canada. An Australian
study compared 418  civilian aircrew using antidepressant
medications with a matched group (Ross 2007). There were
18 accidents in the antidepressant group and 15 in the con-
trol group during the follow-up period; the difference did
not achieve statistical significance. There was no evidence
of adverse safety outcomes.
Current RAF regulations do not permit the use of anti-
depressant medication; in the USA the Army is the only
military organization to allow treatment with SSRIs in air-
crew performing aircrew duties. From April 2010, pilots
can apply for an FAA medical certificate on a case-by-case
basis if they have been successfully treated for 12  months
with one of four common antidepressants: fluoxetine, ser-
traline, citalopram or escitalopram. The CAA accepts cita-
lopram, sertraline or escitalopram as maintenance therapy.
The Australian Civil Aviation Safety Authority (CASA)
accepts sertraline, citalopram and venlafaxine. Transport
Canada has not specified any antidepressants but accepts
medication with similar efficacy and minimal side effects as
SSRIs. There is a general requirement for symptom stability
before returning to flying (Transport Canada, 12  months;
CAA, four weeks; CASA, four weeks). Canadian Forces
aircrew may be returned to restricted flying duties whilst
taking maintenance approved antidepressant medication
after a six-month observation period following resolution
of symptoms.
Vuorio et  al. (2012) concluded that aviators who have
achieved remission of symptoms and who are taking anti-
depressants as a long term strategy to prevent relapse can fly
safely under clinical supervision. Such flying would be ‘as
or with co-pilot’. This is in line with recommendations from
the Aerospace Medical Association and the International
Civil Aviation Organization.
Amitriptyline, a tricyclic antidepressant, is sometimes
prescribed in low dose in the relief of chronic and neuro-
pathic pain. One of the older generation of antidepressants,
its side effects are such that it is not compatible with flying
duties. Sedation occurs at all dose levels.
Anecdotally, aircrew consume prodigious quanti-
ties of coffee, but caffeinism is not a published problem.
Occasionally, the excessive use of caffeine may exacerbate
an anxiety disorder. The USAF has used stimulant drugs
(amphetamines) since at least 1962  (Emonson 1995) to
combat the effects of fatigue in aircrew, and astronauts
also used them during the Apollo spaceflights. Fatigue is
a recognized issue in aircrew: a 2002  survey of US Army
pilots reported fatigue as a widespread problem in military
aviation (Caldwell 2004) and in a 2006  survey of USAF
aircrew 74  per cent reported flying when drowsy enough
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 548  Aviation psychiatry
to fall asleep (Tan 2006). A retrospective aircrew survey
(Emonson 1995) did suggest that over half the pilots who
had used amphetamines considered them to be beneficial
or essential to operations, with very few reported problems.
However, retrospective data is particularly subject to error;
the use of such potentially problematic drugs in the air is not
desirable and it remains RAF strategy to ensure adequate
rest in aircrew through the use of a short acting benzodiaz-
epine with minimal residual effects; currently, temazepam
remains the approved drug for this purpose. For further
detail on the issues and management of sleep see Nicholson
(2011). The routine use of alcohol as a hypnotic cannot be
recommended, in particular because of the development of
tolerance. Similarly, care needs to be exercised in the use
of temazepam, especially in high stress environments. All
anxiolytic medication has a high risk of the development of
dependence and its issue must be closely supervised.
The use of pharmacological strategies to enhance perfor-
mance has had attractions for military operations. A report
on a meta-analysis of studies on modafinil (Kelley 2012), a
drug with the potential for cognitive enhancement, noted
that whilst the efficacy was supported there was a dearth of
evidence on short and long term effects.
RAF aircrew are not permitted to fly whilst taking any
psychoactive medication. All other psychoactive substances
are unacceptable.
OPERATIONAL AVIATION PSYCHIATRY
Exposure to war is a risk factor for subsequent mental ill
health (Jones and Hodgins 2002) and after the relative qui-
etness of the Cold War, operational psychiatric issues have
again become of active concern. The history of operational
psychiatry reflects and illustrates the historical debate over
boundaries between illness (meriting a medical disposal)
and normality (meriting a disciplinary disposal).
Aviation psychiatry makes its first appearance during
World War I, when J L Birley was put in charge of inves-
tigations into ‘flying fatigue’, mainly in France between
1916 and 1918, and only 13 years after Orville and Wilbur
Wright’s first successful powered, heavier-than-air flight on
17  December 1903. Mackersey has described the circum-
stances of the First World War aircrew (Mackersey 2012).
More than half were killed during training; of those who
succeeded in completing training, average life expectancy
at the height of the war was measured in weeks. Their
caps and boots sometimes marked the dead men’s vacated
seats at squadron dinner tables, placed there by their sur-
viving colleagues. The first textbook of aviation medicine
was published in 1919. Oliver Gotch, physician at the RAF
Central Hospital, noted that, ‘From the point of view of
medical interest there is perhaps no more important sub-
ject than the study of the psychology of flying, in that the
practical issues at stake are so great’. He considered that
‘more cases of this nature than of any other present them-
selves in Air Force work’. In Birley’s lecture ‘The Principles
of Medical Science as Applied to Military Aviation’ to the
K17577_C032.indd 548
Royal College of Physicians in 1920, he described the devel-
opment of ‘wind-up’. He considered that, if unrecognized,
this led to the affected individual becoming ‘irritable, unso-
ciable, morose, losing his inspiring personality and adopt-
ing a black outlook on things in general. Although he feels
tired, he is excitable and restless; unable to sit down to read
or write, he must always be pottering about the aerodrome
looking at the weather’. ‘Sooner or later, he must give in’.
‘Wind-up’ was recognized as an anxiety condition; this was
one amongst a variety of names given to anxiety related
symptoms, including respiratory neurosis, cardiac neurosis,
effort syndrome, neurasthenia, shell-shock and De Costa’s
Syndrome. Aetiology, in accord with psychological under-
standing at the time, was held to lie in the gradual erosion,
under the pressures of war, of those ‘defence mechanisms’
developed by the individual to counter his natural instincts
of self-preservation. Once it fully developed, the individu-
al’s career as a war pilot was irrevocably finished. Treatment
consisted of rest and recuperation; the results of mental
therapy were disappointing. It was recognized that the dis-
order was ‘dose-related’ and through the introduction of
‘short shifts’ the permanent wastage from this cause was
reduced. Anderson (1919) is credited with coining the term
‘aeroneurosis’ to describe these functional nervous condi-
tions occurring in aviators and reported that psychological
disorder had developed in 10 per cent of 600 pilots in squad-
rons under his care. Both Gotch and Birley emphasized
the social consequences of the disorder. Gotch described
aeroneurosis developing in flying training and considered
that it was infectious, commenting that ‘one pupil who has
given up flying (is) followed…by two or three more in the
same week’. He advised that once a pupil showed any signs
of the disorder, he must be discharged from the air-station
as unfit for further flying. Birley stated that if individuals
were allowed to remain once the disorder was definitely
established, ‘the results might be disastrous’ and ‘could eas-
ily mar a squadron’. These views remained in place in UK
Policy until the first Gulf War.
Despite the recognition of the overwhelming impor-
tance of psychological stress in precipitating breakdown
in aircrew, by the beginning of the Second World War, the
‘balance of opinion had been tilted back again by the physi-
ological work done between the wars on oxygen lack and
other factors specific to flying’ (Reid 1979). The RAF medi-
cal training manuals of the time recognized that anxiety
and depression would be common, but implied that they
would be chiefly observed in men who had been fatigued by
a long period of operational duty.
During the Second World War, RAF Bomber Command
had an overall casualty rate of 64  per cent, with an aver-
age incidence of psychological breakdown of less than 5 per
cent (Stafford–Clark 1949). There was a peak in the winter of
1942–43, when heavy casualties began to be sustained after
the inception of daylight bombing operations. In the year
ending February 1943, neuropsychiatrists saw 2919 cases of
psychological disorder. Of these, 2200  were considered to
have arisen mainly from flying duties (Symonds 1943). At
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that time, RAF bomber crews had no more than a 10 per cent
chance of surviving a full tour of 30 operations and it was
also at that time that the phrase ‘coffins or crackers’ came
into use. From then onwards, the casualty rate receded.
An exclusively moral and disciplinary attitude remained
common in the executive. It was thought that if men were
excused from operational duties, but retained the privileges
and prestige attached to flying status, there was bound to
be resentment amongst those who ‘successfully struggled to
control their own anxiety and fear and continue to face the
perils of war’. Balfour (1973), the Under-Secretary of State
for Air, has described the need for the category of ‘lacking
in moral fibre’ (LMF). Poor morale was again thought to be
infectious and speedy removal from the squadron was nec-
essary, as perhaps also was dismissal from the service and
enlistment in some other form of national service. The RAF
Medical Branch was given the duty of stating that there was
no medical reason for the man’s behaviour. One in seven of
the men referred for psychiatric assessment was determined
not to be suffering from a mental disorder and referred to
the executive. Whenever there was any conflict of opinion,
the case was reviewed by a representative of the Member
of the Air Council, together with the senior consultants
in neuropsychiatry. It is probable that many individuals
developing psychiatric symptomatology were never referred
for formal psychiatric assessment but managed with local
decision making.
Brandon (1996) and Jones (2006) have explored LMF
further. In 1939, Air Ministry Pamphlet 100 (Air Ministry
1939) charged squadron doctors with responsibility for
‘keeping airmen at the highest possible pitch of efficiency’
whilst detecting and promptly treating men who might
display physical symptoms of combat fatigue. They were,
however, also cautioned against over-enthusiasm in this, as
it ‘would not do to create an expectation of nervous break-
down’. An addendum by the Director General of Medical
Services, warned that ‘there is a tendency for medical officers
to assume too readily that lack of confidence to fly or fear of
flying are necessarily symptomatic of nervous illness and
justify exemption from flying duties on medical grounds.
Pilots or members of aircrews are thus not infrequently
taken off flying with the label “psychoneurosis” without
adequate investigation or assessment of their symptoms’.
The first use of the term ‘LMF’ has been identified as being
in 1940, in a letter outlining the procedures for identifying
those ‘whose conduct may cause them to forfeit the confi-
dence of their Commanding Officer’. The LMF disposal pol-
icy was set out in a letter (Air Ministry 1940) to Commands.
Men identified as showing evidence of physical or nervous
illness were to be treated on the station. If the diagnosis was
unclear, they were to be transferred to Not Yet Diagnosed
Neurosis (NYDN) Centres, initially established during the
First World War, where the neuropsychiatric specialist was
required to make the final diagnosis. If there was considered
to be no evidence of psychiatric disorder the report eventu-
ally found its way to the office of the Director General for
Personnel and from there to the Secretary of State’s office.
K17577_C032.indd 549
Operational aviation psychiatry  549
Once confirmed, ‘LMF’ was stamped on the personal
documents. Officers were cashiered, NCOs reduced to the
lowest rank (Aircraftsman, Second Class) and then either
employed on menial duties or discharged. Once discharged,
they were called up into the army or directed to work in
the mines. There were recorded criticisms of the policy at
the time; the documentary records of the NYDN centres
have disappeared.
The LMF policy appears to have been driven by the per-
ceived need to ensure that there should not be any apparent
reward for having failed in the performance of duty, unless
there was a ‘genuine’ medical illness present. There seems
to have been a view that perhaps such people had joined the
service for glamour or privilege but could not face the pros-
pect of enemy action. As noted above both Gotch and Birley,
writing on the First World War had emphasized the social
consequences of allowing cases of ‘aeroneurosis’ to remain
with their colleagues. Stouffer (1945) reported the results of
a survey of US troops, in which 42 per cent reported signifi-
cantly increased fear after observing a fellow soldier panic
during battle. A comparison of the USAF and the RAF
during the bomber offensive (Wells 1995) shows that both
air forces sustained similar rates of psychiatric casualties,
despite the US view that stress was the prime determinant
of breakdown, rather than character, and there being appar-
ently less concern over the contagious aspects. The US view
was generally less punitive and deterrence based, although
there were notable exceptions. The US Army, from early
in the Second World War, had an explicit policy that men
should be taught, from basic training onwards, that anxi-
ety was a normal phenomenon and was shared by everyone
exposed to combat conditions (Stouffer 1945). It was empha-
sized that even if a man felt afraid, he could keep going and
‘do a good job’, and that after a time his fear would decrease.
Bond (1952) reported that the number of psychiatric casual-
ties amongst US heavy bomber crews had a correlation coef-
ficient of 0.7 with the number of aircraft lost. The incidence
of flying phobia rose sharply once losses exceeded 8 per cent.
He also reported that when 110 psychiatrically disabled air-
men lived for a week with 550 healthy airmen (on leave, at a
rest home), conversation was ‘virtually confined to aviation
and combat’. At follow up, 1 per cent of the healthy airmen
had become disturbed, even though many of them had been
sent to the rest home to recover after a bad crash or ditch-
ing. In the Second World War, a survey of soldiers showed
that they differentiated between men who were cowards and
men who were ill, even though both might show the same
symptoms of anxiety. They emphasized the effort made to
overcome the tendency to withdraw associated with intense
anxiety. Soldiers who were visibly upset were not regarded
as cowards ‘unless they made no apparent effort to stick
out their job’. If, despite trying hard, they could not per-
form adequately, they were regarded as legitimate casualties
(Stouffer 1945). Rachman (1990) has suggested that anxious
individuals tend to over-predict fear. The fear of avoidance
behaviour becoming epidemic seems to underlie many of
the attitudes of the time, possibly dating from the First
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 550  Aviation psychiatry
World War experience. Hysterical epidemics or ‘mass hys-
teria’ remain issues, but are social manifestations of normal
anxiety, rather than of psychiatric disorder. As such, they
are more likely to be minimized through educational means
and the appropriate management of formal psychiatric dis-
order. The particular courage Shakespeare gives to Henry V
prior to the battle of Agincourt in the statement, ‘proclaim
it through my host that he that hath no stomach to this fight,
let him depart’ may remain a rare commodity in a com-
mander faced with the imperatives of war. In operational
situations, all other considerations can become secondary
to the need to be strong and united against the enemy.
During the Cold War operational psychiatric issues
took a back seat, reflecting the perception that any war in
Europe would be brief and that there would be no oppor-
tunity for in-theatre operational psychiatry. In the first
Gulf War the RAF had three pilots who developed ASD;
although on the first occurrence policy still required the
individual’s rapid removal from the operational theatre,
subsequently all made a rapid and full return to opera-
tional flying. The last decade has seen involvement in Iraq
and Afghanistan, with extensive operational involvement,
particularly from rotary wing. Mental healthcare provi-
sion in the UK Armed Forces underwent considerable
development in the first decade of the twenty-first century
(Pinder 2010) to provide a service that was fit for purpose.
This included the development of the multi-disciplinary
Departments of Community Mental Health that provide a
full geographic, tri-service coverage for UK Armed Forces
personnel, the introduction of third location decompres-
sion (TLD) (Jones et al. 2013) and trauma risk management
(TRiM) (Greenberg 2010).
In 2003, the Ministry of Defense (MoD) commissioned
the King’s Centre for Military Health Research (KCMHR)
at King’s College London to conduct a long term, large scale
prospective cohort study in order to explore the impact on
the health of Armed Forces personnel. The study is ongo-
ing. There has been no evidence of any recurrence of the
‘Gulf War Syndrome’ that followed the first Gulf War.
There has been no evidence of an increase in mental health
problems in regular tri-service personnel serving in Iraq or
Afghanistan compared to regular personnel not deployed
to Iraq or Afghanistan; the rate of symptoms of PTSD has
remained low with overall estimates varying between 1.3 per
cent and 4.4 per cent (7 per cent in combat troops). Rates of
PTSD in the UK population are approximately 3 per cent.
Whilst 16–20 per cent of regular personnel report common
mental disorders, similar rates are seen in the general UK
population. Findings from UK Armed Forces personnel
contrast sharply with US data, these rates ranging between
4–15 per cent.
KCMHR has a large publication list. For further
exploration of these topics, readers are advised to read
the KCMHR 15  Year Report: www.kcl.ac.uk/kcmhr/
publications/15YearReportfinal.pdf An extensive and com-
prehensive list and links to KCMHR publications is at:
www.kcl.ac.uk/kcmhr/pubdb/
K17577_C032.indd 550
The KCMHR cohort data has been examined for evi-
dence specific to the RAF. Pook (2008) examined the RAF
elements of the cohort and reported that there was no evi-
dence of a detrimental effect on RAF personnel as a result of
deployment to Iraq. The prevalence of PTSD was 2 per cent.
RAF Support Helicopter Aircrew (SHA), who are amongst
the RAF’s most frequently deployed personnel, have under-
taken a major proportion of the deployment burden. An
examination of the psychiatric referral rates from the main
SHA RAF bases between 2007–2011, as recorded by the
Defence Analytical Services and Advice (DASA), failed to
show any significant statistical differences between them
and the rest of the RAF. A retrospective questionnaire-
based study (Withnall 2013) has compared 264 RAF SHA
with a matched RAF control group of 135 drawn from the
KCMHR cohort. No difference was seen in measured levels
of multiple physical symptoms, general health or alcohol
misuse despite the helicopter personnel having deployed
more frequently and for longer than the controls during
the past three years. The rate of PTSD in RAF SHA was
2 per cent.
Extensive UK studies have not currently found an effect
on the overall prevalence of PTSD in regular armed forces
personnel deployed to Iraq and Afghanistan.
Fear of flying
Fear of flying is best considered from the viewpoint of dif-
ferential diagnosis, especially in experienced aircrew (Jones
2000; Medialdea 2005). Significant fear of flying is com-
mon in the general population, estimated at 10–40 per cent
(Van Gerwen and Diekstra 2000), with 5–10 per cent of the
adult population being unable to fly (Ekeberg, Seeberg and
Ellertsen 1989). The prevalence of fear of flying in a service
population is unknown, but flying has become a routine
operational activity in all services and it can impose severe
career limitations, some personnel facing administrative
discharge if unable to fly. Flying phobia is not screened for
at recruitment and it may develop subsequently in associa-
tion with adverse events.
Flying associated anxiety is not a unitary phenomenon
(Nousi et al., 2008; Oakes 2010); the differential diagnosis
includes adjustment disorder, specific phobia, PTSD, panic
disorder and depressive illness. Other specific phobias (e.g.
claustrophobia, fear of heights, agoraphobia) require their
own treatment, but may initially present as a fear of flying.
Van Gerwen and Diekstra (2000) recommended that there
should be screening and diagnosis for all participants in
flying phobia courses before treatment. Whilst a diagnosis
of specific phobia is probably most common in the general
population the development of flying related anxiety in
experienced aircrew should lead to a full exploration of the
differential diagnosis.
Specific phobia for flying may date from the earliest
exposure to the flying environment and may not be nec-
essarily associated with any specific adverse precipitating
event. A possible mechanism lies in failure of habituation.
17/11/2015 16:02

The startle reflex is an innate defensive reflex of humans
and other vertebrates that occurs in response to unfamil-
iar stimuli such as an unexpected loud noise. Habituation is
the process by which the response diminishes. Habituation
may be slowed or delayed, either as a result of internal
mechanisms or as a result of maintained threat. Normally,
physiological measures of the response show a progressive
decrease in magnitude as the stimulus is repeated and loses
its novelty. However, genetic, developmental and environ-
mental issues impair habituation, resulting in the develop-
ment of sustained arousal maintained and exacerbated by
subsequent voluntary or involuntary avoidance.
There is an extensive literature on treatment pro-
grammes for specific flying phobia. A review of outcome
studies (Van Gerwen and Diekstra 2000) demonstrated that
fear of flying can be effectively reduced, although little is
known about which specific components of programmes
worked best. A study of a multi-component standardized
cognitive behavioural group treatment (Van Gerwen 2003)
showed that the programme was effective at overcoming
fear of flying. The study looked at 1026 patients; data were
collected at pre-treatment and at three-, six- and 12-month
follow-ups. All the variables studied showed statistically
significant improvement, maintained at one-year follow-
up. A further study (Van Gerwen et  al. 2006) compared
outcomes for 150 patients randomly assigned to a one-day
behavioural group treatment programme, a two-day cogni-
tive behavioural group treatment programme and a waiting
list group. Follow-up at three, six and 12  months showed
that both treatments were superior to the waiting list group;
the two-day cognitive behavioural group treatment was sig-
nificantly more effective than the one-day programme on
subjective measures of fear and self-efficacy.
Although in vivo exposure is the current treatment of
choice for specific phobias, contemporary perspectives
emphasize the cognitive restructuring that accompanies
the exposure process and these have become a common
component of fear of flying programmes. There are no stud-
ies specifically addressing the relative efficacy of enhanced
cognitive restructuring in flying phobia; evidence from
empirical studies in the treatment of social anxiety has
been equivocal. However, the difficulty and expense of in
vivo exposure treatment complicates treatment delivery.
Developments in the treatment of specific phobia for fly-
ing have included the use of eye movement desensitisation
and reprocessing (EMDR), virtual reality exposure therapy
(VRE), full motion flight simulation (FMX), rational emo-
tive behaviour therapy (REBT) and computer-assisted ther-
apy. A review of VRE in the treatment of fear of flying (Da
Costa 2008) noted that VRE was a well-accepted tool for
the delivery of exposure treatments in phobic disorders and
that its use as a method to provide exposure in fear of fly-
ing was well established. VRE was effective with or without
cognitive behavioural therapy and/or psychoeducation.
Van Gerwen and Diekstra (2000) recommended that
a treatment programme should cover at least three areas
of change: information on aerodynamics and technical
K17577_C032.indd 551
Operational aviation psychiatry  551
aspects, coping with anxiety and phobic reactions, includ-
ing physiological reactions, and graded exposure with a
test flight.
As noted above, the development of flying phobia in
experienced aircrew merits a full exploration of the differ-
ential diagnosis. The phenomenon of break-off (see below)
can be a significant aetiological factor in the development
of adjustment disorder with associated avoidance in expe-
rienced aircrew. It should be the subject of specific enquiry,
the experiences not being necessarily volunteered. Early
depressive illness may present with flying associated anxi-
ety, especially in aircrew beyond middle age; enquiry will
usually reveal the presence of depressive symptomatology.
Such anxiety may appear without any exceptional flying
associated stressor being present.
Treatment of flying associated anxiety in aircrew should
reflect the diagnosis; the need to avoid psychotropic agents
in aircrew makes cognitive behavioural strategies the treat-
ment of choice. Published studies (Goorney 1970; Bedi 1993;
McCarthy 1994) have shown a good response for both treat-
ment results and freedom from relapse.
Break-off
A risk factor for anxiety problems in aircrew is the phenom-
enon of ‘break-off’, first described by Clark and Graybiel
(1957). They described ‘sensations of separation from the
ground, their environment or from the aircraft while fly-
ing at high altitude in single seat jet aircraft’. In their sur-
vey, approximately one-third of the aircrew reported such
feelings. Of these, two-thirds reported that the experience
was pleasant; one-third expressed fear or anxiety in asso-
ciation with the phenomenon. The term ‘break-off’ derived
from one of the aircrew who reported that he felt as if he had
‘broken off from reality’. Sours (1965) reported on the devel-
opment of anxiety disorders and fear of flying in aircrew
in association with the phenomenon. Subsequently other
but similar experiences have been described, including the
‘knife-edge’ experience in which there is a strong sensation
of being at risk of falling, ‘as if balanced on a knife edge’ and
the Giant Hand Phenomenon. First described by a medi-
cally qualified pilot flying over the frozen wastes of north-
ern Canada, he described experiencing an inability to move
the controls and ‘as though a giant hand was thrusting the
stick…’ (King 1962). The sensation disappeared when grasp-
ing the control between the thumb and index finger, only to
reappear when grasping the control with the entire hand.
More rarely, out-of-body experiences have been reported in
which aircrew view themselves from a position perceived
as outside the aircraft. These phenomena are examples of
dissociative experiences.
The term ‘break-off’ has been used in both the specific
sense referring to the sense of detachment from the earth and
also in a generic sense, referring to the overall class of flying
associated dissociative experiences. These experiences have
also been recognized in rotary wing aircrew and Durnford
(1992) describing a survey of 440 UK Army aircrew reported
17/11/2015 16:02
 552  Aviation psychiatry
a prevalence of 16 per cent. Durnford (1996) also reported
that 14 per cent of 299 US Army rotary wing aircrew had
experienced the ‘Giant Hand’. Lyons and Simpson (1989) in
a survey of 97 aircrew reported that 15 had experienced the
sensation. Sixsmith (2001) in a survey of 92 RAF and Army
aircrew (including fast jet, rotary wing and multi-engine
aircraft) reported that 11 per cent reported episodes of dis-
sociative experiences and that 50 per cent of these reported
that they had found the experience distressing to some
extent. The phenomena may appear for the first time against
a background of environmental and psychosocial stressors.
Benson (1973) considered that the abnormal perception was
associated with the presence of a paucity of orientation cues
in the pilot’s external visual field and a relatively constant
flight path. However, the presence of the phenomenon in
rotary wing would argue against a paucity of sensory input,
these airframes being characterized by high levels of vibra-
tion and noise. However, clinical anecdote is that these
experiences are characteristically associated with the task of
‘dipping’ in which helicopters hover at low level over the sea
for long periods. The precipitant environment is more accu-
rately described as sensory constancy. Similar experiences
have been described in other circumstances, for example,
in long distance lorry drivers, snow cat operators, prisoners
and ‘kayak dizziness’ in Eskimos (Flinn 1965).
Although peer discussion has failed to produce any
examples of aviation accidents associated with these expe-
riences, there is a single account of a USAF single-seat
fighter pilot ejecting in association with the giant hand
phenomenon, although the description of the experience is
not typical.
UK military aircrew are briefed on dissociative phenom-
ena during their aviation medicine training; nonetheless,
patients have frequently reported that they have become the
squadron expert on the issue and are frequently approached
by others describing similar experiences. Civilian aircrew
may not be aware of the phenomenon.
Aviation accidents
Flying accidents are a risk factor for psychiatric disorder in
aircrew. The idea that people carry within them the seeds of
their own catastrophes is ancient (Connolly 1981) and has
led to the concept of accident proneness. Although there
is no evidence for there being accident-prone individuals,
there is retrospective evidence of a temporary increase in
the risk of accidental injury in association with clusters of
life events.
Specific phobic anxiety may develop as an isolated disor-
der following an accident or other adverse event and needs
to be differentiated from PTSD. An early return to flying
duties following such an event may be expected to minimise
the risk of phobic anxiety developing (Marks 1987).
A retrospective study of 175  RAF aircrew that had
ejected suggested that 40 per cent had subsequent feelings
of fear, anger, apprehension, disgust or altered motivation
(Fowlie 1985). Although RAF Policy requires the psychiatric
K17577_C032.indd 552
assessment of aircrew following an accident by the Station
Medical Officer before returning to flying duties, including
the use of the Impact of Event Scale, the prevalence of PTSD
in this group is unknown.
Psychiatric aeromedical evacuation
The evacuation of psychiatric patients by air should not be
undertaken precipitately. The earliest description of aero-
medical psychiatric patients (US Army Air Corps 1941)
specified that psychiatric patients would not be transported
by air except in great emergencies and then only if there
were sufficient attendants (Jones 1980). However, in 1944–
45, 28 000 psychiatric patients were transported, 9000 being
psychotic (Jones 1980). The experience showed that patients
had to be properly classified and prepared, adequate equip-
ment had to available on board the aircraft and properly
trained personnel were essential. By 1970, the aeromedical
transfer of psychiatric patients was a fairly standard proce-
dure (Jones 1980).
Jones (1980) emphasized that most psychiatric patients
required only the good medical care and common courtesy
needed by other ambulatory patients. However, from time-
to-time, some of the patients may behave either unpredict-
ably or unacceptably and some may not see themselves as
ill. They may show resentment and anger. Such patients can
be the cause of anxiety and anger in both the aircrew and in
other patients and passengers. The fear of an unrestrained
psychotic patient injuring others and perhaps endanger-
ing the whole aircraft is always an issue. If inadequately
reassured, an aircraft captain may refuse to fly with such a
patient on-board.
The decision to move a psychiatric patient by air should
be made with care. The acutely ill psychiatric patient may
be the cause of considerable anxiety in both relatives and
medical staff who may be unfamiliar with mental illness
and who may wish to move the patient quickly. Evacuation
flights may be delayed or diverted; it is highly desirable that
the patient is stabilized prior to embarkation.
Preparation of the patient for aeromedical evacuation is
important. Flying is a cause of significant levels of anxiety
in 20  per cent of the general population and enquiry into
previous flying experiences is essential. Flying can be asso-
ciated with a number of unexpected sensations including
unusual noises, the expansion of gases in the abdomen and
changes in middle ear pressure. Moreover, there will be
issues related to the new location that need to be addressed.
A pre-flight briefing on these topics may identify possible
problems and minimize others.
Although a restraint system is carried on board RAF
aircraft roled for psychiatric aeromedical evacuation, its
use is extremely unusual. The choice of medication must be
carefully made. Drugs that over sedate patients will remove
their ability to care for themselves, requiring the attendant
to be especially alert to the development of venous sta-
sis with its risk of thrombophlebitis and the possibility of
peripheral nerve palsies from prolonged maintenance of
17/11/2015 16:02

one position. The capacity of the patient to help himself in
the event of an emergency would be reduced. Many of the
drugs used in psychiatry (phenothiazines, tricyclic antide-
pressants and drugs used to counter the extrapyramidal
side effects of the major tranquillizers) have anticholiner-
gic effects. These may increase the risks of constipation,
increased intestinal gases and acute urinary retention.
Physostigmine 0.5–2.0  mg IM or IV will block anticho-
linergic effects and may be repeated every 30  minutes
as necessary.
Chlorpromazine, 50–200 mg IM is preferable to the less
sedating drug haloperidol for pre-flight and flight sedation.
It is preferable that any drugs given for the flight have been
used on the patient before, avoiding the risk of an idio-
syncratic response in air. The most commonly used seda-
tive drugs, however, are the benzodiazepines. Diazepam
has a half-life of 20–50 hours and a dose of 5–10 mg orally
should be given approximately one hour prior to the flight.
Occasionally these drugs may cause disinhibition.
Lithium carbonate is widely used in the management
of manic-depressive disorder, recurrent depressive disor-
der and schizoaffective disorders. It is potentially toxic and
must be maintained within narrowly defined plasma blood
levels. Blood levels are, therefore, vulnerable to dehydration.
Patients requiring lithium therapy should preferably be
evacuated before it is commenced. Inflight attention should
be given to adequate fluid and electrolyte replacement. The
indications of toxicity include confusion, clouding of con-
sciousness, coma and fits.
Airshows and disaster planning
Mental health considerations should be part of routine
planning for airshows and disasters. At Ramstein Airshow,
Germany in August 1988, an aircraft of the Italian aerobatic
display team, Frecce Tricolori, crashed into the spectator
enclosure. Their display had just started when an aircraft
struck the tail plane of another. One aircraft rolled, out of
control, and hit the aircraft on its left. These two aircraft fell
onto the airfield. One hit the ground immediately in front of
the most densely packed area of the crowd before ploughing
through the spectators. There was a fireball and large pieces
of the aircraft were hurled further into the crowd. Over the
next 77  minutes, over 500  casualties were evacuated from
the site using a ‘scoop and run’ concept.
Although subsequent procedural changes have dimin-
ished the risk to the public and airshows are generally safe,
the potential risk of large numbers of casualties following
an accident is high and appropriate medical support should
be provided. Martin (1990) emphasized the chaos and
panic that ensued, the overwhelming numbers of casual-
ties in widely dispersed groups and the difficulties of apply-
ing concepts of triage in the presence of untrained helpers.
Such a crowd is likely to contain numbers of people, treated
and untreated, suffering from major psychiatric disorders.
A disaster will generate severely distressed people, people
with ASDs, people with acute exacerbation of pre-existing
K17577_C032.indd 553
Operational aviation psychiatry  553
disorders, acute psychotic illness and distraught parents
and relatives of injured children and adults (Burkle 1996).
Psychiatric casualties must be anticipated amongst the
emergency services as well as amongst the survivors. Mental
health support is desirable; if not attended to, these issues
are likely to impede the successful management of the phys-
ically injured. However, the provision of specific counsel-
ling (e.g. Critical Incident Stress Debriefing, CISD), whilst
having considerable immediate attraction and face value,
is unnecessary and may be harmful. The World Health
Organization has specifically recommended that this should
not be used. Although the intent is to prevent later mental
health problems by assisting people to resolve emotional dif-
ficulties early, studies have demonstrated that people given
post-disaster psychological debriefing were subsequently
more likely to develop mental health problems. Although
symptoms of post-traumatic stress disorder are common
immediately following a disaster, recovery without profes-
sional help is usual. Only a minority of individuals progress
to develop disorder.
The risks of disorder include PTSD, a risk of pathologi-
cal grief among those bereaved by the disaster and a risk
of depressive disorder and other psychiatric illnesses.
In the Kegworth air disaster, 79  per cent of 55  survivors
(from total of 79 survivors) met DSM-III-R criteria for psy-
chiatric disorder, of whom 50  per cent had PTSD (Gregg
et al. 1996). The presence of social support is a significant
ameliorating factor. In the UK military, such support has
been institutionalized in the operational context through
the development of trauma risk management (TRiM)
(Greenberg 2010). The skills required are not intrinsically
different from those required following other bereavements
or traumatic events, i.e. supporting emotional expression,
normalizing responses, educating and clarifying and assist-
ing in problem solving. Individuals should be encouraged
to attend funerals, memorial services, etc., and the popula-
tion involved should be included as much as possible in the
planning of such events. Those identified as suffering from
formal disorder, including PTSD and depressive illness,
should be referred to the appropriate psychiatric agencies.
The effects of a disaster are long term and communities are
permanently changed. The need for further support should
be regularly reviewed.
Self-harm, including suicide
The risk of suicide by depressed aircrew is of concern.
However, deliberate suicide by crashing an aircraft into
the ground seems to be reported rarely (Jones 1977).
Gibbons (1968) noted that in four of six apparent suicides
by aircraft, the use of alcohol had been associated. Alcohol
may potentiate suicidal impulses. However, a review of
1000  consecutive fatal aviation accidents (Cullen 1997)
found nine cases of alcohol intoxication and only three
definite suicides, not associated with intoxication. All
self-harm in RAF personnel is the subject of a mandatory
medical downgrading.
17/11/2015 16:02
 554  Aviation psychiatry
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Orthopaedics and trauma
IAN D. SARGEANT AND JON M. KENDREW
Introduction 557
Disability 557
Principles of assessing fitness 558
Issues after fracture management 558
Upper limb 560
Lower limb 561
Spine 561
INTRODUCTION
Aircrew may be expected to suffer from the full range of
orthopaedic disorders seen in the general population of a
similar age. Indeed, pilots may be more likely to engage in
adventurous sports both on and off duty and are therefore
more likely to suffer some form of sport-related trauma
during their career. In addition, their occupation may make
them more vulnerable to certain types of back and neck
injury. This chapter takes a systematic approach to those
problems likely to be encountered in managing aircrew.
The majority of patients suffering musculoskeletal symp-
toms will be managed successfully with analgesics and
the passage of time, or the attention of physiotherapists,
osteopaths, or chiropractors. Orthopaedic surgeons might
operate on the spine or limbs where there is reduced func-
tion due to congenital deformity or there is degenerative
change, or to improve the expected outcome after trauma.
Muscle strength, range of joint movement and dexterity
vary within the population, and there is a spectrum of per-
formance that might be considered normal. These features,
when considered in one person, also vary with age, training
and practice.
DISABILITY
In order to understand the underlying principles of fitness
assessment, it is important to understand the concept of
K17577_C033.indd 557
33
Helicopters 562
Ejection seats and injury 563
Congenital deformity 564
Osteoporosis 564
Ankylosing spondylitis 564
References 565
Further reading 565
disability and to appreciate its implications. Disability is
defined variously and may be considered as the condition of
suffering substantial long-term physical or mental impair-
ment. The UK Disability Discrimination Act (DDA) 1995,
Part I, gives statutory guidance on background information
and matters that should be taken into account when deter-
mining questions relating to the definition of disability.
In the UK, employees of the armed forces, the police and
people working on ships, hovercraft and aeroplanes were
exempted from the provisions of the DDA 1995. However,
the Disability Discrimination Act 1995  (Amendment)
Regulations 2003, which came into force in the UK on
1  October 2004, gives these exempt groups protection
under the Act, although in the UK the armed forces are still
exempt (Department of Work and Pensions 2003).
An employer is discriminating against an employee or
potential employee if the employer treats a disabled person
less favourably than they treat, or would treat, others to
whom that reason does not, or would not, apply and there is
no substantial justification for that decision that is relevant
to the circumstances of the particular case. When perform-
ing medical assessments for potential and current aircrew
employed in the UK, the provisions of the Act should be
remembered. Employees in other countries will be covered
by regional variations in law.
As stated by Foy and Fagg (2001), it is important to dif-
ferentiate between the three linked concepts: impairment,
disability and handicap. Impairment is defined as the loss
557
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 558  Orthopaedics and trauma
or abnormality of physical body structure or function.
Disability is the limitation, or function loss, derived from
impairment that prevents the performance of an activity in
the time lapse considered normal for that activity. Handicap
is the disadvantage derived from impairment and disability,
limiting a person performing a role considered normal in
respect of age, sex, social and cultural factors.
A person suffering from a stiff little toe three years after
a fracture will have a long-term restriction of joint move-
ment, but if that person does not have substantial physical
impairment in daily life then he or she is not disabled. A
person suffering bilateral below-knee amputation might
be considered to have substantial physical and long-term
impairment, even if they are able to walk on artificial limbs
without the help of sticks. With appropriate help, Douglas
Bader was able to return to single-seat active combat flying
during the Second World War. In the UK, an employer now
has a duty to ‘take such steps as it is reasonable’ to reduce
disadvantage to disabled workers that might be caused by
‘provision, criterion or practice applied by or on behalf of
an employer or any physical feature of premises occupied
by the employer’ (Department of Work and Pensions 2003).
For example, it is unlikely that to make major changes to
a flight deck would be thought ‘reasonable’ modifications to
be made by an employer to accommodate a pilot without the
use of one arm, but it appears to be no longer justifiable in
law to reject all aircrew applicants, or remove the licence of
qualified aircrew simply because they do not have a perfect
health record. The applicant with the stiff little toe is likely
to be fully fit for the tasks required, or might need no more
than minor reasonable adjustments, such as the provision of
individually fitted shoes.
PRINCIPLES OF ASSESSING FITNESS
During assessment of the medical fitness of potential air-
crew, the applicant should be functionally capable of sus-
tained performance of the routine and emergency tasks
required. There should be no underlying medical condition
that is likely to cause current function to steadily and signif-
icantly deteriorate. If these conditions cannot be met, then
there is substantial reason not to select the applicant. The
assessment of all musculoskeletal complaints can be made
using the following broad headings (Magee 1992):
●● Mobility: adequate joint mobility is required allow-
ing the pilot, or member of aircrew, to reach all
areas of the working environment and perform an
adequate lookout.
●● Strength: the ability to demonstrate adequate and
sustained limb strength without undue fatigability is
required, allowing sustained force to be applied to con-
trols in routine and emergency situations such as asym-
metric engine failure or rapid operation of emergency
escape systems.
●● Dexterity: movements must be skilled and nimble and
of adequate range and strength.
K17577_C033.indd 558
●● Tendency for sudden change in function: the presence
of conditions that might cause sudden and significant
effects on physical performance, such as a tendency to
shoulder dislocation or locking of the knee, must be
assessed. If they are ongoing, untreated and likely to
occur in the individual’s working environment, and if
the consequence of the occurrence would, or could, be
serious, then the applicant is not fit to perform the task.
●● Pain: the presence of conditions such as back and neck
pain, which might cause gradually increasing and pain-
ful distraction from the primary tasks, need assessment.
Pain might also be referred to the limbs and provoked
by flight duties where there may be no opportunity to
gain relief by simple measures such as a change in posi-
tion or stretching.
When assessing the medical fitness of current aircrew to
return to flying before or after treatment, the above fac-
tors are similarly considered. The history of daily function
is a valuable tool in assessing fitness for duties. The assess-
ment of a person who might have returned to activities of
daily living such as high-level recreational sport, prolonged
driving of a motorcar, lifting, carrying, house maintenance
and gardening can be relatively straightforward, with the
successful performance of these tasks being an indicator
of likely adequate function for duty. Aircrew who report
symptoms provoked by their usual flight workload usually
require management of the complaint. However, there is
undoubtedly an incidence of unreported discomfort with
symptoms among aircrew being treated and unknown to
the employer, because of fear that reporting these symp-
toms might lead to a loss of flying category. The assessment
of performance under normal flight conditions and emer-
gency situations using a flight simulator can be valuable.
If borderline restrictions in function cannot be improved,
then it is often appropriate to allow aircrew to return to
work with a co-pilot suitably qualified on aircraft type, or
to restrict the duration of flights undertaken. A sympa-
thetic, thorough and objective assessment of aircrew should
reduce their fear of inappropriate restrictions on employ-
ment being imposed.
In the presence of a condition that might cause steady
reduction in performance, regular monitoring of the condi-
tion and physical performance of the employee will allow
his or her ongoing fitness for duty to be determined.
The overriding consideration is to determine the ability of
aircrew to perform all duties safely. Appropriate and reason-
able modifications to the workplace and regular assessment
by the employer can allow prolonged and safe performance
in the workplace by expensively trained and valuable air-
crew, even in the presence of musculoskeletal symptoms.
ISSUES AFTER FRACTURE MANAGEMENT
The aims of treatment after fracture are to return the patient
to maximum level of function as soon as possible (Ruedi
and Murphy 2000). To achieve the best possible stable
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position of the fracture, implants such as screws, plates and
intramedullary nails are often used. The implant is chosen
aiming to give stability to the reduced fracture and to allow
early movement of the muscles and joints close to the injury.
The incidence of post-fracture arthritis is reduced by accu-
rate reduction of intra-articular fractures, and the range of
joint motion is improved by early movements of the joint
and avoiding prolonged periods in plaster casts. The non-
surgical treatment of fractures is frequently appropriate and
effective for many fracture patterns.
Return to duties
The demonstration of a ‘healed’ fracture with adequate
function of the affected area, no distracting discomfort and
a satisfactory and relevant functional assessment should be
the criteria used to confirm fitness to return to duties.
Removal of metalwork
After a patient returns to maximum function following a
fracture, the issue of retained metalwork might be discussed.
The historical practice of removing metalwork because it is
there has good reasons to be avoided. These include reduc-
ing prominence and discomfort associated with the retained
implant, or as part of the surgically assisted process of
achieving fracture healing. There is a significant morbidity
associated with metalwork removal, such as infection, pain-
ful scar, re-fracture of the bone through the screw holes,
and damage to nerves or other soft tissue during the sur-
gery. If a patient has returned to pain-free normal function,
then removal of implants can only potentially reduce func-
tion. The long-term systemic effects of long-term retained
metalwork appear to be insignificant.
(a) Non-stressed (b) Bone stressed to just
bone within limit of fracture
Figure 33.1  Effect of force on a bone containing a metal rod.
K17577_C033.indd 559
Issues after fracture management  559
The local mechanical effects of retained metalwork
depend on the site and size of the implant. A retained
single screw in the medial malleolus of the ankle will do
very little to alter the mechanical properties of the tibia.
Conversely, a short femoral nail might significantly alter
the bending properties of the bone and the risk of future
injury under load (Figure  33.1). Surgery to stiffen one or
more segments of the spine following surgery for fracture
or degenerative change will change the points at which axial
loading and compression forces passing through the spine
are concentrated.
The potential for a retained implant to cause increased
risk of future injury varies with the patient and the size, type
and site of the implant. Although the mechanical properties
of the bone might be made more normal by removing the
implant and the potentially increased risk of future fracture
during a high-energy event reduced, the future event itself
might be very unlikely. The risk associated with removal of
metalwork surgery should be balanced carefully against the
risks associated with leaving metal in situ before the person
submits themselves to surgery. The policy of insisting that
pilots in the Royal Air Force (RAF) have lower-limb metal-
work removed before returning to duty has been reviewed.
If there is uncertainty about fitness to return to task or
concern about unacceptable risk associated with retained
metalwork, then the specialist opinion of an orthopaedic
surgeon familiar with the issues should be sought.
The routine removal of metalwork is no longer advocated
in serving soldiers or military recruits.
Post-traumatic arthritis
Post-injury arthritis is usually associated with fractures
that extend into a joint surface. It is likely that injury
Direction Direction
of force of force
applied applied
(c) Similar magnitude of deformation
Stiff segment due to metal rod
Non-stiffened segment
fractures
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 560  Orthopaedics and trauma
that is going to provoke significant degenerative change
will do so within two years or so of the cessation of treat-
ment. The likelihood of arthritis developing is increased
as the complexity of the fracture and the initial displace-
ment increase. It is also associated with residual irregular-
ity in the joint surface after treatment has been concluded.
Some injuries, such as scaphoid fracture, hip disloca-
tion and talar neck fracture, lead to risk of osteonecrosis.
Scaphoid fracture is also associated with a significant non-
union rate. The history of these conditions in an applicant
for a strenuous type of job might reduce their period of
unrestricted employment.
Residual long-bone deformity after fracture
Minor degrees of shortening after fracture of long bones
may be tolerated well and the patient returned to high-level
function. Following fracture to the humerus, significant
healed fracture mal-alignment can be seen, with normal
upper limb function due to the wide arc of movement of
the shoulder possible in abduction, flexion and rotation. In
other areas, such as the tibia, residual angulation that can-
not be compensated for by movement of an adjacent joint in
the plane of the deformity may be tolerated poorly. A his-
tory of mid-shaft forearm fracture and residual angulation
will restrict pronation and supination.
UPPER LIMB
The function of the upper limb should be considered as a
whole rather than by individual joints and areas. Areas of
abnormal movement and stiffness in the upper limb can be
compensated for readily in many patients. For instance, a
patient with restriction of pronation of the wrist and fore-
arm often adapts and compensates by abduction of the
shoulder, thus bringing the palm of the hand towards the
floor. This type of compensation manoeuvre would not be
acceptable if the elbow had to be separated widely from the
body and the applicant was to work in a confined environ-
ment. Minimal body–elbow separation not causing ‘con-
flict’ with other crew members or items of equipment could
be acceptable.
Crushing or cutting injury to the digits of the hand is
frequently associated with long-term stiffness and sensory
abnormality. A normal thumb makes a major contribution
to the hand function, and its dysfunction is not compen-
sated for easily. Conversely, long-term sensory abnormal-
ity of the index finger provokes ready adaptation, with the
majority of people using their middle and ring fingers and
thumb for precision three-point fine pincer grip. As long
as the index finger is not stiff, good function of the hand
is likely.
Shoulder
Normal shoulder function depends on four joints – the
sternoclavicular, acromioclavicular, glenohumeral and
K17577_C033.indd 560
scapulothoracic joints – as well as the surrounding rotator
cuff and other major muscles. These joints move in harmony
to produce shoulder movement. Disorders of the shoulder,
such as arthritis, capsulitis, subacromial impingement and
rotator cuff degeneration or tear, cause certain patterns of
symptoms and complaints. More than one of these condi-
tions may be present and contributing to symptoms. The
effect on function of untreated or residual symptoms and
complaints can be considered, rather than discussing indi-
vidual pathological conditions with overlapping symptoms
and effect on limb function.
RANGE OF MOVEMENT
The shoulder has a large range of normal movement in flex-
ion, abduction and rotation. Significant degrees of stiffness
can be tolerated, with little effect on normal professional,
daily, sporting and social activities. Stiffness in one of these
joints, such as the glenohumeral joint, will still allow move-
ment at the scapulothoracic joint that can be useful, even
where the glenohumeral joint has been surgically fused.
In the environment of the traditional cockpit, aircrew are
expected to reach controls and switches in front, behind,
to the side, above and below them. Significant stiffness in
the shoulder has a profound effect upon reach – and much
more effect than stiffness in the more peripheral limb joints.
Consequently, shoulder stiffness can place major restric-
tions on the ability of pilots and aircrew to perform.
INSTABILITY
The advantages of mobility of the shoulder are balanced by
the disadvantages of a relatively unstable joint. Dislocation
of the shoulder can be associated with intrinsic soft-tissue
laxity and can be habitual and multidirectional. Such a his-
tory in one shoulder suggests a tendency for the other shoul-
der to develop the condition in the future. Dislocation of the
shoulder also often occurs for the first time after trauma.
Dislocation is usually anterior. Re-dislocation after the first
episode is common. The provocative position for anterior
re-dislocation is with the shoulder elevated, extended and
externally rotated, i.e. reaching above and behind the head.
A history of untreated ongoing shoulder instability that
might be provoked in the cockpit would be a major concern.
PAIN AND WEAKNESS
Significant shoulder pain reducing the pain-free arc of
movement or shoulder weakness may have effects on active,
uninhibited reach and, consequently, reduce the ability of
aircrew to perform their duties. However, partial or full-
thickness degenerative tears of the rotator cuff are not inevi-
tably associated with loss of function. Rates of asymptomatic
tear diagnosed with ultrasound ranging from 13 per cent in
the age group 50–59 years to 51 per cent in the age group
over 80  years have been reported (Tempelhof et  al. 1999).
It is important, therefore, to make clear functional assess-
ments of patients when considering fitness for duty, rather
than making an all-encompassing policy based purely on a
diagnostic label.
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Elbow, forearm and wrist
PAIN
The incidence of tennis elbow has been reported as affecting
between 1 and 3 per cent of the population between the ages
of 40  and 60  years. Arthritis, epicondylitis, tenosynovitis,
peripheral nerve compression and other ‘degenerative’ age-
associated conditions tend to cause recurrent symptoms
after first being experienced. The majority of symptoms can
be managed successfully in the population and established
aircrew without significant changes to their work practice.
A history of these types of condition in the young adult is
likely to have more profound implications on their long-
term fitness for duties.
RANGE OF MOVEMENT
Pronation and supination of the forearm require a mobile
radiocapitellar joint and proximal and distal radioulnar
joints. Elbow movement essentially is otherwise a hinge-
type mechanism. Other wrist movements depend on the
radiocarpal joint and the mobility between the proximal
and distal row of the carpals.
Conditions that cause stiffness of these areas will have
less effect on reach when they affect a peripheral joint rather
than a more proximal joint. Loss of the last few degrees of
elbow extension might cause no more than minor embar-
rassment when stretching past a dining companion for the
salt, and wrist stiffness may have little effect on reach at all.
There may be no effect on the ability to perform cockpit
tasks for a pilot.
The effect on the ability to access awkward areas and per-
form tasks is likely to be more affected by stiffness of periph-
eral joints. Minor loss of wrist dorsiflexion might result in
functionally minor symptoms of pain under loaded dor-
siflexion, such as when performing press-ups, but signifi-
cant stiffness might impede the ability of aircrew or ground
crew to access parts of the airplane and perform in-flight or
ground-maintenance tasks.
Pronation and supination of the forearm have been dis-
cussed. An adequate range of movement without the use of
exaggerated compensation manoeuvre is needed for func-
tion in tight working spaces.
Hand
Function of the hand is central to the traditional inter-
face between human and machine (Burke et  al. 1990). If
techniques of adaptation and functional compensation
for minor symptoms can be accepted higher in the limb,
then they are less likely to be acceptable at this level.
Assessment of the hand should ensure the ability to dem-
onstrate adequate power grip, three-point pinch grip, key
grip, rapid skilled precise movements and normal sensa-
tion. Performance below these levels is likely to need a
thorough assessment of the ability to perform tasks safely
and reliably.
K17577_C033.indd 561
Spine 561
LOWER LIMB
As with the upper limb, the effect of lower-limb pathology
on function in the workplace as a whole needs assessment.
Lower-limb dysfunction and symptoms can be referred
from the spine or arise from local pathology. Early symp-
toms of osteoarthritis in the knee or the hip might cause
little pain and no distraction during sitting. If the range of
movement of the joint allows full performance in the work
environment, then aircrew may continue to work safely.
Osteoarthritis may cause more severe symptoms of dis-
tracting ache, stiffness or episodic unpredictable short-lived
severe pain. In these circumstances, fitness for primary task
may be compromised.
Joint replacement
Knee and hip replacement are established surgical proce-
dures with high rates of satisfaction from patients. After
the surgical rehabilitation process has been completed,
the functional outcome is often compatible with return to
full flight-deck duties. A demonstrable ability to enter and
leave the flight deck and perform all lower-limb flight tasks
for an appropriate period should allow return to work. A
discussion during questions at the British Medical Pilots
Association meeting in 2004 revealed an audience member
who had returned to light aircraft flying within two months
of total knee replacement.
Primary total hip replacement is associated with post-
operative dislocation in a small number (about 1 per cent)
of cases. Most of the dislocations occur in the first three
months following surgery. Dislocation is often associated
with flexion and adduction of the hip. It would seem rea-
sonable to allow at least three months for the hip to prove
itself stable before allowing return to duties in possibly
provocative positions. More recently, hip-resurfacing tech-
niques and implants have been developed. Resurfacing
achieves an intrinsically more stable joint because of the
larger femoral head and acetabular radii. A stable range of
movement approaching normal can be achieved. However,
dislocations have been reported from some hospitals using
this technique.
SPINE
The spine is a column of vertebrae and ligaments separated
by discs with two synovial facet joints at each level. The col-
umn is supported by the paraspinal and abdominal muscles.
Ageing is associated with the development of degenerative
changes in the intervertebral discs at one or many levels.
These changes are often asymptomatic and may be visible
on magnetic resonance imaging (MRI) scans performed
for unrelated reasons. The cause of back pain is likely to be
associated with degenerative disc changes and secondary
changes in many cases. These changes make the individual
more likely to experience spontaneous or event-related pain.
Secondary changes, such as disc-space narrowing, facet
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 562  Orthopaedics and trauma
joint osteophytes and soft tissue hypertrophy, may narrow
the nerve root canal, causing referred pain. Local back pain
due to secondary tears of the annulus of the disc, facet joint
degeneration and secondary inflammation occurs.
Other causes of pain, such as spondylolysis and spondy-
lolisthesis, are often found in association with degenerative
changes at the same or other levels. Surgery performed on
these surgically treatable causes of back pain may give poor
results due to the presence of other pain sources. It can be
difficult to guarantee that the site of treatment is the source,
or the only source, of pain.
Low back pain
Non-specific low back pain is variously defined as tension,
soreness and/or stiffness in the lower back region for which
it is not possible to identify a specific cause of the pain.
Several structures in the back, including the joints, discs
and connective tissues may contribute to symptoms.
Back pain is common in the population. The National
Institute for Health and Care Excellence (NICE) reports
that around one third of the UK adult population is affected
each year. Reported lifetime incidence of back pain is
49–69 per cent, with a point prevalence of 12–30 per cent.
Other sources quote higher figures. In a cohort of previ-
ously asymptomatic individuals, 34  per cent of males and
37 per cent of females reported pain in the following year.
A past history of back pain increases the chance of future
back pain. If previous back pain is recognized, then there is
a relative risk of 2.71 of future back pain. Higher incidence
of back pain has been reported in certain groups of work-
ers, such as truck drivers, heavy manual workers and nurses
(Fairbank 2002). Factors that are thought to provoke back
pain include vibration, posture and sudden maximal effort.
HELICOPTERS
Helicopter crew are exposed to vibration and may have to
adopt uncomfortable postures for considerable periods. It
is often not possible to relieve discomfort during flight with
simple stretching manoeuvres. Vibration frequencies of
between 2 and 16 Hz are recorded in helicopters. Exposures
to vibration, smoking and driving have been linked to
disc prolapse. In helicopter crew, backache is perceived as
common, and the majority of sufferers rarely seek medical
advice. Pain can be mild to moderate, appearing during or
shortly after flight, without radiation and sited in the lumbar
region or buttocks. It can also be more severe, radiate to the
lower extremities with paraesthesiae and be longer-lasting
after onset. A study in a mock-up of the UH-1H helicopter
subjected pilots to two test periods of an hour each, one with
vibration and one without. All experienced pain similar to
the pain they reported in flight; the vibration made no dif-
ference to the pain. Other studies seem to suggest that the
asymmetric posture adopted by pilots in helicopters con-
tributes to the experience of back pain. It has been reported
that chronic back pain is associated with the number of
K17577_C033.indd 562
hours flown, developing after a career of 300–500  flight
hours. It seems likely that the posture adopted by helicop-
ter crew contributes to the incidence of back pain, and the
vibration experienced may contribute to disc prolapse and
referred pain. Vibration may cause short-lived regular prov-
ocation of symptoms from an underlying degenerative disc
that would have otherwise been minimally symptomatic.
It is unclear whether the environment in which crew work
actually accelerates or provokes degenerative change.
Symptoms are likely to be reduced by further limitation
of vibration in future helicopter designs and better work-
ing posture. For crew members who are distracted by back
pain, adjustments to the seated position by the manufacture
of relatively inexpensive lumbar supports can be effective.
The natural progress of periods of exacerbation of symp-
toms is for them to usually improve. Physiotherapy aimed at
improving posture and spinal-supporting muscle strength
and coordination may give improvement of base-level
symptoms and reduce frequency of exacerbations of pain.
Given the relative risk of recurrence of back pain in the
general population, and the challenging environment of the
helicopter, potential aircrew with a history of back pain or
sciatica need to be assessed carefully before being accepted
for training.
Although other aircraft types are less likely to submit the
crew to vibration and asymmetric posture, G forces are still
experienced by the crew, and back pain can be troublesome.
Truck drivers have a higher incidence of back pain, even in
the absence of Gz forces, which may be due to the adoption
of prolonged symmetrical seated positions.
Cervical spine
As with the lumbar spine, degenerative change and symp-
toms of neck pain and, to a lesser extent, referred upper
extremity symptoms are common in the population. A
prevalence of 7 or 8 per cent has been reported in the general
population. When considered by age, a prevalence of 2 per
cent in the age group 15–24 years, and increasing to 40 per
cent in the age group 55–64  years, has been reported. An
uninhibited and adequate range of movement to perform
flight tasks such as lookout is required. This required range
of movement is likely to be greater in a single-seat aero-
plane. As stated earlier, it is important to assess adequately a
candidate for aircrew duties who has a history of neck pain
before he or she is subjected to flight duties and stresses.
The potential for repeated exposure to G forces to cause
degenerative change in the cervical spine was addressed
by the Technology Watch (TW), which was established on
the recommendation of the Aerospace Medical Panel of
the former Advisory Group for Aerospace Research and
Development, Working Group 17. The executive summary
reported (Research and Technology Organisation 1999):
This TW noted a very high rate of acute injury to
soft tissues (muscles and ligaments) of the neck
in fighter pilots that was a result of sustained G
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exposures. It also reported that in several pilot
high-sustained G studies there were significantly
greater incidences of degeneration of the cervi-
cal spine compared with low or no G exposed,
age sex matched controls. Meta-analysis of eight
studies determined that there was a direct rela-
tionship between degenerative diseases of the
spine and repeated exposures to sustained G.
The statistical probability of this analysis was P <
0.001. The following hypothesis was developed.
Acute injuries of neck muscles and ligaments
commonly occur in fighter pilots. These injured
soft tissues of the neck are less able to protect the
cervical spine from reoccurring increased G gen-
erated external loads. Thus sub-acute disc injuries
occur that eventually lead to spinal degeneration
and the development of osteophytes with ver-
tebral strengthening. This G effect on the spine
appears to be an acceleration of spinal degenera-
tion that normally occurs with increasing age in
low or non-G controls. Thus it is hypothesized that
both populations will eventually have similar levels
of cervical spine degeneration after pilots are no
longer exposed to sustained G.
EJECTION SEATS AND INJURY
The development of the ejector seat has made escape and
survival from accidents in high-performance aircraft pos-
sible in flight conditions where otherwise there would have
been death. There are three phases during an ejector seat
being used when the pilot may be injured. Injured aircrew
should be treated at the closest unit with experience and
facility to treat poly-traumatised patients; this should ide-
ally be a major trauma centre. Particular patterns of injury
associated with escape equipment can be assessed after ini-
tial life- and limb-saving treatment has been completed.
Seat acceleration
A high rate of onset of G force is associated with axial load-
ing and flexion forces passing through the spine, which
(a) Sitting in ejector seat (b) Ejection vertical forces
Figure 33.2  Ejection forces and injury.
K17577_C033.indd 563
Ejection seats and injury  563
might result in fracture (Figure 33.2). Fractures are concen-
trated at the junctions between the mobile and less mobile
sections of the spine, although they can occur at all levels.
The cervicothoracic junction, thoracolumbar and lumbo-
sacral areas are commonly affected. These injuries can be
missed at initial assessment, particularly if there are other
major injuries causing distracting pain. They can also be
masked by the euphoria of a perceived ‘escape without
injury’. Displaced fractures of the vertebrae will usually be
visible on plain X-ray films. More subtle bony injury may be
demonstrated on the initial trauma CT. MRI is the imaging
modality of choice and will show minimally displaced frac-
tures and trabecular fractures or ‘bone bruise’. It will also
allow the spinal ligaments and soft tissues to be assessed for
otherwise occult injuries.
Wind flail injury
Aircrew ejecting at high airspeed will be subjected to rapid
deceleration forces due to airflow. Mobile parts of the body
may move in an uncontrolled manner past the usual range
of movement and result in soft-tissue injury, dislocation and
fracture (Figure 33.2). Despite the use of limb restraints, the
chance of wind flail injury to the legs and arms increases as
the indicated airspeed at time of ejection increases.
As well as the limbs being subjected to flail forces, the
cervical spine can be submitted to multiplanar forces,
including distraction pulling forces. These forces can result
in severe soft-tissue ligamentous injury.
Injury on landing
The pattern of injury on landing depends on the rate of
descent, the ability of the ejectee to perform parachute land-
ing drills, and the type of surface. Axial loading forces pass-
ing through the foot, calcaneum, tibia, femur, pelvis and the
axial spine can cause fracture at any site. As always in the
presence of life-threatening injury or painful distracting
injury, some of these injuries can be missed unless looked
for specifically. If not identified, a potential treatment win-
dow that might improve long-term performance and func-
tion may be missed.
(c) Wind flail forces
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 564  Orthopaedics and trauma
The particular forces that may be experienced by a per-
son flying an aircraft equipped with an ejector seat mean
that the issues of retained metalwork after fracture and the
presence of joint replacements need to be considered in con-
junction with the forces that might be experienced during
and after ejection.
Management of the ejectee
The ejectee should be managed using standard protocols for
the assessment and treatment of a severely injured patient.
The specific issues of bony or ligamentous injury of the spine
may be obvious with a severe injury, but occult and subtle
injuries of the spine can be overlooked, particularly in the
early euphoria of a successful ejection or if there are other,
more severe distracting injuries. The treating team should
have a high level of suspicion for spinal injury. The use of
diagnostic aids such as MRI is invaluable in order to dif-
ferentiate between minor soft-tissue sprain and more severe
ligamentous injury or non-displaced fracture.
Return to ejection-seat flying
The decision to return to ejection-seat flying after ejection
should be made after considering the functional perfor-
mance of the pilot in general and the specific functional
limitations that residual effect of injury might have after
treatment has been completed. The prospect of returning
to ejection-seat aircraft raises the issue of future ejection
and the potential of increased risk of injury, especially to
the spine. The conservative management of a minimally
displaced anterior wedge fracture will usually give good
functional outcome with minimal residual stiffness; in
this circumstance, the increased risk of injury is slight and
return to ejection-seat flight almost certain. If a more com-
plex spinal fracture of two or more levels has been man-
aged surgically with the insertion of rods and screws, then
there will be a stiff segment of spine, even if the rods and
screws are subsequently removed. Such a stiff segment will
mean that the overall passive range of movement will be
reduced. Future ejection causing passive flexion that might
otherwise have been tolerated could now cause spinal
injury and risk of neurological impairment. Other metal-
work in limbs may change the tolerance to wind flail forces
and landing forces.
CONGENITAL DEFORMITY
As with the previous discussions, the assessment of con-
genital deformity should be performed against functional
criteria and with the potential for future deterioration of
function in mind. Conditions that initially appear to be
isolated and treated well often coexist with subtle or obvi-
ous hypoplasia of the remainder of the limb. For instance,
treated club foot is often associated with a small calf, short
leg and more subtle thigh hypoplasia. A well-treated club
foot may allow all pilot duties to be performed, but is likely
K17577_C033.indd 564
to cause difficulty with other ground tasks and field craft
skills that military pilots might perform.
OSTEOPOROSIS
The measurement of bone density is usually performed as
a screening tool in the middle-aged to elderly person who
has sustained fracture in order to exclude or treat reduced
bone density. The relative risks of fracture, compared with
the normal for age, in the femoral necks and the lumbar
vertebrae are often given. Bone density below one standard
deviation of the normal is considered osteopenic and below
2.5  considered osteoporotic. The history of bone-density
studies being performed in a potential aircrew applicant
should cause the result to be looked at carefully and the
increased risk of fracture quantified. It is unusual for young
people to undergo bone-density studies, and a spectrum
of associated conditions that may be present and led to the
decision to perform bone-density studies, such as previously
treated pituitary hypoplasia, must be considered carefully.
ANKYLOSING SPONDYLITIS
Ankylosing spondylitis (AS) is one of five subsets of the
spondyloarthritides. Diagnosis requires one of three clini-
cal criteria, (1) inflammatory back pain; (2) limitation of
spinal movement in three planes; or (3) deterioration of
chest expansion, and radiological sacroiliac joint changes
(bilateral grade 2 or unilateral grade 3/4).
Sacroiliac radiographs may be normal in early disease
when dynamic MRI of the sacroiliac joints can be helpful in
providing objective evidence of sacroiliitis in clinically sus-
picious cases. Age of onset is commonly in the twenties, with
male:female ratio of 2:1. Early in the course of disease, there
may be no limitation of spinal movement or chest expansion,
but as it progresses there is restriction of lateral flexion, for-
ward flexion, and extension (Braun and Sieper 2010).
The disease and its relevance to aviators have come to the
fore recently after it was implicated in a fatal midair colli-
sion (UK Air Accident Investigation Report 2010).
It must be remembered that some aircrew have had long
careers flying with well-managed AS. Medication with
minimal side effects has not affected their ability to perform
all necessary cockpit duties and the disease has progressed
slowly giving little if any physical limitation.
However, after a midair collision in 2009, the potential
flight safety implications of this variable disease became
apparent. In light of the AAIB report, some institutions no
longer allow pilots to fly solo after a diagnosis of AS. This
approach is under constant review and indeed work is ongo-
ing to try and develop a system by which individuals can
be assessed objectively and functionally by an independent
aviation medicine trained doctor to determine fitness to fly
on an individual case by case basis (Matthews 2012). As spi-
nal stiffness and fixed deformity progress, there may be a
small or large effect on the pilot’s ability to maintain ade-
quate look-out and also difficulty with seated position in the
17/11/2015 16:02

cockpit. These parameters should be borne in mind when
assessing fitness to continue flying in established aircrew.
With specific regard to the question of flying in aircraft
fitted with ejector seats, the opinion of the authors is that
pilots with a diagnosis of AS should not, either as profes-
sional aircrew or passengers, be exposed to the axial spine
loading experienced during ejector seat egress.
REFERENCES
Braun J, Sieper J. Ankylosing Spondylitis, Other
Spondyloarthritides, and Related Condition. In:
Warrell DA, Cox TM, Firth JD (eds). Oxford Textbook
of Medicine. Oxford: Oxford University Press, 2010:
3603–16.
Burke FD, McGrouther DA, Smith PJ. Principles of Hand
Surgery. Edinburgh: Churchill Livingstone, 1990.
Department for Work and Pensions. The Disability
Discrimination Act 1995 (Amendment) Regulations.
London: HMSO, 2003.
Fairbank CTJ. The Thoracic and Lumbar Spine. In: Foy M,
Fagg P (eds). Medicolegal Reporting in Orthopaedic
Trauma. Edinburgh: Churchill Livingstone, 2002: 383–92.
Foy M, Fagg P. Medicolegal Reporting In Orthopaedic
Trauma, 4th edn. Edinburgh: Churchill Livingstone,
2001: 219.
Magee DJ. High Incidence of Occult Spinal Injuries
Following Vertical Aircraft Ejection: A Prospective
Study Using Magnetic Resonance Imaging. In: Magee
DJ, Orthopaedic Physical Assessment. London:
Saunders, 1992.
Matthews R. Ankylosing spondylitis: limitations of func-
tional assessment in determining fitness for aircrew
duties. Aviation, Space, and Environmental Medicine
2012; 83: 3.
K17577_C033.indd 565
Further reading  565
National Institute for Health and Care Excellence. GC88
Low Back Pain. London: NICE, 2009.
Research and Technology Organisation. Cervical Spinal
Injury from Repeated Exposures to Sustained
Acceleration. RTO Technical Report 4. RTO-TR-4
AC/323(HFM)TP/9. Neuilly-sur-Seine, France: Research
and Technology Organisation, 1999.
Ruedi TP, Murphy WM. Principles of Fracture
Management. Stuttgart: Thieme, 2000.
Tempelhof S, Rupp S, Seil R. Age-related prevalence of
rotator cuff tears in asymptomatic shoulders. Journal
of Shoulder and Elbow Surgery 1999; 8: 296–9.
UK Air Accidents Investigation Branch (AAIB). Aircraft
Accident Report No 5/2010. Report on the accident
between Grob G115E (Tutor), G-BYXR and Standard
Cirrus Glider, G-CKHT at Drayton, Oxfordshire on 14
June 2009. Available at www.aaib.gov.uk.
FURTHER READING
Kiely PJ, Lam KS, Kendrew J, et al. Spinal injury from verti-
cal aircraft ejection: a prospective series revealing a
high incidence of occult injury. Journal of Bone and
Joint Surgery-British Volume 2009; 91-B (II): 209–10.
Lam KS, Kerslake RW, Webb JK. High incidence of occult
spinal injuries following vertical aircraft ejection: a
prospective study using magnetic resonance imaging.
Journal of Bone and Joint Surgery [Br] 2005; 87 (III):
240.
Read CA, Pilla J. Injuries sustained by aircrew on ejecting
from their aircraft. Journal of Accident and Emergency
Medicine 2000; 17: 371–3.
Townend M, Parker P. Metalwork removal in potential
army recruits. Evidence-based changes to entry cri-
teria. Journal of the Royal Army Medical Corps 2005;
151: 2–4.
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Decompression illness
JANE E. RISDALL
Introduction 567
Evolved gas disease 567
Arterial gas embolism 568
Ebullism 568
Diagnosis of decompression illness 569
INTRODUCTION
Decompression illness (DCI), encompassing both decom-
pression sickness (DCS) and arterial gas embolism (AGE),
is a potentially life threatening condition encountered as a
result of exposure to a reduction in barometric pressure. It
can occur during ascent in astronauts and aviators as well
as compressed gas divers and caisson workers. DCI is a syn-
drome of numerous possible manifestations, thought to be
initiated by the presence of bubbles of gas in the body tissues
and circulation.
A reduction in environmental pressure may lead to bub-
ble formation by two distinct mechanisms.
EVOLVED GAS DISEASE
Henry’s Law can be applied to describe the amount of dis-
solved gas held in tissues and blood. At sea level, both air
and arterial blood contain approximately 0.8 atmospheres
(80 kPa, 600 mmHg) of nitrogen, since the concentration of
inert gas in arterial blood at equilibrium is approximately
the same as in the gas mixture which is being breathed. This
equates to approximately 1L (standard temperature and
pressure, dry, STPD). The partial pressure of nitrogen in the
inspired air falls during ascent/decompression. Nitrogen is
carried in the blood from the tissues to the lungs, where,
as a result of the pressure gradient developed, it leaves the
body on exhalation. Since the solubility of nitrogen in blood
is relatively low, and some tissues contain large amounts of
nitrogen, the rate of fall of the absolute pressure of the body
K17577_C034.indd 567
34
Presentation of DCI 569
Differential diagnosis 570
Management of decompression illness 571
Prevention of DCI 574
References 576
tissues associated with the ascent is greater than the rate of
fall of the partial pressure of nitrogen in those same tissues.
These tissues, therefore, become supersaturated with nitro-
gen. Under certain circumstances, this supersaturation
gives rise to the formation of bubbles of gas, the main con-
stituent of which is initially nitrogen. This supersaturation
concept describes a critical component in the formation of
bubbles; the supersaturation ratio:
tension of the inert gas in the tissues : ambient pressure
If ascent occurs at a controlled rate, such that the inert gas
tension in the tissues and blood does not achieve a sufficient
level of supersaturation for bubbles to form, decompression
will proceed uneventfully. If the rate and magnitude of the
ascent are such that the capacity of the tissues, circulation,
heart and lungs is overwhelmed, bubbles may start to form.
The driving pressure for bubble formation in a fluid is
the difference between the partial pressure of the gas dis-
solved in the fluid and the absolute hydrostatic pressure.
The greater the partial pressure of the gas and the lower the
absolute hydrostatic pressure, the greater is the tendency
for bubble formation. The increase in the partial pressure
of nitrogen produced in a tissue by a given decompression
depends on the solubility and the rate of diffusion of the
gas in the tissue and the local blood flow. Nitrogen is highly
soluble in fat and adipose tissue has a low blood flow. These
factors result in a greater driving pressure to bubble forma-
tion in tissues with high lipid content. Bubbles will not form
in a fluid even when the driving pressure is large, unless
567
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 568  Decompression illness
suitable nuclei are present. Nuclei for bubble formation con-
sist of microscopic masses of gases attached to irregularities
on the walls of vessels, or small particles suspended in the
fluid. Once formed, bubbles will grow in size as the result of
inward diffusion of nitrogen, oxygen, carbon dioxide and
water vapour from surrounding tissues. At altitude, the
partial pressures of oxygen and carbon dioxide within the
bubble will contribute to the generation of a nitrogen gradi-
ent. Partial pressures of oxygen and carbon dioxide within
a bubble reflect tissue levels and if the alveolar Po2 is main-
tained at sea-level values during ascent, these values will
change very little. However, when barometric pressure is
reduced, the partial pressures of oxygen and carbon dioxide
constitute an ever-greater proportion of the total pressure
within the bubble, increasing the inward diffusion gradient
for nitrogen and promoting faster bubble growth.
Bubbles that form at one site may be carried by the cir-
culation to another. Man is capable of tolerating a certain
bubble load. Venous bubbles are efficiently filtered from the
circulation by the lungs and numerous Doppler studies have
demonstrated the presence of venous bubbles in otherwise
asymptomatic subjects during sub-atmospheric exposures
(Conkin et al. 1998). Venous bubbles or venous gas emboli
(VGE) can be detected using precordial Doppler and sound
recordings of the echoes from the VGE entering the right
atrium and ventricle. They can be graded on a scale of 0 to 4,
depending on the intensity of the visual and audible signals
(Table 34.1).
Bubbles may form in some tissues, such as adipose tissue,
without causing overt symptoms; while in other tissues, such
as the nervous system, the presence of even a small bubble
load may result in tissue damage, symptoms and abnormal
function. In aircrew ascending from sea level, symptoms of
DCI are unlikely to occur below 18 000 feet unless there has
been a recent hyperbaric or diving exposure. In sedentary
individuals, the incidence of DCI between 18 000 feet and
25 000  feet is low; however, in exercising subjects, asymp-
tomatic venous bubbles have been detected  at 10 250  feet
and limb pain has been described at 15 000 feet.
Although the lungs provide an excellent bubble filter,
their capacity is finite. Massive venous gas load may over-
whelm this filter, resulting in venous bubbles transiting
to the arterial circulation. Additionally, the presence of a
right-to-left shunt may allow bubbles to bypass the pulmo-
nary filter. Between 20 and 30 per cent of the normal adult
Table 34.1  Grading of venous gas emboli (VGE) detected
by Doppler echo imaging systems
Grade Intensity of Signal
0 Bubble signals absent
1 Occasional bubbles discernible
2 Fewer than half the cardiac cycles contain
bubbles
3 Most of the cardiac cycles contain bubbles
4 Bubble signals continuous through systole
and diastole and obscure heart sounds
K17577_C034.indd 568
population can be demonstrated to have a patent foramen
ovale (PFO) (Hagen et al. 1984) and, while this relic of the
foetal circulation normally results in no ill effects, it has the
potential to promote arterialization of otherwise relatively
harmless venous bubbles. The significance of a PFO to any
individual aviator is currently uncertain.
ARTERIAL GAS EMBOLISM
The second method of bubble generation arises as the
result of expansion of trapped gas (particularly in the
lungs) as a consequence of Boyle’s Law. If gas from a rup-
tured lung enters the tissue planes, it may present as sub-
cutaneous emphysema or a pneumo-mediastinum, but
if it enters the pulmonary veins, it will be carried to the
left side of the heart and from there be distributed to the
body as AGE. Two target organs, which are particularly
susceptible to AGE, are the brain and the heart. Anyone
who has sustained decompression pulmonary barotrauma
should be carefully assessed for evidence of cardiac or
neurological disturbance.
Pulmonary barotrauma due to lung over-distension has
been considered a rare consequence of the loss of cabin
pressure in flight (as discussed in Chapter 6) but remains
a real risk in experimental hypobaric chamber exposures.
However, the advent of highly agile aircraft, capable of
sustaining high +Gz at high altitude and with life support
systems which deliver positive pressure breathing, has cre-
ated the circumstances in which a sudden loss of cabin
pressure during a +Gz manoeuvre could occur while the
aircrew’s lungs are fully inflated. Additionally, performance
of the anti-G straining manoeuvre will obstruct free flow of
expanding gas from the lungs, further enhancing the risk of
pulmonary barotrauma.
EBULLISM
Exposure to 63 000  feet introduces the additional hazard
of ebullism. At this altitude, ambient pressure (47 mmHg,
6.25  kPa) equals the saturated vapour pressure of water
at body temperature (37°C) and spontaneous boiling and
degassing of body fluids and tissues will occur (ebullism).
Not only will water vapour continuously leave the body,
resulting in rapid cooling, but also changes from the liquid
to gaseous phase in the tissues will produce gas cavities and,
in certain animal species, the body may rapidly increase in
size. The changes are reversed on recompression as the gas
phase reverts to liquid.
Most data available on ebullism are from animal studies
(Billings 1973). These show that involvement of the cardio-
vascular system commences with the formation of bubbles
in the low pressure areas of the circulation (venous and
capillary beds). The elastic walls of the arterial tree provide
a degree of positive pressure protection. The bubbles can
then occlude venous and pulmonary vessels and circulation
ceases. Post-mortem findings generally demonstrate mas-
sive pulmonary damage with haemorrhage and atelectasis.
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However, if recompression is sufficiently rapid and pulmo-
nary function re-established, the bubbles of ebullism revert
to the liquid phase and recovery is possible.
Studies of ebullism in humans have been very limited,
although successful short-term exposures to altitudes above
63 000  feet have been conducted using partial pressure
assemblies which increase intra-pulmonary pressure and
provide counter-pressure to certain areas of the body.
DIAGNOSIS OF DECOMPRESSION
ILLNESS
Pathological mechanisms for the deleterious effects of
bubbles include disruption of tissue architecture, occlusion
of the supporting microcirculation and the triggering of
a range of ‘injury cascades’ at the tissue–bubble interface
(Hernandez et  al. 2014). There are no highly sensitive or
specific diagnostic investigations for DCI but it has been
the practice in aviation medicine to regard any symptoms
arising at altitude or simulated altitude, in the absence of
hypoxia, as manifestations of DCI until proved otherwise.
History and clinical examination are essential, therefore, in
assessing patients and establishing a diagnosis of DCI.
When suspected DCI occurs during flight, the opportu-
nity for the clinician/flight surgeon to elicit a history may be
very limited and, initially, examination of the patient may
not be possible at all. Key facts to establish therefore are:
●● Nature of the symptoms being experienced.
●● Evolution and severity of symptoms.
●● Timing of onset of symptoms relative to exposure to
altitude.
●● Maximum altitude experienced.
●● Rate of altitude exposure.
●● Response of symptoms to oxygen.
●● Response of symptoms to descent.
Onset of symptoms within five minutes or less of attain-
ing altitude is suggestive of AGE, particularly if the decom-
pression was rapid. Symptoms developing after five minutes
at altitude are more likely to be due to evolved gas disease.
Presenting symptoms can range from sudden loss of con-
sciousness or sudden onset of chest pain, through shortness
of breath, impaired conscious level, dizziness or paraesthe-
siae, to joint pain or skin irritation.
PRESENTATION OF DCI
Since DCI can interfere with the function of a wide range of
tissues, the potential number of manifestations is enormous.
The relative incidence of symptoms and signs during two-
hour chamber exposures to 28 000 feet and 37 000 feet are
presented in Table 34.2. In the past, these have been grouped
into ‘syndromes’ according to the anatomical site and pre-
sumed mechanism of disease. These have then been further
subdivided according to the perceived severity resulting in
Mild (Type 1) and Serious (Type 2) decompression sickness
K17577_C034.indd 569
Presentation of DCI  569
Table 34.2  Relative incidence of symptoms of altitude
decompression illness
Incidence (%) Incidence (%)
28 000 ft for 37 000 ft for
Symptoms 2 hours 2 hours
Joint and limb pain 74 56.5
Respiratory 4.5 6.5
Cutaneous 7 1.6
Visual 2 4.8
Neurological 1 0
Collapse 9 25.8
Miscellaneous 2.5 4.8
(Elliott and Kindwall 1982). These terms are still used, but
it is increasingly recognized that they are of limited value
because symptoms from the two groups may co-exist or a
‘Type 1’ injury progress to a ‘Type 2’. A descriptive protocol,
focusing particularly on the evolution and manifestation of
symptoms, is preferred (Francis and Smith 1991).
Evolution
This term is used to describe the development of the symp-
toms prior to descent or recompression. DCI is frequently a
dynamic condition, so this description may vary from one
observation to the next. Typically, DCI presents initially as
being ‘progressive’ as the patient becomes increasingly aware
that something is wrong. If the symptomatology stabilizes,
it may then be considered ‘static’. If there is improvement
or even complete resolution without intervention (including
descent or oxygen administration) it may be described as
‘spontaneously improving’ but if symptoms recur the con-
dition would be described as ‘relapsing’.
Manifestations
There are a number of commonly occurring manifesta-
tions of DCI. While each may present alone, combinations
of symptoms are frequent and should always be actively
sought and/or excluded.
PAIN
Limb pain is probably the most frequent manifestation of
DCI. It describes a deep aching pain in a limb or joint, which
may begin during ascent (decompression) or at altitude. In
aviators, it is the lower limbs, particularly the knees, which
are most commonly involved. The pain usually begins grad-
ually and is poorly localized. It may resolve spontaneously.
Minor pain may migrate from joint to joint, a condition
known as the ‘niggles’, or it may worsen becoming localized
to a particular joint and acquiring a dull, boring character-
istic, frequently likened to toothache. The pain is seldom
made worse by movement and often there are no objective
signs on examination. Patients presenting with isolated
limb pain must be fully examined to exclude any neuro-
logical deficit, as the pain may mask mild paraesthesiae,
17/11/2015 16:03
 570  Decompression illness
numbness or weakness. Limb pain DCI frequently resolves
completely on descent to ground level.
Girdle or back pain often presents as a poorly localized
aching or ‘constricting’ pain that originates in the mid to low
back and often spreads, usually bilaterally, around the pel-
vis or abdomen in a girdle-like distribution. Occasionally, it
may originate in the thoracic spine and spread around the
chest or shoulder girdle. In the context of DCI, pain of this
nature is associated with spinal cord involvement and its
presence may herald neurological deterioration.
NEUROLOGICAL
Involvement of the nervous system may range from the
subtle, multifocal presentations of mild evolved gas dis-
ease to the dramatic catastrophic presentation of severe
cerebral AGE. Both the central and peripheral nervous
systems may be involved, giving a huge range of possible
neurological manifestations. These can include alterations
of higher functions (aberrant thought processes, altered
affect, loss of memory, cognitive impairment), altered level
of consciousness, seizure activity, impaired coordination,
reduced strength or sensation in any distribution, presence
of paraesthesiae, dysfunction of the special senses and loss
of sphincter control.
The audiovestibular system may be damaged directly as
a result of barotrauma or as a consequence of evolved gas
disease affecting the cochlea, eighth nerve nuclei, cerebellar
or cortical pathways. In individual cases, it may be impos-
sible to distinguish between these mechanisms or sites of
injury by clinical examination alone. Consequently, audio-
vestibular DCI may describe any presentation that includes
rotational vertigo, tinnitus, nystagmus or reduced auditory
acuity after a provocative altitude exposure. Nausea and
vomiting may accompany these symptoms, but are insuf-
ficient, in themselves, to imply audiovestibular DCI.
CARDIOPULMONARY
Involvement of the lungs in DCI may be as a result of two
distinct processes, namely decompression pulmonary baro-
trauma and the cardiopulmonary consequences of massive
venous gas embolism. Cardiac involvement may also result
from coronary artery AGE. Although the mechanisms
involved are distinctly different, it may be difficult to dis-
tinguish between them in a clinical setting, because many
of the symptoms and signs are shared. These include dys-
pnoea, tachypnoea, chest pain, cough, haemoptysis, cyano-
sis and rarely, shock. Progression of symptoms at altitude
may be due to either a tension pneumothorax or massive gas
embolism of the lungs. The latter condition, often referred to
as the ‘chokes’, presents initially with a sense of constriction
around the lower chest and any attempt at deep inspiration
is marked by an inspiratory ‘catch’. This is accompanied by
the development of retrosternal discomfort and paroxysmal
coughing on inspiration. Breathlessness and cyanosis fol-
low and, shortly thereafter, progress to collapse if the alti-
tude exposure is maintained. Symptoms of respiratory DCI
may persist for several hours after return to ground level
K17577_C034.indd 570
and are thought to represent the reflex response of the pul-
monary tissues to the venous gas load.
CUTANEOUS
Cutaneous manifestations often occur at altitude. They
are usually transient and consist of itching, tingling (the
‘creeps’) or formication. Occasionally, itching may be severe
and accompanied by hyperaesthesia. More infrequently
erythematous, urticarial rashes or cyanotic mottling and
marbling (cutis marmorata) are observed, usually in con-
junction with other manifestations of DCI.
CONSTITUTIONAL
There are a number of non-specific symptoms, which
may be considered part of the constellation of DCI. These
include headache, malaise, fatigue, nausea, anorexia and
anxiety. In a small proportion of cases presenting with these
symptoms, there is progression to diminished conscious-
ness (primary collapse) without any other manifestations of
DCI. Rapid recovery, often with an accompanying frontal
headache, follows descent.
DIFFERENTIAL DIAGNOSIS
DCI may be mimicked by a variety of disorders including
intercurrent illness arising coincidentally with flight and
conditions arising from the known environmental or psy-
chological stresses of flight or simulated altitude exposure.
Intercurrent illness
This should be rare in the well-screened aircrew popula-
tion. Limbs pains may arise for many reasons, including
postural cramps and injury. Viral illnesses may manifest
as constitutional symptoms evolving over the duration of
longer exposures. More serious conditions, including isch-
aemic heart disease and cerebrovascular disease, may pres-
ent for the first time during flight, provoking concerns of
cardiopulmonary or serious neurological DCI. Descent, in
such cases, will be required immediately and differentiation
should present little difficulty once on the ground.
Environmental flight stresses
HYPOXIA
The clinical features of acute hypobaric hypoxia are sum-
marized in Chapter 4. Almost all of the symptoms listed are
equally applicable to an episode of DCI. The symptoms will
be rapidly reversed by the administration of an increased
partial pressure of oxygen but will also respond favourably
to recompression (descent) as the alveolar oxygen tension
is raised.
GASTROINTESTINAL GAS DISTENSION
Free gas in the intestinal tract will expand as the ambient
pressure is reduced (Boyle’s Law). If not adequately vented,
17/11/2015 16:03

this can cause stretching of the visceral walls with pain and
reflex muscle contraction. In extreme cases, loss of con-
sciousness can supervene.
Significant abdominal pain due to gas expansion during
ascent is uncommon at altitudes below 40 000 feet.
+GZ RELATED ATELECTASIS
The aetiology of +Gz related basal atelectasis is described
in Chapter 7. The symptoms produced include inspiratory
pain and retrosternal discomfort and in some individuals
this will progress to paroxysmal coughing. The resemblance
to cardiopulmonary DCI is clear. A detailed history includ-
ing the type of aircraft, flight profile and life support equip-
ment used should help make the distinction.
ALTERNOBARIC VERTIGO
In susceptible individuals, rotational vertigo, nausea,
vomiting and ataxia may occur if the pressure difference
between the two middle ears exceeds a critical level (around
6 kPa, 45 mmHg). This is thought to be due to asymmetrical
pressure stimulation of the vestibular apparatus. The prob-
lem occurs most commonly during ascent but has also been
described during descent, if a Valsalva or similar manoeu-
vre raises middle ear pressure. If rotational vertigo occurs
during ascent in the erect posture, the sensation of spinning
will be towards the side with the poorest Eustachian tube
function and, consequently, the highest middle ear pressure
(Ross 1976). Alternobaric vertigo is likely to occur at low
altitudes where the pressure changes are greater and gener-
ally below the threshold for DCI.
HYPERVENTILATION
Hyperventilation is not uncommon in conjunction with
altitude exposure. It may be induced by a number of causes
including anxiety, fear and unfamiliarity with breathing
systems. It is usually easy to recognize by the rate and depth
of respiration, development of paraesthesiae and light-head-
edness and the history of the flight or altitude exposure.
Confusing symptoms of recurrent loss of consciousness,
tetany and acute apprehension with tachycardia persisting
for some hours have been described, but are very rare.
MANAGEMENT OF DECOMPRESSION
ILLNESS
First aid
●● Ensure the affected individual is breathing 100 per cent
oxygen, minimize activity and, if symptoms are severe,
lie flat (not head down).
●● Unconscious subjects should be put in the recovery
position, if possible.
●● Increase ambient pressure/descend to ground level as
soon as is practicable.
In flight, a PAN call should be made declaring a physi-
ological emergency and in a simulated altitude exposure
K17577_C034.indd 571
Management of decompression illness  571
appropriate assistance should be summoned to the chamber
hall. The vast majority of cases will have resolved completely
on return to ground level and many will improve spontane-
ously during descent to altitudes below 10 000 feet.
Management on the ground
Initial treatment on the ground should be directed towards
stabilizing the patient along conventional trauma manage-
ment guidelines, as dictated by the severity of symptoms.
The response to first aid treatment should be reviewed, a
full history elicited and a thorough physical examination
(including detailed neurological assessment) performed. If
symptoms have resolved completely and no physical signs
are detected, then the subject should be kept under observa-
tion on 100 per cent oxygen for two hours.
Dehydration almost invariably complicates DCI. All indi-
viduals should be rehydrated at the earliest opportunity with
oral fluids if conscious, or intravenous crystalloid solutions
(not glucose containing) if semi-conscious or comatose.
If symptoms or signs are still present, consider hyper-
baric recompression, with advice from a diving medicine
specialist, plus adjunctive therapy as appropriate, par-
ticularly if recompression is not immediately available. In
England, Wales and Northern Ireland, diving and hyper-
baric medicine advice is provided via the British Hyperbaric
Association emergency line (07831 151523) from doctors
at the Diving Diseases Research Centre, Plymouth. In
Scotland, such advice is available from the on-call hyper-
baric consultant on 0845 4086008.
Role of hyperbaric recompression
Although first aid measures will generally improve the
subject’s condition, recompression remains the definitive
treatment for dysbaric disorders. This is effected, initially,
by returning to ground level; however, persisting symptoms
may be due to the continued presence of bubbles in the tis-
sues or to a developing secondary injury (ischaemic damage,
oedema, inflammation) as a result of trauma from evanescent
bubbles. Further (hyperbaric) recompression will reduce the
volume of any remaining gas bubbles in the tissues, reducing
the pressure/stretch on tissues, restoring tissue architecture
and improving blood flow. Bubble size reduction is not linear
but asymptotic and the biological effectiveness of the volume
reduction will depend, in part, on bubble shape. A spherical
bubble will reduce in all dimensions as its volume declines,
whereas a cylindrical bubble, such as might occur inside a
blood vessel, will experience a relatively greater reduction in
length, but may maintain a diameter sufficient to continue to
impede blood flow for a similar decline in volume.
Administration of hyperbaric oxygen has several benefi-
cial effects: it enhance the ‘wash-out’ of nitrogen from any
remaining bubbles by increasing the diffusion gradients,
it increases the blood oxygen content and, hence, oxygen
delivery to injured tissues, it reduces endothelial dysfunc-
tion and lessens the consequences of reperfusion injury.
17/11/2015 16:03
 572  Decompression illness
Recompression schedules
The diving medicine specialist will guide the choice of
recompression table, but for altitude-induced DCI, com-
pression to depths in excess of 18  m of seawater (msw) is
unlikely to be required since the inert gas burdens are low
and recompression from point of injury to surface has
already occurred.
ROYAL NAVY TREATMENT TABLE 61
Individuals with persisting pain-only or cutaneous symp-
toms can be treated using Royal Navy (RN) Table 61 (equiva-
lent to United States Navy [USN] Table 5), provided there are
no neurological abnormalities in the history or on examina-
tion (Figure 34.1). The subject should start breathing oxygen
on the surface and then be compressed to 18 msw (282 kPa,
2.8  ATA, 60  fsw, 2128  mmHg) over one or two minutes,
stopping only if chamber occupants have difficulty clearing
their ears. The time of treatment starts on reaching 18 msw.
If the symptoms are completely relieved within 10 minutes
of starting treatment, subsequent decompression may pro-
ceed in accordance with RN Table 61. Otherwise, decom-
pression should be conducted in accordance with RN Table
62 (USN Table 6) (Figure 34.2).
18 msw
9 msw
Surface
2 hrs 15 mins
Figure 34.1  Royal Navy Treatment Table 61. White areas
represent oxygen breathing, black areas air breaks. See
text for further detail.
18 msw
9 msw
Surface
4 hrs 45 mins
Figure 34.2  Royal Navy Treatment Table 62. White areas represent oxygen breathing, black areas air breaks. See text for
further detail.
K17577_C034.indd 572
ROYAL NAVY TREATMENT TABLE 62
This table is used for the majority of cases of DCI, which do
not meet the criteria for RN Table 61. Again, descent is to
18  msw on oxygen. If the symptoms have remained static
or improved incompletely after three 20-minute periods on
100 per cent oxygen at 18 msw, the table may be extended
by one, two or three further 20-minute oxygen breathing
periods each separated by a 5-minute air break, on the
advice of the diving medicine specialist. The table may also
be extended at 9  msw if symptoms recur during decom-
pression. One or two one-hour oxygen breathing periods,
separated by 15-minute air breaks, may be added. In the
event of incomplete relief of symptoms after a single hyper-
baric recompression, or if symptoms recur after leaving the
chamber, it is thought to be beneficial to continue to treat
daily with hyperbaric recompression until either there is no
further improvement in the individual’s symptomatology
or complete resolution has occurred (Bennett and Moon
1990). Depending on the severity of the symptoms, retreat-
ment may utilize a second RN Table 62 or follow RN Table
66 (USN Table 9) (Figure 34.3).
ROYAL NAVY TREATMENT TABLE 66
This table was developed specifically for the treatment of
patients who require hyperbaric oxygen therapy. It limits
the depth to 14 msw (242 kPa, 2.4 ATA, 45 fsw, 1824 mmHg)
reducing the probability of oxygen toxicity with repeat
exposures. It should NOT be used as a primary treatment
for DCI.
Descent is to 14 msw on oxygen as quickly or slowly as
the subject’s condition determines. Timing of treatment
commences on reaching 14 msw and consists of three peri-
ods of 30 minutes breathing 100 per cent oxygen, separated
by 5-minute air breaks. Ascent is at a continuous rate of
1.4 msw per minute directly to surface.
Adjunctive measures
While oxygen and recompression are the primary methods
of treatment in DCI, hyperbaric recompression facilities
17/11/2015 16:03

14 msw
Surface
1 hr 40 mins
Figure 34.3  Royal Navy Treatment Table 66. White areas
represent oxygen breathing, black areas air breaks. See
text for further detail.
are not always immediately available. Adjunctive therapies
are recommended to optimize a subject’s condition prior to
transfer to more distant recompression facilities and to pre-
vent or ameliorate secondary patho-physiological insults.
FLUIDS
The microcirculation is compromised in DCI, even in the
absence of dehydration. This is thought to be the result of
endothelial damage caused by circulating bubbles leading
to plasma extravasation, platelet and leucocyte adhesion
and platelet thrombi formation.
The efficacy of oral fluids in the treatment of DCI is not
proven. However, fluids containing 60  mM sodium and
80–120 mM glucose have been used successfully for rehydra-
tion in other conditions (Cunha–Ferreira 1989). Provided
the subject is not vomiting an oral intake of 1–2 L of fluid
per hour is safe and tolerable. The gastric distension that
occurs will stimulate gastric emptying, unless there is pro-
tein or high concentrations of glucose in the fluid ingested.
If significant symptoms are present, intravenous fluids
are preferred since:
●● Administration of oral fluids will interrupt breathing of
100 per cent oxygen.
●● Most people have to sit up to swallow.
●● Plasma volume can be more rapidly replaced with intra-
venous fluid administration.
●● Oral fluids may increase the risk of vomiting and
aspiration.
Isotonic intravenous fluids are preferred. Hypotonic
solutions can induce osmolar gradients favouring entry
of water into cells, possibly contributing to tissue oedema
and glucose solutions should be avoided since they may
lead to worsening of neurological damage for similar rea-
sons. The end point for fluid therapy should include a nor-
mal blood pressure, heart rate and haematocrit and a urine
output of at least 1 mL/kg per hour. Accurate fluid balance
recording is essential, since oliguria or anuria despite fluid
K17577_C034.indd 573
Management of decompression illness  573
administration may indicate persistent haemoconcentra-
tion or possible bladder dysfunction as a result of spinal cord
damage. In either case, urinary catheterization is warranted.
The role of central nervous system (CNS) oedema in the
outcome of neurological DCI has been debated. Circulating
bubbles denude endothelial cells of surfactants, transiently
increasing the permeability of the blood–brain barrier
(BBB). Although this causes brain water to increase, this
only appears to affect function if it is severe enough to cause a
mass effect. BBB integrity is generally restored within hours
(Hills and James 1991). In contrast, brain function after gas
embolism usually correlates well with blood flow and con-
sequently fluid load should be adequate to maintain cerebral
perfusion. This is especially important after cerebral AGE
as cerebral autoregulation of blood flow is lost and cerebral
perfusion passively follows systemic blood pressure.
LIDOCAINE
Lidocaine is a cationic amide used therapeutically as a local
anaesthetic and as a class Ib antiarrhythmic agent in ven-
tricular tachyarrhythmias. At therapeutic (non-toxic) lev-
els, it has been shown to have the following CNS effects in
animal models:
●● Preservation of neuroelectrical function.
●● Reduction of infarct size.
●● Preservation of brain blood flow.
●● Reduction of brain oedema.
●● Reduction of intracranial pressure.
Possible mechanisms for such cerebral protection include:
●● Reduction of sodium influx and neuronal depolarisa-
tion in ischaemic cells.
●● Reduction in cerebral metabolic demand for oxygen.
●● Reduced release of glutamate and other
ischaemia-related excitotoxins.
●● Inhibition of leucocyte accumulation and migration.
Maturation of an ischaemic neurological lesion and par-
ticularly an ischaemia-reperfusion injury such as is seen
in cerebral AGE, will take place over many hours and will
involve activation of leucocytes whose activities may be
influenced by lidocaine. It follows that for optimal neuro-
protection, lidocaine should be present in adequate concen-
trations for some time. Since plasma levels decline rapidly
after a single bolus dose, a continuous infusion or repeated
bolus doses will be required. With respect to dysbaric dis-
ease, there is sufficient evidence and a sufficiently low risk
to justify expeditious use of lidocaine in cerebral AGE. Its
use should be considered as an adjunct to first aid oxygen
therapy and hyperbaric recompression but not as an alter-
native to recompression, unless the latter is unobtainable.
The infusion should follow a conventional antiarrhythmic
protocol, including ECG monitoring, with a target plasma
concentration in the lower half of the therapeutic range and
should be maintained for at least 24 and probably 48 hours.
17/11/2015 16:03
 574  Decompression illness
There is less evidence to support the use of lidocaine in
DCI other than AGE. However, there are anecdotal favour-
able case reports in the literature and the relevant neuro-
protective spectrum of action would seem to favour its
use in cases with significant neurological symptoms when
there is likely to be a time delay in accessing hyperbaric
recompression facilities.
ASPIRIN AND NON-STEROIDAL ANTI-
INFLAMMATORY DRUGS
Bubbles induce platelet accumulation, adherence and
thrombus formation. Consequently, a variety of anti-plate-
let agents, including aspirin, have been tried, both prophy-
lactically and therapeutically, in DCI without significantly
influencing outcome. There is class IIb evidence of benefit
for the use of non-selective COX inhibitors in pain-only
DCI, in that there appears to be a reduction in the number
of recompressions required to achieve complete resolution
of symptoms (Bennett et al. 2003). Operationally, the anti-
platelet effects, adversely affecting outcome in any subse-
quent trauma, outweigh this benefit.
PREVENTION OF DCI
Most altitude exposures are planned to reduce the risk of
DCI to a minimum. Where DCI does occur, a detailed his-
tory of events surrounding the development of the symp-
toms is necessary to identify any predisposing factors that
can be rectified or eliminated.
Risk factors
Exposure profile: the more rapid the rate of ascent and the lon-
ger and higher the exposure to altitude, the greater the risk
of bubble formation and hence the opportunity for DCI to
occur. In sedentary subjects, DCI is rare below 22 500 feet but
this threshold is lowered for individuals exercising during the
exposure (Figure 34.4). The circulatory turbulence induced by
significant physical exertion prior to or during exposure may
generate micronuclei around which bubbles can form.
Recent diving/hyperbaric exposure is likely to increase
the residual inert gas load, particularly if multiple dives have
been performed over several days, predisposing to bubble
formation during shorter exposures to lower altitudes than
would otherwise be predicted.
The risk of DCI increases with increasing age, possibly
reflecting alterations in tissue perfusion and inert gas wash-
out. In the analysis of the decompression tests in which air-
crew were exposed to a simulated altitude of 28 000 feet for
two hours, a nine-fold increase in the likelihood of develop-
ing symptoms was demonstrated between the age bands of
17–20 years and 27–29 years. Furthermore, analysis of a US
Air Force hypobaric research database has confirmed the
trend toward increased susceptibility with age, particularly
in people older than 42 years.
Areas of anatomical change, particularly tissue scar-
ring, may have altered/reduced perfusion and be more
K17577_C034.indd 574
80
Incidence of forced descents (%)
60
40
Exercise
20 Rest
0
20000 30000 40000
Altitude (feet)
Figure 34.4  Incidence of forced descents as a result of
decompression illness during two-hour exposures to
various altitudes with subjects either seated at rest or
undertaking moderate exercise.
susceptible to the effects of any bubble formation. This may
also account for the observation that DCI symptoms often
recur at sites previously affected (Case study 34.1). Equally,
however, regions of reduced perfusion will also have an
increased susceptibility to hypoxia at altitude.
Other potential risk factors that need to be considered
include:
●● Gender: females with their proportionally higher body
fat content are more susceptible to DCI for any given
inert gas load.
●● Poor aerobic fitness/obesity: increasing body fat content
predisposes to DCI.
●● The presence of a right-to-left shunt: increases the
possibility of arterialization of venous gas emboli and
may account for the presentation of symptoms after an
otherwise non-provocative exposure.
A single exposure is likely to generate bubble micronu-
clei, even if bubbles are not detectable. Repeat exposures may
facilitate the development of bubbles around these nuclei
and hence may predispose to symptoms (Case study 34.2).
However, the experimental data to support this are incon-
clusive. Studies comparing the incidence of VGE and DCI
symptoms between continuous altitude exposures for two
hours at 25 000 feet with a cumulative series of four 30-min-
ute exposures in a 4-hour period, indicated that the cumu-
lative exposures had a decreased risk (Pilmanis et al. 2002).
It is possible that during the alternating recompressions to
ground level in this cumulative exposure series, nitrogen
reabsorption by the tissues was less than the desaturation
that occurred in the preceding sojourn at 25 000 feet. At the
present time, however, the results of these studies are not
sufficient to warrant changing the current recommendation
17/11/2015 16:03

CASE STUDY 34.1
A 32-year-old long-haul cabin crew member suf-
fered acute neurological DCI after a weekend SCUBA
diving. Symptoms resolved completely after recom-
pression treatment following RN TT62 with three
extensions at 18 m and five further daily treatments
following RN TT66.
She was advised not to return to work until cleared
to do so by her company medical officer and not to
dive for six weeks.
Three weeks later, she flew long haul as a pas-
senger and during the flight developed paraesthe-
siae, impaired coordination, fatigue and malaise,
which resolved spontaneously over the subse-
quent 24 hours. She reported no problems on the
return flight.
At the six week diving clinic review, she had mini-
mal evidence of impaired co-ordination, which was
unchanged following a further RN TT66. In conjunc-
tion with her company medical officer, the decision
was made to refer her for contrast echocardiography,
which revealed a PFO. After successful endovas-
cular closure she was referred for aviation medical
assessment to determine her fitness to return to
flying duties.
She underwent a 2-hour hypobaric chamber
‘flight’ and on a separate occasion a 12-second rapid
decompression from 8000 to 25 000 feet without any
recurrence of symptoms and was made fit to return
to flying.
that exposures to altitudes above 25 000 feet are separated
by at least 24 hours.
Ambient temperature may be a predisposing factor, as
some evidence exists that cold may be responsible for an
increase in susceptibility to DCI. This view is supported by
the higher incidence of DCI observed in Royal Air Force
(RAF) aircrew occupying inadequately heated areas of the
Canberra aircraft when it was in service.
Strategies to reduce the risk of DCI
Standard schedules and procedures for altitude exposure
should be followed, both in training and operational flights.
If operational circumstances force the use of less conserva-
tive schedules, then cognisance must be taken of the fact
that in aviation DCI will occur while the subjects are on task
with possibility of mission compromise (whereas in the div-
ing environment DCI usually occurs on return to surface).
Pre-exposure denitrogenation, by breathing 100 per cent
oxygen, can be undertaken prior to provocative exposures
or by subjects who know themselves to be susceptible to DCI.
Including a period of exercise, while oxygen is being breathed
can further enhance the inert gas washout by increasing the
K17577_C034.indd 575
Prevention of DCI  575
cardiac output (Webb et  al. 2004). However, the exercise
should be at the beginning of the pre-oxygenation period and
be followed by resting oxygen breathing to allow clearance of
the micronuclei generated. Although pre-oxygenation may be
most effective when carried out at ground level, it can also be
of considerable value at altitude in certain operational circum-
stances, such as high-altitude deployment of parachutists. The
parachutists breathe 100 per cent oxygen in the pressurized
cabin of the dispatching aircraft (normally at a cabin altitude
of 6000–8000 feet) during transit to the dropping zone and
then proceed to exit the aircraft and descend using systems
that deliver 100 per cent oxygen. Ideally, the duration of pre-
oxygenation should be not less than one hour.
Staging the decompression, where possible, will also
reduce the risk of DCI. This, together with pre-oxygenation,
is the strategy followed by NASA astronauts prior to extra
vehicular activity (EVA) or spacewalk.
Adequate protection against hypoxia and adequate
thermal protection will minimize the circulatory redis-
tribution that may compromise inert gas washout from
particular tissues.
Where specific correctable factors are identified in an
individual, correction is performed and subsequent con-
trolled altitude exposures reveal no evidence of problems,
return to full flying duties with a reduced DCI risk is pos-
sible (see Case study 34.1). For other aviators where the cor-
rectable factors are not identified, aeromedical disposal and
return to flying have to be managed on an individual basis
(see Case study 34.2).
Flying after diving and air transport of the
diving casualty
A diver at surface with an inert gas load from recent div-
ing is at increased risk of DCI when exposed to the reduced
pressure of a commercial aircraft cabin or unpressur-
ized helicopter. In 1982, the UK Diving Medical Advisory
Committee (DMAC) convened a workshop to examine the
matter of flying commercial offshore divers back to shore.
This group recommended a pre-flight surface interval for
both nitrogen and helium based diving prior to ascent to
cabin altitudes of 2000  and 8000  feet (610  and 2438  m).
They later revised the times conservatively prior to ascent to
8000 feet (DMAC 2001). In 2002, the Divers Alert Network
hosted a one-day workshop to review the flying after diving
guidelines for recreational divers (Sheffield and Vann 2002).
The following recommendations represent the consensus
reached by the attendees at the workshop:
A single no-decompression dive: a minimum pre-flight
surface interval of 12 hours is suggested.
Multiple dives per day or multiple days of diving: a mini-
mum pre-flight surface interval of 18 hours is suggested.
These recommendations apply to air dives followed by
flights at cabin altitudes of 2000 to 8000 feet (610 to 2438 m)
for divers who do not have symptoms of DCI. The consen-
sus recommendations should reduce DCI risk during fly-
ing after diving but do not guarantee avoidance of DCI.
17/11/2015 16:03
 576  Decompression illness
CASE STUDY 34.2
A 30-year-old C130 pilot, with 2000 hours experi-
ence, was flying as co-pilot on a sortie which included
planned decompressions from 18 000–24 000 feet.
The crew all went onto oxygen at 8000 feet and the
first decompression run was conducted uneventfully.
During the second run at 24 000 feet the co-pilot
developed paraesthesiae in both hands, which
resolved spontaneously and a dull ache over his lower
back with an abnormal sensation in the overlying
skin. These symptoms resolved on recompression to
18 000 feet and the third run was undertaken without
any untoward events.
On landing, he reported well. Two and a half hours
later, he developed pain in both knees, girdle pain at
T12, headache, profound fatigue and a sensation of
‘dizziness’ on standing.
He was referred for hyperbaric recompression
and transferred to the chamber by road, on oxygen.
Examination at the chamber was unremarkable but a
diagnosis of joint pain and probable neurological DCI
was made from the history.
Recompression following RN TT62 with three
extensions at 18 m resulted in complete resolution
of his symptoms. Unfortunately, he experienced a
mild relapse of symptoms the following day and
required three further daily treatments following
RN TT66 until no further symptomatic improvement
could be demonstrated.
After discussion at aviation medical review, he
declined any further clinical investigations. He was
restricted to an altitude of 18 000 feet and UK-based
flights only for three months. At his second review,
having had no further problems, his altitude restric-
tion was lifted but his geographical restriction was
retained. During this period, he was selected for and
successfully completed his Captain’s course. He had no
further problems and at his third review all restrictions
were lifted but, should he experience another episode
of DCI at altitude, he will require clinical investigation.
Pre-flight surface intervals longer than the recommenda-
tions will reduce DCI risk further.
For dives requiring decompression stops, a pre-flight
surface interval in excess of 18 hours is deemed prudent.
More stringent rules still should apply to divers who have
been successfully treated for DCI to avoid the risk of precip-
itating recurrent symptoms. Where a diver has been treated
but has residual symptoms or where a casualty with DCI
needs to be transported by air, advice should be obtained
from the diving medicine specialist managing the case, but
this will usually include the requirement to transport on
oxygen and maintain the lowest practicable cabin altitude
for the duration of the flight.
K17577_C034.indd 576
SUMMARY
●● Decompression illness occurs as a result of acute
exposure to a reduction in ambient pressure.
●● It can present in a wide variety of ways and is a
clinical diagnosis.
●● Symptoms are thought to be initiated by the pres-
ence of gas bubbles in the tissues or circulation.
●● First aid treatment consists of breathing 100 per
cent oxygen, minimizing physical activity and
increasing ambient pressure/descending to
ground level.
●● Since this condition occurs predominantly at alti-
tude (on task), it has implications for both flight
safety and mission success.
REFERENCES
Bennett M, Mitchell S, Dominguez A. Adjunctive treat-
ment of decompression illness with a non-steroidal
anti-inflammatory drug (tenoxicam) reduces compres-
sion requirement. Undersea and Hyperbaric Medicine
2003; 30: 195–205.
Bennett PB, Moon RE. Diving Accident Management.
Bethesda, MD: Undersea and Hyperbaric Medical
Society, 1990.
Billings, CE. Barometric Pressure. In: Parker JF, West
VR (eds). NASA SP-3006 Bioastronautics Data Book:
35–63. Washington, DC: US Government Printing
Office, 1973.
Conkin J, Powell MR, Foster PP, Waligora JM. Information
about venous gas emboli improves prediction of hypo-
baric decompression sickness. Aviation, Space, and
Environmental Medicine 1998; 69: 8–16.
Cunha–Ferreira R. Optimizing oral rehydration solution
composition for the children of Europe. Acta Paediatrica
Scandinavica 1989; 364(Supplement): 31–39.
Diving Medical Advisory Committee. DMAC 07 Flying
after Diving (Revised 1st edn). London: DMAC, 2001.
Elliott DH, Kindwall EP. Manifestations of the
Decompression Disorders. In Bennett PB, Elliott DH
(eds). The Physiology and Medicine of Diving, 3rd edn.
London: Ballière Tindall, 1982: 461–72.
Francis TJR, Smith DH. Describing Decompression Illness.
In: The Forty-Second Undersea and Hyperbaric
Medical Society Workshop. Bethesda, MD: Undersea
and Hyperbaric Medical Society, 1991.
Hagen PT, Scholz DG, Edwards WD. Incidence and size
of patent foramen ovale during the first 10 decades
of life: an autopsy study of 965 normal hearts. Mayo
Clinic Proceedings 1984; 59: 17–20.
Hernandez R, Blanco S, Peragon J, Pedrosa JA,
Peinado MA. Hypobaric hypoxia and reoxygenation
induce proteomic profile changes in rat brain cortex.
Neuromolecular Medicine 2014; 16(1): 1–2.
17/11/2015 16:03

Hills B, James P. Microbubble damage to the blood-
brain barrier: relevance to decompression sickness.
Undersea Biomedical Research 1991; 18: 111–6.
Pilmanis AA, Webb JT, Kannan N, Balldin U. The effect
of repeated altitude exposures on the incidence
of decompression sickness. Aviation, Space, and
Environmental Medicine 2002; 73: 525–31.
Ross HE. The direction of apparent movement during
transient pressure vertigo. Undersea Biomedical
Research 1976; 3(4): 311–4.
K17577_C034.indd 577
References 577
Sheffield P, Vann R. 2002 Consensus Guidelines for Flying
after Recreational Diving. In: Sheffield P, Vann R (eds).
DAN Flying after Diving Workshop Proceedings.
Durham, NC: Divers Alert Network, 2004: 8.
Webb JT, Pilmanis AA, Balldin U. Altitude decompres-
sion sickness at 7620 m following pre-breathe
enhanced with exercise periods. Aviation, Space, and
Environmental Medicine 2004; 75: 859–64.
17/11/2015 16:03
K17577_C034.indd 578 17/11/2015 16:03

Medication in aircrew
ANDREW TIMPERLEY
Introduction 579
Traditional herbal medicines 580
Homeopathy 580
INTRODUCTION
The Oxford English Dictionary (2013) defines medication
as ‘a drug or other form of medicine that is used to treat or
prevent disease’. Therefore, in the broadest sense, medica-
tion includes prescription only and over the counter drugs,
traditional herbal medicines and homeopathic remedies.
In the United Kingdom alone, approximately 24  new
drugs are launched each year (Ward et  al. 2013), none of
which are tested in the aviation environment prior to release.
Some aviation authorities opt to produce a list of ‘safe drugs’
for aircrew, reflecting previous decision making. This may
ensure consistency of prescribing but it also limits the drugs
available to the prescriber, particularly if the list is not kept
up to date. A more useful list may be one of ‘unsafe drugs’
since once the decision has been made that a particular drug
is unsafe in aircrew that decision is unlikely to change unless
new information comes to light. This then allows the pre-
scriber to consider all other drugs on a case-by-case basis.
For acute, self-limiting illnesses such as a chest infection,
it will be the condition rather than the medication that will
require a pilot to be temporarily grounded. For chronic con-
ditions requiring long term treatment, once symptoms have
been adequately controlled, it might then be the medication
that may delay or even prevent a return to flying.
When assessing the appropriateness of using a particular
medication in aircrew, the following should be considered:
●● Efficacy. In order to justify its use there should be good
evidence that the treatment will have the desired effect.
Sometimes evidence is scarce or controversial in which
case expert opinion may need to be sought.
K17577_C035.indd 579
35
Common and important drugs 581
Conclusion 581
References 581
●● Side effects. Minor clinical or biochemical side effects,
which are predictable and can be monitored, may be
compatible with flying; however, this will not be the
case for medication with significant or unpredictable
side effects. Medication that may result in adverse
effects occurring weeks, months or even years after
stopping treatment are particularly troublesome.
●● Observation. It is usual for aircrew to be grounded or
at least restricted in their flying duties when starting
treatment. If, during this period of observation, there
is a good clinical response to treatment and no signifi-
cant clinical or biochemical side effects develop, it may
be possible to lift or reduce the flying restrictions. The
duration of this observation period should be dependent
on the drug in question; however, it is often arbitrary
and varies between aviation authorities. Four weeks for
most drugs is not an unreasonable default stance.
●● Dependency. Medication should be taken regularly.
Aircrew may need to be grounded if there is a risk that
distracting or incapacitating symptoms or an adverse
effect on their prognosis could occur if the individual
were to stop taking treatment. This is particularly rel-
evant to military aircrew that may lose or be otherwise
separated from their medication.
●● Frequency. Compliance is improved if the medica-
tion can be given just once or twice daily. This may be
achieved by using drugs which have a long pharmaco-
logical half-life or are available in modified-release form.
●● Route. Medication is usually taken orally; however, some
may require parenteral administration. The inhalation
route is not usually problematic for aircrew. There is no
evidence that inhalers are less effective at altitude, though,
579
17/11/2015 16:03
 580  Medication in aircrew
it may be necessary to warm them by hand in cold envi-
ronments. Transdermal patches are generally well toler-
ated; however, drug absorption may increase with fever
and high ambient temperature. Patches may fall off in hot,
humid conditions or if the subject is sweating, e.g. when
wearing an immersion suit or body armour.
●● Storage. Most medication needs to be kept dry and
stored within a specific temperature range. Some also
need to be kept out of direct sunlight. Aircrew, particu-
larly in the military, may not have access to appropriate
storage facilities during long-haul flights, stopovers
or deployment.
●● Supply. Aircrew must have easy access and resupply of
their medication. This may be a significant issue for
deployed military aircrew where supply chains may be
unreliable and the range of drugs available limited.
The ideal medication for aircrew, therefore, would be
known to be effective and free of side effects and be a once daily,
modified-release, oral preparation with a long half-life, no
storage restrictions and available worldwide. Unfortunately,
no such drug exists; therefore, prescribing for aircrew is always
a compromise, as it is with all patients. The importance of the
principle of ‘treat the patient not the pilot’ cannot be over
emphasized. The potential for reducing morbidity and mortal-
ity should not be compromised for the sake of keeping a pilot
flying. For example, maintaining a poorly controlled diabetic
pilot on metformin, which may be compatible with solo fly-
ing, rather than adding insulin, which may not be compatible
with unrestricted flying, is counterproductive. Poor glycaemic
control alone warrants grounding the pilot. In the short term,
hyperglycaemia can result in blurred vision and cognitive
impairment and, in the long term, a significant increase in car-
diovascular risk. A pilot with a well-controlled condition but
on medication is much more likely to return to flying duties
than one not on medication but with poor control.
TRADITIONAL HERBAL MEDICINES
The medicinal properties of some plants are indisputable,
e.g. the cardiac glycoside digoxin derived from the fox-
glove plant Digitalis purpurea and the potent antimalarial
artemisinin extracted from the sweet wormwood herb
Artemesia annua. Modern ‘conventional’ drugs, including
those derived from plant extracts, are required to undergo
rigorous safety and efficacy studies before being licensed for
therapeutic use; however, this is not always the case for tra-
ditional herbal medicines. Worldwide, regulation of herbal
medicines is inconsistent. Some authorities such as the UK
Medicine and Healthcare Products Regulatory Agency
(2013) maintain a register of prohibited or restricted herbal
ingredients and a list of products granted registration. The
aeromedical concerns of herbal medicines include:
●● Safety and efficacy. It is often difficult to find high-
quality data from randomized controlled trials for
herbal medicines. This may result in the patient being
K17577_C035.indd 580
grounded ‘just to be safe’. If the medication is ineffective
or simply masks underlying disease, an opportunity for
early intervention with more conventional treatments
may be missed. There may also be significant interac-
tions with regular prescription drugs.
●● Concealment. A minority of aircrew may opt to self-
medicate with non-prescribed herbal medicines in order
to avoid consulting with and being grounded by their
aviation medical examiner.
●● Ingredients. The specific contents of herbal medicines,
including the dose of any active ingredients, cannot
always be guaranteed. In addition, they may contain
substances known to be harmful such as heavy metals.
●● Source. Herbal medicines are often bought via the
Internet, often from overseas and sometimes in order
to obtain banned substances. There have been reports
of both conventional and herbal medicines bought this
way containing no active ingredient.
If aircrew are determined to use herbal medicines, they
should be encouraged to seek advice from their aviation
medical examiner before starting treatment. They must be
made aware that the use of herbal medicines may result in
temporary or even permanent restrictions in their flying
duties and possibly grounding.
HOMEOPATHY
Samuel Hahnemann founded homeopathy in the late eigh-
teenth century (Loudon 2006). He noticed that ingestion
of the bark from the Cinchona tree, a known source of
quinine, resulted in symptoms similar to mild malaria. It
was already known at that time that small doses of quinine
could be used therapeutically for the treatment of fevers
including malaria. Hahnemann concluded that ailments
could be cured if you gave a diluted solution of a compound
known to cause similar but milder symptoms of the illness
to be treated – ‘the principle of similars’ or ‘like cures like’.
The multiple dilutions of homeopathy in water or alcohol
result in little or no ‘active’ compounds in the remedies.
The principles on which homeopathy is based are scientifi-
cally implausible and there is no evidence that homeopathic
remedies are any more effective that placebos, a conclusion
supported by a UK 2010  House of Commons Science and
Technology Committee report (Science and Technology
Committee 2010).
The aeromedical concerns of homeopathy are similar
to those of traditional herbal medicines (see above) but
without the potential benefit of being efficacious. Highly
diluted remedies are unlikely to cause significant side
effects but some remedies may be less dilute and contain
ingredients that could produce adverse effects and drug
interactions. It should be noted that some liquid remedies
contain alcohol at higher concentrations than permitted
in conventional medications. Aircrew insistent on taking
homeopathic remedies should be warned that this might
affect their flying status.
17/11/2015 16:03

COMMON AND IMPORTANT DRUGS
It is not possible to discuss the aeromedical implications
of all drugs, which could affect a pilot’s ability to safely
fly an airplane; however, three classes of drugs are consid-
ered below as they have been the topic of recent debate and
change of policy.
●● Antihypertensives. All antihypertensives have the poten-
tial to lower resting blood pressure below that intended
and to blunt the normal physiological response to
posture and acceleration, thereby reducing G-tolerance.
Adrenergic neurone blocking drugs can cause profound
hypotension and are therefore incompatible with flying
duties. Alpha- and beta-blockers have a lesser effect on
postural blood pressure and G-tolerance and may be
used in aircrew not exposed to greater than +2.5 Gz. A
similarly cautious approach was previously taken with
angiotensin-converting enzyme inhibitors (ACEIs) but
after many years of centrifuge-testing, RAF aircrew tak-
ing these drugs were not found to have any demonstrable
decline in G-tolerance. Both ACEIs and angiotensin II
receptor blockers (ARBs) are now considered compatible
with unrestricted flying duties. Calcium channel block-
ers are generally acceptable in aircrew as are thiazide
diuretics but not loop diuretics, which may result in
significant naturesis, hypovolaemia and hypotension,
particularly when combined with an ACEI or ARB.
All centrally acting antihypertensive drugs have the
potential to impair cognition and should not be used in
aircrew. Similarly, beta-blockers may have a subtle effect
on psychomotor function leading some authorities to
restrict aircrew taking these drugs to dual only, in addi-
tion to being unfit for exposure to greater than +2.5 Gz.
●● Anti-diabetic medication. Until recently, pilots were per-
manently grounded if they needed to take any antidia-
betic medication known to cause hypoglycaemia. This
limited glycaemic control to lifestyle, alpha-glucosidase
inhibitors, biguanides and thiazolidinediones. However,
the introduction of glucagon-like peptide-1 agonists
and dipeptidyl peptidase-4 inhibitors, which are not
known to cause hypoglycaemia, has expanded the lists
of drugs available for diabetic aircrew. These new drugs
are currently acceptable in the UK for solo civilian flying
and dual military flying. In addition, the UK Civilian
Aviation Authority (CAA) has now introduced policy
permitting limited flying duties in commercial aircrew
taking drugs known to cause hypoglycaemia such as sul-
phonylureas, meglitinides and even insulin. Pilots taking
these drugs require regular review and self-monitoring
of capillary blood glucose, including in-flight testing.
●● Antidepressants. The use of modern talking therapies
and antidepressants now offers the potential for aircrew
with depression to return to limited flying duties whilst
on treatment. The UK CAA now permits the use of the
selective serotonin reuptake inhibitors (SSRIs) citalo-
pram, escitalopram and sertraline in aircrew; the UK
K17577_C035.indd 581
References 581
military are considering their use. Commercial pilots
may return to dual flying once they are established on
maintenance treatment only. The driving force for this
change in policy is as for many another type of treat-
ment – it is better to have a pilot with a well-controlled
condition known to the authorities than to have aircrew
avoid seeking treatment or covertly take unaccept-
able treatment because of their fear of losing their
flying license.
CONCLUSION
Aircrew need to be aware of their responsibility of seeking
advice from an aviation specialist whenever they are ill and/
or taking medication, including over the counter prepara-
tion, traditional herbal medicines and homeopathic rem-
edies. The aviation medical examiner needs to carefully
consider the implications of both the illness and its treat-
ment on the aviator, particularly with regard to flight safety.
SUMMARY
●● Medications include prescription only treat-
ments, over-the-counter drugs, traditional herbal
medicines and homeopathic remedies.
●● The key points of efficacy, side effects, observa-
tion, dependency, frequency, route, storage and
supply should be considered before prescribing
medication to aircrew.
●● Herbal and homeopathic compounds may
contain ingredients incompatible with fly-
ing or prove ineffective and delay the start of
conventional treatment.
●● The uses of anti-hypertensive, anti-diabetic and
anti-depressant medications in aircrew have
all been the topics of recent debate and policy
change.
REFERENCES
House of Commons Science and Technology Committee.
Evidence Check 2: Homeopathy, Fourth Report of
Session 2009–10. London: The Stationery Office
Ltd, 2010.
Loudon I. A brief history of homeopathy. Journal of the
Royal Society of Medicine 2006; 99: 607–10.
Medicines and Heathcare Products Regulation Agency,
2013; www.mhra.gov.uk.
Oxford English Dictionary. Oxford: Oxford University
Press, 2013.
Ward DJ, Martino OI, Simpson S, Stevens AJ. Decline in
new drug launches: myth or reality? Retrospective
observational study using 30 years of data from
the UK. British Medical Journal Open. 2013; 3:
pii: e002088.
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K17577_C035.indd 582 17/11/2015 16:03

Aviator fatigue and relevant fatigue
countermeasures
JOHN A CALDWELL
Background 583
The causes of operational fatigue 584
Effects of operational fatigue on aircrew performance 584
Alertness-management techniques 585
BACKGROUND
Almost from the dawn of commercial aviation back in the
early 1900s, the mitigation of pilot fatigue has been rec-
ognized as an important factor for the assurance of flight
safety. Even though a solid scientific understanding of pilot
fatigue was not to be realized until the late 1900s, flight
duty regulations were proposed as a way to preserve air-
crew performance shortly after the first commercial airline
flight in 1914. In 1931, the US Commerce Department set
monthly flight-time limits for pilots, and despite revisions
that were made in the 1930s and 1940s (Johnson 2010), the
basic hours-of-service regulatory approach remained rela-
tively unchanged for the next 70–80 years. This strategy of
duty-time regulation was embraced around the world as
well. In 1944, the Chicago Convention that established the
International Civil Aviation Organization (ICAO) devel-
oped regulations requiring operators to ensure adequate
rest periods as well as to install flight duty limitations for
airmen so that fatigue would not compromise passenger
safety (Kenya Law Reports 2012). Of course, it was much
later in history that science revealed that the physiological
underpinnings of fatigue required far more than ‘time-on-
task’ rules alone, but the traditional focus on duty hours at
least was a good place to start.
In 2013, as a new century of aviation operations begins,
an advanced understanding of pilot fatigue is impact-
ing modern counter-fatigue efforts. In the US, after years
of study, new Federal Aviation Administration (FAA)
K17577_C036.indd 583
36
Conclusion 596
References 596
Further reading 600
regulations have incorporated aspects of the latest under-
standing of fatigue science to set standards for pilot flight
time, duty-period durations, and pilot rest requirements
based on the time of day pilots begin their first flight, the
number of scheduled flight segments, and the number of
time zones crossed (Federal Register 2012). Meanwhile,
the European Aviation Safety Agency (EASA) is likewise
in the process of updating aircrew scheduling regulations.
In October of 2012, a proposal was published which would
revamp previous flight and duty-time guidance with more
than 30  safety improvements such as reducing night-time
duty periods, increasing rest requirements for flights with
time-zone crossings, and limiting crew standby periods.
It is anticipated the new rules will be fully implemented
by 2015  (Mark 2012). Note that both the FAA and EASA
have made a concerted effort to consider the latest scientific
understanding of human fatigue rather than continuing an
outdated reliance on hours-of-service regulations.
Flight duty regulations have lagged far behind the sci-
entific understanding of human fatigue for many years.
Unfortunately, at least in the US, regulatory authorities
sometimes appear to need a fatal wake-up call before pay-
ing serious attention to issues such as safe aircrew schedul-
ing practices. Although the issue of pilot fatigue had been
on the National Transportation Safety Board’s (NTSB) Top
10 Most-Wanted list for two decades (Office of the Secretary
of Transportation 2011), it took the 2009  crash of a com-
muter airplane and 50 fatalities to highlight the issue of pilot
fatigue and spur the adoption of the new FAA safety rules.
583
17/11/2015 16:04
 584  Aviator fatigue and relevant fatigue countermeasures
Hopefully, a similar scenario will not be repeated in Europe,
although the passage of new regulations is presently fac-
ing difficulties. Among the most contentious factors is the
struggle between protecting safety while safeguarding com-
mercial profitability (European Cockpit Association 2012).
However, it is encouraging that regulators are looking to the
scientific community to ensure that proposed regulatory
changes are in line with sound, evidence-based knowledge
of the true nature of human fatigue (Moebus 2008).
THE CAUSES OF OPERATIONAL FATIGUE
According to the American College of Occupational and
Environmental Medicine, hours-of-service guidelines alone
are not sufficient to minimize fatigue and optimize on-
the-job alertness in safety-sensitive contexts (Lerman et al.
2012). Instead, consideration must be given to the type of job
being performed, the time of day at which the job is being
performed (relative to the individual’s circadian rhythm),
the work environment itself, the presence or absence of
fatigue-detection methods, the amount of pre-duty or off-
duty sleep, and the quality of this sleep. In addition to these
factors, the FAA adds that the accumulation of chronic sleep
debt, the extent of continuous wakefulness, the amount of
time on task, and the level of individual fatigue resistance
all must be considered (Federal Register 2012).
The published literature on pilots’ perceptions about
fatigue factors substantiates the complexity of fatigue man-
agement in real-world settings. Rather than citing long duty
periods per se, long-haul pilots instead are more likely to
attribute their fatigue to both sleep deprivation and circa-
dian disturbances associated with time zone transitions.
Short-haul (domestic) pilots most frequently blame their
fatigue on sleep deprivation and high workload (Bourgeois-
Bougrine et  al. 2003). Both long- and short-haul pilots
commonly associate their fatigue with night flights, jet lag,
early wake-ups, time pressure, multiple flight legs, and con-
secutive duty periods without sufficient recovery breaks.
Corporate/executive pilots experience fatigue-related prob-
lems similar to those reported by their commercial counter-
parts. However, again, they most frequently cite scheduling
issues which affect sleep and circadian rhythms (multi-seg-
ment flights, night flights, late arrivals and early awaken-
ings) as the most noteworthy contributors (Rosekind et al.
2000). Weather, turbulence, and sleep deprivation, in com-
bination with consecutive and lengthy duty days, time zone
transitions, and insufficient rest periods, are blamed as well.
Thus, rather than focusing on duty hours alone, the evi-
dence highlights the fact that the underpinning of opera-
tor fatigue centres around: (1) whether or not (and when)
the biologically determined sleep quota is being consis-
tently met; (2) when, according to the ‘body clock’, work
and wakefulness are required; and (3) whether or not the
work environment is alertness-promoting or alertness-
reducing. These components interact with one another such
that improvements in one can, to some degree, attenuate
deficits in another; however, when there are simultaneous
K17577_C036.indd 584
problems in two areas or in all three areas as is often the
case in aviation operations, aircrew alertness will invariably
be significantly compromised. For example, a pilot who is
sleep deprived due to sleep difficulties during a short lay-
over, has been awake for an excessive amount of time per-
forming crew duties during a long-haul flight home, and is
now on a cruise descent for a night-time landing in a dark-
ened sterile cockpit will not only be struggling to stay on
top of routine flight tasks, but will be in a serious battle to
simply stay awake! Under these circumstances, all of the
major fatigue factors are working against alertness, safety
and performance, and no amount of motivation, training
or professionalism will overcome the physiological realities
of the situation. Furthermore, while fatigue causes perfor-
mance deficits in everyone, research indicates that some
individuals will be far more affected than others. Individual
differences in fatigue tolerance are stable, trait-like charac-
teristics that persist across time and circumstances (Rupp
et al. 2009; Van Dongen et al. 2004, 2005).
EFFECTS OF OPERATIONAL FATIGUE ON
AIRCREW PERFORMANCE
Common symptoms of fatigue include delayed reaction
time, reduced performance accuracy, lapses in sustained
attention, impaired logical reasoning, compromised
decision-making, inaccurate risk assessment, reduced
situational awareness, and poor motivation (Caldwell and
Caldwell 2003). Thus, it is little wonder that aircrew fatigue
has been associated with involuntary sleep episodes on the
flight deck (Wright and McGown 2001; Neri et  al. 2002),
as well as with procedural errors, unstable approaches,
attempts to land on the wrong runway, and landing without
clearances (Federal Register 2012).
Pilot fatigue has been blamed at least in part for such
incidents and accidents as the 2009 crash of a Continental
Connection flight in which 50 people were killed (National
Transportation Safety Board 2010), the 2004  crash of
Corporate Airlines flight 5966  in which 13  people per-
ished (National Transportation Safety Board 2004), the
1997 crash of Korean Air flight 801 in which 228 people died
(National Transportation Safety Board 1999), the 1985 near
crash of China Airlines flight 006 in which 24 people were
injured (National Transportation Safety Board 1985), and
the 1999 mishap involving American Airlines Flight 1420 in
which 11 people were killed (National Transportation Safety
Board 2001). In the UK, approximately one-third of reports
to the Confidential Human Factors Incident Reporting
Programme blame pilot fatigue for incidents, errors or
other flight-related problems (Jackson and Earl 2006). In
the US, the NTSB indicates pilot performance or fatigue has
caused or contributed to four of the last six fatal accidents
involving regional air carriers, and from FY 2007 through
FY 2010  NASA’s voluntary Aviation Safety Reporting sys-
tem has recorded 484 reports of fatigue-related operational
problems from commercial flight crewmembers (Office of
the Secretary of Transportation 2011).
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ALERTNESS-MANAGEMENT TECHNIQUES
Although the general approach to managing aircrew
fatigue is evolving towards comprehensive Fatigue Risk
Management Systems (FRMS) instead of the traditional
prescriptive approach, the fact remains that humans sim-
ply were not designed to effectively cope with the multiple
flight legs, long duty hours, limited time off, early report
times, less-than-optimal sleeping conditions, rotating and
non-standard work shifts, and jet lag that have become the
hallmarks of today’s flight operations. Whether conduct-
ing short-haul commercial flights, long-range transoceanic
operations, or around-the-clock military missions, a well-
planned, science-based, alertness-management strategy is
critical for countering both acute and chronic sleep loss/
sleep debt, the sustained periods of wakefulness, and the
circadian factors that are primary contributors to fatigue-
related flight mishaps (Rosekind et al. 1996).
Fortunately, there are a number of countermeasures
available to help optimize on-duty alertness as well as off-
duty fatigue recovery (Caldwell et al. 2009). When schedule-
related fatigue cannot be altogether avoided, it at least can be
mitigated via schedule-optimization strategies. The impact
of these optimization strategies can be bolstered by the uti-
lization of technologies that permit ongoing monitoring of
pre-duty sleep quantity and sleep/wake timing. Sleep dif-
ficulties (which are at the heart of on-duty crew fatigue) can
be attenuated by educating aircrew members on techniques
designed to improve pre-duty and layover sleep. Inflight
counter-fatigue measures can be relied upon to improve
in-flight alertness despite any scheduling or pre-duty sleep
problems that proved difficult or impossible to resolve.
Although no ‘one-size-fits-all’ solution to pilot fatigue exists,
a comprehensive program that takes into account human
physiological make-up, unique mission characteristics, and
the specific requirements of available alertness-management
techniques can optimize safety in operational contexts.
Non-pharmacological strategies
The most palatable measures for the prevention or rem-
edy of operator sleepiness/fatigue often are those of a non-
pharmacological nature. These measures are generally
viewed as benign and natural ways of improving on-the-job
alertness since they do not require ‘medical’ intervention.
Non-pharmacological strategies generally include admin-
istrative/regulatory and educational approaches (i.e. better
crew scheduling, potentially monitoring crew sleep, and
education about fatigue factors and alertness enhancers)
and behavioural interventions (i.e. breaks and/or naps), but
some environmental countermeasures (i.e. bright lights) are
occasionally included as well.
Schedule optimization
As regulatory agencies increasingly recognize the physi-
ological realities of human fatigue, they are beginning to
K17577_C036.indd 585
Alertness-management techniques  585
require airlines to address these realities in their schedul-
ing practices. For instance, Attachment K Annex 6  to the
Convention on International Civil Aviation guidance on
dealing with fatigue risks in aircraft operations requires the
development and maintenance of processes for fatigue haz-
ard identification. One of these processes is the predictive
process, which involves identifying flight hazards by exam-
ining scheduling from the standpoint of ‘factors known to
affect sleep and fatigue and their effects on performance’
(Section 2.1.1). A major component of this examination
involves the use of bio-mathematical models to help account
for the way in which scheduling will affect the circadian and
sleep-regulation systems that are primary fatigue determi-
nants (International Civil Aviation Organization 2011).
A bio-mathematical model is basically a set of integrated
equations that predict human fatigue based on such factors
as recent sleep quantity, sleep quality and sleep/wake tim-
ing; the current time of day (during duty); and workload in
terms of things like number of recent take-offs and landings
and/or other factors. Prior to use in operational contexts,
models are validated against various types of performance
data (such as reaction-time or accuracy measures) collected
in laboratory sleep-restriction or sleep-deprivation studies,
or against accident probability and/or accident severity data
collected in real-world environments. Models are typically
updated in an iterative process as new data and/or new sci-
entific information become available; they are quite useful in
applied contexts because they translate basic scientific prin-
ciples established from empirical investigations into gener-
alized predictions that are relevant to operational settings.
At present, airlines can utilize different types of bio-
mathematical models to optimize duty schedules from a
fatigue-risk standpoint. Several models are available to
help determine the impact of work/rest schedules on avia-
tor performance. In addition, the models can be used to
explore scheduling modifications that will mitigate fatigue
factors. The Civil Aviation Safety Authority provided a
recent overview of six fatigue models (Civil Aviation Safety
Authority 2010). Of these, two were specifically tailored
for the aviation environment – the Sleep, Activity, Fatigue,
and Task-Effectiveness (SAFTE) model and the System for
Aircrew Fatigue Evaluation (SAFE). The UK Civil Aviation
Authority (CAA) sponsored the development of the SAFE
model for assessing flight time limitations for operators. It
has been validated using operator data and is used by the
CAA for fatigue risk assessment of rosters. The SAFE model
was not available for commercial use as of 2010, but plans
include making it available to companies who design pilot
schedules, as well as to individual operators.
The SAFTE model (Hursh et  al. 2004) which has been
instantiated in the Fatigue Avoidance Scheduling Tool
(FAST) software (Hursh et al. 2006) was validated in ground
transportation operational studies and has been tailored to
accept aviation-specific input. The SAFTE model has been
validated as an accurate predictor of sleep-restriction on per-
formance (Van Dongen 2004). In addition, it has been shown
to accurately predict the impact of scheduling factors on
17/11/2015 16:04
 586  Aviator fatigue and relevant fatigue countermeasures
accident risk (Hursh et al. 2006). Although the precision of
SAFTE fatigue predictions, as well as those from other avail-
able bio-mathematical models of fatigue and performance,
are adversely affected by individual differences and uncer-
tain pre-duty conditions (Van Dongen et al. 2007), model-
based optimization of crew schedules represents a step in the
right direction towards mitigating operational fatigue risks.
Ongoing sleep monitoring
Bio-mathematical models such as SAFE and SAFTE pro-
vide an excellent quantification of the expected fatigue risks
associated with crew schedules. However, in most cases the
models must rely on sleep estimates that are based on the
characteristics and timing of off-duty periods rather than
sleep measurements obtained from an accurate and reli-
able source. Software instantiations of the SAFTE model
include a routine called AutoSleep which estimates an oper-
ator’s sleep based on what science has determined about
the sleep propensity of people who have sleep opportuni-
ties of varying durations at different points in the circadian
cycle. AutoSleep considers factors such as the commuting
time to and from the workplace, as well as the influence of
body-clock factors when determining the estimated dura-
tion and quality of off-duty sleep. This is certainly a better
approach than assuming that the amount of off-duty sleep
is equal to the amount of off-duty time, but it is nonethe-
less an estimate and not a measurement of sleep. Thus, in
cases during which the sleep environment is unknowingly
poor, or some unidentified stressor prevents or disrupts
sleep, the AutoSleep routine would predict more sleep than
would actually be obtained, and the fatigue-risk scores sub-
sequently based on this overestimation would be lower than
they actually should be. Thus, when possible, it is always
better to measure sleep directly.
The gold standard for sleep assessment is polysomnog-
raphy, a procedure which involves the measurement and
scoring of several physiological parameters to quantify the
Figure 36.1  A wrist-activity monitor for sleep and fatigue monitoring.
K17577_C036.indd 586
characteristics and duration of each sleep episode. If feasible,
it would be best to monitor the off-duty and pre-duty sleep of
crew members in an ongoing fashion via polysomnographic
techniques since this would provide the most accurate input
to the bio-mathematical models that calculate the impact
of different sleep patterns on fatigue risk. Unfortunately,
the effort and expense involved in continuous physiologi-
cal sleep monitoring make it impractical for day-to-day
real-world application. However, direct, empirical mea-
surements of sleep and sleep/wake timing can be obtained
via another, far more feasible, methodology. Wrist-activity
monitoring in conjunction with validated ‘sleep-scoring’
classification algorithms have long been used to assess basic
sleep characteristics in situations where polysomnography
is impractical (Sadeh and Acebo 2002; Morgenthaler et al.
2007). Recent advances in sleep-monitoring via actigra-
phy have made this technique applicable for more routine
fatigue assessment applications (Figure 36.1).
Wrist-activity monitoring basically translates the fre-
quency and time-course of body movements into measures
of sleep quantity, sleep quality, and sleep/wake timing. Since
these measurements provide the necessary input for bio-
mathematical models which consider sleep and the circa-
dian rhythm to be the primary determinants of fatigue risk,
they are well-suited to fatigue-management applications in
aviation and other operational contexts. Although sleep cal-
culations based on activity monitoring are not completely
fail-safe since activity monitoring cannot accurately detect
relaxed (movement-free) wakefulness or microsleeps, it is
better at tracking bed times, wake-up times and sleep times
than subjective sleep logs. Individuals unfortunately are not
the best judges of their own sleep, and they certainly are not
good judges of the full impact of their sleep patterns on their
fatigue status, particularly when a considerable amount of
time passes prior to their recording of recent sleep. Thus,
activity-based sleep histories are a solid foundation for the
calculation of operational fatigue risk levels attributable to
sleep loss and disrupted sleep/wake cycles.
17/11/2015 16:04

Given the accuracy of actigraphs in predicting sleep/
wake activity, they could be used to establish a conservative
fitness-for-duty programme even without submitting the
recorded recent sleep-history data to a model analysis. Since
it is well known that the average adult needs a minimum
of 8 hours of sleep in order to be fully rested (Van Dongen
et al. 2003), the actigraphy record of pilots reporting to duty
could be examined, and those showing significantly less
than eight hours of sleep in the preceding 24-hour period
could be excluded from upcoming flights (or at least warned
about their potential level of impairment).
Education
Various studies have demonstrated that sleep restrictions
of as little as one or two hours per day rapidly compromise
vigilance and performance in subsequent duty periods, and
that following sleep restriction, people rarely recover fully
after only a single night of recovery sleep (Belenky et  al.
2003; Van Dongen et al. 2003). Thus, it is critical that avia-
tion personnel be educated about the dangers of fatigue, the
importance of acquiring adequate sleep, and the fact that
full recovery from fatigue may take longer than previously
anticipated. Ultimately, the pilots themselves and those
scheduling the pilots’ duty periods must be convinced that
quality off-duty sleep is the best possible anti-fatigue strat-
egy. Aircrews should be taught that (1) fatigue is a physi-
ological problem that cannot be overcome by motivation,
training or willpower; (2) even small chronic reductions in
sleep duration will quickly create a performance-degrading
sleep debt; (3) recovery from sleep debt occurs more slowly
than most people believe; (4) people cannot reliably judge
their own level of fatigue-related impairment; (5) there are
wide individual differences in fatigue susceptibility that
cannot be reliably predicted; and (6) there is no one-size-
fits-all ‘magic bullet’ (other than adequate sleep) that can
counter fatigue for every person in every situation. In addi-
tion, they should be advised that (1) adequate off-duty sleep
is the key to optimal on-the-job alertness; (2) an average of
eight hours of sleep per day, either in a consolidated block
or in a series of naps, is the goal even during long trips or on
rotating schedules; and (3) that the ‘good sleep habits’ sum-
marized in Table  36.1  are essential for maximizing sleep
quantity and quality (Caldwell and Caldwell 2003).
Techniques designed to improve pre-duty
and layover sleep
As already discussed, the greatest driver of fatigue in the
aviation context is insufficient or disrupted sleep. Of course,
some sleep problems are unavoidable, but others are ame-
nable to modification, especially if the crew member has a
pre-arranged strategic sleep strategy. There are general sleep
habits that are relevant for any situation (see Table 36.1), and
in addition, there are tips to deal with the special problems
associated with poor layover sleep opportunities or envi-
ronments. Details on each recommendation are covered in
K17577_C036.indd 587
Alertness-management techniques  587
Table 36.1  Sleep-optimization strategies
Strategy
Stick to a consistent wake-up and bedtime every day of
the week
Use the bedroom only for sleep and sex
Resolve daily dilemmas outside of the bedroom
Establish a bedtime routine
Establish an aerobic exercise routine and stick to it
Create a comfortable sleep environment (e.g., light,
noise, temperature, and sleep surface)
Make the sleep environment more familiar
Properly manage dietary issues, including caffeine and
alcohol consumption
Avoid watching the clock
Pass up naps during the day (if you have trouble sleeping
at night)
Avoid smoking cigarettes immediately before bedtime
Get up and go to another room if sleep doesn’t come in
30 minutes
the text that follows. Due to the aviation scheduling context,
some recommendations will be more difficult to follow than
others, but crew members should strive to adhere to as many
of the suggestions as possible whether at home or on trips.
STICK TO A CONSISTENT WAKE-UP AND BEDTIME
EVERY DAY OF THE WEEK
Although adhering to a consistent sleep/wake schedule
every day of the week may be impossible for many crew
members because of changing duty hours and time-zone
transitions, variations in bedtimes should be avoided when
possible. This is because circadian rhythms have a strong
effect on sleepiness levels across the 24-hour period, and
constant fluctuations in sleep timing can interfere with
these rhythms and/or place sleep-initiation attempts at
inopportune times. Note that maximum sleepiness occurs
near the low point of the body’s temperature rhythm (i.e.
after midnight: body-clock time), and it is easiest to fall
asleep for a reasonable period of time before or after this
point (Lack and Wright 2007). But this period of sleepiness
is preceded by ‘a wake-maintenance zone’, which occurs
six to ten hours before the core temperature minimum (i.e.
from around 17:00  to 21:00  for most adults on consistent
day-shift schedules). During this zone, it is quite difficult to
fall asleep even under the best of circumstances as anyone
who has ever tried to go to sleep earlier than normal will
verify. In particular, the evening wake-maintenance zone is
problematic for travellers and night workers because, even
though they realize the need for sleep during the late after-
noon or early-evening hours, they simply are unable to fall
asleep during this period. Unfortunately, people who fail to
adhere to a regular bedtime routine also can develop prob-
lems going to sleep if they inadvertently time their attempt
at sleep onset inside of the wake-maintenance zone. While
this may not be a problem if it happens only occasionally,
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 588  Aviator fatigue and relevant fatigue countermeasures
it may pave the way for the development of psychological
apprehension about sleep initiation, and this could ulti-
mately lead to insomnia. Thus, for this reason and many
others, it is best to adhere to a consistent well-placed bed-
time as much as possible.
USE THE BEDROOM ONLY FOR SLEEP AND SEX
Using the bedroom only for things that are compatible
with sleep is important because keeping non-sleep-related
activities out of the bedroom avoids the development of
associations between the sleep environment and potentially
sleep-disrupting thoughts, actions and habits (Morgenthaler
et al. 2006). Few people think about the power of stimulus
control in day-to-day life, but a good example is the way in
which the sight and smell of good food promotes feelings
of hunger even at times when the last meal was not so long
ago. Another example is how the simple act of entering a
health club promotes the willingness to exercise even when
feelings of fatigue almost resulted in a workout cancellation
moments before. When people make their bedroom a sleep-
only area, simply entering this area will begin to promote
sleep. However, when people read, watch television, talk on
the phone, play computer games, answer emails and engage
in stressful discussions about the day’s events while lying
in bed, the bedroom becomes a confusing place from a
mental-association standpoint.
RESOLVE DAILY DILEMMAS OUTSIDE THE
BEDROOM
Resolving ‘worry issues’ outside the bedroom can help
minimize the time spent lying awake in bed worrying about
tomorrow. Prior to bedtime, worriers should make a ‘worry
list’ and write a brief action item beside each concern. This
can eliminate the process of thinking about something in
the bedroom when the focus should be on sleep. Creating
a written worry list will not solve the problem itself, but it
can bring a sense of closure regarding a reasonable course of
action which sometimes can stop the process of re-thinking
(i.e. cognitively perseverating) the same situation over and
over throughout the night. Another technique which can
help those who suffer sleep problems due to anxiety and
worry is relaxation training. Progressive muscle relaxation
techniques or biofeedback strategies can reduce muscle
tension, override intrusive thoughts and set the stage for a
comfortable consolidated sleep period (Morgenthaler et al.
2006).
ESTABLISH A BEDTIME ROUTINE
The value of establishing and maintaining a consistent pre-
bedtime routine is based on an operant technique called
chaining in which each behaviour in a routine series of
actions is reinforced by the next action, and all the behav-
iours in the chain ultimately lead to the final occurrence in
the chain, which in this case is sleep. Chaining is a highly
effective strategy for creating complex sequences of behav-
iours, and it can help promote rapid sleep onset if routinely
followed. An example of a good pre-bedtime chain of events
K17577_C036.indd 588
would be to turn off the television at 9 p.m., take a bath, lay
out a wardrobe for the next day, read a relaxing book for
30–45 minutes, set the alarm clock and go to bed by 10.30.
Once this same routine is completed night after night for
several nights, the very first action in the chain (turning
off the television at 9 p.m.) will signal the brain that sleep-
time is near. As each action in the series is completed, the
association with ‘closing in on bedtime’ becomes stronger
so that by the time the alarm clock has been set for the next
morning, the brain is fully prepared for the onset of sleep.
ESTABLISH AN AEROBIC EXERCISE ROUTINE
The importance of exercise to restful sleep has been clearly
established in the scientific literature (Uchida et  al. 2012).
Studies have shown that activities such as running, cycling,
and swimming during the day will subsequently enhance
the ability to fall asleep and stay asleep during the night.
Weight-lifting exercises might not be as helpful as aerobic
exercise, but it appears that any exercise is better than noth-
ing. The only caveat about exercise is that the exercise period
should not be too close to bedtime since physical activity is
known to have a short-term alerting or stressor effect. As
indicated in the review by Uchida et al. (2012), exercise peri-
ods close to bedtime result in reduced amounts of the deep-
est (and presumably most-restorative) stages of sleep. The
rule of thumb is that exercise should be performed each day,
but it usually should not be performed within three to four
hours of bedtime.
CREATE A COMFORTABLE SLEEP ENVIRONMENT
The restorative value of every sleep opportunity can be
enhanced by attending to several environmental and/or
psychological factors. Creating a dark, quiet, cool, comfort-
able and familiar sleep environment is important for the
best possible sleep both at home and when staying in lodg-
ing facilities during layovers.
It is important for the bedroom (or hotel room) to be
completely dark since research indicates that light exerts
alerting effects on a variety of brain regions in addition to its
influence on circadian regulation (Vandewalle et al. 2011).
A good rule of thumb with regard to the recommended level
of darkness is that the bedroom should be sufficiently dark
to prevent seeing a hand-held object within one or two feet
in front of the eyes. To promote this level of darkness in the
home bedroom, windows should be covered with blackout
shades, and light-emitting devices (such as digital clocks)
should be hidden from view or removed altogether. Pilots
who must sleep in hotels during layovers should carry
clothes pins or metal clips to help securely close hotel-room
curtains; in the event that this strategy fails to create suf-
ficient darkness, they may use a good sleep mask.
The minimization of noise also is important for promot-
ing good sleep. Warwick (2011) reports that road, railway
and aircraft noise can significantly detract from sleep qual-
ity. Thus, foam earplugs should be used along with some
type of masking-noise device (even a typical box fan is good)
to create the least noise-contaminated sleep environment
17/11/2015 16:04

possible. When selecting hotel rooms in which to stay dur-
ing layovers, rooms closest to roadways, runways, elevators,
stairways, vending machines and housekeeping staging
areas should be avoided.
Ensuring an appropriate room temperature is also criti-
cal to optimizing each sleep opportunity. Studies show
that about 68°F (16–20°C) is most conducive to good sleep,
whereas bedrooms that are too hot or too cold will lead to
sleep disturbances (Onen et  al. 1994). Keeping the home
sleep environment at the appropriate temperature usually
is not a problem, but when considering the layover envi-
ronment, pilots should check and adjust hotel room ther-
mostats upon arrival so that there is plenty of time for the
room to reach the optimal temperature prior to bedtime. If
possible, the heating/cooling unit in the room should be set
in such a way that the fan runs continuously while the heat-
ing/cooling components cycle on and off since the continu-
ous fan noise will keep air circulating while simultaneously
masking potentially disruptive hallway noises.
Regarding the importance of the sleep surface, research
has shown that the firmness of the bed surface exerts
an impact on both physical comfort and sleep quality
(Jacobson et al. 2006). Home mattresses should be rotated
regularly. They also should be replaced every five to seven
years in most cases. When sleeping in hotels, pilots should
check the comfort of the bed immediately upon arrival
and request another room if the bed is not satisfactory. If
another room is not available, pilots should check to see if
the other side of the bed is less worn, and when all else fails,
they should either request a bed board or actually pull the
mattress on to the floor in an effort to promote a satisfactory
level of comfort.
FAMILIARIZE THE SLEEP ENVIRONMENT
Creating some degree of familiarity within the sleep envi-
ronment can be as important as many of the previously
mentioned comfort factors; clinical studies have shown
first-night effects, such as increased wakefulness, decreased
sleep and reduced sleep efficiency in unfamiliar places
(Agnew et al. 1966). The home sleep environment is of course
already familiar, but when staying in unfamiliar places dur-
ing layovers, the novelty of the hotel room can be a sleep
disrupter even when the physical environment is perfect in
other respects. To overcome this problem, pilots can bring
along familiar items such as their own pillows, small blan-
kets or family pictures. They can sleep in the same type of
clothing as when at home, and should make every effort to
engage in the same type of pre-bedtime routines as those
used in the home setting.
PROPERLY MANAGE DIETARY ISSUES
Optimizing the sleep environment can have a surpris-
ing effect on the quality and quantity of sleep obtained
both at home and when travelling. However, it is likewise
important to properly manage dietary habits particularly
when work or travel schedules introduce meal-time and
bedtime complications.
K17577_C036.indd 589
Alertness-management techniques  589
Eating too much food immediately prior to bedtime or
eating the wrong kinds of food can create sleep difficulties;
conversely, being hungry can cause awakenings during the
night (Urponen et  al. 1988). When in the home environ-
ment, it is usually easy to plan appropriate meal timing and
content, but when travelling, things become more difficult
due to unpredictable schedules and limited availability of
suitable dietary choices. When departing on trips that will
involve sleep away from the home setting, pilots should
pack light snacks such as dried fruit, granola bars or nuts,
in preparation for the possibility of very late hotel arrivals.
Such light snacks will help in preventing night-time hunger
pangs while avoiding indigestion from late consumption
of large meals. In general, heavy meals should be avoided
within two hours of bedtime, and particularly when trav-
elling across time zones in which jet lag will be a factor.
Unfamiliar and overly spicy foods should be avoided since
these may exacerbate the stomach discomfort that often
accompanies rapid schedule changes.
Caffeine consumption should be carefully managed to
ensure that caffeine ingestion at the wrong times does not
delay sleep initiation or interfere with sleep maintenance.
Caffeine is a readily available stimulant that is sometimes
contained in products where it might not be expected (such
as in some brands of carbonated orange sodas). Caffeine’s
alerting properties can help create or maintain wakefulness
during duty periods where fatigue becomes an issue; how-
ever, it is known to exert a negative effect on sleep quality if
taken too close to bedtime, despite protests on the part of
chronic caffeine users that this is not the case (Committee
on Military Nutrition Research 2002). People should avoid
caffeine within four hours of bedtime, and even longer in
people who already have sleep difficulties. Note that the
impact of caffeine on sleep quality changes with age since
sleep architecture becomes more fragile with age, and the
amount of caffeine that had little effect at the age of 20 may
wreak havoc on sleep quality at age 45.
Alcohol has long been considered a ‘sleep promoter’ and,
while it is true that alcohol reduces sleep-onset latency, it
also increases wakefulness after sleep onset and suppresses
rapid eye movement (REM) sleep (Ramakrishnan and
Scheid 2007). The negative impact of alcohol on sleep qual-
ity combined with its effects on next-day blood-sugar lev-
els makes it a bad choice as a sleep aid. No more than two
drinks should be consumed within four hours of bedtime.
AVOID WATCHING THE CLOCK
The caution against being a clock watcher is especially
important for someone who is already worried about sleep.
Checking the time throughout the night may be one of the
most difficult habits to overcome, but it is very important to
fight the temptation to check the time constantly through-
out the night. Watching the clock sets up a maladaptive
pattern of thinking that can destroy the chances of getting
enough sleep. Knowing the time will not improve the qual-
ity of sleep, it will not make it easier to go back to sleep and
it will not increase the amount of available sleep time. If
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 590  Aviator fatigue and relevant fatigue countermeasures
concern about waking up in time for a meeting or a flight
departure prompts the desire (or compulsion) to constantly
check the time during the sleep period, this worry can be
managed by setting two different alarm clocks and/or by
setting clocks and then arranging for a back-up wake-up
call from the hotel operator during layovers.
PASS UP NAPS AS LONG AS YOU HAVE A FULL
EIGHT-HOUR SLEEP PERIOD COMING UP
The longer the period of continuous wakefulness, the greater
the pressure to fall asleep, and since napping is a form of
sleep, it reduces sleep pressure. This is a great feature of naps
when they are used to supplement sleep that is unavoidably
shortened or disrupted due to work or travel demands. But
in people who have satisfactory upcoming sleep opportuni-
ties, naps during the day are likely to create sleep initiation
problems later on. Pilots who are transitioning to new time
zones in the eastward direction should be particularly wary
about napping upon arrival because, although they might be
quite sleepy due to the prolonged wakefulness necessitated
by travel, alleviating this sleepiness with a daytime nap any
longer than about 45 minutes will ultimately make it harder
to fall asleep when the upcoming bedtime arrives. Earlier in
this chapter, the wake-maintenance zones were discussed.
The reason eastward travellers often have difficulties fall-
ing asleep in the new time zone is because the destination
bedtime occurs earlier than usual – within one of the wake-
maintenance zones. Pilots can partially combat this prob-
lem by forcing themselves to remain awake for longer than
usual (post flight) prior to the advanced sleep time so that
the sleep pressure from extended wakefulness counteracts
the circadian-driven urge to remain awake. In general, either
when staying at home or when travelling abroad, naps should
be used only when some factor is interfering with normal
off-duty sleep and not as a solution to boredom or inactivity.
AVOID SMOKING CIGARETTES IMMEDIATELY
BEFORE BEDTIME
Smoking cigarettes right before bedtime is one more action
that falls in the category of a chemical sleep disrupter.
Tobacco smoke contains nicotine, and because smoke is
inhaled into the lungs, its constituents are rapidly absorbed
into the bloodstream. Although nicotine is a weak stimulant
compared to caffeine, it should be avoided by those experi-
encing sleep difficulties for obvious reasons. Research has
shown that cigarette smokers are significantly more likely
than non-smokers to report problems going to sleep and
problems staying asleep (Phillips and Danner 1995). Try not
to smoke within one hour of bedtime.
GET OUT OF BED AND GO TO ANOTHER ROOM IF
SLEEP DOES NOT COME IN 30 MINUTES
A final helpful sleep habit is to get out of bed and out of the
bedroom for a few minutes on those occasions during which
sleep onset fails to occur within 30  minutes of lights out.
Simply lying in bed fretting about being unable to sleep will
not only make things worse for the night on which the sleep
K17577_C036.indd 590
problem occurs, but if done excessively it could become a
chronic problem leading to longer-term bouts of insom-
nia. Everyone has problems going to sleep on occasion, and
when this happens, it is best to just take it in stride, get out
of bed, and go and do something relaxing in another part
of the house for a while. Reading a book, meditating and
listening to music are good choices since these activities are
easy to stop when sleepiness returns. Conversely, working
or socializing on the computer, watching television, playing
video games, or watching a movie are less desirable since
they tend to be more engaging and are likely to compete
with the motivation to return to bed.
On-board sleep
For some commercial and military flight operations, in-
flight, out-of-cockpit sleep is permitted when an augmented
crew (at least three pilots) is on-board and on-board rest
facilities are available (in the US, augmented crews are
mandated for commercial long-haul flights greater than
12 hours in duration). This provision offers pilots an oppor-
tunity to partially attenuate the increased homeostatic sleep
drive that occurs due to the longer duty period between
take-offs and landings on long-duration flights (Rosekind
et al. 2000). On transoceanic flights, one of the pilots in a
three-person crew and two of the pilots comprising a four-
person crew can leave the cockpit during the cruise segment
of the flight to gain some in-flight sleep (obviously, another
pilot or other pilot(s) fly the aircraft when this occurs). In
some military operations, a modified strategy is some-
times implemented in multi-crew aircraft. For instance, in
the case of the B-2  bomber, in which the maximum crew
complement is only two individuals, one of the pilots may
sleep in a cot located behind the seats during low-workload
flight phases while the other pilot maintains control of the
aircraft. Such in-flight sleep is an absolutely essential tool
for B-2 flights which often remain aloft for 44 continuous
hours. Clearly, on-board crew sleep is an important aviation
fatigue countermeasure in any situation, military or civil-
ian, involving flights longer than 10–12 hours. Although the
quality of on-board sleep may not equal the quality of what
would be obtained in a normal home setting (Rosekind
et al. 2000), it is nevertheless profoundly beneficial in com-
parison to an extended period of continuous wakefulness.
Cockpit naps
A strategy related to on-board crew rest is the cockpit nap in
which one pilot actually sleeps in his/her cockpit seat (rather
than moving to another part of the aircraft) while the other
pilot assumes command of the flight deck. NASA studies on
commercial pilots have shown that cockpit naps averaging
approximately 30 minutes in duration are both safe and effec-
tive (Rosekind et al. 1995). As a result, many international
airlines (including those of the UK, but not the US) currently
take advantage of cockpit napping to promote or maintain
flight-crew alertness on long flights. Specific cockpit napping
17/11/2015 16:04

procedures vary as a function of the airline and the govern-
ing organization, the crew complement on board, and other
factors, but on British carriers, a nap duration of 30 minutes,
to be followed by a recovery period of 20 minutes, is recom-
mended (for circumstances in which napping is permitted).
The 20-minute recovery period is designed to give the pilot
time to recover from any sleep-inertia (post-nap grogginess)
that may be present upon awakening. Sleep inertia is a com-
mon experience when awakening from sleep. The magnitude
of sleep inertia is thought to be a function of the amount of
prior wakefulness, the depth of sleep that was obtained, and
possibly the time of day at which the sleep period occurred.
However, most scientists agree that sufficient recovery in most
cases occurs in 20–30 minutes. In some military operations
(US and others), cockpit naps also are used in multi-crew air-
craft as long as another alert pilot is at the controls. Although
cockpit napping is not as beneficial as on-board sleep in a des-
ignated out-of-cockpit facility, it is nonetheless an effective
strategy for partially attenuating the increased sleepiness that
accompanies extended periods of continuous wakefulness.
Controlled rest breaks
The liberal distribution of rest breaks is recommended as
a method to provide short-term relief from boredom and
fatigue especially during long, tedious and repetitious tasks
(Rosa 1995). Pilots often use some type of rest-break strat-
egy (chatting, standing up, walking around) to help sus-
tain alertness during lengthy flights. Although controlled
studies of the efficacy of this countermeasure in aviation
contexts are scarce, Neri et al. (2002) reported that Boeing
747 pilots who were offered brief hourly breaks during a six-
hour simulated night flight showed significant post-break
reductions in slow eye movements, theta-band electroen-
cephalographic (EEG) activity, unintended sleep episodes
and subjective sleepiness for 15–25 minutes. Benefits were
particularly noticeable near the time of the circadian trough.
Along similar lines, Caldwell et al. (2003a) found that sim-
ply assuming a more upright posture, as opposed to remain-
ing seated, reduced the amount of slow-wave EEG activity
and enhanced performance on a ten-minute vigilance task
during the latter part of a 28-hour continuous wakefulness
cycle. Although no information was provided on how long
alertness was improved following this manipulation, it is
certainly possible that posture-related benefits contributed
to the positive effects of rest breaks found earlier by Neri
et  al. (2002). Thus, simply walking off the flight deck for
a few minutes each hour during long-duration flights can
provide at least a brief respite from operator fatigue.
The use of light for circadian adjustment
and alertness management
Some studies have shown that properly timed bright light
can facilitate circadian resynchronization after schedule
changes (Daan and Lewy 1984; Gander et  al. 1989; Samel
et al. 1997). However, at present, there remains debate over
K17577_C036.indd 591
Alertness-management techniques  591
the optimal levels of light exposure, as well as whether per-
sonnel are able to readily determine the appropriate times
at which bright light exposures should occur. Kolla and
Auger (2011) discuss how to use both melatonin and light to
adjust circadian rhythms, and this detailed reference should
be consulted in an effort to maximize the success of using
either strategy. The difficulties in appropriate timing of both
methods suggest that perhaps the safest self-administered
strategy for jet-lagged pilots seeking to adjust to new sched-
ules is simply to take advantage of naps and local zeitgebers
when possible (Kolla and Auger 2011). Natural light expo-
sure is most readily useable by westward travellers after
transitions of up to eight hours because, in this situation, it
is reasonably clear that sunlight in the evening will promote
adjustment to the new time zone. For eastward transitions,
the proper timing of light exposure is far more complex, and
incorrect timing can unfortunately prolong the adaptation
period (Kolla and Auger 2011). For pilots, who are likely
suffering from shift lag as well as jet lag, the best strategy
may be to simply avoid light exposure (or minimize it with
very dark glasses) before a period of daytime sleep. Also, it
should be noted that since aviation personnel often remain
in the new time zone or on the new work shift only tempo-
rarily, attempts at adaptation may not be beneficial.
Recently, research has found photoreceptive retinal gan-
glion cells (RGCs) are sensitive to short light wavelengths
with maximal sensitivity to blue light (approximately
480 nm) (Schmidt et al. 2011; Vandewalle et al. 2011). The
practical application of these findings is that alertness and
performance may be improved with short exposure to blue
light. Chellappa and colleagues (2011) exposed participants
to cool blue light (6500  K) for two hours in the evening.
Their results indicated that this light exposure enhanced
subjective alertness and improved reaction time during
sustained attention tasks compared to that during warmer
light doses (i.e. those in the yellow spectrum: 3000 K and
2500 K). Taillard and colleagues (2012) exposed drivers to
blue light placed on the dashboard during a four-hour in-car
driving test to determine whether blue light could be used
as a countermeasure for sleepiness during night driving.
Results indicated that drivers exposed to the blue light had
fewer driving errors than those exposed to the placebo con-
dition; and in fact, performance during the blue light condi-
tion was similar to the performance after consumption of
200  mg of caffeine (in 125  mL of coffee). However, 17  per
cent (four of 24  participants) of the drivers reported eye-
related discomfort and/or visual problems which impaired
driving performance, so it should be kept in mind that this
particular countermeasure (like others discussed here) may
have drawbacks for certain individuals.
Overall, given the results of real-world studies, it appears
that blue light may be beneficial for improving alertness
and performance in some environments. While there are
no studies in which blue light was presented in cockpits, the
aviation community may wish to consider the feasibility of
placing blue light in cockpits, bearing in mind that some
individuals may experience exposure-related discomfort.
17/11/2015 16:04
 592  Aviator fatigue and relevant fatigue countermeasures
Pharmacological strategies
The comprehensive application of all of the strategies previ-
ously discussed will solve a large percentage of the fatigue-
related problems in aviation. However, in situations where
the non-pharmacological approaches are either not feasible
or not sufficient (as is sometimes the case in military or
emergency operations), pharmacological fatigue counter-
measures should be considered.
Medication-based options are useful (1) for optimizing
sleep opportunities when such opportunities are available
but difficult to utilize, and (2) for sustaining alertness in
the face of unavoidable sleep deprivation. In aviation set-
tings where there is a high degree of medical oversight, such
drug-based avenues are both safe and effective. Both the US
military and the Royal Air Force have approved the use of
certain hypnotics to optimize the sleep of their aircrew. In
the US military, although not in the Royal Air Force, the
use of stimulants for aircrew has also been authorized. The
present discussion will include information on the com-
pounds that are currently authorized under US Air Force
policy for preventing or mitigating severe fatigue in specific
operational contexts. Although numerous other potentially
useful medications are currently on the market (and many
new ones are being developed), a complete review of these
compounds is beyond the scope of this chapter.
Sleep-promoting compounds
Sleep is often difficult to obtain in operational contexts,
even in situations where efforts have been made to ensure
the existence of adequate sleep opportunities. There are a
number of reasons for this, but generally speaking, the dif-
ficulties are due to the fact that (1) the sleep environment is
less than optimal (too noisy, hot and/or uncomfortable); (2)
the state of the individual is incompatible with the ability
to sleep (too much excitement, apprehension or anxiety); or
(3) the sleep opportunity occurs at a time that is not bio-
logically conducive to rapid sleep onset and/or sufficient
sleep maintenance due to shift lag or jet lag. For such cir-
cumstances, the US military has approved the limited use
of temazepam, zolpidem and zaleplon. These hypnotics can
optimize the quality of crew rest in circumstances where
sleep is possible, but difficult to obtain. The choice of which
compound is best for each circumstance must take several
factors into account, including time of day, half-life of the
compound, length of the sleep period and the probability of
an earlier-than-expected awakening. However, appropriate
hypnotic therapy is clearly a valuable adjunct to the non-
pharmacological strategies previously discussed.
TEMAZEPAM
Temazepam (10–30 mg) may be the best choice for optimiz-
ing eight-hour sleep periods that are out-of-phase with the
body’s circadian cycle because, under these circumstances,
sleep is often easy to initiate, but difficult to maintain due
to the circadian rise in alertness. Personnel who work at
K17577_C036.indd 592
night often can easily fall asleep after the work shift since
sleep pressure is high from the previous night of wakeful-
ness. However, once the day progresses, they are frequently
plagued by late-morning or noontime awakenings that
result from circadian-based alerting cues. The day sleep of
night workers is typically two or more hours shorter per day
than their typical night sleep (Tilley et al. 1982; Costa 1997).
For these individuals, the long half-life of temazepam is
desirable because the problem usually is one of sleep main-
tenance and not sleep initiation. Temazepam, particularly
in the 30 mg dose and in the 20 mg soft gel formulation, has
been shown to objectively and subjectively improve daytime
sleep (Muller et  al. 1987) and as a result, temazepam has
been found to improve night-time performance (Porcu et al.
1997). A study of US Army pilots who were working and fly-
ing at night in a simulated shift-work environment verified
that night-time performance, vigilance and alertness were
significantly enhanced as a function of temazepam-induced
improvements in daytime sleep (Caldwell et al. 2003b). Thus,
short-term temazepam therapy can be extremely valuable
to pilots rotating from day to night schedules. Temazepam
also is a good choice for temporarily augmenting the night-
time sleep of personnel who are deployed westward across
as many as 9 to 11 time zones (Nicholson 1990; Stone and
Turner 1997). Upon arrival at their destination, these indi-
viduals likely will be able to fall asleep quickly since their
local bedtime in the new time zone is much later than the
one established by their circadian clock (from the origi-
nation time zone); however, they may be unable to sleep
throughout the night. While awaiting adjustment to the
new time zone, temazepam can support adequate sleep
maintenance despite conflicting circadian signals and the
obvious benefit will be less performance-degrading sleep
restriction. It is important to note that in the UK and several
other countries, temazepam is now only available in tablets
of 10 and 20 mg formulation, the gel capsules having been
withdrawn because of intravenous drug abuse.
ZOLPIDEM
Zolpidem (5–10  mg) may be the optimal choice for sleep
periods less than eight hours or sleep periods that could be
unexpectedly shortened due to operational need. This com-
pound is especially useful for promoting short- to moderate-
length sleep durations (4–7 hours) when sleep opportunities
occur at the ‘wrong’ circadian times. Daytime naps fall into
this category because, like daytime sleep in general, these
naps are difficult to maintain (Tilley et al. 1982; Lavie 1986;
Costa 1997). Furthermore, unless the naps are placed early
in the morning or shortly after noon, they can be extremely
difficult to initiate (Gillberg 1984). Zolpidem is a good
choice for facilitating such naps because its relatively short
half-life of 2.5 hours promotes rapid sleep onset with mini-
mal post-nap hangover. A US Army study (Caldwell and
Caldwell 1998) demonstrated that zolpidem-induced pro-
phylactic naps enhanced the subsequent (post-nap) alert-
ness and performance of sleep-deprived pilots during the
last portion of a 38-hour period of continuous wakefulness
17/11/2015 16:04

without producing troublesome hangover effects. Thus, zol-
pidem is useful for shift-work environments and sustained
operations. Zolpidem also is helpful for promoting the sleep
of personnel who have travelled eastward across between
three and nine time zones (Suhner et al. 2001). Unlike west-
ward travellers who experience sleep maintenance difficul-
ties, eastward-bound personnel will likely suffer from sleep
initiation problems. Zolpidem can help these personnel by
rapidly initiating sleep and maintaining sleep until normal
circadian factors take over. Since the drug’s half life is short,
hangover effects will be minimized. As was the case with
temazepam, the zolpidem-enhanced sleep will not com-
pletely alleviate the symptoms of jet lag, but it will attenuate
the sleep restriction and sleep disturbances that can degrade
subsequent alertness and performance.
ZALEPLON
Zaleplon (5–10  mg) may be the best choice for initiating
very short naps (between one and two hours) or for initiat-
ing early sleep onset in personnel who are trying to sleep
earlier than usual in preparation for a very early start time
the next morning. With regard to facilitating early report
times, zaleplon is an option to zolpidem, but both com-
pounds are important for the same reason. Since it is typi-
cally difficult for people to initiate sleep two to four hours
prior to their usual bedtimes (Lavie 1986; Akerstedt 2003),
requirements to be at the flight line in the pre-dawn hours
often lead to two to three hours of sleep restriction. Since
this amount of sleep truncation has been shown to sig-
nificantly impair both alertness and performance (Roehrs
et  al. 1970; Belenky et  al. 2003; Van Dongen et  al. 2003),
it is understandable that short-haul pilots often attribute
a large part of their fatigue-related problems to such early
duty schedules (Bourgeois-Bougrine et  al. 2003). Zaleplon
can help in this situation by hastening sleep-initiation
(Chagan and Cicero 1999) (thus extending the overall sleep
period), and its ultra-short one-hour half-life is unlikely
to pose hazards in terms of residual drug effects. Paul
et  al. (2004) suggest zaleplon can be safely used to sup-
port sleep periods as short as three hours since a study of
10-mg zaleplon revealed minimal drowsiness three to five
hours post dose. Thus, zaleplon (10 mg) is a good hypnotic
for promoting early-to-bed sleep periods and short naps
(2–4  hours) which would otherwise be difficult to initiate
and maintain. In addition, as was the case with zolpidem,
zaleplon can be considered useful for the treatment of
sleep-onset insomnia in eastward travellers who are expe-
riencing mild cases of jet lag. For instance, those who have
transitioned eastward only three to four time zones can use
this short-acting drug to initiate and maintain what the
body believes to be an early sleep period.
GENERAL PRECAUTIONS FOR HYPNOTIC THERAPY
Sleep promoting compounds can be extremely useful for
overcoming sleep problems in operational contexts. How­
ever, like all medications, there are both benefits and risks
that should be considered by the prescribing flight surgeon
K17577_C036.indd 593
Alertness-management techniques  593
and the individual pilot receiving treatment. Although
temazepam, zolpidem and zaleplon are widely recognized as
being both safe and effective, personnel should be cautioned
about potential side effects and instructed to bring any that
occur to the attention of the flight surgeon. Potential prob-
lems may include performance-impairing hangover effects,
dizziness and amnesia associated with premature awaken-
ings (before the drug is fully metabolized), and/or various
idiosyncratic effects (Nicholson 1990; Roth and Roehrs
1991; Balter and Uhlenhuth 1992; Menkes 2000). The
appearance of side effects may necessitate discontinuation
of therapy, the use of an alternative compound, or the mod-
ification of dosing strategies (Nicholson 1990). Hypnotics
should not be used with personnel who are on-call and may
be awakened for immediate duty. Operational use of hyp-
notics should be preceded by a test dose given under medi-
cal supervision. When using hypnotics to aid in advancing
or delaying circadian rhythms in response to time-zone
shifts, caution is advised because of the many complexities
associated with properly resynchronizing internal rhythms
(Nicholson 1990; Stone and Turner 1997; Waterhouse et al.
1997). All of these cautions should be weighed against the
fact that in many cases, the administration of hypnotics is
the only practical means by which severe sleep deprivation
(and the consequent negative effects of fatigue) can be pre-
vented. Thus, while there are potential drawbacks associ-
ated with the use of these medications, the payoff can be far
more significant.
Alertness-enhancing compounds
For special military and emergency situations in which,
despite the best intentions, adequate sleep opportunities
are simply nonexistent, stimulants or alertness-enhancing
drugs represent a viable option for temporarily staving off the
deleterious effects of fatigue. Unavoidable manpower con-
straints, hostile environmental circumstances, extremely
high workloads, and/or unexpected enemy attacks all may
require a postponement of sleep until a break in the opera-
tional tempo permits rest and recuperation. Stimulants can
be life-saving in circumstances in which sleep deprivation
is unavoidable (Cornum et  al. 1997). Stimulants have the
advantages of being effective and easy to use, and because
their feasibility is not dependent upon environmental
manipulations or scheduling modifications, their useful-
ness, especially for short-term applications, is significant
(for example, see Kenagy et  al. 2001). These advantages
explain why pharmacological compounds, such as amphet-
amines, have been used extensively to overcome unavoid-
able sleep deprivation in several past military conflicts.
Although stimulants other than caffeine are not cur-
rently authorized for civilian or military use in the UK, caf-
feine, modafinil and dextroamphetamine are approved for
certain aviation operations by the US Air Force and the US
Army. Caffeine and modafinil are approved for limited use
by the US Navy. Each of these compounds will be briefly
discussed below.
17/11/2015 16:04
 594  Aviator fatigue and relevant fatigue countermeasures
CAFFEINE
Caffeine is a good choice for situations in which medical
oversight of drug administration is not available. Caffeine
is already in widespread use, it is not a prescription drug,
and it is generally viewed as quite safe. It is readily available
in many forms to include tablets, gums, candies, beverages
and foods. An 8-fl oz cup of drip-brewed coffee contains an
average of 135 mg of caffeine, an 8-fl oz cup of brewed tea
contains approximately 50 mg of caffeine, and a 12-fl oz cola
drink contains an average of 44 mg caffeine. An 8-fl oz cup
of Starbucks coffee contains 250 mg of caffeine (Schardt and
Schmidt 1996). Research has shown that caffeine’s effects
are quite variable depending on the dose administered, the
task measured, and the level of tolerance (Lieberman et al.
1987; James 1998; Yeomans et  al. 2000). Side effects can
include increased heart rate, nervousness, anxiety, restless-
ness, nausea and increased frequency of urination, as well as
reductions in fine motor control (Serafin 1996). In general,
caffeine improves reaction time and cognitive performance,
elevates mood and reduces sleepiness in fatigued subjects
(Lieberman et al. 1987; Penetar et al. 1993; Committee on
Military Nutrition Research 2002). Studies have shown that
600  mg doses of caffeine can temporarily restore the per-
formance and alertness of sleep-deprived personnel kept
awake for over 50 continuous hours (Wesensten et al. 2002).
For shorter periods of sleep loss (less than 24 hours), 150–
300 mg bolus doses of caffeine are beneficial as well (Penetar
et al. 1993). However, despite these and other positive find-
ings, wholesale dependence on caffeine to mitigate the
effects of sleep deprivation in the operational environment
is controversial since the effects of caffeine tolerance have
not been adequately studied (Wyatt et al. 2004). Although a
recent report suggested that doses of 200–800 mg of caffeine
should be considered a first-line remedy for the drowsiness
associated with insufficient sleep in operational military
settings (Committee on Military Nutrition Research 2002),
Rogers and Dernoncourt (1998) concluded that many of caf-
feine’s effects result more from the alleviation of caffeine
withdrawal in habitual users than from a true performance-
enhancing action. At present, further research on the tol-
erance issue is required for the following reasons: (1) over
80 per cent of adults in the US daily consume behaviourally
active doses of caffeine; (2) tolerance to caffeine’s subjec-
tive effects has been shown to occur within four days of
chronic dosing; and (3) tolerance to caffeine’s sleep-disrupt-
ing effects has been observed after seven days of consistent
caffeine administration at 1200  mg per day (Griffiths and
Mumford 1995). Together, these facts suggest the possibility
that the already widespread use of caffeine may diminish its
effectiveness as a wake-promoting agent in severely fatigued
individuals. Nonetheless, caffeine’s generally positive
impact on alertness combined with its safety and availabil-
ity make it a good starting point for the pharmacologically
based management of aviation fatigue. Although there is
some indication that caffeine’s short half-life of between
four and six hours may make it undesirable for situations in
which a long-term boost is needed, this same quality may
K17577_C036.indd 594
make caffeine optimal for situations in which there is the
possibility that an unexpected sleep opportunity may arise
shortly after the dose administration time.
MODAFINIL
The prescription drug modafinil (100–200  mg) may be a
better choice than caffeine for sustaining alertness and per-
formance in operational contexts as long as sufficient medi-
cal oversight is available to supervise its use. Although doses
in the range of 200–800 mg have been observed to increase
anxiety, insomnia, headaches, palpitations, blood pressure
and pulse rate (Buguet et al. 2003), the frequency of adverse
side effects is low. There appears to be little or no drug toler-
ance with modafinil even after weeks of continuous use, and
the abuse liability is limited (Cephalon 1998). Furthermore,
modafinil exerts only a small adverse effect on recovery
sleep even when given fairly close to the time of sleep onset
(Buguet et al. 1995). Thus, it may be optimal for sustained
operations in which there is a possibility that an unexpected
sleep opportunity could arise. Modafinil exerts a wide array
of positive effects on alertness and performance. Lagarde
and Batejat (1995) found that 200-mg doses every eight hours
reduced episodes of microsleeps and maintained more nor-
mal (i.e. rested) mental states and performance levels than
placebo for 44 hours of continuous wakefulness (but not the
full 60 hours of sleep deprivation). Wesensten et al. (2002)
found 200–400 mg doses of modafinil effectively countered
performance and alertness decrements in volunteers kept
awake for over 48 hours. Caldwell et al. (2000) found that
200 mg of modafinil every four hours maintained the simu-
lator flight performance of pilots at near well-rested levels
despite 40 hours of continuous wakefulness, but that there
were occasional idiosyncratic complaints of nausea and
vertigo (likely due to the high dosage used). A more recent
study with US Air Force F-117  pilots indicated that three
100 mg doses of modafinil (administered every five hours)
sustained flight performance within 27 per cent of baseline
levels during the latter part of a 37-hour period of continu-
ous wakefulness. Performance under the no-treatment con-
dition degraded by over 82 per cent (Caldwell et al. 2004).
Similar beneficial effects were seen on measures of alertness
and cognitive performance. Furthermore, the lower dose
produced these positive effects without causing the side
effects which might have been associated with modafinil in
the earlier study (Caldwell et al. 2000a). Due to these and
other positive results, modafinil is gaining popularity as a
way to enhance the alertness of sleepy personnel, largely
because it is considered safer and less addictive than com-
pounds such as the amphetamines. Modafinil also produces
less cardiovascular stimulation than amphetamine, and
despite its half-life of approximately 12–15 hours (Robertson
and Hillriegel 2003; Physicians’ Desk Reference 2010b), the
drug’s impact on sleep architecture is minimal. Modafinil
has received approval for use in certain US Air Force and
Navy missions, and further research will likely pave the way
for wider reliance on this compound as an effective fatigue
countermeasure, at least for military applications.
17/11/2015 16:04

AMPHETAMINE
Dextroamphetamine (5–10  mg) has been researched for
many years and several studies have provided evidence that
this compound is effective for maintaining alertness and
performance in sleep-deprived people in a variety of settings.
Although dextroamphetamine can produce side effects such
as palpitations, tachycardia, elevated blood pressure, rest-
lessness, euphoria and dryness of mouth (Physicians’ Desk
Reference 2010a), the properly controlled administration of
this compound remains a viable strategy for the sustainment
of combat performance in select military aviation opera-
tions where sleep is difficult or impossible to obtain. The US
Navy’s Performance Maintenance Guide (US Naval Strike
and Air Warfare Center 2000) and the US Army’s Leader’s
Guide for Crew Endurance (Comperatore et al. 1996) both
discuss the use of dextroamphetamine for the sustainment
of aviator performance in continuous flight operations.
Both of these documents are currently under revision with
updated policies concerning the use of stimulants. The US
Air Force has authorized the use of dextroamphetamine in
certain types of lengthy (i.e. 12 or more hours) single-seat
and dual-seat flight missions. In comparison to caffeine,
dextroamphetamine appears to offer a more consistent and
prolonged alerting effect (Weiss and Laties 1962). In com-
parison to modafinil, studies of 40-hour sleep-deprivation
periods suggest that amphetamine is at least equivalent
(Pigeau et al. 1995; Caldwell 2001; Wesensten et al. 2004). In
terms of the efficacy of amphetamine as a fatigue counter-
measure, Newhouse et al. (1992) studied d-amphetamine (5,
10 or 20 mg) in people deprived of sleep for over 48 hours
and found that 20 mg d-amphetamine (administered after
41  hours of continuous wakefulness) produced marked
improvements in addition/subtraction (lasting for over ten
hours), a gradual improvement in logical reasoning (signifi-
cant between 5.5  and 7.5  hours post-dose), a long-lasting
improvement in the speed of responding during the choice
reaction-time task (ten hours), and an increase in alertness
for seven hours. It was noted that the drug did not impair
judgment. The 10-mg dose exerted fewer and shorter-lasting
effects, whereas the 5-mg dose was ineffective. Two flight
simulation studies involving US Army pilots indicated that
repeated 10-mg doses of dextroamphetamine (given at mid-
night, 04:00 and 08:00) maintained flight performance and
alertness nearly at well-rested levels throughout 40  con-
tinuous hours of wakefulness (Caldwell et  al. 1995; 1997).
Benefits were especially noticeable between 03:00 and 11:00,
when fatigue-related problems were most severe. In a later
study, ten pilots completed a series of one-hour sorties in a
specially instrumented UH-60  helicopter during 40  hours
of sleep deprivation. The results revealed that 10-mg doses
of dextroamphetamine sustained performance nearly
as well under actual in-flight conditions as in the labora-
tory (Caldwell and Caldwell 1997). A follow-on simulator
investigation extended these findings by showing that with
additional amphetamine dosing, pilot performance and
alertness could be sustained for over 58 continuous hours
of wakefulness (two nights of sleep loss) (Caldwell et  al.
K17577_C036.indd 595
Alertness-management techniques  595
2000b). Reports from the field indicate dextroamphetamine
has been used successfully in a number of combat situa-
tions such as Vietnam (Cornum et al. 1995), the 1986 Air
Force strike on Libya (Senechal 1988) and Operation
Desert Shield/Storm (Cornum et  al. 1997). Emonson and
Vanderbeek (1995) found that US Air Force pilots who were
administered dextroamphetamine during Operation Desert
Shield/Storm were better able to maintain acceptable perfor-
mance during continuous and sustained missions, and that
the medication contributed to both safety and effectiveness.
To date, no major side effects or other problems have been
reported from the medical use of dextroamphetamine in
military settings. In light of these and other findings, dex-
troamphetamine doses of 10–20  mg (not to exceed 60  mg
per day) are recommended for situations in which heavily
fatigued military pilots simply must complete the mission
despite dangerous levels of sleep deprivation.
GENERAL PRECAUTIONS FOR STIMULANT THERAPY
Alertness-enhancing compounds can be extremely useful
for temporarily mitigating the impact of sustained wake-
fulness in operational contexts where sleep opportuni-
ties are severely limited. However, there are both benefits
and risks associated with the use of these compounds that
deserve consideration from the prescribing flight surgeon
and the individual pilot prior to use. Although caffeine,
modafinil and dextroamphetamine are widely recognized
as being both safe and effective when used under proper
medical supervision, personnel should be cautioned about
potential side effects that may include irregular heartbeats,
accelerated heart rate, elevated blood pressure, dry mouth,
diarrhoea, constipation, loss of appetite, restlessness, dizzi-
ness, light-headedness, tremor, headaches, nausea and/or
reduced libido (Physicians’ Desk Reference 2010a, 2010b).
Furthermore, pilots/flight surgeons considering the use/
administration of dextroamphetamine should remain cog-
nisant of the risks associated with abuse and dependence.
Also, with amphetamine, it should be noted that people have
experienced psychotic episodes on rare occasions; however,
this typically occurs when recommended dose levels are
exceeded or the drug is injected rather than taken orally
(Kosman and Unna 1968; Poole and Brabbins 1996; Segal
and Kuczenski 1997). If any difficulties occur during the
course of treatment with caffeine, modafinil or dextroam-
phetamine, alertness-enhancement therapy may need to be
discontinued altogether, the specific compound may need to
be changed, or the dosage may need to be modified. It should
be noted that the potential difficulties associated with the
use of stimulants must be weighed against the fact that these
medications are often the only practical means available to
preserve the performance of severely sleep-deprived pilots.
Although stimulants should never be used as a replacement
for sound work/rest scheduling, they can make the differ-
ence between life and death when, despite everyone’s best
efforts, significant sleep loss is simply unavoidable. It is well
known that personnel cannot otherwise overcome severe
fatigue even when they are highly motivated to do so.
17/11/2015 16:04
 596  Aviator fatigue and relevant fatigue countermeasures
CONCLUSION
Sleep and circadian factors are the primary underpinnings
of human fatigue, and aviation schedules exert a powerful
effect on both. Fortunately, newer flight regulations in both
the US and Europe are increasingly recognizing the need to
consider the true physiological nature of fatigue rather than
focusing on simplistic and outdated ‘hours of service’ rules.
Better scheduling practices are now possible via the use of
mathematical models which can predict the fatigue impact
of proposed rosters prior to their implementation. Wrist-
activity monitoring can track the actual sleep hours obtained
by aircrew members to help gauge whether sleep disruptions
are likely to degrade performance. Efforts to educate per-
sonnel about scientifically based fatigue facts will safeguard
against counterproductive fatigue-management strategies.
Proven behavioural and sometimes pharmacological inter-
ventions can bridge the gap between unavoidable schedule-
driven fatigue and the physiological adaptability of aviation
personnel. Altogether, an integrated, scientifically based,
multifaceted approach to fatigue-risk management can sig-
nificantly mitigate fatigue and improve operational safety in
today’s fast-paced aviation environment.
SUMMARY
●● The following brief points highlight the key
fatigue-management issues for aviation opera-
tions discussed in this chapter:
●● The traditional strategy of managing fatigue via
hours-of-service restrictions began long ago, at
the dawn of aviation.
●● However, since those early days, science has
revealed that fatigue management requires
consideration of more than time-on-task.
Rather, the amount and quality of sleep and the
body’s circadian rhythms are key factors in the
fatigue equation.
●● Furthermore, it has recently been discovered that
some individuals are physiologically more resis-
tant to fatigue than others.
●● However, despite the complexity of the fatigue
phenomenon, it is possible to effectively manage
fatigue with scientifically validated strategies.
●● Crew schedules can be optimized via the com-
bined use of bio-mathematical models and wrist-
actigraphic sleep/wake tracking.
●● Crew members and schedulers can be better
educated about the nature of fatigue and its
proper management.
●● Scientifically validated countermeasures such as
pre-flight sleep optimization, in-flight rest breaks,
properly managed light exposure and pharmaco-
logical interventions can offer significant benefit
even when duty schedules are less than optimal.
K17577_C036.indd 596
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FURTHER READING
Kennedy C, Kay G (eds). Aeromedical Psychology.
Farnham: Ashgate Publishing Ltd, 2013.
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17/11/2015 16:04

Infectious disease and air travel
ANDREW D. GREEN, DAVID HAGEN AND DAVID W. MULVANEY
Introduction 601
Travel trends 601
Travel and disease 602
Transmission of infections aboard aircraft 602
Respiratory infections 602
International guidelines 603
Gastrointestinal infection 604
Aeromedical evacuation of infectious patients 604
INTRODUCTION
International travel has grown at a remarkable rate over the
last 50 years and much of this has been due to the increased
accessibility and falling cost of air travel. The World Tourism
Organization estimates that numbers of tourist arrivals will
continue to rise and that by 2030 there will be in excess of
1.8  billion (World Tourism Organization 2013). Although
there are large numbers of sea and land travellers, the
majority of people crossing international borders do so by
air. Many of these passengers will be ill, since travel-related
disease is common, and some will directly or indirectly
come to the attention of the aviation medicine specialist.
This chapter examines the relationship between infec-
tious diseases and travel, with particular reference to the
issues relating to aviation. It does not intend to be a defini-
tive text on infectious diseases or infection control, but
highlights those areas of practical importance.
TRAVEL TRENDS
International travel has increased rapidly over recent
decades. The categories of traveller and their reasons for
travel are varied, and the activities undertaken complex.
Holidays are by far the most common reason for travelling
abroad, and other reasons for travel include business trips,
international sports, medical tourism and humanitarian
K17577_C037.indd 601
37
Infection control in the air 606
Movement of patients with highly transmissible infections 606
Ebola virus outbreak, 2014–2015 606
International response to infectious disease 607
SARS – a milestone for public health 608
Update on emerging infectious diseases 608
Malaria 609
References 612
aid. In the United Kingdom, people visiting friends and
relatives account for 20 per cent of the total visits abroad.
Over the past six decades, tourism has become one of the
largest and fastest-growing economic sectors in the world.
In 2012, UK residents made an estimated 50.3 million visits
abroad, unchanged from 2011 despite the continuing eco-
nomic downturn. Forecasts suggest that the financial situa-
tion has had a more significant effect on travel trends than
international conflict and infectious disease threats, and
that numbers of travellers will rise dramatically again once
economic stability returns.
Although Western Europe and the USA remain the com-
monest destinations for British travellers, international tour-
ist arrivals in the emerging economy destinations of Asia,
Latin America, Central and Eastern Europe, the Middle
East and Africa are growing at double the pace of that in
advanced economy destinations. This reflects increasingly
adventurous travel patterns, the increased accessibility of
previously remote destinations made popular by film and
television, and by international sporting events being held
in less developed nations.
These factors combine to produce a rapidly growing
number of travellers who are returning from remote loca-
tions with exposures to significant health hazards, often
associated with high risk activities. The groups visiting
friends and relatives are exposed to different risks, but are
also more likely to be exposed to disease.
601
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 602  Infectious disease and air travel
TRAVEL AND DISEASE
There is no systematic collection of information on ill-
ness related to travel, either for people who become sick or
injured whilst overseas or for people who develop disease on
their return. This is true for both the British travellers and
for those of other countries.
The data that is available is limited and collected from
travellers who receive pre-travel advice from selected inter-
national clinics (GeoSentinel), specific studies conducted
on defined groups of travellers and observational research
based on reported cases of disease following travel. This is
inevitably biased, and may not be a true picture. There are,
however, indicators that overseas travel is associated with a
significant burden of disease and injury, and a correspond-
ing economic impact:
●● In 2012 the Association of British Insurers reported that
56 per cent of travel insurance claims were made for
medical reasons.
●● The Foreign and Commonwealth Office reported that
there were 6193 deaths of British nationals overseas for a
12-month period spanning 2012–2013.
●● In 2012, there were 1378 cases of malaria reported in the
UK, all of which were travel related.
●● Gastrointestinal disease is reported in up to 60 per cent
of travellers to some destinations, with the risk of infec-
tion being higher in those areas of the world with poor
water supplies and sanitation.
Specific studies have also identified variable morbidity
from trauma (especially road traffic accidents) and psy-
chiatric disease (including suicides). Data from medical
repatriation companies suggest that accidental injury is
the commonest cause of morbidity in younger age groups,
whilst cardiovascular disease accounts for most disease in
older groups. Vaccine-preventable diseases cause a small
number of infections, despite the emphasis given to vaccine
delivery in many pre-travel health care settings.
Travellers are also recognized as the means by which
many new and emerging infectious diseases move around
the globe. The introduction of novel pathogens may have
profound consequences for both the health systems of receiv-
ing countries and longer term economic effects. Examples
from the last 20 years include HIV/AIDS and the spread of
multi-drug resistant bacteria. In the last decade, there have
been significant public health problems caused by travellers
with severe acute respiratory syndrome (SARS), and more
recently H1N1 influenza and Middle East respiratory syn-
drome coronavirus (MERS-CoV). These episodes led to the
World Health Organization (WHO) revising and updating
the International Health Regulations in 2005 (implemented
in 2012) to take account of travellers with novel infectious
diseases (see below).
A relatively new phenomenon is that of medical tour-
ism, with patients travelling to different countries to receive
medical care (including surgery) before returning to their
K17577_C037.indd 602
homeland. There is increasing evidence that this is asso-
ciated with the spread of difficult-to-treat multi-drug
resistant bacteria which are acquired in the healthcare envi-
ronment and subsequently spread when the patient returns
to their home.
The net effect of changing travel patterns and the like-
lihood of associated disease is that there is now an inter-
national recognition of the importance of air travel and
infectious disease, both in terms of the transmission aboard
aircraft and the impact on global epidemiology of a variety
of infections.
TRANSMISSION OF INFECTIONS ABOARD
AIRCRAFT
For all practical purposes, person-to-person transmission
of disease occurs from people who are symptomatic. This
has important implications for passenger aircraft:
●● Asymptomatic individuals uncommonly transmit infec-
tions to others.
●● Identification of symptomatic individuals will
allow targeting of resources in order to reduce
disease transmission.
●● Infection-control precautions can be tailored to the
symptoms of the individual, e.g. respiratory precautions
for a coughing patient.
●● Exclusion of symptomatic people from aircraft will fur-
ther reduce the risks of in-flight disease transmission.
●● Passengers who have been incubating disease may
become symptomatic for the first time during flight.
●● Patients who require aeromedical evacuation may be at
higher risk of transmitting disease. The risk will vary
according to diagnosis and symptoms.
RESPIRATORY INFECTIONS
Infection by the respiratory route is most commonly by
droplets (particles greater than 10μ in diameter) that fall
to the ground rapidly after being generated. The majority
of patients with respiratory symptoms (such as coughs and
sneezes) produce droplets containing microorganisms that
can directly infect the upper respiratory tracts of other peo-
ple. For practical purposes, these are relatively easy to con-
tain by the use of physical barrier methods (such as simple
masks and ventilator filters) around the airways of patients
and medical attendants. Other mucous membranes, such as
conjunctivae, may also require protection. Environmental
contamination is common in the immediate area of a
symptomatic individual, and hands are easily colonized;
organisms are then passed readily to the mouth or mucous
membranes of the patient or another person. Hand washing
is probably the single most important factor in preventing
the spread of respiratory disease.
Particles measuring less than 10μ in diameter remain
suspended in the air and are termed aerosols. They behave
17/11/2015 16:05

more like gases and are able to penetrate as far as the
alveoli, together with any organisms they contain. Higher
levels of respiratory protection are required to contain
spread. Aerosol transmission is much less common than
droplet spread.
Examples of diseases spread by the respiratory route
include the following:
●● Legionella pneumophila. No person-to-person spread,
aerosol inhalation of environmental organisms.
●● Mycobacterium tuberculosis. Low transmission, person-
to-person droplet spread.
●● Varicella (chickenpox). Highly transmissible, person-to-
person spread by droplets and aerosols.
Evidence for transmission of respiratory diseases on
aircraft is scanty. Reports of respiratory symptoms (such
as drying of mucous membranes or cough) following
extended flights are common but are usually related to
environmental conditions rather than infection. These
symptoms are easy to record through subjective ques-
tionnaire surveys, since many individuals on each flight
report such symptoms. In contrast, the nature of infec-
tious disease makes a transmission event irregular and
unpredictable, and large scale prospective studies with
microbiological investigations would be required to pro-
vide an accurate estimate of risk.
There are few reports of incidents, and these generally
have been identified through a series of unusual circum-
stances. They include:
●● Influenza A. Transmitted during an internal flight in
Alaska, when weather and geography combined to
aid early recognition and investigation of the incident
(Moser et al. 1979).
●● Flu-like illness. Transmitted during an internal flight in
Australia, where illness was recognized early in a closed
mining community (Marsden 2003).
●● Mycobacterium tuberculosis. A series of incidents in the
mid-1990s were investigated by the Centers for Disease
Control in the USA, but in only six cases was there evi-
dence of any disease transmission (Kenyon et al. 1996).
●● Severe acute respiratory syndrome (SARS). During the
early stages of the epidemic, a number of patients flew
between countries and, in three flights, transmission to
other passengers was subsequently recognized, albeit
only to those in close contact with symptomatic cases
(Olsen et al. 2003).
●● Meningococcal disease. There are nine published inci-
dents of follow-up investigations of meningococcal
disease cases presenting on aircraft, but in only one was
there evidence of transmission. In other settings the
organism is not easily spread (albeit the consequences
of infection are serious) and generally confined to those
individuals with extended periods of close contact to
the index case. The risk is considered to be no higher on
aircraft than in any other setting (O’Connor et al. 2005).
K17577_C037.indd 603
International guidelines  603
●● Measles. Five incidents of inflight transmission of
measles are published and in all cases the flights were in
excess of eight hours. In common with disease spread
elsewhere, secondary cases were seated some distance
from the index case, indicating the high infectivity of
the disease.
In the absence of any compelling evidence of regular
disease transmission aboard aircraft (based on outbreak
reports), research has focused on the theoretical mecha-
nisms for spread of microorganisms. The total number of
bacteria present in air in passenger aircraft during quiet
periods in flight is no different from that found in equiva-
lent locations on the ground, such as buses and public meet-
ing areas. No increase in numbers has been demonstrated
with recirculation of cabin air (Wick and Irvine 1995), the
highest numbers of bacteria being observed during embar-
kation and disembarkation when passengers are most fre-
quently in movement (in transit or moving)(Dechow et al.
1997). Despite the absence of data implicating recycled air
as a risk, high efficiency particulate air (HEPA) filters are
now fitted to air-conditioning systems of most new passen-
ger aircraft, as it is perceived to be of commercial benefit to
address the theoretical mode of disease transmission.
Patterns of air movement have been studied in various
aircraft types. In commercial airliners, this has been used
to determine optimum levels of comfort without creation
of draughts or temperature loss. This varies with both the
type of aircraft and its configuration. In military aircraft,
this has been extended to predict theoretical transmission of
infection. The United States Air Force (USAF) has assessed
airflow patterns in all of its aircraft used for aeromedical
evacuation. Although there is no evidence that this is associ-
ated with disease transmission, it has advised that only those
with front-to-rear air flows should be used for potentially
infectious patients, in order to reduce the risk to aircrew
(United States Air Force Transportation Command 2003).
INTERNATIONAL GUIDELINES
●● Influenza. A series of specific guidelines appeared
following international outbreaks of influenza due
to H5N1 (in 2006) and H1N1 (in 2009). These were
tailored to these particular types of influenza infection,
and more generic guidance has been produced by the
Centers for Disease Control for management of annual
influenza (Centers for Disease Control 2013).
●● Tuberculosis. WHO guidance on tuberculosis stresses
the importance of pre-flight identification of open
cases of disease and preventing their travel, advises
on contact-tracing procedures following the inadver-
tent transportation of a case on a long-haul flight, and
emphasizes the low risk to those not in the immediate
proximity. However, the guidance also recommends
that HEPA filters are fitted to all commercial passenger
aircraft, despite acknowledging that there is no evidence
base for this advice (World Health Organization 2008).
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 604  Infectious disease and air travel
●● SARS. Guidance for SARS has been produced by the
Centers for Disease Control and Health Canada. As
with tuberculosis, the emphasis is on identification of
symptomatic individuals before flight and delaying
travel until they are symptom-free. Should a passen-
ger develop symptoms during flight, then basic source
isolation (if practical) is advised, with a facemask for
the individual rather than all other passengers. Contact
details are collected from everyone on the flight, but
enhanced surveillance measures are undertaken only
for those people in close contact with the case. No
further action is recommended for flights when asymp-
tomatic individuals have travelled but developed disease
later. (Centers for Disease Control 2005).
●● Meningococcal disease. Several countries have produced
local guidelines, but these reflect the public health poli-
cies in place in those nations. No international guid-
ance exists and any incidents should be managed by the
relevant public health authorities.
●● Investigation of Aviation Outbreaks. In 2009, the
European Centre for Disease Prevention and Control
undertook a systematic review of all reported episodes
of disease transmission aboard aircraft and relevant
research studies and produced a series of recommenda-
tions that were, wherever possible, evidence based. The
expert body included aviation medicine specialists as
well as infectious diseases clinicians. The conclusion
was that risk assessment and the decision for contact
tracing should be specific for each event, and should
take into account factors such as the disease epidemiol-
ogy, the infectivity and pathogenicity of index patients,
onboard ventilation systems and seating details of pas-
sengers (European Centre for Disease Prevention and
Control 2009).
GASTROINTESTINAL INFECTION
Gastrointestinal diseases are spread by the faecal–oral
route. In the aircraft cabin, the principal sources of infec-
tive organisms are likely to be the food and water consumed
and other passengers with disease. Catering practices and
water management are dealt with more fully in Chapter 56:
Aircraft Hygiene.
Incidents of food poisoning on aircraft are reported infre-
quently, with fewer than 50 incidents recorded (Tauxe et al.
1987). In part, this is due to poor recognition and reporting,
but it also reflects the high standards now adopted by airline
operators. The improved international surveillance systems
developed in recent years have helped identify some inci-
dents that previously would have passed unnoticed, but the
low ratio of cases suggests that aircraft catering is now well
regulated. In many of the reported incidents, the implicated
foodstuff was ingested pre-flight, with symptoms develop-
ing during flight after an incubation period 24–48  hours
later. In contrast, for a food-poisoning incident resulting
from food ingested in flight, the incubation period for ill-
ness must be short enough for symptoms to appear before
K17577_C037.indd 604
landing. Very few conditions have an incubation period
shorter than even the longest long-haul flights.
The greatest threat to passengers of infective gastrointes-
tinal disease is transmission from other passengers. Many
are likely to have contracted an infective condition before
flight, and some will be unwell when they travel; depending
on location, rates of acute gastrointestinal disease in travel-
lers may be as high as 80 per cent. In common with other
infections, people without symptoms are unlikely to pose
a threat to others. The infecting dose of many organisms
(most notably Shigella species and the enteric viruses) may
be extremely small. Minimal environmental contamina-
tion may lead to disease spread in the absence of high stan-
dards of personal hygiene. Despite this, reports of incidents
aboard aircraft are rare and when they occur they are gener-
ally reported widely by the media (CBS News 2013).
AEROMEDICAL EVACUATION OF
INFECTIOUS PATIENTS
Any passenger may have been exposed to an infectious
agent prior to travel, and at embarkation be symptomatic
or asymptomatic. They may be incubating disease without
symptoms, have a non-specific or ‘prodromal’ illness, have
a mild or atypical infection, have a textbook characteristic
disease or be recovering from their acute illness. For some
infections, an extended healthy carrier state may develop
post-infection. Only those individuals with symptoms pose
any infective risk to other passengers or crew.
Patients who are being aeromedically evacuated will
have been exposed to the same risks as any other traveller.
However, they pose a greater risk of transmitting an infec-
tion for a number of reasons:
●● Infectious disease may be the diagnosis leading
to repatriation.
●● They may have been hospitalized and acquired a
healthcare-associated infection.
Their clinical condition may require the use of support-
ive medical techniques such as assisted ventilation, vascular
access and renal support, each with associated hazards to
medical personnel.
●● Aeromedical flights often carry multiple patients.
Transmission of infectious agents between susceptible
individuals with predisposing factors is common in any
environment, but particularly when staff are working
under pressure in difficult surroundings.
●● Aeromedical patients will usually be repatriated to a
medical facility. The consequences of introducing a
novel infectious agent into a hospital environment may
be serious.
●● Clinical waste is generated in flight creating a biohazard.
A pragmatic approach is to try to identify those patients
who might prove to be an infective hazard. Although this
17/11/2015 16:05

is impractical for routine commercial passenger flights, it
can be achieved for aeromedical evacuation since an expert
medical assessment is required for every patient. The aim
of the initial screen is to identify those patients with symp-
toms that may indicate the presence of an infective agent
and may prove hazardous to other passengers and crew.
It does not try to make a diagnosis or confirm an infec-
tive aetiology; in practice, the risk is related to the symp-
tom rather than the agent involved. The screen should be
sensitive rather than specific, and should aim to try to
identify every patient with any potentially transmissible
infective condition.
A series of simple questions can be added to the initial
aeromedical assessment. These might include asking about
specific symptoms associated with increased risk of disease
transmission such as:
●● Cough.
●● Vomiting or diarrhoea.
●● Bleeding.
●● Rash.
●● Fever.
There is no need to accurately define each of these terms,
since the aim is to identify potentially hazardous patients as
opposed to making an accurate case definition for diagnos-
tic or epidemiological purposes. Any patient with a suspect
symptom is referred for a specialist aeromedical opinion so
that more detailed assessment of the relevant feature can be
made. This allows a judgement to be made about the like-
lihood of a transmissible infectious agent being involved.
If doubt exists, then infectious diseases specialist advice
is sought.
For patients who are assessed, there may be a number of
possible outcomes:
Table 37.1  Examples of diseases where transportation might be delayed
Disease Unfit flying
Rubella Until 4 days after the appearance of
the rash
Measles Until 7 days after the appearance of
the rash
Mumps Until parotid swelling has subsided
Varicella zoster Until 7 days after appearance of last
new spot
Tuberculosis Until at least 2 weeks of adequate
treatment have been completed
Multi-drug resistant Should only be moved when shown to
tuberculosis be sputum culture negative
K17577_C037.indd 605
Aeromedical evacuation of infectious patients  605
●● The symptom does not indicate that an infectious agent
is involved and no special precautions are required (e.g.
rash due to drug allergy).
●● An infectious agent may be involved and the patient
should not be aeromedically evacuated (e.g. patient with
profuse vomiting).
●● An infectious agent may be involved and special
precautions may be required in flight (e.g. patient with
jaundice).
The decision to delay aeromedical evacuation normally
takes into account the patient’s clinical condition, the risks
of transmission in flight and the operational circumstances
such as standards of medical care on site or physical dangers
from the environment including adverse weather or armed
conflict. In most cases, however, it is possible to delay evac-
uation until the symptoms have resolved. Should the need
dictate, individuals who are possibly infective can be moved
with specialist infection-control precautions, sometimes
coupled with enhanced surveillance of other passengers and
medical attendants.
The decision and mode of repatriation may also be influ-
enced by the following factors:
●● Numbers of patients affected. With large groups of
patients, it may be impractical to move; with smaller
numbers of patients, patients with similar symptoms
may be nursed as a cohort and evacuated together.
●● Specialist medical staff. Potentially infective patients
ideally should have dedicated medical attendants. In
some circumstances, this might not be possible and
repatriation might be delayed.
●● Diagnosis. A credible suspected diagnosis of a viral
haemorrhagic fever might dictate the use of a specialist
evacuation technique.
Transmission
reported on
aircraft Comment
Yes Travellers from many countries are not
immunized
Yes Measles carries a high morbidity in
some populations
Yes Frequent outbreaks reported in young
adults in Europe
Yes Highly transmissible, severe disease in
adults
Yes Patients with organisms on sputum
microscopy (‘smear positive’) are the
only ones generally considered to be
infectious
No Low infectivity but high impact
infection. Could be moved using
specialist precautions
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 606  Infectious disease and air travel
INFECTION CONTROL IN THE AIR
The basic principles of infection control on aircraft are the
same as those in any other setting. The only difference is the
environment, which imposes constraints that may increase
the risk of transmission of some infections. These can be
summarized as follows:
●● Lack of space (on commercial passenger aircraft).
●● Fixed seating locations for passengers (and patients)
during flight results in prolonged close contact between
those who may be infective and susceptible individuals.
●● Cabin ventilation, which may be relevant for some
patients with transmissible respiratory infections.
●● Lack of patient isolation capability.
●● Restricted hand washing facilities and, if present, these
may be unsuitable for clinical use (low water flow rates,
absence of hands-free taps, shallow sinks).
●● Very few chemical disinfectants are safe to use on air-
frames without causing corrosive damage.
●● Limited supplies of consumable items, such as equip-
ment for cleaning spills of body fluids, liquid soaps
and masks.
However, difficult is not the same as impossible; patients
with transmissible infectious diseases can be carried with
appropriate planning and resources.
MOVEMENT OF PATIENTS WITH HIGHLY
TRANSMISSIBLE INFECTIONS
The WHO advises that the transport of patients with a
viral haemorrhagic fever from endemic to non-endemic
areas should only occur in exceptional circumstances,
since the risk of disease transmission is high. However,
there are occasions when the absence of medical support
or a hostile military environment dictates that aeromedical
evacuation is required. There are also clinical indications
for urgent movement of patients with other highly trans-
missible infections, such as individuals with novel strains
of influenza who require extra-corporeal membrane oxy-
genation (ECMO) because of primary lung damage. This
operational need can be met by the use of specially designed
high-containment isolators.
Several military forces have developed specialist teams
who use such isolators, including the United States Air
Force (USAF), the Italian Air Force Unità di Isolamento
Aeromedic and the Royal Air Force (RAF). The larger air
transportable isolators and smaller patient isolation units
provide a sealed patient microenvironment that incorpo-
rates a protective envelope, HEPA filters and negative pres-
sure capability. The RAF team is operated in conjunction
with the English Department of Health, and has deployed to
Sierra Leone on three separate occasions to recover patients
with suspected Lassa fever. In October 2012, the team
moved a patient from Glasgow to London with laboratory-
confirmed Crimean Congo haemorrhagic fever. The latter
K17577_C037.indd 606
patient was severely ill and subsequently died shortly after
transfer. However, the aeromedical evacuation showed that
such transportation can be undertaken safely with mini-
mal risk to airframe and medical personnel. This, in turn,
reduced the ongoing risk of health care associated infection
in the hospital where the patient had presented.
EBOLA VIRUS OUTBREAK, 2014–2015
Epidemiology
During 2014, an outbreak of Ebola virus was recognized
affecting a number of countries in West Africa. In retro-
spect, the first case probably occurred in rural Guinea
during December 2013, with subsequent spread to neigh-
bouring areas of Liberia and Sierra Leone. Progression into
an outbreak was reported in March 2014, but it was not
until August 2014 that the WHO declared a Public Health
Emergency of International Concern (PHEIC).
The outbreak was, in many ways, typical of the 24 previ-
ously recorded outbreaks of Ebola since it was first identi-
fied in 1976. Each probably begins with a human–animal
interaction although the details of the chain of transmis-
sion are never entirely clear. The asymptomatic reservoir
host appears to be fruit bats, which then transmit infection
up the food chain, facilitated by the practice of consum-
ing ‘bushmeat’ to provide protein from wild animals in
diets where domesticated sources are expensive or scarce.
‘Bushmeat’ sources range from small animals such as rats,
deer or bats to chimpanzees, gorillas or monkeys.
Given that all the countries involved have very low states
of healthcare infrastructure, preparedness and resources,
it is hardly surprising that the outbreak rapidly escalated
from a small, local incident to a regional outbreak. There
was criticism of the WHO, individual countries concerned
and multinational companies for not accurately reporting
the increasing numbers of cases, most notably by Médecins
Sans Frontières. There was also criticism for the delay in
recognizing the scale of the outbreak subsequent to it being
declared a PHEIC on 8 August 2014.
By 25 March 2015, the total number of reported cases was
24 907, of which there were 10 326 deaths (WHO 2015). The
epidemiology suggests that control measures had made an
impact by this time, and that numbers of new cases are fall-
ing. Final control of the outbreak is estimated to be achiev-
able by late 2015.
In common with many Western countries, the UK
introduced passenger screening of returning travellers in
October 2014. Standardized passenger questionnaires gath-
ered information on demographic and travel history, as well
as contact with suspected Ebola cases and current health
status. Medical screening relied on tympanic temperature
to supplement this information. Although there are numer-
ous issues in detecting affected passengers, this seemed to
fulfil the primary role of ensuring people arriving from
or passing through high-risk countries were aware of the
symptoms, as well as when and how to access healthcare
17/11/2015 16:05

services. This required liaison between a number of differ-
ent government agencies both locally and nationally, which
will lead to an improved early response to similar episodes
of infectious disease in the future.
Aeromedical evacuation aspects
Prior to 2014, aeromedical evacuation operators had rarely
dealt with cases of viral haemorrhagic fever as described
previously, and expertise was confined to a handful of orga-
nizations. Most international aeromedical transportation
contractors had not planned to move such patients, yet it
rapidly became clear in mid-2014 that there was a national
and international requirement for this capability.
From July 2014  onwards, patients were moved by air
to the US, the UK, the Netherlands, Denmark, Sweden,
Norway, Italy, Spain, Switzerland and France. Aeromedical
transportation systems used have incorporated a variety of
specially designed isolation units (man-portable or wheeled
units, or larger units fixed inside airframes). These generally
have included a combination of negative pressure, HEPA fil-
tration or a flexible or fixed protective envelope, and some
can be carried aboard fixed-wing and rotary aircraft.
In September 2014, the WHO estimated that there would
be an international requirement for seven international
aeromedical evacuations each month for the duration of
the outbreak response, and that at least three providers of
this capability would be required (WHO 2014). The estimate
proved to be very accurate. By April 2015, 65 international
aeromedical evacuations had been conducted over the pre-
ceding eight months by at least seven different organiza-
tions (ECDC 2015). All were conducted without reported
incident, with the spectrum of patients ranging from the
severely ill with significant symptoms associated with
increased disease transmission (such as profuse diarrhoea)
to asymptomatic individuals who had suffered ‘high-risk
possible exposure’ to Ebola virus.
By 30  March 2015  the RAF had moved seven patients
from West Africa using an air transportable isolator (ATI),
and one patient within the UK (from Glasgow to London).
These aeromedical evacuations required significant liai-
son both between nations and between different national
government departments and non-governmental organi-
zations. Timelines for moves from West Africa frequently
were greater than 24 hours, taking account of preparation
and transfer of the patient to the airhead, loading and sta-
bilization, flight time, and subsequent disembarkation and
road transfer on arrival in the UK. Tasking of a military
aircraft prior to each move and deploying stand-by special-
ist medical personnel generally required a further 24 hours
prior to each patient being embarked, while turnaround
time after each move required an additional 24–48 hours.
An entire mission, therefore, would generally commit air-
craft and personnel for up to four to five days.
Providing the necessary capability involved not only
procurement of sufficient patent isolation systems for use
in aircraft, but also identification and training of specialist
K17577_C037.indd 607
International response to infectious disease  607
aeromedical personnel. The small numbers of specialist air-
craft available also led to delays in some evacuations, while
the limited number of high-security isolation unit beds in
home countries meant that relatively few receiving airports
were used. The latter, in turn, needed to have well-rehearsed
plans for management and transfer of patents on arrival.
INTERNATIONAL RESPONSE TO
INFECTIOUS DISEASE
WHO issued its first set of regulations intended to prevent
the spread of diseases in 1951. This first response to the
international spread of disease in the modern age of wide-
spread air travel concentrated on six ‘quarantinable’ dis-
eases: cholera, plague, relapsing fever, smallpox, typhus and
Yellow Fever. These ‘International Sanitary Regulations’
were renamed the International Health Regulations (IHRs)
in 1969, and were refined to apply only to cholera, plague,
smallpox and Yellow Fever.
By 2005, it was recognized that a response to other issues
needed to be considered. New diseases had emerged: SARS,
existing uncommon diseases such as viral haemorrhagic
fevers and common diseases such as H5N1  influenza had
caused significant effects on travel and commerce. In addi-
tion, a new age had dawned of deliberate release of bio-
logical agents. As a result the IHRs were revised and three
fundamental principles were incorporated:
●● The list of specific diseases was replaced with more
generic illness.
●● Chemical, biological and radiological agents were added
in addition to infectious diseases.
●● Some incidents were made notifiable (within 24 hours)
to the WHO if they fulfilled the criteria to constitute
a PHEIC.
The reporting of a PHEIC is the responsibility of the
individual state and is reported through a National Focal
Point for each country, usually within the existing public
health structure. In addition to this, the priority for WHO
member states has evolved from controlling the borders (an
unrealistic proposition) to containment at source for inter-
national threats. This is consistent with the stated intention
of the IHRs to ‘prevent, protect against, control and provide
a public health response to the international spread of dis-
ease in ways that are commensurate with and restricted to
public health risks, and which avoid unnecessary interfer-
ence with international traffic and trade’ (WHO 2005).
The first challenge to the revised IHRs came in
2009  when there was a global response to the influenza
A(H1N1) 2009 pandemic. A review of their effect suggested
that although the IHRs assisted in coping with the public
health emergency, the IHRs were not yet fully operational
and that the world remained ill-prepared to respond to a
severe influenza pandemic or to any similarly global, sus-
tained and threatening public health emergency (Nguyen–
Van–Tam and Sellwood 2013).
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 608  Infectious disease and air travel
International organizations concerned with
aviation and public health
There are three main sources of advice for the commercial
air travel industry on issues concerning public health:
●● The International Civil Aviation Organization (ICAO)
which represents its contracting countries and whose
responsibilities are at country level.
●● The Airports Council International (ACI) which repre-
sents individual airports.
●● The International Air Transport Association (IATA)
which is a trade association representing the airline
industry worldwide.
These three organizations provide regularly updated
sources of information in the form of plans and guidelines
for their respective areas of responsibility, most of which are
freely available on their websites.
Cooperative arrangement for the
prevention of spread of communicable
disease through air travel (CAPSCA)
This project is managed by ICAO in close collaboration with
the WHO and additional partners including the ACI and
IATA. It was commenced in 2006 in order to provide guid-
ance for the commercial aviation sector for all public health
related events. It was first established in the Asia Pacific
region following the SARS epidemic and intended to devise
and amend ICAO guidelines, facilitating their implemen-
tation through workshops, seminars and training. These
guidelines provide guidance on specific areas such as opera-
tions, air traffic services, aerodromes and procedures for air
navigation services (CAPSCA 2015).
SARS – A MILESTONE FOR PUBLIC HEALTH
Those planning for an international response to pub-
lic health events often look at the SARS outbreak in
2003  for lessons. SARS demonstrated how rapidly inter-
national spread of disease can occur in the modern age
of air travel. It first appeared in the Guangdong province
of southern China in November 2002  and took only four
months to spread to 26  countries, causing an estimated
800 deaths and over 8000 cases of infection. Transmission
was facilitated by the travel by air of a Chinese doctor
who treated patients with an unknown respiratory illness.
This was compounded by failures in isolation and infec-
tion control measures in health care facilities as far afield
as Canada and Europe.
SARS was a milestone in that it was the first emerging
global threat in modern times, whose spread was facilitated
by air travel and whose discovery brought into play the
requirement for public health actions on an international
basis.
K17577_C037.indd 608
At the time, there was much political activity concern-
ing exit screening at borders of affected countries, both
by medical questionnaires or thermal imaging; however,
these measures proved disruptive, ineffective and costly. It
required both individual and public health action for any
febrile persons or those showing signs or symptoms of con-
cern. According to flight schedule provider OAG (formerly
Official Airline Guide) the number of scheduled flights
worldwide fell by three per cent in mid-June 2003 (equiva-
lent to 2.5 million passengers) compared to the same period
in 2002. More specifically, flights to and from China showed
a 45 per cent drop in passenger numbers and the outbreak is
estimated to have cost the world’s airlines and travel-related
industries approximately US $40 billion (Lee and McKibbin
2004). In addition, this episode reinforced the public’s per-
ception of the heightened risk of in-flight transmission of
disease, despite little evidence for this.
UPDATE ON EMERGING INFECTIOUS
DISEASES
Recent planning for public health events has concentrated
on establishing cross sector collaboration between health,
veterinary, wildlife and environmental organizations.
There are increasing concerns at the rate newly identified
agents are able to cross the species barrier from animals to
humans, causing human illness and death. These agents
include new influenza viruses, Lassa fever-like viruses and
most recently, the appearance of a new severe respiratory
illness caused by the MERS-CoV in the Arabian Peninsula
and surrounding countries.
Highly pathogenic avian influenza (HPAI) or H5N1 virus
infection of humans emerged in 2003  and although rela-
tively rare, cases of human infection with high case-
fatality rates were reported. In total by November 2013,
more than 600 human HPAI H5N1 cases had been reported
from 15 countries in Asia, Africa, the Pacific and Europe.
Although around 60  per cent of the cases died, they were
associated with direct contact with infected poultry sources
and the two reported ‘clusters’ of infection were in imme-
diate family groupings or households. It was thought that
either a genetic component and/or infection from the same
source were the causative factors. Since efficient person-to-
person transmission does not seem to occur, advice remains
to avoid sources of exposure. Transmission on aircraft has
not been demonstrated.
Influenza A(H1N1) or Swine Flu emerged in 2009 with
the first cases in travellers returning from Mexico to the USA
and, within days, travel-associated cases emerged in New
Zealand. The virus remains in circulation and has replaced
the ecological niche of the existing pre-pandemic A(H1N1)
seasonal virus. This shows that the distinction between pan-
demic and seasonal influenza can be artificial and somewhat
arbitrary. The rapid global spread of the virus and the sub-
sequent difficulty in control demonstrated the effect of air
travel in speeding disease spread, and a number of cases were
shown to have been acquired during flight (Baker et al. 2010).
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A new avian influenza A (H7N9) virus was first
reported in China in April 2013, with the virus being
simultaneously detected in poultry and humans. More
than 130  human infections with H7N9  were reported,
and it was noted that those affected reported contact
with poultry. Like the previous avian influenza outbreak
in 2005  most patients had severe respiratory illness and
44  people died. As in normal public health response to
such situations, close contacts of confirmed H7N9 patients
were followed up to determine whether any human-to-
human spread was occurring and no evidence was found.
No cases of H7N9  outside of China have been reported
and the new H7N9  virus has not been detected in people
or birds outside the area.
Coronaviruses are common worldwide and usually
cause colds; however, a new Middle East Respiratory
Syndrome Coronavirus (MERS-CoV), formerly called
‘novel coronavirus (nCoV)’, was identified in 2012 in Saudi
Arabia. MERS-CoV caused severe acute respiratory illness
with symptoms of fever, cough and shortness of breath
with about half dying. SARS was also caused by a corona-
virus, but was significantly different from this virus. As of
November 2013, there are 130  cases with 58  deaths asso-
ciated with MERS-CoV and the source seems confined
to the Arabian Peninsula. Although no transmission has
been shown to occur aboard aircraft, the European Centre
for Disease Control (ECDC) has issued guidance for man-
agement of suspected cases who present inflight (ECDC
2013).
MALARIA
Malaria is a parasitic infection of blood transmitted by
the bite of the female anopheline mosquito. Over 400 mil-
lion people are infected annually worldwide. There are
four human species of malaria: Plasmodium falciparum, P.
malariae and P. ovale are true tropical diseases found only
in equatorial regions, while P. vivax can be transmitted in
temperate areas during summer months. In addition, there
is one animal type of malaria that is now known to occa-
sionally affect humans, Plasmodium knowlesi, which has its
normal reservoir in macaque monkeys in South East Asia.
In the UK there are over 2000  cases imported each year,
most in travellers who have returned recently from endemic
areas. The vast majority of cases occur in people who have
taken no chemoprophylaxis.
Deaths from malaria occur regularly; in non-immune
populations, this is frequently the result of delayed or
missed diagnosis. The disease may be deceptively innocu-
ous, even with high levels of parasitaemia, and terminal
decline may occur within hours. Malaria-carrying mosqui-
toes may, occasionally, be carried aboard aircraft, and rare
reports of ‘airport malaria’ result from disease transmission
in non-endemic countries. The aim of disinfection pro-
cesses (as described in Chapter 56) is to prevent the acciden-
tal introduction of insect vectors into a receptive area and
is particularly concerned with the vectors of yellow fever
K17577_C037.indd 609
Malaria 609
and dengue. Such introductions are felt to be unimport-
ant from the public health perspective at this point in time;
more problematic is the importation of a human reservoir
that might act as a focus for transmission by endogenous
Anopheles species (Zucker 1996).
The principles of malaria prevention are simple. The risk
of acquiring disease can be reduced by a series of precau-
tions; importantly, however, the risk cannot be eliminated
entirely. The key points are as follows:
●● Awareness. Travellers must be educated regarding:
●● Mode of malaria transmission: by mosquito bite.
●● Symptoms: any illness, especially non-specific
‘flu-like symptoms’.
●● Actions to take if disease is suspected: seek immedi-
ate medical advice.
●● Bite avoidance. Measures to reduce the number of
potentially infective bites include:
●● Repellents: diethyltoluamide (DEET) or citronella-
containing preparations are available widely and
effective.
●● Bed-nets: impregnated with an insecticide such as
permethrin and used appropriately.
●● Knockdown insecticides: for use in confined areas.
●● Clothing covering wrists and ankles after dusk:
preferably impregnated with insecticide.
●● Window screens on rooms.
●● Chemoprophylaxis. Drugs should be:
●● Appropriate for area of travel: up-to-date advice is
required.
●● Suitable for individual: different drugs may be con-
traindicated for different people.
●● Taken: even the best drugs are ineffective if they do
not enter the body.
●● Started before exposure and continued for an
appropriate time after return.
●● Diagnosis. Since no precaution will be entirely effec-
tive, malaria must be considered as a diagnosis in any
individual who has been in an endemic area. Although
most cases present within a few weeks of return, a
small proportion will not become ill until a year or
more later.
Aviation issues
The incidence of malaria in aviators is difficult to assess, as
cases are rarely reported by occupational group. For com-
mercial pilots, it has been argued that their risks are lower
than for other travellers, since they generally stay overnight
for short periods in good-standard accommodation in large
cities, where malaria transmission is relatively low. Studies
that have looked prospectively at commercial pilots suggest
that malaria is uncommon in those staying for short peri-
ods and that chemoprophylaxis might not be required for
this group (Byrne and Behrens 2004). In other groups, this
will not be true, and the risks will be the same as for other
comparable travellers.
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 610  Infectious disease and air travel
Bite prevention
Most discussion about malaria and aviation deals with
choice of chemoprophylaxis. It must be emphasized that this
forms only one part of the approach to malaria prevention:
bite-reduction measures are of equal or greater importance.
When the UK deployed a large military force to West Africa
in May 2000, over 200  cases of malaria resulted. The first
six cases were in aircrew who had taken appropriate chemo-
prophylaxis; they had deployed in field conditions without
impregnated uniforms or bed-nets and not been trained in
the same bite-prevention techniques as their infantry coun-
terparts (Tuck et al. 2003). A number of countries are now
using flying suits impregnated with insecticide for military
personnel. These suits are technically difficult to produce
without compromising the flame-retardant properties of the
material. They are useful in reducing malaria incidence only
if aircrew are night-flying or sleeping in their flying suits.
Chemoprophylaxis and self-treatment
The use of drugs to prevent an infectious disease is not
unique but is practised widely only for malaria. Adverse
events to drugs when used for therapy may be acceptable
to clinicians and patients, since the underlying condition
requires treatment and relatively few patients are involved.
In contrast, the same drugs are required to be almost
entirely free of adverse events when used for disease pre-
vention in otherwise healthy individuals, despite the use of
lower doses than for therapy.
There is a perception by some individuals that malaria
is a mild disease and that precautions are not always
needed. The relative rarity of the disease in non-endemic
areas means that knowledge there is scanty; in contrast,
the frequent repeated infections in semi-immune adults in
endemic areas leads to its trivialization. In the latter situ-
ation, it is often forgotten that the adults are the survivors
and that up to 30 per cent of their peers will have died from
malaria in childhood.
Maps of malaria distribution may be misleading, as
the data supporting them is often lacking. They are fre-
quently based on national reports of malaria cases, and do
not reflect local transmission rates which can be markedly
different, especially in countries that embrace several cli-
matically different regions. Maps can be useful to describe
malaria risk to travellers, but should be used with caution
unless the source of supporting data is known. One reliable
source is the Malaria Atlas Project (MAP) based in Oxford,
which utilizes accurate and updated transmission informa-
tion (MAP 2015).
Finally, there is an interesting aspect of traveller psy-
chology. People often compare malaria chemoprophylaxis
regimens when meeting others on their travels and then
decide to follow the advice of the individual taking the least
intrusive protocol. Frequently, this means stopping effec-
tive chemoprophylaxis and deaths have been recorded as a
direct result.
K17577_C037.indd 610
These factors all combine to help explain poor compli-
ance with malaria chemoprophylaxis. Aviators as a group
are generally well educated and very concerned about their
health. Despite this, their compliance with recommended
prophylaxis is extremely poor and in one recent study was
less than four per cent (Selent et al. 2012).
The drugs advised for travellers are usually based on the
guidance of national expert groups. There is no interna-
tional consensus, since not only do opinions differ but also
licensing, manufacture, costing and distribution of prepa-
rations vary markedly. Consistent advice within countries
is important, and every effort should be made to ensure that
the latest guidance is available widely to both health profes-
sionals and travelling populations (Chiodini et al. 2013).
Not all chemoprophylactic drugs are recognized as safe
to use in aircrew. There has been some debate regarding the
suitability of mefloquine in aviators, with research focused
on trying to establish the true incidence of psychomotor
impairment when the drug is used in low doses (Schlagenhof
et  al. 1997). Few national bodies recommend the use of
mefloquine in aircrew and this is unlikely to change, even if
research fails to demonstrate an effect on simulated flight per-
formance studies. A low-incidence event cannot be detected
easily in the laboratory when small numbers of subjects are
examined and usually appears during post-marketing sur-
veillance after introduction of a new product to a large popu-
lation. The known effects on motor coordination of the high
doses of mefloquine used during malaria therapy mean that
any use in aviators is unlikely to be approved.
The advent of sensitive and specific rapid diagnostic kit
technology that can be used by non-laboratory personnel
has allowed new strategies to be developed. In the past, some
travellers opted to treat themselves for suspected malaria,
but this often resulted in overuse of therapeutic drugs, as
many mild illnesses were treated mistakenly. Accurate
diagnosis combined with effective oral therapies such as
atovaquone/proguanil and co-artemether (artemether with
lumefantrine) means that early treatment of infection has
become a practical option.
A number of approaches to chemoprophylaxis in aircrew
have been suggested:
●● No antimalarials:
●● Practised effectively by many non-compliant aircrew.
●● Appropriate for selected destinations
and accommodation.
●● Requires educated aircrew who report sickness early
and are either treated or repatriated urgently.
●● Rapid diagnostic kits (point-of-care testing):
●● Can be used if not taking prophylaxis, or for
all travellers.
●● Education and hands-on training required
before travel.
●● Best for groups, so that a sick individual does not
test him- or herself.
●● Needs appropriate therapeutic drugs included as
part of protocol.
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 Malaria 611

●● First-aid measure – individuals should seek expert ●● Adverse events uncommon in prophylactic doses.
advice as soon as practical. ●● Once-weekly dose – started one week before first expo-
●● Tailored advice for each trip: sure (three weeks advised in some countries) until four
●● Consistent with advice for other travellers. weeks after last exposure.
●● Impractical for aircrew flying frequently to ●● Parasite resistance uncommon – still effective in
malaria areas. sub-Saharan Africa.
●● Difficult to provide individual advice to ●● Long-term use safe
many aviators. ●● Suitable for use in aircrew who are not in control of
●● Continuous prophylaxis: aircraft and in ground-support personnel.
●● Assumes unpredictable work patterns and regular
flying to malaria areas. DOXYCYCLINE
●● Suitable for some selected groups, e.g. military ●● Effective antimalarial – similar level of protection as
transport crews on a defined tour of duty. mefloquine.
●● Compliance likely to be very poor. ●● Considered safe in aircrew.
●● Concerns about long-term tolerability for drugs ●● Adverse events not common. Photosensitivity uncom-
taken over many years. monly reported when used for chemoprophylaxis
●● ‘Cluster’ tours of duty: ●● Daily dose – started one week before first exposure until
●● Work pattern adjusted to allow all flying into four weeks after last exposure.
malaria areas to be grouped together over a period ●● Short half-life means rigorous compliance is essential in
of weeks or months. order to maintain protection.
●● Chemoprophylaxis taken only when required – not ●● Parasite resistance uncommon – effective in
taken throughout remainder of year when under- sub-Saharan Africa.
taking other duties.
●● No evidence base of improved compliance. ATOVAQUONE/PROGUANIL
●● Requires sympathetic and motivated employers. ●● Effective antimalarial – similar level of protection as
●● Difficult to implement for military aviators. mefloquine.
●● Considered safe in aircrew (Paul et al. 2003).
The choice of drugs used for chemoprophylaxis will vary ●● Adverse events not common.
according to the type of travel and the destination and will ●● Daily dose – two days before first exposure until seven
usually follow national guidance, as described above. There days after last exposure.
are particular aviation issues with each of the commonly ●● Parasite resistance uncommon – effective in
used drugs: sub-Saharan Africa.

CHLOROQUINE The addition of atovaquone/proguanil to the available

●● Much experience – considered safe in aircrew. drugs for chemoprophylaxis has significant potential ben-
●● Once-weekly dose – started one week before first expo- efits for aviators. The drug combination is safe to use in
sure until four weeks after last exposure. flying crew and has a pharmacokinetic profile and mode
●● Has been used continuously for up to 30 years in of action that allows it to be taken for a much shorter
some individuals. time before and after exposure. This means that good
●● No evidence of cumulative eye toxicity when used in compliance is much more likely. There is also the possi-
malaria-prophylaxis doses. bility of starting the drug around the time of first expo-
●● Parasite resistance is now widespread, and the drug is of sure, meaning that it could be suitable for both passengers
limited utility. and crew on aircraft that make unscheduled diversions to
high-transmission areas.
PROGUANIL
●● Much experience – considered safe in aircrew.
●● Rarely used alone – usually in combination with chloro- SUMMARY
quine or in fixed combination with atovaquone.
●● Daily dose – started one week before first exposure until ●● Infectious diseases are common. All aircrew and
four weeks after last exposure. all passengers may be affected by an infection
●● Considered safe for long-term use. related to their travel, which may be both a risk to
●● Parasite resistance now widespread and the drug is of themselves and their fellow travellers.
limited utility. ●● PHEICs may be declared at short notice by the
WHO. These may have a significant impact on
MEFLOQUINE international air travel, since disease control mea-
●● Very effective antimalarial agent. sures may be imposed to limit disease spread.
●● Not generally accepted as safe to use in aircrew.

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 612  Infectious disease and air travel
●● Aeromedical evacuation of patients with infec-
tious diseases can be conducted if required.
If there is a compelling clinical need or opera-
tional reason to move any patient, then this can
be done in the same way as any other medical
evacuation but utilizing infection control precau-
tions specific to the infectious disease concerned.
●● Infection control in all aircraft should be a
‘standard operating procedure’. Basic principles
can be applied, including isolation of symp-
tomatic individuals when practical, and use of
simple hygienic measures. Caution needs to be
exercised with chemical disinfectants, which can
damage airframes.
●● Malaria is a preventable infectious disease that
still carries significant morbidity and mortality.
Aircrew are not inherently immune to this dis-
ease and should adopt similar measures to reduce
risk as used by all other travellers.
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Human immunodeficiency virus
EWAN HUTCHISON
Introduction 615
Background 615
Assessing current health and causes of incapacitation 617
Disease progression 620
INTRODUCTION
For decades now, human immunodeficiency virus (HIV)
infection has been a source of controversy and stigma both
in society and in the field of aviation medicine. There have
been many advances in our understanding of the virus and
the ways in which infection can be better managed. These
have resulted in significant changes in life expectancy. New
areas of interest have arisen around living with chronic
infection for 40 years or more and the long term effects of
antiretroviral medication. Despite the better outlook, it is
likely that many HIV-positive flight crew do not declare
their condition to their aviation medicine practitioner until
many years after initial infection. This could be because
they are unaware that they have been infected or because
they are afraid of the impact on their flying career. This
chapter seeks to provide an overview of HIV infection and
the key areas for aeromedical consideration.
BACKGROUND
The virus
HIV is a Lentivirus, a subgroup of retroviruses, and is known
for latency, persistent viraemia, infection of the nervous
system and weak host immune responses. Currently there
are two forms (HIV-1 and HIV-2) that have been described.
HIV-1 is the predominant type and responsible for most of
the infections throughout the world. HIV-2 was discovered
and is most prevalent in Western Africa, although there are
a few cases in the Americas and Western Europe. As there is
high genetic variability, both forms are further subdivided
K17577_C038.indd 615
38
International standards 621
Travel vaccination 621
References 622
into groups and subtypes. The subtypes are of epidemio-
logical interest but aside from the possibility that some sub-
types may be associated with faster disease progression, the
knowledge of a particular subtype does not usually affect an
individual’s medical management.
Transmission
HIV infects both men and women and can be transmitted
via sexual contact and via any infected body substance that
comes into contact with mucous membranes, non-intact
skin or the bloodstream. Vertical transmission from mother
to child may also occur during pregnancy. The major route
of transmission worldwide is through sexual contact.
Parenteral transmission occurs largely among intravenous
drug users; transmission by contaminated blood products
is now rare in developed countries but remains a problem in
developing countries.
Course of infection
The typical course of HIV infection in untreated patients is
presented in Figure 38.1 (Pantaleo et al. 1993).
The process begins with acute HIV infection, which is
usually defined as starting at the point of virus entry and
lasting until the end of seroconversion. Following infection,
the virus replicates rapidly in CD4+ T lymphocyte cells
and lymphoid tissue and becomes widespread. The initial
immune response may take days to get going by which time
viraemia with several million viral copies per millilitre of
plasma has occurred. The development of symptoms of
615
17/11/2015 16:11
 616  Human immunodeficiency virus
1200 Primary
infection Possible acute HIV syndrome
1100
Wide dissemination of virus
Seeding of lymphoid organs
1000
900
800
CD4 T cells/mm3
)
700
600
(
500
400
300
200
100
0 0
0 3 6 9 12
Weeks
Figure 38.1  Typical course of HIV infection.
acute retroviral syndrome is experienced in an estimated
40–90  per cent of patients (Kahn and Walker 1998) and
usually coincides with high level viraemia and the initial
immunological response. Symptoms and signs are non-
specific and occur 2–6  weeks after exposure. They often
resemble a mononucleosis-like illness and so are mistaken
for other infections. These symptoms include fever, fatigue,
maculopapular rash, headache, lymphadenopathy, phar-
yngitis, myalgia, arthralgia, retro-orbital pain, weight loss,
depression, gastrointestinal distress, night sweats and oral
or genital ulcers. Occasionally there are neurological pre-
sentations with meningeal signs. Opportunistic infections
can also occur during this phase e.g. oesophageal candidia-
sis, cerebral toxoplasmosis and pneumocystis pneumonia.
Seroconversion symptoms usually last for around 14  days
but may persist in some for weeks. The formation of HIV
specific antibodies marks the completion of seroconversion
and they are usually detectable by weeks 3–12 of infection
but can take months to form. Shortly after this the viral
load tends to stabilize at a set point and it has been estab-
lished that the set point viral load is highly prognostic of the
patient’s rate of disease progression (Lyles et al. 2000). HIV
diagnosis utilizes p24 antigen and HIV antibody testing to
look for the presence of the virus and the immune response.
Present testing regimes can achieve sensitivities of >99 per
cent and specificities of >98 per cent (Chou et al. 2005).
From this point, the virus is never cleared completely and
a chronic infection ensues with levels of virus replication
varying between individuals. During this period of clini-
cal ‘latency’ there is minimal direct clinical evidence of HIV
infection and most will have no HIV related symptoms, but
occasionally some clinical manifestations may be recognized.
These include persistent generalised lymphadenopathy (PGL),
diffuse infiltrative lymphocytosis syndrome (DILS), throm-
bocytopenia, skin complaints, mucosal candida infections,
K17577_C038.indd 616
Death
Opportunistic
diseases 1:512
Clinical latency
1:256
1:128
Constitutional
Plasma viremia titer
1:64
symptoms
)
1:32
1:16
(
1:8
1:4
1:2
1 2 3 4 5 6 7 8 9 10 11
Years
oral hairy leukoplakia, tuberculosis, community acquired
pneumonia and various constitutional symptoms such as
fever, weight loss, diarrhoea, fatigue and headache. Although
many will have no symptoms during this latent period, there
is, in nearly all, a gradual deterioration of the immune system
and in particular a depletion of CD4+ T cells.
The most advanced stage of HIV infection is acquired
immunodeficiency syndrome (AIDS) which, depending
on the individual, can take from 2  to 15  years to develop
in the absence of antiretroviral therapy. The World Health
Organization (WHO) has produced a four-level clinical
staging system for HIV disease with lists of AIDS defining
infections or conditions also known as severe or stage 4 clini-
cal disease (Table 38.1) (WHO 2007). The Centers for Disease
Control and Prevention (CDC) in the USA have published a
similar list. These lists were initially intended for epidemio-
logical use as a surveillance tool. HIV-2 is associated with
a lower morbidity and longer time to the development of
AIDS. In addition to these conditions, a CD4 cell count of
<200/μL is also considered by WHO and CDC to be AIDS-
defining even in the absence of any signs and symptoms of
HIV disease. If individuals do not receive treatment then
their viral load gradually increases and CD4+ T cells gradu-
ally decrease and eventually severe opportunistic infec-
tions develop. There are a rare group of HIV-positive people
(<0.5 per cent) who remain clinically well without antiret-
roviral therapy after 20 years of infection. These ‘long term
non-progressors’ or ‘elite controllers’, as they are known,
maintain stable CD4 cell counts and low viral loads com-
parable with those people receiving antiretroviral therapy.
Prognosis
The prognosis for people with HIV has changed dramati-
cally since the first cases of AIDS were diagnosed in the early
17/11/2015 16:11

Table 38.1  Clinical stage 4/AIDS defining conditions
HIV wasting syndrome
Pneumocystis pneumonia
Recurrent severe bacterial pneumonia
Chronic herpes simplex infection (orolabial, genital or
anorectal of more than one month’s duration or
visceral at any site)
Oesophageal candidiasis (or candidiasis of trachea,
bronchi or lungs)
Extrapulmonary tuberculosis
Kaposi’s sarcoma
Cytomegalovirus infection (retinitis or infection of other
organs)
Central nervous system toxoplasmosis
HIV encephalopathy
Extrapulmonary cryptococcosis including meningitis
Disseminated non-tuberculous mycobacterial infection
Progressive multifocal leukoencephalopathy
Chronic cryptosporidiosis (with diarrhoea)
Chronic isosporiasis
Disseminated mycosis (coccidioidomycosis or histoplasmosis)
Recurrent non-typhoidal Salmonella bacteraemia
Lymphoma (cerebral or B cell non-Hodgkin) or other
solid HIV-associated tumours
Invasive cervical carcinoma
Atypical disseminated leishmaniasis
Symptomatic HIV-associated nephropathy or
symptomatic HIV-associated cardiomyopathy
Some additional specific conditions can also be included in
regional classifications (such as reactivation of American trypano-
somiasis [meningoencephalitis and/or myocarditis]) in the World
Health Organization (WHO) Region of the Americas and dissemi-
nated penicilliosis in Asia).
1980s. For instance, AIDS deaths in the UK have fallen from
a peak of over 1500 in 1994 (The UK Collaborative Group
for HIV and STI Surveillance 2006) to approximately 500 in
2011 (Health Protection Agency 2012). The use of highly
active antiretroviral therapy (HAART) from the mid-1990s
onwards has significantly contributed to this improvement.
Many HIV doctors now believe that, provided a person
with HIV receives effective anti-HIV treatment before their
immune system is severely damaged by the virus, and if they
take their drugs properly and can tolerate them, they could
live a more or less normal life span. A study in Denmark
reports an estimated median survival of more than 35 years
for a young person diagnosed with HIV infection (Lohse
et al. 2007). Similarly, data in the UK have shown that life
expectancy has improved so that for a group of 20 year olds
starting antiretroviral in the period 1996–1999 life expec-
tancy was 30.0 years compared to 45.8 years for those starting
in 2006–2008 (May et al. 2011). Delay in HIV diagnosis and
starting antiretroviral therapy late are significant adverse
factors as the immune system can already be severely dam-
aged. These drugs can also reduce the rate of sexual and verti-
cal transmission of the virus probably as a result of reducing
viral load in genital secretions and plasma.
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Assessing current health and causes of incapacitation  617
Global prevalence and incidence
The World Health Organization (WHO) estimated that, in
2011, 34 million people were living with HIV globally, which
represented an increase on previous years (WHO 2013). An
estimated 2.5 million people worldwide were newly infected
with HIV, which was over 20 per cent less than the 3.2 mil-
lion people newly infected in 2001. During the same year, an
estimated 1.7 million people died from AIDS-related causes
worldwide, which was 24 per cent less than in 2005. These
figures reflect the transformation from fatal to chronic life-
long infection. As access to antiretroviral therapy in low
and middle income countries improves (8  million people
in such countries received treatment in 2011) it is expected
that the population living with HIV will continue to grow as
fewer people die from AIDS-related causes. Approximately
69 per cent of all those living with HIV are in sub-Saharan
Africa with the same region accounting for 70 per cent of all
deaths from AIDS-related causes.
By the end of 2011, an estimated 96 000  people were
living with HIV in the UK, approximately one quarter of
whom were undiagnosed and unaware of their infection
(Health Protection Agency 2012). This figure also repre-
sents an increase from previous years. The number of new
diagnoses per annum has declined slightly from a peak in
2005. The estimated prevalence of HIV in 2011 was 2.1 per
1000  men and 1.0  per 1000  women with the highest rates
reported among men who have sex with men and in the
black African community.
The prevalence in pilots and air traffic controllers is
unknown as in many countries there is no mandatory test-
ing. In Europe, at the time of their routine medical, both
groups are asked to declare whether they have had a posi-
tive HIV test. It is likely that many HIV-positive pilots and
ATCOs are unaware of their status or have not declared it for
fear, rightly or wrongly, of losing their medical certificate.
ASSESSING CURRENT HEALTH AND
CAUSES OF INCAPACITATION
HIV with its associated opportunistic infections and ill-
nesses presents complex scenarios for an aviation medical
practitioner. From acute infection, through subtle cognitive
decline, to the impact of multiple drug therapy, HIV infec-
tion has it all. This section looks at some of the key areas for
consideration for current functional ability and sources of
possible incapacitation.
HIV immunological status
CD4  cell count and plasma HIV viral load are routinely
used to monitor disease progression, to determine the opti-
mum time for commencing antiretroviral medication and
for monitoring its effectiveness. These two parameters are
also used to determine the risk of disease progression. The
number of CD4  cells varies diurnally, being higher in the
morning, increasing slightly with smoking and decreasing
17/11/2015 16:11
 618  Human immunodeficiency virus
acutely with stress and with intercurrent infection and so
it is important to monitor trends over time and repeat a
test to confirm a value rather than take a decision on one
specific measurement. Sudden changes in the count need
to be confirmed by a second determination. Plasma viral
load rises sharply during acute infection and tends not to
be a reliable indicator of disease progression until the set
point has been achieved around 6–9  months after initial
infection. Two measurements help to confirm a set point
and thereafter measurements occur at regular intervals to
monitor disease progression. There are a number of national
guidelines available that advise on routine investigation and
monitoring including the material published by the British
HIV Association (Asboe et al. 2012).
Other routine blood tests including haematology, bio-
chemistry and co-infection serology are discussed in sub-
sequent paragraphs. CD8+ T cells are not widely measured
in the UK. The numbers of these cells rise from seroconver-
sion until late HIV infection and leads to an inversion of the
ratio of CD4:CD8 (as CD4 cell numbers decline). A delay in
the time from seroconversion to inversion is thought to be
associated with a more favourable prognosis and may indi-
cate long-term non-progressors.
Co-infection
There are a number of co-infections found frequently in
people with HIV. These include hepatitis B and C, which
can cause progressive liver disease especially in those
receiving antiretroviral therapy. In developing countries,
tuberculosis is a common associated opportunistic infec-
tion, as is Pneumocystis jirovecii infection in the USA and
Europe. Other sexually transmitted diseases such as syphi-
lis should also be considered. Cytomegalovirus is a frequent
cause of retinitis in advanced HIV infection. Other associ-
ated co-infections include schistosoma, Epstein–Barr virus,
Toxoplasma gondii (associated with multiple CNS lesions)
and JC virus (which causes progressive multifocal leukoen-
cephalopathy) and cryptococcal meningitis.
Many of these co-infections are tested for routinely at
the time of diagnosis. Immunological status for a number of
other commonly encountered pathogens such as measles and
rubella may also be checked so that where appropriate, immu-
nization can be offered. Serological tests should be available
when considering aeromedical certification after initial infec-
tion and co-infection reviewed at intervals thereafter.
Neurological disease
HIV enters the central nervous system (CNS) early in the
course of infection and aside from the relatively few cases
whose seroconversion illness presents with HIV-associated
meningitis, the majority of CNS signs and symptoms take
years to appear. Significant CNS impairment does not appear
to occur in those with CD4 cell counts above 350 cells/mm3.
Neurological disorders may arise for a number of causes
other than the direct result of HIV infection including
K17577_C038.indd 618
opportunistic infection, AIDS defining neoplasm and anti-
retroviral therapy. Distal sensory peripheral neuropathy is
common in advanced HIV infection and may be caused
directly by the virus or antiretroviral medication. It tends to
develop in a symmetrical pattern and is associated with pain
or paraesthesia in the feet. Ankle jerks are usually decreased
and there is distal sensory loss (Richman 2003).
The risk of new onset seizures in asymptomatic individu-
als is low. In the majority of cases, seizures in HIV-positive
individuals are caused by disorders that generally occur in
late stages of HIV infection and are associated with AIDS
defining conditions, such as encephalopathy, neoplasm or
opportunistic infections (Pascual–Sedano et al. 1999). It is
likely that by this stage air crew would have been grounded
due to the decline in CD4  cell count and the increasing
risk of disease progression. There is controversy about the
diagnostic use of electroencephalography (EEG) in patients
who are otherwise asymptomatic and so this investigation is
unlikely to be of use in aeromedical decision making.
Neurocognitive symptoms have been a noted feature of
HIV infection from soon after the virus was first identified.
These range from mild cognitive symptoms to more severe
memory loss, executive functioning difficulties and cogni-
tive impairment. They usually present as a late complication of
HIV disease in those with very low CD4 cell counts. Following
the introduction of HAART the incidence of severe disor-
ders has reduced according to some reports by around 50 per
cent compared to the early 1990s. However, the prevalence
has increased due to improvements in survival and although
most cases tend to occur in those with low or very low CD4 cell
counts there have been cases of HIV associated dementia in
those with normal or near normal CD4 cell counts. Milder
forms of impairment have continued in a proportion of people
and there is much debate about the prevalence, risk factors for,
and prognosis of, mild-to-moderate cognitive impairment in
persons taking effective HAART.
The changing prevalence of impairment in the post-
HAART era has prompted a review of the categorisation of
associated conditions and the term HIV associated neuro-
cognitive disorders (HAND) is now frequently used to cover
these disorders. Three syndromes are described within
this spectrum: asymptomatic neurocognitive impairment
(ANI); mild neurocognitive disorder (MND); and HIV asso-
ciated dementia (HAD). The criteria in each are described
primarily for research purposes and the emphasis is on the
outcome of cognitive function testing (Antinori et al. 2007).
The latter two syndromes consist of symptoms that would
be incompatible with safe flying as they interfere with daily
functioning. ANI presents more of a challenge and could be
complicated by the presence of a major depressive episode
or substance dependence.
There is no single ‘gold standard’ battery of tests for
neurocognitive impairment in HIV-positive persons and,
therefore, approaches to assessment vary between medical
facilities and across national boundaries. In general, tests
should include the ability domains of verbal/language,
attention/working memory, abstraction/executive, memory
17/11/2015 16:11

(learning, recall), speed of information processing, and sen-
sory-perceptual and motor skills.
Caution is required when determining which cognitive
function tests to deploy as they may not have been validated
in all languages or appropriate normative standards may
not be available for particular populations. Other factors
that can affect the outcome of cognitive function testing
include age, education and cultural background, premorbid
neurological disease and alcohol and drug use, fatigue and
constitutional symptoms and mood. A lack of pre-infection
data may also make determining the significance of minor
deficits difficult.
There are test batteries that have been developed for
assessing cognitive function of pilots following a range of
illness or injury. These are used in parts of the world to
assess pilots with HIV. Some were developed in the pre-
HAART era and may not have been re-evaluated since.
Many asymptomatic people who are HIV positive will
have no demonstrable cognitive impairment. Those that
do can often demonstrate a fluctuating pattern with some
returning to normal on later retesting. Others show a sta-
ble deficit and a few deteriorate further. The findings sug-
gest that it would be prudent to have all aircrew undertake
cognitive function testing following declaration of HIV
seropositivity, in part, to obtain ‘baseline’ data for future
reference. Testing can be repeated at intervals thereafter,
particularly in association with adverse trends in serologi-
cal markers or with initiation of HAART and during subse-
quent follow-up. In those with deficits it is not always clear
how the findings relate to every day functioning and indeed
whether there would be associated functional impairment.
Functional testing may enhance the assessment of cogni-
tive function testing. This could take the form of the pro-
ficiency checks that commercial pilots undertake regularly
in a flight simulator. This may be particularly useful where
cognitive function testing has detected mild impairments
of uncertain significance or instead of cognitive function
testing in asymptomatic individuals who are at low risk of
disease progression.
In general, simulator checks test two main abili-
ties, which are learned skills, e.g. controlling an aircraft
after engine failure, flying an instrument approach with
engine(s) failed, and decision making, e.g. choosing an
appropriate course of action given more than one option,
and determining the cause of a malfunction from a given
set of data (International Civil Aviation Organization 2012).
Controlling a twin-engine aircraft after an engine failure
following takeoff or while flying an approach are demand-
ing psychomotor tasks and should be part of any routine
simulator test. Memory tasks are also necessary as a rou-
tine, but can be emphasized by the airline medical advisor
in discussion with the training captain. Delegation of rele-
vant tasks to the second pilot should not be permitted. Tasks
such as recall of six digits when changing frequencies can be
required of the affected pilot to test short-term memory, and
conditional clearances (‘after waypoint X, descend to flight
level 120’) can test longer term memory.
K17577_C038.indd 619
Assessing current health and causes of incapacitation  619
Unfortunately, there are no established thresholds for when
cognitive impairment becomes incompatible with aeromedi-
cal certification. Detection of a minor deficit with uncertainty
about its functional impact may require further assessment of
performance with a medical flight test conducted in a flight
simulator or with a flying instructor. Minor deficits should
also be considered along with other parameters such as serol-
ogy when determining fitness for certification.
Psychiatric disease
Depression is common in individuals with a variety of med-
ical illnesses. Studies in people living with HIV/AIDS in the
pre-HAART era have shown that up to 50 per cent of outpa-
tients have significant depressive symptoms. Some of these
looked specifically at military personnel. However, since the
advent of HAART there is evidence of a lower prevalence of
mood disorders reported in studies looking at those attend-
ing HIV outpatient clinics.
Depression may present for reasons similar to non-HIV/
AIDS populations but could also occur as a secondary or
‘organic’ depression, e.g. in association with possible neu-
rotropic effects of the virus. Psychiatric symptoms can be
associated with some antiretroviral medication.
The aeromedical assessment should include an assess-
ment of mental health, particularly at the first assessment
after seroconversion, with subsequent reviews following the
introduction of HAART that includes drugs with known
psychiatric side effects.
Cardiovascular disease
Cardiovascular disease (CVD) is a leading cause of non-
AIDS morbidity and mortality among HIV-positive indi-
viduals, who appear to have an increased risk of CVD
events when compared with seronegative populations.
Lipodystrophy may arise as an interaction between HIV
disease and/or immune recovery and antiretroviral medi-
cation. Patients receiving combination antiretroviral ther-
apy frequently experience metabolic complications such as
dyslipidaemia and insulin resistance, increasing the risk
of CVD and diabetes mellitus. Risk factors for diabetes in
the general population, such as older age, male sex, obesity,
lowered high density lipoprotein and raised total cholesterol
have also been found to contribute to the risk of diabetes
in the HIV-positive population. It is important that car-
diovascular risk factors are assessed after initial diagnosis
and periodically thereafter, including both before and after
commencing antiretroviral medication.
Although there is no specific risk calculator recom-
mended for HIV-positive populations it appears that stan-
dard CVD risk calculators appear to work reasonably well
but it should be remembered that they were each developed
using specific populations. Measures to reduce cardiovascu-
lar risk are the same as in the non HIV-positive population
and include smoking cessation and managing blood pres-
sure and dyslipidaemia.
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 620  Human immunodeficiency virus
Other associated diseases
Kidney disease may affect up to 30 per cent of HIV-infected
patients but acute disease usually occurs in hospitalized
patients with infection, liver disease or malignancy. Chronic
kidney disease is associated with advanced HIV infection,
older age, diabetes mellitus and hypertension. Although
most antiretroviral drugs may cause renal injury, there are
some that are more frequently nephrotoxic and basic renal
function tests are generally part of a regular review.
Reduced bone mineral density, including osteopenia and
osteoporosis, is more common among HIV-infected patients
compared with HIV negative populations and most studies
have identified the importance of traditional risk factors for
low bone mass (including older age, hypogonadism or early
menopause, low body mass, white ethnicity, high alcohol
intake and smoking). Some nucleoside reverse transcriptase
inhibitor (NRTI) and protease inhibitors can also adversely
affect bone density. As part of routine practice in the UK it
is advised that people over the age of 50 years, who are HIV
positive, have their fracture risk assessed at initial diagno-
sis and periodically during follow-up, both before and after
initiation of ART. There are risk assessment tools available
to help with this, such as FRAX® which was developed by
the WHO.
Antiretroviral therapy
Highly active antiretroviral therapy (HAART) does not
cure HIV infection so, once started, lifelong therapy is
always necessary. However, for many people therapy will
result in adequate viral suppression which can be defined
as a reduction of viral load to undetectable levels. CD4 cell
counts usually show a gradual increase over a period of a
few years until a threshold is reached. This threshold may
be within the normal range for CD4  cell counts. There
are cases in which adequate viral suppression may not be
achieved despite appreciable increases in CD4 cell count.
Guidelines for the use of antiretroviral agents in the
USA and the UK are broadly similar, with a recommenda-
tion that all patients with a CD4  cell count of <350  cells/
mm3 or an AIDS diagnosis should initiate treatment. There
are some variations in what is recommended for those with
hepatitis B and C co-infections but generally therapy is ini-
tiated at higher CD4 cell counts. There is some debate about
whether asymptomatic patients should commence antiret-
roviral medication at much higher CD4 cell counts includ-
ing 500 cells/mm3 and above and this needs to be considered
against the commitment to lifelong therapy, the importance
of adherence to treatment, drug resistance and the impact
of side effects.
For HIV-1, initial therapy in those who have not been
on ART previously, usually consists of two NRTIs plus
one other drug: a protease inhibitor (PI), a non-nucleoside
reverse transcriptase inhibitor (NNRTI) or an integrase
inhibitor (INI). This may need to be tailored slightly differ-
ently in those with HIV-2.
K17577_C038.indd 620
From an aeromedical perspective, it is helpful if clinicians
treating aviation personnel can carefully design drug regi-
mens to take account of the future risk of co-morbidities,
potential adverse effects and the interactions between the
various drugs and other concomitant medication for other
conditions. This includes over the counter preparations
available from pharmacies that can be obtained without
prescription. However, many of the important interactions
are with drugs used to treat conditions that are unaccept-
able for aeromedical certification, e.g. anti-epileptics, anti-
microbials and anti-cancer drugs.
During the initiation of therapy and when adjustments
are made to the regimen, flight crew should be grounded.
A further assessment should then be made for side effects
that are likely to be disabling after treatment has been
stable for around 2–6  months, depending on the drug,
before any decision on recertification is made. There is con-
siderable variability in the occurrence of adverse effects
between drugs and between individuals. The possible cog-
nitive effects of HAART, relevant for flight safety, may be
assessed with validated neuropsychological test batteries or
a functional evaluation, e.g. flight simulator check. Regular
review is required to monitor treatment efficacy, adherence,
evidence of drug resistance and side effects. This should
include measuring blood parameters such as haemoglobin
and liver and renal function.
DISEASE PROGRESSION
Without treatment there is a latent period of on average
around 10 years from seroconversion to the development of
an AIDS defining condition. During the period of clinical
latency most HIV-infected persons are asymptomatic and
those who are aware of the infection should be undertaking
regular review to monitor CD4  cell count and viral load.
This review should enable monitoring of the risk of disease
progression and indicate an optimum time for commencing
antiretroviral medication. If HIV seropositivity is detected
relatively soon after infection, those engaged in aviation
duties may be able to continue their careers for several years
until therapy is started and for many years if HAART is suc-
cessfully established. There is variability between individu-
als on the length of the latent period, the development of
symptomatic disease and in the occurrence of side effects
from antiretroviral medication.
Symptomatic HIV-related disease including cognitive
impairment, AIDS-defining conditions and some of the
adverse effects of HAART are incompatible with aviation
duties. Therefore, prediction and/or early detection of these
conditions or effects are essential for the aeromedical assess-
ment of an HIV-seropositive applicant. Predictive models
are available that use parameters such as CD4 T cell counts,
viral load and age to assess the likelihood of developing an
AIDS defining condition.
There have been large group studies that have published
data that can be used in the assessment of the risk for those
who are treatment naive and those who have commenced
17/11/2015 16:11

therapy. The Concerted Action on Seroconversion to AIDS
and Death in Europe Collaboration (CASCADE) have pro-
duced a model for asymptomatic seropositive subjects who
have had no antiretroviral therapy, to predict the six-month
risk of developing an AIDS defining condition (Phillips
et al. 2004). This can be modified to give a 12-month risk.
For those who have already commenced HAART, data
from EuroSIDA or the Antiretroviral Therapy (ART) Cohort
Collaboration can provide a basis for assessing the risk of
disease progression. The former reports on the risk of a diag-
nosis of a new AIDS defining condition or death. Those with
a CD4 cell count of >200cells/mm3, viral load <500 copies/
mL and a normal haemoglobin were likely to have a risk of
1 per 100 person years or less (Lundgren et al. 2002). The
ART Cohort Collaboration found that the CD4 cell count
and viral load measured six months after starting HAART
were strongly associated with subsequent disease progres-
sion and not the baseline values (Chene et al. 2003). The data
presented by the collaboration are limited for aeromedical
use by its broad categories, i.e. their best prognostic group
contains people with symptomatic conditions who would
not be considered fit for aeromedical certification.
The populations used in these studies are predomi-
nantly Western European, Israeli and Australian and so
caution may be required when applying the data to pilots
from outside these regions. The socioeconomic groups of
pilots and air traffic controllers may also differ from the
study populations.
INTERNATIONAL STANDARDS
As the understanding of HIV infection has developed and
the prognosis for those infected has improved, so the regu-
lations and policies that affect those who wish to be pilots or
air traffic controllers have gradually evolved, albeit under-
standably more cautiously.
Seropositivity is generally disqualifying for military
flying training and nearly always results in permanent
grounding for current aircrew.
A number of civilian agencies and national aviation
authorities have published guidance relating to the assess-
ment of HIV-positive applicants, including Transport
Canada, the Federal Aviation Administration (FAA), the
South Africa Civil Aviation Authority and the United
Kingdom Civil Aviation Authority (CAA). The International
Civil Aviation Organization (ICAO) Manual of Civil
Aviation Medicine contains a chapter with guidance on
assessing HIV-positive pilots. The ICAO Standards and
Recommended Practices allow for the certification of HIV-
positive pilots and the European Aviation Safety Agency
(EASA) regulations permit the possibility of initial certifica-
tion for all certificates.
There is a lot of congruence between the various national
policies. Assessments generally require individual consid-
eration and most policies include an assessment of serology
including CD4 cell count and viral load, an assessment of
symptoms and cognitive function. In the case of the FAA,
K17577_C038.indd 621
Travel vaccination  621
cognitive function assessment preferably utilizes CogScreen
and is performed annually for first and second class appli-
cants. Other authorities require regular functional assess-
ment such as a licence proficiency check in a flight simulator.
Applicants will be considered either on or off antiretroviral
medication. Following certification it is generally recom-
mended that CD4 cell count and viral load levels should be
determined every 3–4 months and that clinical condition,
including general, neurological and, if indicated, psychi-
atric examinations should be assessed every six months.
These generally fit well with the routine clinical assessments
many HIV-positive persons undertake. A neuropsychologi-
cal evaluation may be considered every 12 months and this
may be enhanced or substituted by regular assessment of
cockpit performance in asymptomatic, stable applicants
with very low risk of progression. Further co-infection test-
ing will be required where clinically indicated and those
with new positive tests may require specialist evaluation
prior to further certificatory assessment.
TRAVEL VACCINATION
For those pilots who are able to continue to fly and travel
globally there is the issue of travel vaccination. This is rela-
tively straightforward as asymptomatic HIV-infected per-
sons with a current CD4 cell count >400 cells/μL (who make
up the group of pilots most likely to be fit to fly) are gener-
ally regarded as sufficiently immunocompetent. Regardless
of the CD4  cell count, the contraindications to the use of
live vaccines that apply to the general population also apply
to HIV-infected persons. Transient increases in plasma HIV
RNA load have been reported after the administration of
several vaccines but these are not thought to be of clinical
significance and should not preclude the use of any vaccine.
SUMMARY
●● The introduction of highly active anti-retroviral
therapy (HAART) has transformed the prog-
nosis for HIV infection and, for many, this has
shifted the clinical focus to one of managing a
chronic infection.
●● National aviation policies have evolved over
recent years so that it is possible to commence
or continue a commercial flying career after
becoming infected.
●● An aeromedical assessment requires consider-
ation of a range of factors relating to infection
and should include serological status, co-infec-
tion, neurological and neurocognitive impair-
ment, mental health, cardiovascular disease and
the effects of anti-retroviral therapy.
●● This assessment can be supplemented by an
assessment of the risk of disease progression
made possible by data from large group studies.
17/11/2015 16:11
 622  Human immunodeficiency virus
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Antinori A, Arendt G, Becker JT, et al. Updated research
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Asboe D, Aitken C, Boffito M, et al. British HIV Association
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Chene G, Sterne JA, May M, et al. Prognostic importance
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Chou R, Huffman LH, Fu R, et al. Screening for HIV:
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Health Protection Agency. HIV in the United Kingdom:
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International Civil Aviation Organization. Manual of Civil
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Kahn JO, Walker BD. Acute human immunodeficiency
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Lohse N, Hansen ABE, Pedersen G, et al. Survival of
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Lundgren JD, Mocroft A, Gatell JM, et al. A clinically
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Lyles RH, Munoz A, Yamashita TE, et al. Natural history
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Phillips A, Pezzotti P, CASCADE Collaboration. Short term
risk of AIDS according to current CD4 cell count and
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Infections, 2006.
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17/11/2015 16:11

Cabin crew health
NIGEL DOWDALL
Background 623
Cabin crew role 623
Regulatory medical requirements 624
BACKGROUND
The world’s first cabin crew member is thought to have been
Heinrich Kubis, who started work as a steward on Zeppelin
airships in March 1912. He later served on the Hindenburg
and survived the airship’s loss due to fire in 1937. Although
it is unclear whether he received any formal safety training,
he is credited with encouraging other crew and passengers
to jump to safety as it neared the ground when the airship
crashed (Russell 2013).
In the 1920s, Imperial Airways recruited ‘cabin boys’,
whose role was to load luggage, assist passengers on the
aircraft and reassure nervous passengers (Career in Travel
2013). The first female flight attendant was Ellen Church,
a registered nurse, who joined Boeing Air Transport in
1930 (Boeing 2013) and subsequently proposed that all flight
attendants should be qualified nurses, able to assist any pas-
sengers who became unwell during flight. For a time, air-
lines in the USA only recruited nurses as flight attendants,
but these requirements were progressively relaxed as more
women were recruited. These days cabin crew (sometimes
referred to as flight or cabin attendants) are recruited from
a wide range of backgrounds, with emphasis on the impor-
tance of their customer service capabilities as well their
safety role.
CABIN CREW ROLE
In a presentation at the Royal Aeronautical Society in 1986,
Dr Roy Maclaren, Director of Health Services at British
Airways, described the role of cabin crew in commercial air
transport operations as ‘assisting in the provision of rapid,
K17577_C039.indd 623
39
Fitness assessment 625
Acknowledgements 628
References 628
comfortable and safe travel through an environment that is
potentially hostile and occasionally lethal’.
The European Aviation Safety Agency (EASA) regula-
tions advise that cabin crew should be assessed for medical
fitness to:
1. ‘Undergo the training required for cabin crew to acquire
and maintain competence, e.g. actual fire-fighting,
slide descending, using protective breathing equipment
(PBE) in a simulated smoke-filled environment, provid-
ing first aid;
2. Manipulate the aircraft systems and emergency equip-
ment to be used by cabin crew, e.g. cabin management
systems, doors/exits, escape devices, fire extinguishers,
taking also into account the type of aircraft operated
e.g. narrow-bodied or wide-bodied, single/multi-deck,
single/multi-crew operation;
3. Continuously sustain the aircraft environment whilst
performing duties, e.g. altitude, pressure, recirculated
air, noise; and the type of operations such as short/
medium/long/ultralong haul; and
4. Perform the required duties and responsibilities effi-
ciently during normal and abnormal operations, and in
emergency situations and psychologically demanding
circumstances, e.g. assistance to crew members and pas-
sengers in case of decompression; stress management,
decision-making, crowd control and effective crew
coordination, management of disruptive passengers and
of security threats. When relevant, operating as single
cabin crew should also be taken into account when
assessing the medical fitness of cabin crew (European
Aviation Safety Agency 2011).
623
17/11/2015 16:12
 624  Cabin crew health
REGULATORY MEDICAL REQUIREMENTS
Although there are International Civil Aviation
Organization (ICAO) Standards and Recommended
Practices (SARPS) covering the minimum number of cabin
crew and the training requirements, including require-
ments for training in safety procedures and first aid, there
are no requirements for cabin crew medical fitness assess-
ment (International Civil Aviation Organization 2010).
National Aviation Authorities vary in their regula-
tory requirements for cabin crew medical fitness. Many
authorities, such as those in the USA and Australia, have
no regulatory requirements whereas others, such as the
authorities in South Africa and the UAE, require cabin crew
to hold a medical certificate. In Europe, the Joint Aviation
Authorities (JAA) regulations introduced a requirement for
an assessment of cabin crew medical fitness, although the
interpretation of the requirements by national authorities
resulted in wide variation in the assessment and standards
required. The EASA cabin crew medical fitness require-
ments, which were implemented in all EASA states by April
2014, introduce more detailed requirements (Commission
Regulation [EU] 2011). It remains to be seen whether this
will result in the desired harmonization of standards across
the national authorities.
Regulatory medical assessment
The disparity between states in determining the regulatory
requirements for cabin crew medical fitness is in contrast to
the broad agreement and increasing harmonization of the
requirements for pilots, particularly commercial air trans-
port pilots. It is also generally considered necessary to have
regulatory requirements that apply to passengers who are
seated in emergency exit rows.
There is no doubt that cabin crew have an important role
in contributing to passenger safety. It is, therefore, evident
that they must have both the physical and mental capacity
to be able to complete their training and to carry out their
duties. In addition, their working environment presents
physiological challenges both in the cabin environment and
in the work patterns of shift work and trans-meridian travel.
Some authorities believe that these issues justify regulatory
medical standards and regular medical assessment/exami-
nation for cabin crew, while others maintain that this is a
matter for occupational health.
A risk-based approach
The increasing use of safety management systems in avia-
tion safety requires a risk-based approach – the identifica-
tion of safety hazards, the assessment of the likely frequency
and consequences of an occurrence (the risk) and, where
possible, the actions that can be taken to mitigate the risk.
The approach also requires the determination of a standard
– the acceptable level of risk.
K17577_C039.indd 624
It is evident that impairment or incapacitation of a pilot
represents an immediate threat to flight safety, particularly
in single pilot operations. The potential for impairment or
incapacitation of pilots due to medical causes was recog-
nized early in the history of aviation and led to the develop-
ment of regulatory medical requirements and later to the
widely used standard of the 1 per cent rule – that the risk of
incapacitation due to a medical condition should not exceed
1 per cent per annum.
Dalitsch investigated the prevalence amongst cabin
crew of medical conditions which would be potentially
disqualifying for Federal Aviation Administration (FAA)
Class 3 (private pilot) medical certification. He found that
38.35  per cent of cabin crew had been diagnosed with a
potentially disqualifying condition, including 5.1  per cent
who had a history of alcohol or other substance abuse or
dependence. He concluded that many of the conditions had
the potential to interfere with passenger safety and that
only a thorough medical history and physical examina-
tion would identify crew who might not be fit for the role
(Dalitsch 2001).
However, the evidence for the risk associated with cabin
crew incapacity or impairment is less apparent. In a review
of the UK Mandatory Occurrence Report database January
1997–December 2006, Mitchell and Johnstone reported
810 incidents of inflight cabin crew illness or incapacitation.
Although many of the incidents resulted in the crew mem-
ber being stood down for the remainder of the flight, often
resulting in the flight being operated with below the crew
minimum number, none of the incidents resulted in a flight
safety incident (Mitchell and Johnson 2008).
Similarly, in a comments submitted by the Association
of European Airlines (AEA) to EASA’s Notice of Proposed
Amendment 2009e, one AEA member reported 676  inci-
dents of cabin crew incapacitation over a three year period,
a rate of 1.27 per 10 000 sectors. These had resulted in one
diversion, due to an acute traumatic event, but no other
operational or safety implications (European Aviation
Safety Agency 2009).
As well as the lack of evidence for a significant flight
safety risk, the potential for any such risk to be mitigated
by medical assessments should be considered. Ahmed
reported the outcome of an audit of onboard medical inci-
dents, medical boards and suspensions and medical exami-
nations involving Emirates Airline cabin crew in 2007. Of
the 725 onboard medical incidents, none were due to signif-
icant undeclared medical conditions and only one incident,
in which a crew member with no previously known medi-
cal condition had collapsed and become unconscious, led
to a diversion. One hundred and sixty-four crew members
were temporarily suspended from duty on medical grounds
and two were permanently suspended. None of the suspen-
sions related to previously known medical conditions and
all had valid medical certificates at the time of their sus-
pension, with no evidence to suggest an undiagnosed or
unreported condition at the time of the last medical exami-
nation. Of the 2032 initial applicant medical examinations,
17/11/2015 16:12

272 (13 per cent) required some form of further assessment,
of whom one was found to be unfit and three resigned, i.e.
99.8 per cent continued into training (Ahmed 2008).
The report of an audit of questionnaire based medical
assessments of British Airways new-entrant cabin crew
also demonstrated the limited benefit of medical screen-
ing. During a 5-year period, 5266  new entrant crew were
recruited, of whom 91 had declared a potentially significant
medical condition requiring further follow-up before they
were assessed as fit. A further 15 crew members were sub-
sequently found to have an undeclared, potentially signifi-
cant medical condition, but of these only one crew member
was found to be unfit and their employment terminated on
medical grounds (Dowdall 2008).
FITNESS ASSESSMENT
Although the evidence to justify regulatory medical require-
ments is weak, the work of cabin crew can be physically and
psychologically demanding and the nature of the working
environment does have physiological effects with potential
implications for those with specific medical conditions.
The evaluation of an individual’s fitness for a particu-
lar role requires a clear understanding of the nature of the
role, including the physical and psychological demands of
the role and the potential impact and, where possible, miti-
gation of the impact of any health conditions. Ideally, the
outcome of the fitness assessment would be determined by
evidence-based health and fitness standards but, as noted
by McGregor, there is no published work on health stan-
dards in relation to safety for cabin crew. However, on the
basis of an analysis of the cabin crew task, he did identify
a number of pre-placement health assessment questions
intended to identify applicants with medical conditions
which would either have the potential to affect the safety
of others or to put the individual at risk (McGregor 2003)
(Table 39.1).
Airline requirements
The information provided by airlines on the physical attri-
butes and fitness requirements for cabin crew vary consid-
erably. Most airlines specify a minimum (and sometimes
maximum) height, in some cases with a requirement for
weight to be ‘in proportion’, and many also indicate the
need for a level of physical capability.
For example, easyJet requires applicants to be between
158  cm and 190  cm in height, with weight in propor-
tion, physically fit and able to pass a medical assessment,
visual acuity of 6/9  (unaided or aided) and able to swim
25 m and tread water for at least one minute (easyJet 2013).
Lufthansa requires applicants to be a minimum of 160 cm
in height with appropriate weight and able to meet the
visual standard with correction of no more than +/– 5 diop-
tres (Lufthansa 2013). However, not all airlines specify
height limits. Emirates Airline, for example, requires that
K17577_C039.indd 625
Fitness assessment  625
Table 39.1. Aims of cabin crew pre-employment health
assessment
1 Any health condition with increased risk of medical
incapacitation from safety role, e.g. severe asthma,
migraine, insulin-dependent diabetes, epilepsy.
2 Any health condition affecting ability to lift/bend/
push/pull/use emergency slides/open aircraft doors/
use firefighting equipment, e.g. back problems, joint
disease.
3 Any health condition affecting the use of smoke
hoods, e.g. claustrophobia.
4 Any health condition affecting ability to communicate
effectively in an emergency, e.g. poor hearing,
inability to shout loudly and repeatedly.
5 Any health condition affecting safe food handling,
e.g. risk of transmissible disease.
6 Any health condition affecting ability to see adequately
for the role.
7 Any health condition likely to be aggravated by rapid
circadian rhythm change and irregular pattern of
sleep and meals, including disturbances of mood,
sleep or eating, insulin-dependent diabetes and some
bowel diseases, such as irritable bowel syndrome.
8 Any health condition which may render the individual
at increased risk from infectious disease, including
history of splenectomy (risk of serious infections with
Streptococcus pneumoniae, Haemophilus influenzae,
meningococcus and malaria), immune suppression
from any cause, those in whom there is a
contraindication to the use of immunizations,
including yellow fever and other live virus vaccines,
and inability to take suitable antimalarials.
9 Any health condition which may impair the ability to
work on aircraft, with particular regard to cabin
pressure changes. This includes those with recurrent
otitis media or hay fever if associated with Eustachian
tube dysfunction and recurrent sinusitis.
10 Any health condition which may put an individual at
risk by virtue of isolation from home and family or by
the ‘lifestyle’ and hours worked, e.g. chronic or
recurrent conditions such as psychosis, depression,
eating disorder, alcoholism, drug dependence, fear
of flying, mental abnormality and claustrophobia.
11 Any health condition which could threaten life or
incapacitate when remote from medical help on long
flight sectors or at some locations overseas, e.g.
asthma, although this is acceptable if mild and well
controlled on suitable treatment.
12 Any health condition which could be aggravated by
hypoxia, e.g. history of severe anaemia,
haemoglobinopathy.
From McGregor A. Fitness standards in airline staff. Occupational
Medicine 2003; 53: 5–9.
applicants should have a minimum reach of 212 cm when
standing on tiptoes and be physically fit to meet the airline’s
requirements (The Emirates Group 2013).
17/11/2015 16:12
 626  Cabin crew health
Qantas is an example of an airline which provides more
detailed requirements. As well as being within the height
range of 163–183  cm and having an excellent level of
health and fitness including the ability to swim 50 m fully
clothed, applicants are also advised that during training
they will have to perform a range of safety tasks includ-
ing lifting a 28 kg aircraft window exit and move disabled
people in evacuations (Qantas 2013). Continental Airlines
goes even further, with requirements including body
size not exceeding various aircraft dimensions, the abil-
ity to push/pull beverage carts and lift specified weights
and to complete a pre-employment medical examination
(Gblcareers 2012).
Task analysis
A pre-requisite in developing standards for occupational
health assessment is to define the key tasks involved in the
work, by means of job analysis, and to define the perfor-
mance standards necessary to be able to perform the tasks.
Factors which may need to be considered include the physi-
cal capacity or attributes required to perform the task, the
frequency of the task, how critical the task is to the role and
whether the requirements for the task can be mitigated, e.g.
by redesign or by procedural changes to allow two individu-
als to carry out the task together. The final step is to iden-
tify appropriate tests or simulations of the most demanding
and/or critical tasks which will predict an individual’s abil-
ity to perform the task (Rayson 2000).
British Airways Cabin Crew Study (Evetts
et al. 2005)
In 2005, British Airways commissioned Cranfield University
to carry out a study of cabin crew roles, to enable them to
understand the physical demands and to identify the pre-
requisite characteristics which are required for employment
as British Airways cabin crew. This was done with a view
to the development of a set of physical assessments which
would assist the company in the selection and ongoing
assessment of cabin crew. Aircraft studied were representa-
tive of the fleets used by British Airways in both long haul
and short haul operations.
A comprehensive task analysis was undertaken, encom-
passing a variety of techniques to identify the tasks and sub-
tasks undertaken by the crew, both in normal operations
and during abnormal and emergency procedures:
Table 39.2. The highest mean heart rates for the steady state cardiovascular tasks
Minimum heart
Task rate value
Pushing full size trolley on own 72
Pulling full size trolley on own 79
Pushing full size trolley with colleague 76
Pushing full size waste trolley on own 87
K17577_C039.indd 626
●● Document review. This stage included review of
service guidelines, technical manuals, training manu-
als, safety equipment procedure (SEP) manuals and
procedural manuals.
●● Direct observations. Members of the research team
flew on operational flights to observe directly the
tasks as they were undertaken by crew, including the
equipment used and environment in which the tasks
were undertaken.
●● Crew discussions. Informal discussion with crew on
operational flights.
●● SEP training observation. As abnormal and emergency
procedures occur infrequently on operational flights,
data was gathered during observation of SEP training.
●● Stage two data collection. Following initial development
of the task analyses, these were further refined following
discussion with subject matter experts and cabin crew
focus groups.
●● Problems in removing trolleys and containers that had
become stuck in stowages were identified by crew as an
issue of particular concern.
Following identification of the physical tasks involved
in the role, further work was undertaken to identify the
most physically demanding tasks. The data required for this
stage involved:
●● Physical data. Information on the physical cabin envi-
ronment was collected from aircraft documents and
direct measurements, including heights of galley items,
overhead lockers; aisle widths; door assist space; crew
harness dimensions; length of cabin sections; aircraft
incline; maximum weight of trolleys and galley equip-
ment; force required to close overhead lockers, push
trolleys and lift canisters.
●● Heart rate data of crew completing tasks on board.
Volunteer crew wore heart rate monitors throughout
flights, during which their activities were logged by
direct observation by research staff. The data were ana-
lyzed by correlating the timed activity with the down-
loaded record of heart rate and calculating minimum,
maximum and average heart rate for each activity. The
results of the data collection indicated that no undue
cardiovascular stress was imposed, with heart rate typi-
cally between 80–120 beats per minute. The most physi-
cally demanding tasks, identified as showing the highest
mean heart rates, are shown in Table 39.2.
Maximum heart Mean heart rate Number of
rate value value participants
123 101.4 8
132 100.5 8
125 96.9 6
106 99.1 2
17/11/2015 16:12
 Fitness assessment  627

The information gathered in the initial stages was used

to develop a battery of measurements and tests, which could
potentially be used to test the suitability of individuals for
employment as cabin crew.
Data collected included:

●● Age.
●● Weight.
●● Height.
●● Vertical functional reach (VFR) – vertical height from
the floor to the metacarpophalangeal joint of the domi-
nant arm when maximally extended above the head.
●● Body mass index (BMI).
●● Body width and girth (circumference) at shoulder, chest,
waist, hips and thighs.
●● Maximum grip hand strength.
●● Chest (bench) press.
●● Seated pulley row.
●● Shoulder press.
●● Standing pull.
●● 7 kg to 9 kg bag lift to shelf at shoulder height. Figure 39.1  Vertical functional reach (VFR): Vertical height
●● General fitness test – 20 m trolley push/pull, either between the floor and knuckles (metacarpophalangeal
on the flat or at a 5 degree incline, using a maximally joints) of the dominant hand when the dominant arm is
weighted (120 kg) trolley. maximally extended above the head.

Finally, a group of volunteer cabin crew were asked to
undertake the battery of tests, with the aim of confirming
that the procedures and equipment would be appropriate
and effective for the assessment of cabin crew.
Conclusions of the study:
●● The study cabin crew population exhibited similar
physical characteristics to other non-athletic adults in
the same age range.
●● The use of height as a selection criterion did not neces-
sarily correlate with ability to reach a high object and
that VFR (as used by the Royal Air Force) would be a
more suitable measure (Figure 39.1).
●● However, it was also noted that the largest distances to
be spanned by crew were 207 cm on long haul aircraft
and 213 cm on short haul – distances that would exceed
the VFR of many serving crew.
●● Some crew had body widths in excess of minimum aisle
widths at various heights, but in practice this could be
accommodated by body rotation.
●● The ability to pass through entry/exit points and aid
in emergencies may be determined by body girth,
with waist girth being possibly of greater significance
because of greater resistance to compression. A waist
girth less than 116 cm, the circumference of the Airbus
A320 Door 2 assist space, might therefore be adopted as
an employment standard.
●● Measures of strength. In order to be useful as selection
criteria, the use of simple lift tests would require tests of
lifting weights to heights and/or spans which are limited
by manual handling guidelines. The majority of crew
volunteers were unable to close the heaviest overhead
locker, but a suitable test might be the ability to apply
a force of half of this figure in a shoulder press test, on
the assumption that two crew would perform this task
together. Measures of chest pull, seated pull and stand-
ing pull strength suggested that most crew might not be
able to move a heavy trolley, but all were able to perform
the 20 m trolley test.
●● General fitness test. The task analysis heart rate data
showed that the four most strenuous activities dur-
ing routine flight involved movement of food trolleys.
However, the level of cardiovascular stress associated
with these activities was such that any healthy adult of
working age would be expected to be able to undertake
the task and this was borne out by the results of the
trolley test.
●● Abnormal and emergency procedures. A number
of strenuous tasks were observed during SEP train-
ing, including CPR, firefighting, disruptive passen-
ger restraint and door closure without power assist.
However, as the ability to perform these tasks is a
pre-requisite for successful completion of SEP training,
there would be no additional benefit in including these
in the assessment package.
●● Stuck trolleys and containers. The ability to free
something that is stuck is related to absolute strength.
Maximal grip strength, as assessed in the study, has
been shown to be an excellent predictor of func-
tional capability and norms for this are widely avail-
able. If this were to be used as a selection criterion,
the acceptable threshold value should be based on a
value appropriate for females to give a single pass/fail
assessment level.

K17577_C039.indd 627 17/11/2015 16:12

 628  Cabin crew health
Recommendations:
On the basis of the study outcomes, an assessment proto-
col was recommended:
●● Height and weight, to allow calculation of BMI. This
would be used to provide health education and a
warning of potential grounding if warranted by other
measurements, e.g. girth.
●● VFR – minimum acceptable to be determined by the
airline.
●● Width and girth, with maximum limits of 45 cm width
below 63.5 cm from floor level, 51 cm width above
63.5 cm and girth of 116 cm.
●● Maximum isometric hand grip should be greater than
17 kg.
●● Shoulder press should be greater than 13 kg.
●● Inflight assessment of ability to push/pull fully loaded
trolleys and to lift items into overhead lockers.
●● Pass/fail assessment of door opening/closing, firefight-
ing, disruptive passenger restraint and CPR during
SEP training.
In view of the relatively small sample of equipment, air-
craft and staff evaluated during the study, it was also rec-
ommended that further evaluation should be undertaken
following implementation of the protocol in order to vali-
date and/or refine the requirements.
The findings and recommendations of this study repre-
sent an important contribution to the knowledge base on
the assessment of cabin crew physical fitness, particularly
in the absence of any published studies. British Airways
selection and assessment criteria now include height, reach
and girth, as well as assessment of ability to undertake
tasks and drills associated with manual handling and flex-
ibility in the cabin environment through practical dem-
onstration in training. In addition, role specific manual
handling training has been developed and implemented,
the principle of which is to avoid injuries occurring
through the assessment of weight and force, prior to and
during manual handling activities. This has significantly
reduced the occurrence of manual handling injuries for
British Airways cabin crew. Work is currently underway,
with reference to the Cranfield protocol, to further develop
the selection and assessment criteria so that the expected
levels of fitness and capability are appropriately assessed
periodically throughout an individual’s career as cabin
crew (Bell 2013).
ACKNOWLEDGEMENTS
The author would like to acknowledge the contribution of
British Airways, Cranfield University and King’s College
London in permitting the use of previously unpublished
material from the British Airways Cabin Crew Study. The
author would also like to thank Simon Evetts for permit-
ting the use of an image from the study in which he was
the subject.
K17577_C039.indd 628
SUMMARY
●● The role of cabin crew has evolved since the earli-
est days of commercial air transport and encom-
passes both safety and customer service aspects.
●● In order to fulfil the role, crew must have the
physical and mental capacity to carry out all
of the duties, as well as being able to cope with
the physiological challenges of this unusual
working environment.
●● There is no international consensus on the fitness
and medical requirements for cabin crew and this
is reflected in variations in both regulatory and
operator requirements and fitness standards.
●● A risk-based approach to the risk of cabin crew
incapacitation and the role of medical assessment
is discussed.
●● The report of a previously unpublished academic
study of the physical demands of and consequent
prerequisite characteristics for the role, under-
taken on behalf of an operator with a view to
informing the selection and ongoing assessment
of cabin crew, is summarized.
REFERENCES
Ahmed N. Are Comprehensive Cabin Crew Medical
Examinations Worthwhile? Presented at the Aerospace
Medical Association Annual Scientific Meeting,
Boston, 2008.
Bell A. Manager safety and quality – cabin crew inflight
customer experience. British Airways. Personal com-
munication 19 July 2013.
Boeing. History: The Boeing Logbook: 1927–32. [Online.]
Available from: www.boeing.com/boeing/history/chro-
nology/chron03.page. Accessed 25 June 2013.
Career in Travel. Who Are Cabin Crew? [Online.] Available
from www.careerintravel.co.uk/cabin-crew-career-
information-who-are-cabin-crew.php. Accessed 25
June 2013.
Commission Regulation (EU) No 1178/2011 of 03/11/2011.
Laying down technical requirements and administra-
tive procedures related to civil aviation aircrew pursu-
ant to Regulation (EC) No 216/2008 of the European
Parliament and of the Council. Official Journal of the
European Communities L311: 3 November 2011.
Dalitsch W. Prevalence of Potentially Disqualifying Physical
and Mental Conditions among Commercial Airline
Flight Attendants. MPH dissertation. University of
Kansas, 2001.
Dowdall N. Pre-employment Assessment of Cabin Crew:
The BA Approach. Presented at the International Air
Transport Association Aviation Health Conference,
Geneva, 2008.
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easyJet. The Recruitment Process. [Online.] Available from
http://careers.easyjet.com/careers-in-the-air/cabin-
crew-careers/recruitment-process.aspx. Accessed
1 July 2013.
European Aviation Safety Agency. Acceptable Means
of Compliance and Guidance Material to Part-MED.
[Online.] Available from http://easa.europa.eu/system/
files/dfu/AMC%20and%20GM%20on%20the%20medi-
cal%20certification%20of%20pilots%20and%20medi-
cal%20fitness%20of%20cabin%20crew.pdf. Accessed
1 July 2013.
European Aviation Safety Agency. Comment Response
Document (CRD) to Notice of Proposed Amendment
(NPA) 2009-02e [Online.] Available from http://
easa.europa.eu/system/files/dfu/CRD%20a.1%20
Explanatory%20Note%20to%20CRD%20OPS%20II.
pdf. Accessed 1 July 2013.
Evetts SN, Muir HC, McKeown R, Wilson RL, Ernsting JE.
British Airways Cabin Crew Study. Cranfield, UK:
Cranfield University, 2005.
Gblcareers. Continental Airlines Recruits for Flight
Attendant Positions. [Online.] Available from http://
gblcareers.com/2012/02/continental-airlines-recruits-
for-flight-attendant-positions. Accessed 1 July 2013.
International Civil Aviation Organization. Annex 6 to
the Convention on International Civil Aviation. Part 1
International Commercial Air Transport – Aeroplanes,
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References 629
9th edn. Montreal: International Civil Aviation
Organization, 2010.
Lufthansa. Flight Attendant (M/F). [Online.] Available from
www.be-lufthansa.com/jobs_and_career.html#/en/
jobs/flight-attendant-mf. Accessed 1 July 2013.
McGregor A. Fitness standards in airline staff.
Occupational Medicine 2003; 53: 5–9.
Mitchell SR, Johnson RV. Cabin Crew Health Assessments:
Hands On or Hands Off? Evidence from In-flight
Occurrence Reports. Presented at the Aerospace
Medical Association Annual Scientific Meeting,
Boston, 2008
Qantas. International Flight Attendants based in Australia.
[Online.] Available from www.qantas.com.au/travel/
airlines/careers-fa-intl-aus/global/en. Accessed 1 July
2013.
Rayson MP. Fitness for work: the need for conducting a
job analysis. Occupational Medicine 2000; 50: 434–6.
Russell P. Faces of the Hindenberg: Heinrick Kubis.
Weblog. [Online.] Available from http://facesofthe-
hindenburg.blogspot.co.uk/search/label/Heinrich per
cent20Kubis. Accessed 25 June 2013.
The Emirates Group. Cabin Crew Requirements. [Online.]
Available from www.emiratesgroupcareers.com/eng-
lish/Careers_Overview/cabin_crew/requirements.aspx.
Accessed 1 July 2013.
17/11/2015 16:12
K17577_C039.indd 630 17/11/2015 16:12

Commercial passenger fitness to fly
MICHAEL BAGSHAW
Passenger health 631
Considerations of physical disability or immobility 632
Scheduled oxygen 634
In-flight medical emergencies 634
Good Samaritans 635
Aircraft medical diversion 635
PASSENGER HEALTH
Introduction
Flying as a passenger should be no problem for the fit,
healthy, and mobile individual. But for the passenger with
certain pre-existing conditions, the cabin environment may
exacerbate their underlying problems.
Although many problems relate to the physiological
effects of hypoxia and expansion of trapped gases, it should
be remembered that the complex airport environment can
be stressful and challenging to the passenger, leading to
problems before even getting airborne.
Whereas passengers with medical needs require medi-
cal clearance to travel from the airline, passengers with dis-
abilities do not. Disabled passengers do need to notify the
requirement for special needs, such as wheelchair assistance
or assignment of seats with lifting armrests, and this should
be done at the time of booking.
An in-flight medical emergency will initially be dealt
with by the cabin crew, who may make use of the on-board
emergency medical kit. In some cases, advice will be taken
from a ground-based medical professional utilizing radio
or satellite communication. This may involve transmis-
sion of digitized medical data, or might simply involve
speech communication. A medical professional travel-
ling as a passenger who offers assistance to the crew is
known as a Good Samaritan. The outcome may involve an
K17577_C040.indd 631
40
Telemedicine 635
Aircraft emergency medical equipment 636
Resuscitation equipment 637
Conclusion 639
References 639
unscheduled diversion and landing at the nearest suitable
airport, or the aircraft may return to the airport of origin
or continue on to the planned destination, depending on
the circumstances.
Pre-flight assessment and medical clearance
The objectives of medical clearance are to provide advice to
passengers and their medical attendants on fitness to fly, and
to prevent delays and diversions of the flight as a result of
deterioration in the passenger’s well-being. It depends upon
self-declaration by the passenger, and upon the attending
physician having an awareness of the flight environment
and how this might affect the patient’s condition.
Most major airlines provide services for those passen-
gers who require extra help, and most have a medical advi-
sor to assess the fitness for travel of those with medical
needs. Individual airlines work with their own guidelines,
but these are generally based on those published by the
Aerospace Medical Association (2003) on fitness for travel.
The International Air Transport Association (IATA)
publishes a recommended Medical Information Form
(MEDIF) for use by member airlines, and it is available
from the airline’s reservations department or web site. The
MEDIF should be completed by the passenger’s medical
attendant and passed to the airline, or travel agent,  at the
time of booking to ensure timely medical clearance.
Medical clearance is required when:
631
17/11/2015 16:13
 632  Commercial passenger fitness to fly
●● Fitness to travel is in doubt as a result of recent illness,
hospitalization, injury, surgery or instability of an acute
or chronic medical condition.
●● Special services are required (e.g. oxygen, stretcher or
authority to carry or use accompanying medical equip-
ment such as a ventilator or a nebulizer).
Medical clearance is not required for carriage of an
invalid passenger outside these categories, although special
needs (such as a wheelchair) must be reported to the airline
at the time of booking. Cabin crew members are unable to
provide individual special assistance to invalid passengers
beyond the provision of normal in-flight service. Passengers
unable to look after their personal needs during flight (such
as toileting or feeding) will be required to travel with an
accompanying adult who can assist.
It is vital that passengers carry with them any essential
medication, and not pack it in their checked-in hold baggage.
Deterioration on holiday or on a business trip of a previ-
ously stable condition – such as asthma, diabetes, or epi-
lepsy – or accidental trauma may give rise to the need for
medical clearance for the return journey. A stretcher may be
required, together with medical support, and this can incur
considerable cost. It is important for all travellers to have
adequate travel insurance, which includes provision for the
use of a specialist repatriation company to provide the nec-
essary medical support.
Assessment criteria
In determining the passenger’s fitness to fly, a basic knowl-
edge of aviation physiology and physics can be applied. Any
trapped gas will expand in volume by up to 30 per cent dur-
ing flight, and consideration must be given to the effects of
the relative hypoxia encountered at a cabin altitude of up
to 8000  ft above mean sea level. The altitude of the desti-
nation airport may also need to be taken into account
in deciding  the fitness of an individual to undertake a
particular journey.
The passenger’s exercise tolerance can provide a useful
guide on fitness to fly; if unable to walk a distance greater
than about 50  m without developing dyspnoea, there is a
risk that the passenger will be unable to tolerate the relative
hypoxia of the pressurized cabin. More specific guidance
can be gained from knowledge of the passenger’s baseline
sea level blood gas levels and haemoglobin concentration.
Table  40.1  shows the guidelines recommended by one
international carrier. This list is not exhaustive, and indi-
vidual cases might require assessment by the attending phy-
sician in consultation with a specialist in aviation medicine.
More detailed guidelines are published on-line by the IATA
(http://www.iata.org/whatwedo/safety/health/Documents/
medical-manual-2013.pdf) and by the Aerospace Medical
Association (AsMA) (http://www.asma.org/asma/media/
asma/Travel-Publications/medguid.pdf).
The prolonged period of immobility associated with long
haul flying can be a risk for those individuals predisposed to
K17577_C040.indd 632
develop deep venous thrombosis (DVT). Pre-existing risk
factors include:
●● Blood disorders and clotting factor abnormalities.
●● Cardiovascular disease.
●● Malignancy.
●● Major surgery.
●● Lower limb/abdominal trauma.
●● DVT history.
●● Pregnancy.
●● Oestrogen therapy (including oral contraception and
hormone replacement therapy).
●● Older than 40 years of age.
●● Immobilization.
●● Pathological body fluid depletion.
●● Smoking.
●● Obesity.
●● Varicose veins.
Although many airlines promote lower limb exercise via
the in-flight magazine or videos, and encourage mobility
within the cabin, those passengers known to be vulnerable
to DVT should seek guidance from their attending physi-
cian on the use of compression stockings and/or anti-coag-
ulants. There is currently no evidence that flying, per se, is
a risk factor for the development of DVT, but those at high
risk should avoid any form of prolonged immobilization.
CONSIDERATIONS OF PHYSICAL
DISABILITY OR IMMOBILITY
In addition to the reduction in ambient pressure and the rel-
ative hypoxia, it is important to consider the physical con-
straints of the passenger cabin. A passenger with a disability
must not impede the free egress of the cabin occupants in
case of emergency evacuation.
There is limited leg space in an economy class seat and
a passenger with an above-knee leg plaster or an ankylosed
knee or hip may simply not fit in the available space. The
long period of immobility in an uncomfortable position
must be taken into account, and it is imperative to ensure
adequate pain control for the duration of the journey, par-
ticularly following surgery or trauma.
Even in the premier class cabins with more available leg-
room, there are limits to space. To avoid impeding emer-
gency egress, immobilized or disabled passengers cannot be
seated adjacent to emergency exits, despite the availability
of increased leg room at many of these positions. Similarly,
a plastered leg cannot be stretched into the aisle because of
the conflict with safety regulations.
There is limited space in aircraft toilet compartments
and if assistance is necessary, a travelling companion
is required.
The complexities of the airport environment should not
be under-estimated, and must be considered during the
assessment of fitness to fly. The formalities of check-in and
departure procedures, particularly security clearance, are
17/11/2015 16:13
 Considerations of physical disability or immobility  633

Table 40.1  Guidelines for medical clearance

Category Do not accept Remarks

Cardiovascular disorders Uncomplicated myocardial infarction within Myocardial infarction less than 21 days requires
7 days MEDIF assessment
Uncontrolled heart failure
Open heart surgery within 10 days This includes CABG and valve surgery
MEDIF assessment required up to 21 days
post-op
Transpositions, ASD/VSD, transplants etc. will
require discussion with airline medical adviser
Circulatory disorders Active thrombophlebitis of lower limbs
Bleeding/clotting conditions Recently commenced anti-coagulation therapy
requires assessment
Blood disorders
Hb less than 7.5 g/dL MEDIF assessment required for Hb less than
10 g/dL
History of sickling crisis within 10 days
Respiratory disorders Pneumothorax which is not fully inflated, or
within 14 days after full inflation
Major chest surgery within 10 days MEDIC assessment required up to 21 days post
surgery
If breathless after walking 50 m on ground Consider mobility and all aspects of total
or on continuous oxygen therapy on journey
ground
Gastrointestinal General surgery within 10 days Laparoscopic investigation may travel after 24 h
disorders if all gas absorbed. Laparoscopic surgery
requires MEDIF up to 10 days
GI tract bleeding within 24 h MEDIF required up to 10 days
CNS disorders Stroke including subarachnoid haemorrhage Consider mobility/oxygenation aspects. MEDIF
within 3 days up to 10 days
Generalized seizures within 24 h Petit mal or minor twitching – common sense
prevails
Brain surgery within 10 days Cranium must be free from air
ENT disorders Penetrating eye injury/intraocular surgery If gas in globe, total absorption necessary – may
within 1 week be up to 6 weeks, specialist check necessary
Acute psychiatric Unless escorted, with appropriate MEDIF required. Medical, nursing or highly
disorders medication carried by escort, competent competent companion/relative escort
to administer such
Pregnancy After end of 36th week for single Passenger advised to carry medical certificate
uncomplicated
After end of 32nd week for multiple
uncomplicated
Neonates Within 48 h Accept after 48 h if no complications present
Infectious disease If in infectious stage As defined by the American Public Health
Association (Benenson)
Terminal illness Until individual case assessed by airline Individual case assessment
medical advisor
Decompression Symptomatic cases (bends, staggers, etc.) May need diving or aviation physician advice
within 10 days
Scuba diving Within 24 h
Fractures in plaster Within 48 h unless splint bi-valved Extent, site and type of plaster may allow
relaxation of guidelines. Exercise caution with
fibreglass casts
Burns Consult airline medical adviser

K17577_C040.indd 633 17/11/2015 16:13

 634  Commercial passenger fitness to fly

demanding and can be stressful, and may be compounded IN-FLIGHT MEDICAL EMERGENCIES
by illness and disability, as well as by language difficulties
or jet lag. An in-flight medical emergency is defined as a medical
The operational effect of the use of equipment such as occurrence requiring the assistance of the cabin crew. It may
wheelchairs, ambulances and stretchers must be taken into or may not involve the use of medical equipment or drugs,
account, and the possibility of aircraft delays or diversion and may or may not involve a request for assistance from a
to another airport must be considered. It may be necessary medical professional travelling as a passenger on the flight.
to change aircraft and transit between terminals during the It can be something as simple as a headache or a vaso-vagal
course of a long journey, and landside medical facilities will episode, or something major such as a myocardial infarc-
not be available to a transiting passenger. tion or impending childbirth.
There is often a long distance between the check-in desk The incidence is comparatively low, although the media
and the boarding gate. Not all flights depart from or arrive impact of an event can be significant. One major interna-
to jetties, and it may be necessary to climb up or down stairs tional airline reported 3022  incidents occurring in some-
and board transfer coaches. Passengers should specify the thing over 34  million passengers carried in one year. The
level of assistance required when booking facilities such breakdown of these incidents into generalized causes is
as wheelchairs. shown in Table  40.2  (Bagshaw 1996; Bagshaw and Byrne
1999).
SCHEDULED OXYGEN The top six in-flight emergency medical conditions
reported by the same airline are shown in Table  40.3
In addition to the main gaseous system, all commercial air- (Bagshaw 1996; Bagshaw and Byrne 1999). Similar results
craft carry an emergency oxygen supply for use in the event have been reported by other airlines, but the data are based
of failure of the pressurization system or during emergen- on incidents and conditions reported by non-medically
cies such as fire or smoke in the cabin. The passenger sup- qualified crew members, and may not be completely accu-
ply is delivered through drop-down masks from chemical rate (Sirven et  al. 2002; Delaune et  al. 2003; Ruskin 2009;
generators or an emergency reservoir, and the crew sup- Sand et al. 2009; Shaner 2010; Valani et al. 2010; Mahoney
ply is from oxygen bottles strategically located within the et al. 2011; Mattison and Zeidel 2011).
cabin. The drop-down masks are automatically released Any acute medical condition occurring during the
en masse (the so-called ‘rubber jungle’) in the event of the course of a flight can be alarming for the passenger and crew
cabin altitude exceeding a pre-determined level of between because of the remoteness of the environment. The cabin
10 000 and 14 000 feet. This passenger emergency supply has
a limited duration if provided by chemical generators, usu- Table 40.2  In-flight incidents reported in one year by a
ally in the region of 10–15 minutes. The flow rate is between major airline
4 and 8 L (NTP)/min, and is continuous once the supply is
Type of medical incident %
triggered by the passenger pulling on the connecting tube.
Oxygen supplied from a reservoir of liquid or gaseous gas is Gastrointestinal system 22.3
delivered to the cabin via a ‘ring main’, and in some aircraft Cardiovascular system 21.8
it is possible to plug a mask into this ring main to provide Musculo-skeletal system/skin 13.4
supplementary oxygen for a passenger. Central nervous system 15.5
Airworthiness regulations require the carriage of suffi- Respiratory system 10.2
cient first aid oxygen bottles to allow the delivery of oxygen Uro-genital system 3.3
to a passenger in case of a medical emergency in-flight, at a Metabolic system 2.5
rate of 2 or 4 L (NTP)/min. This cannot be used to provide Oto-rhino-laryngology (ENT) 1.4
a pre-meditated supply for a passenger requiring it continu- Miscellaneous 9.6
ously throughout a journey however, since it would then not
Total 3022 incidents in 34 million passengers.
be available for emergency use.
If a passenger has a condition requiring continuous
(‘scheduled’) oxygen for a journey, this needs pre-notifica- Table 40.3  Six most common in-flight medical incidents
tion to the airline at the time of booking the ticket. Most air- reported in one year by a major airline
lines make a charge to contribute to the cost of its provision. Type of medical incident %
Normally, it is not possible for a passenger to supply his
Faint 14.9
or her own oxygen. Oxygen bottles, regulators and masks
Diarrhoea 11.5
must meet minimum safety standards set by the regulatory
Head injury 6.3
authorities, and the oxygen must be of ‘aviation’ quality,
which is a higher specification than ‘medical’ quality with Vomiting 6.1
respect to water content. For further information regard- Collapse 5.4
ing therapeutic oxygen for airline passengers, see websites: Asthma 4.9
www.medaire.com and www.airsep.com. Total 3022 incidents in 34 million passengers.

K17577_C040.indd 634 17/11/2015 16:13


crew receive training in advanced first aid and basic life
support and the use of the emergency medical equipment
carried on board the aircraft. Many airlines give training in
excess of the regulatory requirement, particularly when an
extended range of medical equipment is carried.
GOOD SAMARITANS
Although the crew are trained to handle common medical
emergencies, in serious cases they may request assistance
from a medical professional travelling as a passenger. Such
assisting professionals are referred to as ‘Good Samaritans’.
Cabin crew members attempt to establish the bona fide of
medical professionals offering to assist, but much has to be
taken on trust.
The international nature of air travel can lead to com-
plications in terms of professional qualification and certi-
fication, specialist knowledge and professional liability. An
aircraft in flight is subject to the laws of the state in which
it is registered, although when not moving under its own
power (i.e. stationary at the airport) it is subject to the local
law. In some countries, it is a statutory requirement for a
medical professional to offer assistance to a sick or injured
person (e.g. France), whereas in other states no such law
exists (e.g. UK or USA).
Some countries (e.g. USA) have enacted a Good Samaritan
law, whereby an assisting professional delivering emergency
medical care within the bounds of his or her competence
is not liable for prosecution for negligence. In the UK,
the major medical defence insurance companies provide
indemnity for their members acting as Good Samaritans.
Some airlines provide full indemnity for medical pro-
fessionals assisting in response to a request from the crew,
whereas other airlines take the view that a professional
relationship is established between the sick passenger and
the Good Samaritan and any liability lies within that rela-
tionship. At the time of writing, there has been no case of
successful action against a Good Samaritan providing assis-
tance on board an aircraft.
Recognition by the airline of the assistance given by the
Good Samaritan is complicated by the special nature of the
relationship between the professional, the patient and the
airline. Indemnity, whether provided by the airline or the
professional’s defence organization, depends upon the fact
that a Good Samaritan act is performed.
If a professional fee is claimed or offered, the relation-
ship moves away from being that of a Good Samaritan act to
one of a professional interaction with an acceptance of clini-
cal responsibility. This implies that the professional is suit-
ably trained, qualified and experienced to diagnose, treat
and follow up the particular case, and the Good Samaritan
indemnity provision no longer applies.
Follow-up of the passenger after disembarkation is fre-
quently difficult because the sick passenger is no longer in
the care of the airline and becomes the responsibility of the
receiving hospital or medical practitioner who is bound by
the ethics of medical confidentiality.
K17577_C040.indd 635
Telemedicine 635
AIRCRAFT MEDICAL DIVERSION
Responsibility for the conduct of the flight rests with the
aircraft captain who makes the final decision as to whether
or not an immediate unscheduled landing or diversion is
required for the well being of a sick passenger. The captain
has to take into account operational factors as well as the
medical condition of the sick passenger.
In practice, it is rarely possible to land immediately
because even if a suitable airport is in the immediate vicin-
ity, the aircraft has to descend from cruising altitude, pos-
sibly jettison fuel to reduce to landing weight, and then fly
the approach procedure to land.
Consideration has to be given to the availability of appro-
priate medical facilities, and in many cases, it is of greater
benefit for the sick passenger to continue to the scheduled
destination where the advantage of appropriate facilities
will outweigh the risks of continuing the flight.
Operational factors to be considered include the suitabil-
ity of an airport to receive the particular aircraft type. The
runway must be of sufficient length and load bearing capac-
ity, the terminal must be able to accommodate the number
of passengers on the flight, and if the crew go out of duty
time, there must be sufficient hotel accommodation to allow
an overnight stay of crew and passengers.
The cost to the airline may be substantial, including
the effects of aircraft and crew unavailability for the next
scheduled sector, as well as the direct airport and fuel costs
of the diversion. In making the decision whether or not
to divert, the captain will take advice from all sources. If
a Good Samaritan is assisting, he or she has an important
role to play, perhaps in radio consultation with the airline
medical advisor.
TELEMEDICINE
Many airlines use an air-to-ground link, which allows the
crew members and/or the Good Samaritan to confer with
the airline medical adviser regarding the diagnosis, treat-
ment and prognosis for the sick passenger. The airline oper-
ations department is also involved in the decision-making
process. Some airlines maintain a worldwide database of
medical facilities available at or near the major airports;
others subscribe to a third party provider giving access
to immediate medical advice and assistance with arrang-
ing emergency medical care for the sick passenger at the
diversion airport.
The link from the aircraft is made using radio-telephone
voice or data link (VHF or ACARS), high-frequency radio
communication (HF) or a satellite communication system
(Satcom). Satcom is installed in modern long-range aircraft,
and is gradually replacing HF as the industry norm for long-
range communication. The advantage is that Satcom is unaf-
fected by terrain, topography or atmospheric conditions,
and allows good transmission of voice and data from over
any point on the globe. Digitization and telephone trans-
mission of physiological parameters is a well established
17/11/2015 16:13
 636  Commercial passenger fitness to fly

practice, particularly in remote areas of the world. An air-
craft cabin at 37 000 ft can be considered a remote location
in terms of availability of medical support, and the digital
technology used in Satcom is similar to that used in modern
ground-to-ground communication. The advent of Satcom
has enabled the development of air-to-ground transmis-
sion  to assist in diagnosis. Pulse oximetry and ECG are
examples of data that can assist the medical advisor to give
appropriate advice to the aircraft captain, although the cost/
benefit analysis of installing such equipment and training
crew in its use has to be weighed very carefully.
AIRCRAFT EMERGENCY MEDICAL
EQUIPMENT
National regulatory authorities stipulate the minimum
scale and standard of all equipment to be carried on aircraft
operating under their jurisdiction, which includes emer-
gency medical equipment. These standards stipulate the
minimum requirement, although in practice many airlines
carry considerably more equipment.
Tables 40.4 and 40.5 give the minimum standard of equip-
ment mandated by the Federal Aviation Administration

Table 40.4  Federal Aviation Regulations Part 121: first aid and emergency medical kits

First aid kits Emergency medical kits

Approved first-aid kits required by 8121.309 must meet the The approved emergency medical kit required by 8121.309
following specifications and requirements: for passenger flights must meet the following
specifications and requirements:
(1) Each first-aid kit must be dust and moisture proof, and (1) Approved emergency medical equipment shall be
contain only materials that either meet Federal stored securely so as to keep it free from dust, moisture
Specification GG-K-291a, as revised, or are approved and damaging temperatures
(2) Required first-aid kits must be distributed as evenly as (2) One approved emergency medical kit shall be provided
practicable throughout the aircraft and be readily for each aircraft during each passenger flight and shall be
accessible to the cabin flight attendants located so as to be readily accessible to crew members
(3) The approved emergency medical kit must contain, as
The minimum number of first-aid kits required is set forth in a minimum, the following appropriately maintained
the following table: contents in the specified quantities:
No. of
first aid
No. of passenger seats kits
0–50 1
51–150 2
151–250 3
More than 250 4
(4) Except as provided in paragraph (5), each first-aid kit must
contain at least the following or other approved contents:
Contents Quantity Contents Quantity
Adhesive bandage compresses, 10-inch 16 Sphygmomanometer 1
Antiseptic swabs 20 Stethoscope 1
Ammonia inhalants 16 Airways, oropharyngeal (3 sizes) 3
Bandage compresses, 4 inch 8 Syringes (sizes necessary to administer required 4
Triangular bandage compresses, 10 inch 5 drugs)
Burn compound, 1/8-ounce or an equivalent of 6 Needles (sizes necessary to administer required 6
other burn remedy drugs)
Arm splint, non-inflatable 1 50% Dextrose injection 50 cc 1
Leg splint, non-inflatable 1 Epinephrine 1:1000, single dose ampule or 2
Roller bandage, 4 inch 4 equivalent
Adhesive tape, 1 inch standard roll 2 Diphenhydramine Hcl injection, single dose 2
ampule or equivalent
Bandage scissors 1
Nitroglycerin tablets 10
Basic instructions for use of the drugs in the kit 11
(5) Arm and leg splints that do not fit within a first-aid kit
may be stowed in a readily accessible location that is as
near as practicable to the kit

K17577_C040.indd 636 17/11/2015 16:13


(FAA) to be carried by aircraft registered in the USA, while
Table 40.6 gives the standard determined by the European
Aviation Safety Authority (EASA) for aircraft registered
in European states (see ECAC Manual on Air Passenger
Health Issues, https://www.ecac-ceac.org/file_pub/file.
php?idDoc=4672; ECAC Recommendation ECAC/28-1  of
13  April 2005: https://www.ecac-ceac.org/file_pub/file.
php?idDoc=4599).
In determining the type and quantity of equipment and
drugs to include in the medical kits, the airline must obvi-
ously fulfil the statutory requirements laid down by the reg-
ulatory authority. Other factors to be considered are:
Table 40.5  US Aviation Medical Assistance Act (1998)
Rule issued by Federal Aviation Administration (FAA),
April 2001
US Aircraft weighing more than 7500 lb and having at
least one flight attendant must carry an automated
external defibrillator (AED) and enhanced medical kit
(EMK) on all domestic and international flights within
3 years
The following items will be added to each EMK
Oral antihistamine
Non-narcotic analgesic
Aspirin
Atropine
Bronchodilator inhaler
Lidocaine and saline
IV administration kit with connectors
CPR masks
An EMK is already equipped with
Sphygmomanometer (measures blood pressure)
Stethoscope
Three sizes of airways (breathing tubes)
Syringes
Needles
50% dextrose injection (for hypoglycaemia or insulin
shock)
Epinephrine (for asthma or acute allergic reactions)
Diphenhydramine (for allergic reactions)
Nitroglycerine tablets (for cardiac-related pain)
Basic instructions on the use of the drugs
Latex gloves
All crew members will receive initial training on the EMK
and on the location, function, and intended operation
of an AED. Flight attendants will receive initial and
recurrent training in CPR and on the use of AEDs.
Medical personnel are frequently onboard and can
assist fellow passengers during an in-flight medical
event. In addition, a ‘Good Samaritan’ provision in the
Aviation Medical Assistance Act of 1998 limits the
liability of air carriers and non-employee passengers
unless the assistance is grossly negligent or wilful
misconduct is evident
K17577_C040.indd 637
Resuscitation equipment  637
●● The route structure and stage lengths flown. Different
countries of the world vary in their regulations on what
might be imported and exported, particularly in terms
of drugs. For example, it is illegal to import morphine
derivatives into the USA, even if securely locked in a
medical kit.
●● Passenger expectations. Premier class business pas-
sengers from the developed world expect a higher
standard of care and medical provision than pas-
sengers travelling on a relatively inexpensive package
holiday flight.
●● Training of cabin crew. The crew must have a knowl-
edge and understanding of the kit contents, for use
by themselves or in assisting a Good Samaritan. They
must be proficient in first aid, resuscitation and basic
life support.
●● Differences in medical cultures. Ideally, the kit contents
should be familiar to any Good Samaritan irrespec-
tive of nationality or training. Some authorities require
information and drug names to be given in more than
one language.
●● Equipment and drugs appropriate for likely medical
emergencies. It is important to audit the incidence and
outcome of in-flight medical emergencies and maintain
a review of the kit content. This review should also take
into account changes in medical practice.
●● Space and weight. The medical equipment must be
accessible, but securely stowed. Some airlines divide
the equipment and drugs between basic first-aid kits,
which are readily accessible on the catering trolleys,
and a more comprehensive emergency medical kit that
is sealed and stowed with other emergency equipment.
Space and weight are always at a premium within the
cabin, and the medical kits must be as light and com-
pact as possible.
●● Shelf life and replenishment. A tracking system for
each kit must be in place to ensure that contents have
not exceeded their designated shelf life. Similarly,
after use of a kit, there has to be a procedure for
replenishment. In practice, the aircraft can depart
if the kit contents meet the statutory minimum,
even though drugs or equipment have been used
from the non-statutory part of the kit. Many airlines
subcontract the tracking and replenishment to a
specialist medical supply company.
RESUSCITATION EQUIPMENT
Although basic cardiopulmonary resuscitation (CPR) tech-
niques are an essential part of cabin crew training, the
outcome of an in-flight cardiac event may be improved if
appropriate resuscitation equipment is available. This can
range from a simple mouth-to-mouth face guard, to a resus-
citation bag and mask and airway, to an endotracheal tube
and laryngoscope, to an automatic external defibrillator
(AED).
17/11/2015 16:13
 638  Commercial passenger fitness to fly

Table 40.6  European Requirements: EU-OPS 1 sub-part L

First-aid kits Disposable gloves
Equipment Needle disposal box
Bandages (assorted sizes) Urinary catheter (2 sizes) and anaesthetic gel
Burn dressings (unspecified) Basic delivery kit
Adhesive dressings (assorted sizes) Bag-valve masks (masks 2 sizes: 1 for adults, 1 for
Adhesive tape children)
Adhesive wound closures Thermometer – non mercury
Safety pins Forceps
Scissors* Intubation set
Antiseptic wound cleaner Aspirator
Disposable resuscitation aid Blood glucose testing equipment
Disposable gloves Scalpel1
IV cannulae (if IV fluids are carried in the FAK a sufficient Automated external defibrillator†
supply of IV cannulae should be stored there as well) Instructions
Medications A list of contents (medications in trade names and
Simple analgesic – may include liquid form generic names) in at least 2 languages (English and one
Antiemetic other). This should include information on the effects
Nasal decongestant and side effects of medications carried. Basic
Gastrointestinal antacid instructions for use of the medications in the kit. ACLS
Anti-diarrhoeal medication Cards (summarizing and depicting the current
algorithm for Advanced Cardiac Life Support)
Bronchial dilator spray
Medications
Other
Coronary vasodilator
A list of contents (medications in trade names and
generic names) in at least 2 languages (English and one Anti-spasmodic
other). This should include information on the effects Epinephrine/adrenaline 1:1 000
and side effects of medications carried. Adrenocortical steroid
First-Aid handbook Major analgesic
Medical incident report form Diuretic, e.g. furosemide
Biohazard disposal bags Antihistamine, oral and injectable form
Ground/Air visual signal code for use by survivors Sedative/anticonvulsant, injectable rectal and oral forms
Note: An eye irrigator whilst not required to be carried in of sedative
the first-aid kit should, where possible, be available for Medication for hypoglycaemia, e.g. hypertonic glucose
use on the ground Antiemetic
Emergency medical kit Atropine
Equipment Bronchial dilator – injectable and inhaled form
Sphygmomanometer – non mercury IV fluids, in appropriate quantity
Stethoscope Acetylsalicylic acid (aspirin) 300 mg in oral and/or
Syringes and needles injectable form
IV cannulae (if IV fluids are carried in the FAK a sufficient Antiarrhythmic
supply of IV cannulae should be stored there as well) Antihypertensive medication
Oropharyngeal airways (3 sizes) Injectable antibiotic
Tourniquet

*For security reasons items like scalpel and scissors should be stored securely.
†Should be carried on the aircraft – not necessarily in the emergency medical kit.

The decision on the scale of equipment to be carried has
to take account of the same parameters used in determining
the content of the emergency medical kits (Table 40.5).
In addition, a cost/benefit analysis has to balance the cost
of acquisition, maintenance and training against the prob-
ability of need and the expectation of the travelling public.
The European Resuscitation Committee and the
American Heart Association endorse the concept of early
defibrillation as the standard of care for a cardiac event
both in and out of the hospital setting. However, the pro-
tocol includes early transfer to an intensive care facility for
continuing monitoring and treatment, which is not always
possible in the flight environment.
Despite this inability to complete the resuscitation chain,
it is becoming increasingly common for commercial air-
craft to be equipped  with AEDs and for the cabin crew

K17577_C040.indd 638 17/11/2015 16:13


to be trained in their use. This has been mandated in the
USA by the FAA (Table 40.5) and recommended by EASA
(Table 40.6). Experience of those airlines which carry AEDs
indicates that there may be benefits to the airline operation
as well as to the passenger. Some types of AED have a cardiac
monitoring facility, and this can be of benefit in reaching
the decision on whether or not to divert. For example, there
is no point in initiating a diversion if the monitor shows
asystole, or if it suggests that the chest pain is unlikely to be
cardiac in origin.
Lives have been saved by the use of AEDs on aircraft and
diversions have been avoided, so it could be argued that the
cost/benefit analysis is weighted in favour of carrying AEDs
as part of the aircraft medical equipment. Nonetheless, it is
important that unrealistic expectations are not raised. An
aircraft cabin is not an intensive care unit and the AED forms
only a part of the first aid and resuscitation equipment.
Many airlines have in place a procedure for the follow-
up of crew members involved in a distressing event, such
as a serious medical emergency. This can be valuable in
avoiding long term post-traumatic  stress disorder, and
also in reinforcing the training that the crew member has
already undergone.
CONCLUSION
The passenger cabin of a commercial airliner is designed
to carry the maximum number of passengers in safety and
comfort, within the constraints of cost effectiveness. It is
incompatible with providing the facilities of an ambulance,
an emergency room, an intensive care unit, a delivery suite,
or a mortuary.
The ease and accessibility of air travel to a population of
changing demographics inevitably means that there are those
who wish to fly who may not cope with the hostile physical
environment of the airport, or the hostile physiological envi-
ronment of the pressurized passenger cabin. It is important
for medical professionals to be aware of the relevant factors,
and for unrealistic public expectations to be avoided.
Most airlines have a medical advisor who may be con-
sulted before flight to discuss the implications for a particu-
lar passenger. Such pre-flight notification can prevent the
development of an in-flight medical emergency that is haz-
ardous to the passenger concerned, inconvenient to fellow
passengers, and expensive for the airline.
For those with disability, but not an acute medical prob-
lem, pre-flight notification of special needs and assistance
will reduce the stress of the journey and enhance the stan-
dard of service delivered by the airline.
The importance of adequate medical insurance coverage
for all travellers cannot be over-emphasized. Finally, as is
normal practice in commercial aviation, there is a continu-
ing audit of activity and an on-going risk/ benefit analy-
sis. The industry is under constant evolution, and is now
truly global in its activity. Application of basic physics and
physiology, and an understanding of how this may affect
underlying pathology, will minimize the medical risks to
K17577_C040.indd 639
References 639
the travelling public (Aerospace Medical Association 2003;
British Medical Association 2004).
SUMMARY
●● Flying as a passenger should be no problem for
the fit, healthy, and mobile individual, but for the
passenger with certain pre-existing conditions,
the cabin environment may exacerbate their
underlying problems.
●● Although many problems relate to the physiologi-
cal effects of hypoxia and expansion of trapped
gases, the complex airport environment can be
stressful and challenging to the passenger, lead-
ing to problems before even getting airborne.
●● Whereas passengers with medical needs require
medical clearance from the airline to travel, pas-
sengers with disabilities do not.
●● The objectives of medical clearance are to provide
advice to passengers and their medical atten-
dants on fitness to fly, and to prevent delays and
diversions of the flight as a result of deterioration
in the passenger’s well-being. It depends upon
self-declaration by the passenger, and upon the
attending physician having an awareness of the
flight environment and how this might affect the
patient’s condition.
●● An in-flight medical emergency will initially
be dealt with by the cabin crew, who may make
use of the on-board emergency medical kit. In
some cases, advice will be taken from a ground-
based medical professional utilizing radio or
satellite communication.
●● The importance of adequate medical insur-
ance coverage for all travellers cannot be
over-emphasized.
REFERENCES
Aerospace Medical Association. Medical Guidelines for
Airline Travel, 2nd ed. Aviation, Space, Environmental
Medicine 2003; 74(5) II: A1–19.
Bagshaw M. Telemedicine in British Airways. Journal of
Telemedicine and Telecare 1996; 2(1): 36–8.
Bagshaw M, Byrne NJ. La sante des passagers. Urgence
Pratique 1999; 36: 37–43.
British Medical Association. The Impact of Flying on
Passenger Health (May 2004). Available from www.
bma.org.uk.
Delaune EF, Lucas RH, Illig P. In-flight medical events and
aircraft diversions: one airline’s experience. Aviation,
Space, and Environmental Medicine 2003; 74: 62–8.
ECAC Manual on Air Passenger Health Issues. Available
from https://www.ecac-ceac.org/file_pub/file.
php?idDoc=4672.
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 640  Commercial passenger fitness to fly
ECAC Recommendation ECAC/28-1 of 13 April 2005.
Available from https://www.ecac-ceac.org/file_pub/
file.php?idDoc=4599.
Mahony PH, Myers JA, Larsen PD, et al. Symptom-based
categorization of in-flight passenger medical incidents.
Aviation, Space, and Environmental Medicine 2011;
82(12): 1131–7.
Mattison MLP, Zeidel M. Navigating the challenges
of in-flight emergencies. Journal of the American
Medical Association 2011. Published online May 6,
2011.
Ruskin KJ. In-flight medical emergencies: time for a regis-
try. Critical Care 2009; 13(1): 121.
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Sand M, Bachara FG, Sand D, Mann B. Surgical and
medical emergencies on board European aircraft; a
retrospective study of 10189 cases. Critical Care 2009;
13: R3.
Shaner DM. Up in the air-suspending ethical medical prac-
tice. New England Journal of Medicine 2010; 363(21):
1988–9.
Sirven JL, Claypool DW, Sahs KL, et al. Is there a neurolo-
gist on this flight? Neurology 2002; 58: 1739–44.
Valani R, Cornacchia M, Kube D. Flight diversions due
to onboard medical emergencies on an international
commercial airline. Aviation, Space, and Environmental
Medicine 2010; 81(11): 1037–40.
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Military aeromedical evacuation
IAN A. MOLLAN
Introduction 641
History 641
General principles 642
Forms of military AE 642
Categorization of patients 643
Aircraft considerations 643
INTRODUCTION
Aeromedical evacuation (AE) can be simply defined as the
movement of patients by air. It involves a wide spectrum of
clinical care and utilizes a wide range of aerial vehicles. AE
provides movement for ill and injured personnel from the
point of wounding (or illness) to medical facilities and also
between medical facilities, both within the theatre of opera-
tions and beyond. AE provides key advantages when com-
pared with other evacuation methods, particularly when
speed, range and accessibility are not practical by the other
options, either due to patient clinical acuity, geography or
the location of medical assets. By its very nature, AE needs
to be flexible, responsive and must provide for the clinical
care needs between the points in the evacuation chain in
which it operates. Patients for AE can be stable, stabilized
or unstable. Stable patients require minimal treatment in
flight, but will often require careful observation because the
demands of the flight environment may impose physiologi-
cal stress which may cause their condition to deteriorate.
Stabilized patients will have received initial treatment but
will be moved for urgent treatment elsewhere. They require
careful observation and treatment in flight, but they will
usually have a stabilized airway, haemorrhage will be con-
trolled and fluid replacement may be in progress, and any
fractures will be stabilized. Stabilized patients have a higher
risk of medical decompensation than patients who are sta-
ble. Unstable patients are moved by air only when they can-
not be treated before flight. They require a full medical team
K17577_C041.indd 641
41
Organization of AE 644
General medical considerations 644
Clinical considerations 645
Future of AE 647
Further reading 648
with resuscitation and airway-management skills. By defi-
nition, their condition is life-threatening and the purpose
of AE is to bring them as quickly as possible to a medical
facility capable of stabilizing them.
Without AE, mortality and morbidity would be
increased; deployed medical facilities would become satu-
rated. Today’s AE provides expedient and swift patient
movement through escalating levels of medical facilities,
reducing the overall need for bed spaces, specialist person-
nel and equipment in the deployed environment. Current
rapidly mobile forces with a light forward medical pres-
ence rely heavily on the system of AE linking casualties
to life-saving medical care. Survival rates in the traumati-
cally injured in the most recent conflict in Afghanistan are
the highest ever in the history of warfare. This chapter will
examine the background of AE, investigate its principles,
forms, differences from civilian patient movement and look
forward to its future.
HISTORY
The history of AE is nearly as old as powered flight itself.
Although often anecdotally quoted, the evacuation of
patients via balloon during the siege of Paris in 1870 during
the Franco-Prussian War is not supported in contempora-
neous record. The birthplace of AE does, however, appear to
be within Europe. Marie Marvingt from France ordered the
construction of an air ambulance in 1912; sadly however, the
factory in which it was to be built failed in 1913. A colleague
641
17/11/2015 16:13
 642  Military aeromedical evacuation
and French medical officer, Dr Eugene Chassaing, con-
vinced the French Government to allow him to test the air
ambulance concept by converting a Dorand AR-2 into the
first documented air ambulance. This flew demonstration
and test flights at Villacoublay in October 1917 and later flew
in combat operations at Moulin de Laffroux on the Aisne
Front in November of the same year. AE was not used to any
great extent in the First World War; the seriously injured
were expected to die irrespective of medical care given and
they were unlikely to return to fighting duties. Between the
two world wars, Great Britain, France and the United States
all used modified aircraft to transport patients.
During the Second World War, there was a rapid expan-
sion in casualty movement by air. The Vietnam War dem-
onstrated the particular suitability of the helicopter for the
rapid removal of injured personnel close from the point of
wounding. Because of the ‘scoop-and-run’ system, no sol-
dier was more than 35 minutes from a medical facility and
rapid transfer to specialized medical care almost certainly
contributed to the lower mortality rate of wounded casual-
ties in Vietnam compared with earlier conflicts. During the
recent conflicts in Iraq and Afghanistan, the utilization of
air assets to move injured and the unwell has increased and
the death rate has continued to reduce since Vietnam. The
successes in mortality and morbidity are due to the efficient
and far-forward deployment of medical care, improved
training and protective equipment for military combatants
and the high capabilities and availability of AE assets, both
aircraft and appropriately trained personnel.
GENERAL PRINCIPLES
Military AE is not confined solely to patient movements
conducted on military aircraft; military personnel are
employed globally and may require repatriation on non-
military assets, including civilian airliner or air ambulance.
A range of in-flight medical care can be provided: a flight
medic, flight nurse or more specialized capabilities which
could include critical care. There are, however, a number of
fundamental principles that should be considered when AE
is proposed for any patient:
●● AE must offer a clear advantage to the patient. This may
be obvious when more sophisticated medical care is
required urgently, however the advantage of AE has to
Table 41.1  Forms of military AE
Name Description
Forward AE Medically escorted patient movement from the
point of wounding to the first medical facility.
May include those injured or unwell
Tactical AE Medically escorted patient movement between
medical facilities within a theatre of operations
Strategic AE Medically escorted patient movement away from
a theatre of operations
K17577_C041.indd 642
be weighed against the benefits of maintaining medi-
cal care on the ground and the potential complications
of AE.
●● AE is not a therapeutic intervention, however it does
have side effects and complications.
●● AE requires careful planning and risk assessment to
ensure that potential problems are anticipated and pro-
vided for; all aspects of the patient journey and poten-
tial care requirements throughout need consideration
and mitigation.
●● Although there are no absolute contraindications to
AE, some medical problems can place a heavy burden
on the AE team or require a very high level of care to be
provided in the air.
●● Patients must be reassessed regularly throughout the
AE process.
FORMS OF MILITARY AE
The North Atlantic Treaty Organization (NATO) terms the
non-medically supervised, or opportunistic movement of
the injured or unwell from the battlefield, casualty evacu-
ation (CASEVAC); this is not a medical function and will
not be considered further in this chapter. However, the
medically supervised process termed medical evacuation
(MEDEVAC) and its different forms via air transportation
assets (AE) are shown in Table 41.1.
An AE system can comprise up to three forms: forward,
tactical and/or strategic, depending on the nature of the
military deployment.
Forward AE
Forward AE is the medically escorted movement of patients
from the point of wounding to the first medical facility. It
requires speed and flexibility and it is therefore usual for
this function to be carried out on rotary wing assets. Two
broad strategies could be provided: either ‘scoop-and-run’,
or ‘stay-and-play’. The operational situation may preclude
‘stay-and-play’, so to be medically effective the capability
must be able to balance speed of delivery to an appropri-
ate medical facility for those severely traumatically injured,
with the ability to provide life-saving care in the air. The key
medical capabilities which forward AE assets could provide
are listed in Table 41.2.
Example
Helicopter movement of a casualty with a Medical
Emergency Response Team (MERT), or military
Search and Rescue (SAR)
Helicopter or fixed wing movement of patients
between medical facilities for medical treatment, or
to a hub from which strategic AE can be obtained
Usually fixed wing (due to the distances involved)
17/11/2015 16:13

Table 41.2  Medical capabilities for forward AE
Treatment area Medical capabilities
Catastrophic Combat Application Tourniquet
haemorrhage (CAT)
Israeli First Field Dressing (FFD)
Early intervention, High quality pre-hospital trauma care
rapid evacuation with Medical Emergency Response
Team (MERT) operating within the
principles of the ‘golden hour’ and
‘platinum ten minutes’
Hypovolaemia, Intravenous access
acidosis and Intraosseous access
hypothermia Infusion systems
Blood product replacement (blood
and plasma)
Blood warming system
Survival blanket
Patient heating system
However, as forward AE capabilities do not exist in isola-
tion, their capability must be matched to ground medical
capabilities within the deployed, pre-hospital trauma care
and medical treatment facility environment. At the high
end, the capabilities of the Emergency Department have in
effect been projected forward into forward AE.
Tactical AE
Tactical AE is the medically escorted movement of patients
between medical facilities within a theatre of operations.
There are no specific rules which govern the type of aircraft
to be used, both helicopter and fixed wing aircraft may be
suitable. Patients may be moved either to obtain further
treatment which is not available at their current location,
or to a hub from which strategic AE can be obtained. In
tactical AE, transit time is relatively short when compared
to strategic movements. Nonetheless, the condition of the
patient must be maintained or enhanced during the transfer
and therefore the level of in-flight medical escorting must
be carefully considered. If the patient requires critical care
support on the ground, they will require at least the same
level of care in the air to prevent deterioration and/or death.
A high level of in-flight care may need to be provided to pre-
vent detrimental consequences, particularly for those with
traumatic injury who may only have recently been stabilized.
Strategic AE
Strategic AE is the medically escorted movement of patients
away from a theatre of operations. This may be directly to the
home country or via a hub. Due to the distances involved,
fixed wing aircraft are normally used. There are many con-
siderations when planning strategic AE. Specialized capabil-
ities up to and including a critical care team may be required
to safely transport some patients. Some nations possess
K17577_C041.indd 643
Aircraft considerations  643
super-specialized strategic AE capabilities which in extreme
circumstances have been made available to coalition part-
ners. Currently, some nations share strategic AE assets, while
others have reciprocal arrangements for ‘Inter-fly’, or the uti-
lization of one nation’s aircraft with another’s AE team and
equipment. This latter arrangement requires coordination
of equipment clearance procedures and is possible for com-
mon aircraft types, e.g. C-17 Globemaster. Special attention
should be given to the standards of care and their accredi-
tation when AE is subcontracted to civilian organizations.
CATEGORIZATION OF PATIENTS
The purpose of categorizing patients for AE is to give
medical, nursing and movements staff a simple and stan-
dardized means of assessing the degree of urgency, the
appropriate in-flight equipment and personnel required
and the space requirements for each patient. The theatre of
operations policy will dictate the classification system to
be used for forward AE. In Afghanistan, the Standardised
NATO Agreement (STANAG) 2087  system is used. For
strategic AE, the RAF and most other NATO members use
the STANAG 3204  system for priority, classification and
clinical dependency.
AIRCRAFT CONSIDERATIONS
There are many factors that determine the type of aircraft
used for any particular AE. Only some of these factors will be
medical. The distance the patient is required to move and the
type and length of the nearest landing strip or runway will
limit the choice of aircraft. In turn, the number of patients
and the complexity of the care they require will also deter-
mine the type of aircraft. Sophisticated medical equipment,
consumable supplies, oxygen cylinders and batteries to
power the equipment take up a considerable amount of room
and weight. The electrical equipment must also be checked
to make sure it does not interfere with the operation of the
aircraft; each nation will have its own testing requirements.
The compliance requirements for aircraft chartered from
the civilian register are laid out in the European Aviation
Safety Agency (EASA) Certification Specifications for Large
Aeroplanes CS25  and Federal Aviation Administration
(FAA) Code of Federal Regulations (CFR).
Stretcher access to the aircraft can also be critical. A
retractable ramp is ideal for stretcher loading, but not all
aircraft used for AE will have this facility. Although some
nations have the luxury of dedicated aircraft for AE, most,
particularly in war, will rely on opportunistic aircraft. These
will fly out to the theatre of operations loaded with person-
nel, materiel, and so forth, and then be reconfigured to carry
AE patients back home on the return trip. This requires the
reconfiguration of the aircraft, depending on the number
and type of patients.
The pressurization of the aircraft cabin is an impor-
tant factor in AE. All modern jet aircraft are pressurized
to a cabin altitude of 6000–8000 ft. Although most medical
17/11/2015 16:13
 644  Military aeromedical evacuation
conditions are unaffected by decreased pressure, several
conditions would be critically compromised by this alti-
tude, e.g.  decompression sickness or air in the cranium.
Requesting a ground level cabin altitude can place limita-
tions in terms of air space clearances, fuel and speed on the
operation of the aircraft. The cabin altitude will be such
as to cause a degree of hypoxia in some patients, particu-
larly those with cardiovascular and respiratory disorders.
Oxygen should be considered as potentially necessary in all
AE patients, especially those requiring intensive treatment.
Most aircraft used opportunistically for AE will not carry
medical oxygen, and this may have to be carried in large,
heavy cylinders.
If patients require intensive care during flight, then it is
essential that the medical team has room to operate around
the patient. This can become a problem when patients are
carried in tiers, when the space between patients for most
military AE configurations will be as little as 53  cm. If
procedures need to be carried out, then such patients will
require removal from the stretcher tier. Aircraft used in
civilian practice for single patients may also have limited
space. While the C-21 (Learjet 35) is highly effective for AE
as it requires little runway for take-off and has a good range
and speed, the cabin space is extremely limited with little
headroom and stretcher access is difficult.
The C-130 Hercules has been the workhorse for a great
deal of AE, particularly tactical. Its versatility in take-off
and landing, with its large capacity, make it very useful in
evacuating large numbers of patients from remote locations.
However, the noise level is between 95 and 100 dB, and aus-
cultation is impossible under these circumstances. Aircraft
recently used in the strategic AE role, such as the Lockheed
TriStar, are far more comfortable, are quieter and have bet-
ter temperature control than the C-130, but they could not
operate under the same operational conditions as the versa-
tile Hercules. The C-17 Globemaster has a huge capacity and
can land on almost any semi-improvised airfield. Access is
easy, both to the aircraft and to the stretcher patients when
they are accommodated on the stanchions. Noise levels are
low, lighting is excellent, and climate control is good. It has
been modified to supply piped oxygen to some patient litter
stations and has demonstrated its extremely useful capabili-
ties in recent years.
ORGANIZATION OF AE
When AE is requested, physician-to-physician referral is
always to the patient’s advantage. Whereas contact across
time zones, even with modern communications, does not
always allow for this personal contact, the receiving hospital
should always have notice of the patient’s arrival. After the
request has been made by the referring medical practitioner,
the patient should be assessed for AE. This will involve cat-
egorization and should be carried out by a medical practi-
tioner with experience in aviation medicine; sometimes this
is undertaken by a nurse. Liaison with the AE team should
also take place in order to enable the team to arrive with
K17577_C041.indd 644
the appropriate equipment and medical support. Ground
transport between the airheads and dispatching and receiv-
ing hospitals must always be arranged; usually, the AE team
will deliver patients to the receiving hospital. The patients’
records, including notes written during the flight and
details of any drugs given, should accompany them to the
receiving hospital.
At the time of the AE request and as part of the AE risk
assessment and tasking conducted by the Aeromedical
Evacuation Control Centre, consideration must be given to
potential cabin altitude restrictions, flight duration, num-
ber of sectors, aircraft serviceability and availability of
medical care facilities at intermediate airfields, and level
of in-flight escorting. Before the flight, the AE team leader
will confirm any specific points with the aircraft captain,
e.g. that of an altitude limitation. If the proposed mission
is to be conducted using a civilian airliner, passenger clear-
ance in accordance with IATA Resolution 700  and the
Medical Information (MEDIF) process must be obtained.
The stowage of equipment or disposition of stretchers will
be discussed either with the load master or the senior cabin
steward. AE in peacetime can be relatively straightfor-
ward, but in the operational setting it requires considerable
coordination of aircraft movements, the careful disposi-
tion and composition of the AE teams and the support of
receiving hospitals.
GENERAL MEDICAL CONSIDERATIONS
Gas expansion
At the highest cabin altitude expected during flight in a
pressurized aircraft (8000 ft), gas will increase in volume by
approximately 30 per cent. Gas trapped in body cavities can
cause pain on expansion; this is most likely to happen in
the ears, sinuses, gastrointestinal tract and, rarely, the teeth.
Such pain may be difficult to determine in comatose or dis-
oriented patients. Examination of the tympanic membrane
or abdomen may be necessary if the patient shows increased
irritability or agitation on ascent or descent.
Hypoxia
The decrease in barometric pressure in the cabin will cause
a corresponding fall in the partial pressure of oxygen in
inspired air. The barometric pressure at 8000  ft will be
565 mmHg, with an arterial oxygen pressure (PaO2) of about
55 mmHg. If this is plotted on the oxyhaemoglobin disso-
ciation curve, the blood oxygen saturation is 90  per cent.
Although healthy travellers can compensate for this degree
of hypoxaemia, in patients with pre-existing cardiac or
pulmonary disease or anaemia who already have a lowered
arterial oxygen pressure, this fall may be enough to bring
them to the steep part of the oxygen dissociation curve. This
may cause very low arterial oxygen saturation, resulting in
functional impairment. Oxygen may, therefore, be required
17/11/2015 16:13

in patients with certain medical conditions, even though
they appear well oxygenated before flight.
Vibration
Vibration is common in all forms of transport, particu-
larly in military transport aircraft and most helicopters.
It may interfere with patient assessment and physiological
monitoring, as well as having an effect on the patient per se.
Vibration increases metabolic rate, equivalent to that seen
in gentle exercise. It can also cause hyperventilation and
induce motion sickness, fatigue and irritability. To reduce
the effects of vibration, patients should be secured comfort-
ably and adequate padding should be provided.
Temperature control
Temperature decreases with increasing altitude at a rate of
2°C for every 1000  feet up to 35,000  feet. Aircraft collect-
ing patients from a desert environment and flying back to
a temperate climate at 35,000 feet may subject patients to a
considerable variation in cabin temperature. Sick patients
may also be in metabolic overdrive and may have lost their
thermoregulatory mechanisms. The AE team should, there-
fore, monitor cabin temperature changes and assess the
effect of these changes on their patients.
Noise
Noise, or ‘unwanted sound’, is another characteristic of
helicopters and military aircraft. It interferes with commu-
nication between the AE team and their patients and may
cause fatigue in both staff and patients. Communication
must continue using other methods. These will include
close observation and visual alarm systems. Auscultation
will be impossible, even with specially designed stetho-
scopes. Hearing protection should be worn by staff and
patients in aircraft such as the C-130 Hercules. Disposable
ear plugs or ear defenders should be available for patients,
while staff should be provided with a headset to attenuate
noise and facilitate communication between AE team mem-
bers and aircrew.
Airsickness
This is a variety of motion sickness and is characterized by
nausea, vomiting, pallor and cold sweating. It is a normal
response to unfamiliar motion and will, therefore, disap-
pear as personnel become adapted to the aircraft movement.
Patients, however, may suffer, particularly if the aircraft is
subject to turbulence during AE. If this is anticipated, or
if a patient has a previous history of airsickness, then an
anti-emetic can be given before take-off. Transdermal hyo-
scine is effective but will cause drowsiness. Medication is
unlikely to help once symptoms have occurred. Vomiting
due to airsickness should be avoided in patients who have
recently had any form of abdominal surgery, because of the
increased tension this could put on suture lines.
K17577_C041.indd 645
Clinical considerations  645
Fear of flying
A significant fear of flying is experienced by up to 15  per
cent of the population, with a proportion of this group being
handicapped socially and in their working lives by this
phobia. In the aeromedical situation, this could aggravate
a patient’s condition, making them more vulnerable to the
effects of vibration and airsickness. AE staff should be aware
of the frequency of this condition and should offer reassur-
ance and if necessary and appropriate clinically, mild seda-
tion to those affected. Patients may express anxieties to staff
on the AE team about flying, or they may betray signs of
anxiety such as hyperventilation, pallor and cold sweating,
especially during periods of turbulence.
Medication and time zones
On strategic AE missions, the aircraft may transit through
several different time zones. For medication that has been
started before the flight, it is easiest if the time it has been
given is converted into Coordinated Universal Time (UTC)
which is synonymous with GMT and ZULU, as military air-
craft itineraries are scheduled in UTC. The time and time
zone pertaining to the medication given should be anno-
tated clearly on the drug card and handed over to receiving
medical staff. For patients with type 1  diabetes, it should
be remembered that when travelling east, the travel day
will be shortened. If more than two hours are lost, then
it may be necessary to take fewer units of intermediate-
or long-acting insulin. When travelling west, the travel
day will be extended. If it is extended by more than two
hours, then it may be necessary to supplement with addi-
tional injections of soluble insulin or an increased dose of
intermediate-acting insulin.
CLINICAL CONSIDERATIONS
This section should be read in conjunction with the IATA
Medical Manual 6th edition (May 2013), UK Civil Aviation
Authority publication Assessing Fitness to Fly (2012) and the
Aerospace Medical Association Guidelines for Airline Travel
(2003). In general, the IATA guidance should be followed
to minimize risks to patients, however the operational situ-
ation may dictate that un-stabilized or stabilized patients
may require movement. In these situations, an appropriately
high level of in-flight medical escorting or cabin altitude
restriction can be provided to mitigate potential hazards
and their associated risks.
Cardiovascular conditions
Hypobaric hypoxia is the biggest threat to patients with
heart disease during AE. In addition to the guidance
above, the British Cardiovascular Society has published
clinical guidance on the fitness to fly for passengers with
cardiovascular disease.
17/11/2015 16:13
 646  Military aeromedical evacuation
The AE of a patient with cardiovascular disease may be
operationally required in advance of guidance on ‘safe-to-
fly’ timing and in these situations a higher level of in-flight
medical escorting should be provided, e.g. a physician and/or
critical care team. Patients should be monitored and supple-
mental oxygen should be available. The AE of any patient with
significant heart disease will require a full team that is able to
resuscitate, defibrillate, pace and ventilate, as necessary.
Respiratory disease
In addition the British Thoracic Society (BTS) has published
clinical guidance on the management of passengers with
stable respiratory disease planning air travel. An untreated
pneumothorax is a contraindication to AE and must be
corrected before flight. Unless this is done, there is a risk
that the pneumothorax will expand in flight and a tension
pneumothorax will develop. After successful drainage of
a pneumothorax, and following the BTS guidance in rela-
tion to timing of AE, patients can be aeromedically evacu-
ated with a chest drain in situ without the need for cabin
altitude restriction.
Neurological problems
All patients with head injury need careful assessment, both
before and during AE. Unconscious patients with head
injury need a secure airway and supplemental oxygen to
maintain maximal oxygenation and prevent any degree of
cerebral hypoxia.
Free air within the cranial cavity is hazardous in flight.
It may arise from a recent craniotomy, a penetrating head
wound or a basal skull fracture. The danger is that the air
will expand with increasing altitude and compress vital
structures or cause death. Cerebrospinal fluid (CSF) leak-
age may occur more rapidly with increasing altitude. On
descent, air and bacteria could be drawn back into the
cranium. The presence of air in the cranium can be deter-
mined by a lateral skull X-ray or computed tomography
(CT) scan. Ideally, patients should not fly within nine days
of a craniotomy, but if a patient with air in the cranium does
have to fly, then the cabin pressure must be kept the same as
that at the originating airfield (ground level cabin altitude).
Patients who have suffered a cerebrovascular event,
such as cerebral thrombosis or haemorrhage, already have
an impaired cerebral circulation, and any further cause of
cerebral hypoxia must be avoided. Ideally, the neurologi-
cal condition should be stable before flight. If they require
AE before this occurs, they will need supplemental oxygen
during flight.
Patients with space-occupying lesions (SOL) are safe to
fly, although the stresses of flight, particularly hypoxia, will
make the risk of seizures more likely in those already dis-
posed to seizures because of their SOL.
Following subarachnoid haemorrhage (SAH), 25 per cent
of patients will die within 24 hours and a further 25 per cent
will die within the first month. As the first week is the time
K17577_C041.indd 646
of maximum rebleeding, the aneurysm should be clipped as
soon as possible. As the risk of surgery is high if the patient
is unconscious, it is probably reasonable to fly a stable, con-
scious patient who has had a SAH if this is necessary in
order to obtain access to a neurosurgical facility.
Patients with idiopathic epilepsy are safe to fly if they are
stable, either on or off medication. However, patients with
uncontrolled or poorly controlled epilepsy are at risk, due to
the lowering of the convulsive threshold by hypoxia.
Haematological conditions
In military AE of the traumatically injured, acute anaemia
of less than 10  g/dL should warrant special consideration
as in-flight supplemental oxygen is likely to be required.
Severe anaemia (<7  g/dL) will accentuate the problems of
hypoxia and is a relative contraindication to AE, although
this judgement must take into account the chronicity and
cause of the anaemia, as well as the presence of any other
condition and the capabilities of the in-flight aeromedical
team. Although patients with chronic anaemia are more tol-
erant of their condition, for any given level of haemoglobin
(Hb), than those patients with an acute cause for their anae-
mia, a pre-flight blood transfusion may be necessary.
Surgical conditions
Air within the gastrointestinal tract or free within the
peritoneum are the main concerns, as this will increase
in volume with altitude. Trapped gas in an ileus, hernia or
volvulus can expand and produce pain or even compro-
mise the circulation of blood in the bowel. A cabin altitude
restriction may need to be considered in those who need
early movement.
Orthopaedic considerations
All casts used for splinting fractured limbs should be split
(bivalved) before AE. Free-weight traction devices are not
suitable to be used in AE, due to the adverse effects of move-
ment, turbulence and G forces on these systems. As a gen-
eral principle, the optimum time to transport a patient with
a fracture is when the fracture is stabilized. This will prevent
pain, bleeding and further tissue damage, and reduce the
chance of fat embolism. Consideration should be given to
the need for prophylaxis against venous thrombosis, par-
ticularly for major fractures. Stabilization of the fracture
should be maintained during transport by fixation or splint-
ing. Patients who have had spinal surgery should be assessed
for air in the spinal canal, as this can increase in volume
with altitude and cause further neurological damage.
Ophthalmic patients
The AE of patients with ophthalmic conditions will depend
on the severity of the condition and the availability of skilled
ophthalmic help. The concern is that trapped air may cause
17/11/2015 16:13

a problem at altitude, although if air is present in the eye as a
result of a penetrating laceration, then small amounts would
not be expected to be a significant problem in an open eye.
The risk assessment has to be made between the possibility
of an expanding bubble of trapped air causing additional
ocular damage and the advantage of getting the patient to
more definitive care as quickly as possible.
Patients with infectious disease
The type of AE required by a patient with a known infec-
tious condition will depend on the diagnosis, severity of
the condition and its mode of transmission. Most patients
with infectious disease can be evacuated on commercial
passenger aircraft, provided routine infection control mea-
sures are taken. Specifically for tuberculosis, the WHO has
issued guidance for its prevention and control in relation to
air travel. One of the most important concerns relating to
AE and infectious disease is awareness of the possibility that
any AE patient may have an infectious condition. A seven-
point checklist is used for all RAF AE patients in order to
consider this possibility.
There may be circumstances when it is necessary to evac-
uate patients with severe or highly infectious diseases from
an endemic to a non-endemic area. Whilst only undertaken
in exceptional circumstances, an air transportable isolator
(ATI) system can perform this task safely. Internationally,
different methods were seen in response to the Ebola virus
disease outbreak. An ATI is a totally enclosed unit compris-
ing a sealed plastic envelope enclosing a stretcher system,
which can be moved and adjusted in the horizontal plane.
Sealed access points allow medical and nursing staff to care
for the patient. If necessary, patients can be ventilated in the
ATI. The RAF’s ATIs are operated in partnership with the
NHS and DfID.
Biological and chemical casualties
In the event of casualties being contaminated by chemical
or biological material, either occupationally as a result of an
accident, or as the result of war or terrorist activity, the first
priority is the decontamination of the casualty before AE.
Unless decontamination is complete, AE will present a risk
to aircrew and clinical staff. Once decontamination is com-
plete, further precautions will depend on the agent itself and
the patient’s condition. A patient contaminated with cer-
tain biological agents could be moved in the ATI described
above, although resource limitations would make this
impractical for the large-scale AE of biological casualties.
Psychiatric conditions
The most important element concerning the AE of psychi-
atric patients is the careful assessment of each patient. This
has to be carried out by an individual with training in psy-
chiatry and acquainted with the practice of AE. The major
concern is that a psychiatric patient will harm themselves or
K17577_C041.indd 647
Future of AE  647
others within the confines of an aircraft, with the possibil-
ity of serious interruption to the flight or even danger to the
whole aircraft. Sometimes pressure will be exerted on the
AE team to move a psychiatric patient quickly because he or
she is seen as potentially troublesome. Wherever possible,
psychiatric patients should be stabilized before AE. Careful
pre-flight assessment will indicate those rare patients where
violent behaviour or self-harm is likely and where physical
restraint during flight may be necessary.
Anxiety is a common symptom before and during flight
in 15–20 per cent of the population. It is, therefore, impor-
tant to brief psychiatric patients before flight to forewarn
them about particular noises in flight and of some of the
physiological disturbances they may experience. If they
are on no other sedating medication, then they may ben-
efit from an anxiolytic such as diazepam, taken in a dose of
5–10 mg orally one hour before flight.
AE of pregnant patients
Active bleeding in the first trimester of pregnancy is gener-
ally a contraindication for AE. However, when an ectopic
pregnancy has been excluded and if the bleeding is relatively
light, i.e. less than a menstrual period, and with no abdomi-
nal cramping, then AE can be considered if medical facili-
ties are not available locally. All such patients should have
an intravenous cannula in situ, and the haemoglobin should
be greater than 12 g/dL before AE. The team should com-
prise an appropriate resuscitation capability and the patient
should be haemodynamically stable before flight. Vaginal
bleeding in the third trimester of pregnancy due to abruptio
placenta or placenta praevia, is potentially life-threatening
and is a relative contraindication to AE.
FUTURE OF AE
Ground-based medical and equipment capabilities con-
tinue to advance. It is likely, provided there is benefit to the
patient in the air, that some of these capabilities will form
part of the future of care in the air. NATO has recently
undertaken examination into the safe-ride standards for
CASEVAC using UAVs. These vehicles will be present in the
future operating environment. If their capacity and avail-
able payload allows, they may become useful vehicles in
some instances for forward AE.
SUMMARY
●● AE is an exciting and diverse operational subject.
●● Very high quality care can be provided when
planned and implemented appropriately.
●● With the correct staff training and equipment,
there are few patients who cannot be moved.
●● In recent years, AE has been shown to reduce
mortality and morbidity and by its forward
17/11/2015 16:13
 648  Military aeromedical evacuation

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projection of highly capable resources and swift May, 2013.
expedient movement through escalating levels of Lam DM. Marie Marvingt and the development of
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the overall deployed medical footprint. Environmental Medicine 2003; 74: 863–8.
●● The evolution of AE thus far has changed the way Renz EM. Aeromedical evacuation of burn patients from
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Rödig E, Lam D (eds). Safe Ride Standards for Casualty
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Sariego J. The changing face of wartime casualty manage-
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ment: a 20th and 21st century historical perspective.
Force. Medical guidelines for airline travel. Aviation,
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Space, and Environmental Medicine 2003; 74 (5 suppl.):
Smith D, Toff W, Joy M, et al. Fitness to fly for passengers
A1–A19.
with cardiovascular disease, the report of the work-
AGARD. Recent Issues and Advances in Aeromedical
ing group of the British Cardiovascular Society. Heart
Evacuation (MEDEVAC). AGARD Conference
2010; ii1–ii16.
Proceedings 554. Neuilly-sur-Seine, France: AGARD/
STANAG 2087 AMD, edn 6. Medical Employment of Air
NATO, 1995.
Transport in the Forward Area. Brussels: NATO, 2008.
Ahmedzai S, Balfour-Lynn IM, Bewick T, et al on behalf
STANAG 3204 AMD, edn 7. Aeromedical Evacuation.
of the British Thoracic Society Standards of Care
Brussels: NATO, 2007.
Committee. Managing passengers with stable respi-
Stevens PE, Bloodworth LL, Rainford DJ. High altitude
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Society Recommendations. Thorax 2011; 66: i1–i30.
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Allan PF, Osborn EC, Bloom BB, Wanek S, Cannon JW.
Turner S, Ruth M. Critical Care Air Support Teams. In:
The introduction of extracorporeal membrane oxy-
Neilsen JN (technical evaluator). NATO HFM-157.
genation to aeromedical evacuation. Military Medicine
Proceedings of the Human Factors and Medicine
2011; 176: 932–7.
Specialist Meeting on Medical Challenges in the
Dorlac GC, Fang R, Pruitt VM, et al. Air transport of
Evacuation Chain. Seigburg, Germany, December 2–3,
patients with severe lung injury: development and
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utilisation of the Acute Lung Rescue Team. Journal of
UK Civil Aviation Authority. Assessing Fitness to Fly –
Trauma 2009; 66: S164–S171.
Guidelines for Health Professionals from the Aviation
Fang R, Allan PF, Womble SG, et al. Closing the ‘care
Health Unit. London: CAA, 2012.
in the air’ capability gap for severe lung injury:
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Civilian aeromedical retrieval
GEOFF TOTHILL
Introduction 649
The global assistance industry 650
Airframes 650
The decision to transfer 651
Limitations of commercial flights in the carriage of
patients 651
Fitness to fly 652
INTRODUCTION
The terms used to describe the various types of aeromedical
retrieval vary across the world but one practical classifica-
tion is as follows.
Primary transfer
Primary transfer is usually used to describe the recovery of
a patient from the location where they became ill or suf-
fered injury. The modality of transfer from this location is
influenced by a large number of factors but the use of heli-
copters to deliver medical teams and recover the patient
is commonplace.
It is primary transfer that has arguably benefitted most
from lessons learned by military aeromedical retrieval
teams in times of conflict. Services vary greatly across the
globe but the use of helicopters in primary retrieval pro-
vides a great deal of flexibility in the delivery of medical
expertise and the subsequent recovery of the patient to a
centre with specific capability to treat complex injury or
illness. However, it is not only helicopters that are used in
this role as, in some parts of Australasia, retrievals that are
essentially primary in nature are undertaken in fixed-wing
aircraft where the distances involved are significant.
Two distinct approaches to the transfer of the acute
patient in a primary setting have evolved. The first is per-
haps the closest to the historic origins of rotary retrieval
K17577_C042.indd 649
42
Equipment 652
Modalities of commercial transfer 653
The patient transportation compartment 654
Fixed-wing air ambulance transfer 655
Special transfer modality – the ‘sea level’ cabin 655
Death in flight 656
Further reading 657
in Vietnam in that it calls for an extremely rapid assess-
ment and preparation of the patient (often known as
packaging), followed by a similarly expedited transfer to
a receiving hospital. The second involves taking as much
specialist capability to the patient as possible and provid-
ing more complex stabilization and intervention prior to
transfer to hospital. The first approach is known colloqui-
ally as ‘scoop and run’ while the second is known as ‘stay
and play’.
Clearly, with the evolution of complex services the dis-
tinction between these two modalities has reduced, with
many able to deliver highly complex care on scene without
sacrificing the ability to ‘scoop and run’ when necessary.
While the development of military aeromedical systems
have largely been shaped by the related requirements of
rapid evacuation from hostile environments and decreas-
ing the mortality and morbidity of trauma, civilian systems
have an altogether more complex genesis that is shaped by
local, medical, social and economic drivers.
Secondary transfer
Secondary transfer of a patient is usually undertaken to
deliver them to a higher level of care than is available in the
hospital that initially receives them and, in many countries,
is undertaken by a state-managed system. Destination hos-
pitals tend to be in the largest cities in the country and pro-
vide multiple specialties.
649
17/11/2015 16:20
 650  Civilian aeromedical retrieval
The capability, sophistication and operating models of
these transfer systems tend to reflect the economic status
of the country in which they are based. In many countries,
services have developed in response to a specific local need
(for example, the transfer of neonates to regional tertiary
centres) but because of the cost of providing the aviation
and medical infrastructure, the roles of these services have
broadened over time. This organic evolution sometimes
leads to a situation in which multiple providers, each origi-
nally occupying their own niche, end up completing with
one another in a region.
Co-ordinated transfer systems are less likely to be found
in less well developed countries and patients may only be
able to access the higher levels of care available in tertiary
centres if they can fund transfer themselves or are covered
by an insurance policy, as is the case for many travellers
and expatriates.
Tertiary transfer
Tertiary transfer is a phrase that is usually employed to
describe the transfer of a patient in the acute phase of their
evolution to supra regional facilities. All assistance and air
ambulance companies will have established evacuation
pathways that will deliver a patient into an identified ‘ter-
tiary’ centre of excellence.
In some parts of the world, these transfers involve the
movement of a patient over a considerable distance and
across international borders with the logistical and political
complexity that this often entails.
Quaternary transfer (repatriation)
Quaternary transfer is a rather more recent term that has
come to mean the long haul transfer of patients by air. It
is a term that seems to have evolved to highlight the com-
plexity of such transfers. Again, a quaternary transfer to the
patient’s home country can be referred to as repatriation.
These transfers tend to take place when the patient has
received initial treatment in a suitable regional centre and
make up the bulk of the patient transfer activity undertaken
by assistance companies.
THE GLOBAL ASSISTANCE INDUSTRY
The need for treatment abroad and possible repatriation, in
conjunction with healthcare cost inflation, has driven the
uptake of travel insurance and, in turn, the number of assis-
tance organizations whose role is to provide the traveller with
help should they become ill. A typical European assistance
company might provide services to business and leisure trav-
ellers and some to expeditions or groups travelling to remote
and hazardous environments. The diversity of these travel-
lers, and the unpredictability of the locations in which they
present, make their management extremely challenging.
Travellers enter the local healthcare system via var-
ied pathways. In developed countries, this is often via
K17577_C042.indd 650
self-presentation to local emergency departments or via the
emergency services. In some locations, the overwhelming
factor is direction to private providers by hotels, taxi driv-
ers, tour representatives and even ambulance crews if the
patient is recognized as being insured.
Naturally, the capabilities of the primary receiving hos-
pital are hugely variable and this, combined with the under-
standable concerns of the patient at receiving treatment
abroad, can lead to enormous pressure to evacuate or repa-
triate the patient.
In the initial stages of case management a ‘place of safety’
assessment attempts to determine if the receiving hospital
has the capability to manage the patient’s likely clinical
requirements throughout the stabilization and then defini-
tive treatment phases. This process usually draws upon a
database of global healthcare providers, local agents, direct
discussion with the treating team and patient and an under-
standing of the local healthcare environment. For under-
resourced areas of the world, a parallel logistical evaluation
will be undertaken with a view to initiating the secondary
transfer of the patient.
AIRFRAMES
Just as the type of medical personnel chosen to crew a pri-
mary retrieval service is determined by the probable on
scene and inflight clinical requirement, the choice of air-
frame is determined by a variety of factors.
Aircraft chosen must be capable of operating safely in
the predominant geography and weather conditions so as
to maximize the service delivery and financial investment.
The maximum operating attitude, range and endurance,
total lift capacity (for example, the ability to accommo-
date an augmented crew or heavy additional equipment),
reliability and maintenance arrangements are but some of
the considerations.
The flexibility of helicopters means that they are capable
of flying in a wide range of operational environments and
lend themselves to multiple roles. Because of this, it is criti-
cal to match the airframe with the demands of both. Typical
considerations include:
●● The ability to land at high altitude – a function of a heli-
copter’s Hover in Ground Effect (HIGE) performance.
●● The ability to hover at high altitude (and per-
form winching operations, for example) – a func-
tion of a helicopter’s Hover out of Ground Effect
(HOGE) performance.
●● The ability to operate at night, in Instrument
Meteorological Conditions (IMC), icing or other locally
prevalent weather.
●● The use of NOTAR (no-tail-rotor) systems – often pre-
ferred in urban environments.
●● The total lift capacity, cabin size and accessibility of the
patient once loaded.
●● The ability to reconfigure the airframe to allow for addi-
tional role profiles such as search and rescue (SAR).
17/11/2015 16:20

●● Levels of noise and vibration.
●● Reliability and cost of maintenance.
●● Cost of airframe purchase or leasing.
Similar considerations apply to the selection of a
fixed-wing aircraft:
●● The ability to pressurize the cabin.
●● Type of power plant – piston, turboprop or jet.
●● Single or multi-engine.
●● Aircraft reliability.
●● The ability to operate onto unprepared rural runways.
●● Short takeoff and landing (STOL) capability.
THE DECISION TO TRANSFER
The decision to move a wounded soldier from theatre back
to their country of origin is arguably less complex than the
comparable transfer of a civilian tourist who has become
ill or injured abroad. In a military context, an established
evacuation strategy is likely to be followed and advanced
capability available on the aircraft that allows continuity
of the quality of care once initial surgical management has
been completed. The default position, possible because of
this capability, is often to proceed with transfer, the final
decision being made by experienced teams at the bedside
and dedicated aeromedical flight surgeons.
The civilian situation is altogether more varied. Travellers
of any age can become ill and present to the healthcare pro-
viders in the country in which they are travelling through
a variety of channels. Some may find themselves in highly
capable facilities in large cities, while others may receive
their initial treatment in remote and under-resourced areas.
Decisions to transfer can be influenced by multiple treat-
ing physicians, the patient, relatives or travel companions,
receiving physicians, local agents, assistance company phy-
sicians, transfer teams and travel insurers.
Evacuation
In developed countries with an established framework
for patient escalation, transfer to tertiary centres is often
protocol-driven and initiated, when necessary, prior to the
involvement of a traveller’s assistance company.
In areas where this is not the case, admission should trig-
ger a ‘place of safety assessment’ in an attempt to define the
patient’s initial and ongoing requirements and decide if the
receiving hospital is going to be able to meet these. In those
cases where the patient’s needs demonstrably outstrip the
local hospital, evacuation of the patient to a regional tertiary
centre is planned.
The timing, modality and composition of the transfer
team depend on the clinical status of the patient. Where
massive blood loss or other surgical emergency would
invariably result in the demise of the patient prior to trans-
fer, the decision to proceed with surgery locally may have
to be made.
K17577_C042.indd 651
Limitations of commercial flights in the carriage of patients  651
In these situations, there are usually huge pressures from
patients, relatives and sometimes employers to repatriate
rather than transfer regionally. Despite this, the precept of
evacuation is that the patient should not be transferred fur-
ther than is necessary to receive definitive care. Embarking
on a long haul, rather than regional, transfer simply to
return the patient to their home country is fraught with
risk and should only be undertaken when the clinical status
of the patient is clearly understood and their deterioration
can be managed in the air ambulance. By definition, this is
almost always not the case in an evacuation.
Given that the evacuation of a patient is usually time crit-
ical, the advantages of deploying a highly specialist transfer
team is usually outweighed by the time it takes to mobilize
them and usual practice is for air ambulance providers to
deploy similar teams to recover all categories of patients.
Given the impossibility of surgical intervention en-route,
a common configuration is an intensive care physician
and nurse.
Consistency in the transfer team ensures conversance
with equipment and flight environment as well as mini-
mizing ‘stand up’ time. In many parts of the world, routes
are flown regularly and crew familiarity with referring
and accepting hospitals, customs, security formalities and
other logistical factors can be important in securing an
uneventful transfer.
In most patient transfer scenarios, it is remoteness from
definitive care (often surgical) that is the biggest threat to
the patient’s survival. This risk continues during the trans-
fer phase, only ending once the patient has been assessed at
the receiving hospital. It is, therefore, important to mini-
mize the duration of exposure to that risk, while maintain-
ing supportive care in flight.
Repatriation
Tertiary and quaternary transfers in a civilian environment
tend to be made from places of safety, when any treatment
required to make a patient fit to fly has been undertaken and
when specific aeromedical risk factors have been addressed.
For various reasons, not least being cost, most repatria-
tions are undertaken aboard the scheduled services of com-
mercial carriers and are subject to their clearance process.
From a funding perspective, there is a balance between
the cost of ongoing treatment in a hospital abroad until a
significant recovery has been made and that of earlier trans-
fer in a critical care air ambulance. One of the roles of a
physician working for an assistance company is defining the
clinical risk that attaches to each and advising the insurer
and patient accordingly.
LIMITATIONS OF COMMERCIAL FLIGHTS
IN THE CARRIAGE OF PATIENTS
Historically, commercial carriers have accommodated those
who are recovering from acute illness or injury either as
seated passengers or on stretcher assemblies that are fitted,
17/11/2015 16:20
 652  Civilian aeromedical retrieval
usually in economy, in the space usually occupied by either
six or nine seats.
Commercial airlines are necessarily concerned with the
impact that the carriage of patients has on their operation
and impose a range of restrictions designed to reduce the
risk of patient deterioration in flight, with the concomitant
possibility of aircraft diversion. This consideration extends
to ground handling (where the boarding and disembar-
kation of the patient should not cause delay) and in flight
where the patient should not cause offence to other passen-
gers or endanger the orderly conduct of the flight.
The introduction, in Europe, of financial penalties for
missed departure has led airlines to examine the time it
takes to install stretchers down route. Mindful of the risk
that this process will delay departure (and in an overall
effort to simplify their operation) some have withdrawn this
service. Others continue to provide stretchers and, in one
case, offer a specialized intensive care compartment (vide
infra).
Although airlines vary in their process, almost all will
require a medical information form (MEDIF) to be submit-
ted, identical to or based upon the version published as an
appendix to the International Air Transport Association’s
(IATA) medical manual (IATA 2013). In its latest iteration,
this not only acts as an information-gathering tool but is
also accompanied by a useful fitness to fly framework.
The review of submitted MEDIFs varies widely, from
carriers who simply require a local physician’s assertion that
the patient is fit to fly through to systematic review by com-
pany medical staff either based centrally or in the country
from which the passenger is travelling. While this process
requires the treating physician to understand their respon-
sibility to make accurate declarations of a patient’s condi-
tion, the carriage of those cleared tends not to result in a
significant number of aircraft diversions (Cocks and Liew
2007).
FITNESS TO FLY
As has been mentioned, the sources of the clinical informa-
tion upon which a decision on fitness to fly is made are alto-
gether more disparate than those in a military setting. The
information provided by a treating team is naturally influ-
enced by local clinical practice as well as cultural and some-
times financial factors. In poorly resourced environments,
where patients are not routinely transferred to more capable
hospitals, physicians might be unaware of the capabilities of
aeromedical retrieval teams and oppose transfer in favour
of the patient receiving the customary level of local care.
In cases where there is a high degree of suspicion that
the patient is receiving sub-optimal care, secondary transfer
may be initiated in the absence of detailed medical infor-
mation. These air ambulance transfers are effectively patient
evacuations and require that the transfer team employ not
only great clinical but also interpersonal skills.
In these situations, as experienced a team as possible
should be sent to the originating hospital prepared to make
K17577_C042.indd 652
significant alterations in the patient’s management as part
of the pre-flight preparation. They should be empowered
to make the final judgement on the advisability of transfer
and have access to the assistance company and receiving
hospital’s physicians.
When planning the repatriation of a patient from a capa-
ble referring hospital abroad, a systematic assessment of fit-
ness to fly needs to be undertaken, usually in conjunction
with the treating team. The following are considerations
Intrinsic deterioration
This is the risk that the patient’s condition will deteriorate
in the transfer period regardless of the flight environment.
An assessment requires knowledge of the patient’s clinical
condition and the natural history of their pathology. It is
followed by an appraisal of whether any required interven-
tion would be possible to deliver in flight.
The effect of the flight environment
An assessment of the effect of the decreased cabin pressure,
vibration, accelerative forces and general patient handling
on the patient’s primary pathology is made. This informs
the requirement for further intervention prior to departure
and ultimately the modality of transfer.
Specific aeromedical considerations
Although there are no absolute contraindications to the
transfer of patients by air, it is important to identify con-
comitant conditions that might cause issues. Sinusitis and
otitis media, for example, can occur independently of more
significant pathology and need to be identified and treated
prior to transfer if the risk of barotrauma is to be avoided.
Once this systematic assessment has been made and
possible deterioration scenarios identified, an appropriate
transfer team can be selected and the necessary clearances
applied for.
EQUIPMENT
Physicians contemplating escorting patients aboard sched-
uled flights should understand the resources available to
them in the cabin and the consequences of their remoteness
from hospital care in the event that the patient deteriorates.
It is in both these areas where civilian aeromedical retrieval
most differs from the military setting.
Commercial repatriation organizations equip their
transfer teams with highly portable, ruggedized equipment
suitable for long duration use in an aircraft cabin, as well as
standard drug sets. In addition, escorts will be able to aug-
ment this equipment with items thought specifically neces-
sary for the patient in question. The goal of the team should
be to be completely autonomous and not rely on commercial
aircraft systems (particularly power, which is notoriously
unreliable in the cabin), save perhaps for oxygen.
17/11/2015 16:20

There is much written in this volume about aircraft
oxygen systems, so obviously pivotal is the prevention of
hypoxia in the cabin. For the patient in transit, this is even
more important as their pathology might mean that they
are hypoxic at cabin pressures tolerated well by fit passen-
gers. Supplemental oxygen must be reliably provided in
all stages of the flight if ambient partial pressures are low
enough to compromise the patient.
The source of this oxygen varies by airline and aircraft
type. Traditionally, oxygen was supplied in cylinders that
were either fastened to the floor or in a case that simply
stood in front of the patient. The advantage of this system
was that cylinders were often provided with variable flow
regulators that made up to 8 L/min flow rates possible. The
disadvantage was that they could become projectiles in tur-
bulence and were rarely issued by crew until the aircraft was
at cruising altitude, exposing the patient to a period of rela-
tive hypoxia throughout the climb.
More modern aircraft provide cylinder oxygen but dis-
tributed by a ‘ring main’ that is accessed via a bayonet valve
in the passenger overhead. In most cases, this is drawn from
the same source that provides emergency oxygen to passen-
gers in the event of decompression. While the airline should
carry additional oxygen, some may not. If a flight sector takes
the aircraft over terrain whose elevation would prevent an
immediate descent in the event of depressurization, the cap-
tain of the flight might consider that all the available oxygen
would be required and limit or prohibit the use of oxygen by
the patient until after this point has passed. Transfer teams
should be aware of this possibility and assess the require-
ment for an alternative oxygen supply for this period.
One of the major issues with providing supplemental
oxygen aboard commercial flight has been the weight of
the cylinders and the concomitant cost of carriage. The
advent of lighter composite cylinders and on-demand regu-
lators has seen a return to cylinder delivery on some air-
lines. Pulsed dosed, oxygen sparing delivery systems, while
widely used, are not reliably triggered by all patients, espe-
cially when sleeping. Predicting those in which this is likely
is difficult and carriers providing alternative delivery sys-
tems should be considered for patients thought at risk. A
trial of the aircraft’s pulsed dose delivery system should be
undertaken prior to departure and if the patient is unable to
reliably trigger on the ground they should not be carried in
the absence of an alternative supply.
The advent of portable oxygen concentrators has removed
the dependency on the airline for the supply of oxygen in
flight as well as simplifying provision on the ground (for
example, when transiting). Increasing portability, battery
life and oxygen flow rate, combined with the increasing
numbers of airlines who sanction use of these devices on
their flights, have simplified logistical arrangements and
allowed the use of carriers unable to provide supplemental
oxygen for patients. Most portable systems currently pro-
vide pulsed dose delivery up to 4 L/min and larger (although
still portable) continuous flow generators exist, currently
providing up to 3 L/min flow rates.
K17577_C042.indd 653
Modalities of commercial transfer  653
Pulsed dose oxygen concentrators suffer from the same
‘triggering issues’ as their cylinder mounted equivalents,
but newer devices purport to be able to change the sensitiv-
ity of the device in order to ‘recapture’ triggering.
MODALITIES OF COMMERCIAL TRANSFER
Seated
Typically, patients aboard commercial flights occupy the
same types of seats as other passengers. Cost constraints
usually dictate that the class of travel is determined by clini-
cal need, for example, the requirement for regular mobility
around the cabin, maintaining leg elevation, being recum-
bent for the majority of the journey or the requirement for
space for medical equipment. The practical consequence is
that patients tend to be seated in economy for short haul
sectors because the seat configuration is no different in
business class and confers no benefit in the management of
the patient.
While many long haul business class cabins provide seats
that allow a patient to be fully reclined, carriers impose a
variety of conditions designed to minimize the impact on
adjacent passengers. These include the ability to sit upright
during takeoff and landing and being able to mobilize to
the toilet. Practically, patients need to be able to sit for at
least an hour at the start and end of the flight to accommo-
date boarding, taxi and the initial stages of the ascent. The
patient’s mobility around the cabin can be assisted by the
medical escorts and the use of compact, narrow wheelchairs
known as aisle chairs. Both the airline and the assistance
company need to be confident that the patient will not fall
because of both the clinical and the litigation risk and that
adequate space will be available to provide treatment in the
event of deterioration.
Stretchers
Patients who cannot be cared for in business class seats
may be candidates for transfer on a stretcher provided by
the carrier. Civilian stretcher assemblies are designed to
be fitted rapidly and not require the removal of the econ-
omy seats whose backs fold down to accommodate the
frame upon which the stretcher itself sits. In its most basic
form, the stretcher simply consists of a padded top and a
four-point harness, the use of which is mandated when the
seatbelt signs are illuminated. Oxygen is either provided by
cylinders anchored to the floor under the stretcher or from
a piped supply accessible via a valve in the overhead. In both
cases, the nominal maximum flow rate available is 4 L/min.
A curtain provides a degree of privacy and adjacent seats are
usually allocated to escorts and equipment.
Stretchers are most commonly used to move patients
who have mobility issues that preclude carriage in business
class seats or who cannot sit for a sufficiently long period
(for example, those who have sustained spinal or lower limb
injuries). That is not to say that it is impossible to utilize
17/11/2015 16:20
 654  Civilian aeromedical retrieval

them in the transfer of patients requiring complex support.

There are several carriers who still allow ventilated stretcher
patients aboard their flights but the time taken to ‘set up’
the patient on the aircraft can be protracted and must be
compatible with the turnaround time and cleaning and
servicing the cabin. Stability is an important factor in the
decision to transfer patients requiring complex support
on commercial flights. While, for example, patients with
resolving respiratory failure might be candidates for a com-
mercial transfer prior to what might be a protracted period
of weaning, those with unstable multi-organ failure would
not – both because of the limitations of the care that can
be provided and also because of the risk of diversion in the
event of deterioration.

THE PATIENT TRANSPORTATION

COMPARTMENT
There are considerable challenges to be overcome when
transferring a patient requiring intensive care in any envi-
ronment, but particularly aboard a commercial flight. The
amount of equipment necessary to maintain the level of
care being provided by the referring hospital may be high
and will usually include a ventilator, multimode monitor-
ing, infusion pumps and syringe drivers, a defibrillator and
consumables, as well as the physical aids to patient han-
dling in the relatively confined space of the cabin. More
specialist equipment might also be required depending
on the needs of the individual patient. Reliable supplies of
power and oxygen, with up to 50  per cent more than the
estimated requirement, combined with equipment redun-
dancy, mandate multi-handed crews and often a dedicated
equipment officer.
Some of the earliest transfers of these complex patients
were the result of the efforts of multidisciplinary teams
who created bespoke services modules on which the
patient stretcher lay. These pioneering transfers were far
from routine, but with the advent of smaller, lighter and
multimodal devices there was a period when ventilated
critical care patients were transferred on unmodified
stretchers aboard commercial flights relatively frequently
(Figure 42.1). Currently, the practice seems to be confined
to those patients receiving palliative care being moved
for humanitarian reasons (vide infra) and on those routes
serving very specific locations. At the time of writing, one
example of the latter is the ‘air bridge’ provided by Air
France from Martinique in the Caribbean to Paris, which
routinely transfers high dependency patients to tertiary
centres in France.
The reasons for the decline in the numbers of ventilated
patients being carried in a commercial cabin are probably
similar to those explaining the reduction in stretcher avail-
ability overall. Intensive care patients can take a much lon-
ger time to ‘set up’ on the aircraft, demand high levels of
care throughout the flight and, arguably, are more likely to
be the cause of diversion, although there is little evidence to
support the last contention. Nonetheless, operators see the
Figure 42.1  An early intensive care services module built
by engineers at Med-Plane and Aerolineas Argentinas in
1995.
carriage of these patients as posing a significant risk to their
schedules and clearance in these cases is usually denied. In
addition, well-resourced and medically capable air ambu-
lance providers have built on their capability to provide
more truly long haul services.
Cognisant, perhaps, of the void left by the gradual with-
drawal of stretchers on other carriers and in an attempt
to address the problems of ‘ad hoc’ critical care trans-
fers, Lufthansa offers a dedicated ‘patient transportation
compartment’ (PTC) which can be installed into their
wide-bodied aircraft in Frankfurt. This provides a private
compartment within the economy class cabin in which lies
a sophisticated services module and stretcher, as well as core
critical care equipment and drugs. In addition, when the
unit is commissioned, a paramedic familiar with the equip-
ment and operating of the unit is provided by the airline to
accompany the transfer team (Figure 42.2).
There are often pervasive reasons for a patient to be
transferred on a commercial flight, particularly over very
large distances and the PTC provides a clinical environment
Figure 42.2  The Lufthansa Patient Transportation
Compartment.

K17577_C042.indd 654 17/11/2015 16:20


aboard a commercial flight similar to that of a dedicated
air ambulance. At the time of writing, however, significant
complications include the fact those flights must either
begin or end in Frankfurt or Munich and that the service
is only available on certain sectors. The consequence of this
being that air ambulances are often required at each end
of the long haul sector, with the additional risk that each
patient transfer entails.
FIXED-WING AIR AMBULANCE TRANSFER
Patients and physicians often seize upon the use of dedi-
cated fixed-wing aircraft for patient transfer. While there
are many circumstances in which this is appropriate, those
responsible for arranging transfer should undertake a risk
benefit analysis that includes any commercial alternatives.
Advantages of commercial flights
●● Shorter duration long haul flights without the need for
frequent ‘tech stops’.
●● Reduction in the number of departures, landings,
ascents and descents, which may be significant for
some patients.
●● Greater room to provide care to the patient.
●● Higher pressure cabin (lower cabin altitude) than some
airframes commonly used as dedicated air ambulances.
●● Hot food and toilet facilities for patients and
medical crew.
●● The ability to deploy ‘multi-handed’ teams for long
haul transfer.
●● More consistent cabin temperature.
Advantages of air ambulances
●● Few time constraints on departure allowing extended
patient preparation.
●● The ability to fly at an altitude that provides a cabin
pressurized to sea level.
●● Availability of on board services – piped oxygen, elec-
tricity, suction, etc.
●● Complex therapy possible – extracorporeal membrane
oxygenation (ECMO), intra-aortic balloon pump
(IABP), left ventricular assist devices (LVAD), etc.
●● High oxygen flow rates available.
●● Rapid diversion to predetermined locations possible.
●● The carriage of patients with infectious disease.
●● The ability to operate from unprepared runways and
unlicensed airfields (depending on aircraft type).
Fixed-wing patient transfer services, like their primary
rotary counterparts, have often developed as a solution
to the transfer of patients over relatively large distances
when suitable care is not available locally. The Royal Flying
Doctor Service in Australia and AMREF in West Africa
are examples of services that have been shaped by their
local geography.
K17577_C042.indd 655
Special transfer modality – the ‘sea level’ cabin  655
SPECIAL TRANSFER MODALITY – THE
‘SEA LEVEL’ CABIN
One of the advantages of a dedicated air ambulance is the
ability to provide a ‘sea level’ cabin. Given that the most
significant physiological risks to which a patient in flight is
exposed (gaseous expansion and relative hypoxia) are both
a consequence of the low-pressure cabin environment, the
ability to provide the same-pressure environment as the
referring hospital can be critical.
At normal cabin altitudes of up to 8000  feet above sea
level (ASL), the giving of supplemental oxygen via face-
mask or nasal cannula can reverse the effects of hypoxia
in most patients but does not address the other hypobaric
consequences of ascent. Prevention of the expansion of
occult gas is, therefore, the most common reason for the
decision to transfer a patient in a ‘sea level’ cabin.
During the ascent, as the ambient pressure in the cabin
falls, gas in enclosed spaces (unable to vent into the cabin)
expands, with the associated risk to adjacent structures.
Typical scenarios include:
●● Intracranial gas secondary to head trauma.
●● Retro-orbital gas secondary to orbital fracture.
●● Un-drained pneumothorax.
●● Mediastinal gas.
●● Intraluminal intestinal gas in the presence of
intestinal obstruction.
●● Subcutaneous emphysema.
The degree to which the patient is compromised by
expansion of entrapped gas, as with any expanding mass,
depends on the magnitude of that expansion and the criti-
cality of the surrounding structures. In circumstances
where there is a continuing leak of air into a closed cavity
(such as in some pneumothoraces) it must be remembered
that although the maintenance of a sea level pressure in the
cabin prevents the expansion of the existing volume with
the aircraft’s ascent, it does not prevent the underlying air
leak or the risk of tension which that might entail.
Venting the entrapped gas by the placement of a drain
addresses the risk of tension and obviates the need for a sea
level cabin environment and illustrates the general rule that
entrapped gas should be drained or allowed to adsorb prior
to transfer.
The provision of a sea level cabin has several addi-
tional consequences. The first is that, in order to maintain
a safe differential pressure across the cabin wall, the air-
craft must fly at well below its operational ceiling. For a
Lear 35, this is approximately 27 000  feet, as opposed to
a normal cruising altitude of above 40 000  feet. This con-
siderably increases the fuel burn (up to 30  per cent) and,
therefore, reduces the aircraft’s range and endurance. The
decision to provide a sea level cabin thus becomes a bal-
ance between the effect of the environment on the patient
and the increase in transfer time that is associated with
the lower operating altitude.
17/11/2015 16:20
 656  Civilian aeromedical retrieval
The second is that for patients with large, un-drained
and critically positioned collections of occult gas, survival
in transit is reliant on the maintenance of the sea level envi-
ronment. While a thankfully rare event, depressurization of
the cabin, with the rapid expansion of that gas, could cause
extensive barotrauma to surrounding structures. It should
be noted, in addition, that flight conditions, terrain avoid-
ance and air traffic control requirements might mandate an
ascent during which the maintenance of a sea level cabin
might prove impossible.
A pragmatic approach, adopted by some experienced
transfer physicians, is to increase the altitude of the air-
craft (and cabin) incrementally, while assessing the effects
on the patient. Understanding the pathophysiology of the
gas entrapment allows careful selection of those patients in
which this is unlikely to cause the patient harm and those
in which clinically significant increases in gas volume
might occur.
A specialist use of the sea level cabin is in the transfer
of patients with decompression injury (DCI). In the civil-
ian environment, the majority of patients in this category
become symptomatic following the use of self-contained
underwater breathing apparatus (SCUBA) equipment
and often in remote locations without a local recompres-
sion facility. Retrieval of patients from these environ-
ments is frequently arranged locally and undertaken in
non-pressurized aircraft.
Recommendations for the maximum cabin altitude
above the departure point (and, therefore, by definition the
maximum aircraft altitude for unpressurized aircraft) when
transferring patients with DCI range from 500–1000  feet
(MacDonald et  al. 2006) but it has been pointed out that
this altitude recommendation might be both impossible
and also pose a flight safety risk in some environments
(Stephenson 2009).
Clearly, the availability of an aircraft capable of provid-
ing a sea level cabin is a council of perfection but should
not delay transfer in these cases. The provision of high flow
oxygen and the rapid transfer of a DCI patient to a recom-
pression facility at the minimum altitude compatible with
flight safety is the goal.
One therapeutic use of cabin pressurization recognized
by retrieval physicians, but poorly described in the litera-
ture, is in the management of high altitude cerebral or pul-
monary oedema (HACE or HAPE). By definition, patients
presenting with these conditions are at altitude, often in
inaccessible locations some distance from hospitals at lower
altitudes or recompression chambers.
If a patient with HACE or HAPE can be delivered to a
pressurized aircraft for evacuation, the very act of pres-
surizing the aircraft cabin during departure is therapeu-
tic, given that the altitude sustainable in that cabin will be
orders of magnitude lower than that at which the patient
became symptomatic.
K17577_C042.indd 656
DEATH IN FLIGHT
As has been said, the death of patients in flight who have
been declared to the airlines appears rare. From a clearance
perspective, it becomes important when the transfer of a
patient known to be dying is contemplated.
If a carrier does accept a patient thought likely to die it
will be on the basis that a ceiling of care has been agreed in
advance of transfer.
Carriers may require that the patient (or next of kin if the
patient lacks capacity) agree formally that resuscitation and
diversion will not be undertaken and that all those travel-
ling with the patient are aware of this position.
SUMMARY
●● Aeromedical transfer can be defined as primary,
secondary, tertiary or quaternary depending
largely on the status of the receiving hospital.
●● The aircraft used in patient transfer need to be
carefully chosen by operators depending on the
predominant role profile, the geography of the
operating area and prevalent weather conditions.
●● In a civilian environment, the decision to transfer
a patient is multifactorial and influenced by a
multiplicity of clinical, financial, cultural and
social factors. These change as the patient is esca-
lated to progressively higher levels of care.
●● The clinical assessment of fitness to fly involves
an appreciation of the intrinsic risk associated
with the patient’s primary pathology, modified
by the additional risks associated with the flight
environment and the presence of any specific
conditions known to be problematic in the cabin
of a pressurized aircraft.
●● Patient transfer should be undertaken in
an aircraft consummate with clinical need.
Commercial scheduled flights provide many
advantages over long distances and can be appro-
priate even for patients with complex require-
ments if appropriately planned and resourced.
For all patients where transfer is contemplated, a
comparison of the risks and benefits of commer-
cial and air ambulance transfer should be made.
●● The provision of a ‘sea level’ cabin in an air
ambulance can mitigate the risk of transfer for
those patients who have entrapped gas which
would otherwise expand and pose a risk of
trauma to surrounding structures.
●● One consequence of the cabin pressurization
system is in the emergency management and
transfer of those with high altitude cerebral and
pulmonary oedema.
17/11/2015 16:20

FURTHER READING
Cocks R, Liew M. Commercial aviation in-flight emer-
gencies and the physician. Emergency Medicine
Australasia 2007; 19(1): 1–8.
International Air Transport Association. IATA Medical
Manual, 6th edn. Montreal: IATA, May 2013. Available
at www.iata.org/whatwedo/safety/health/Documents/
medical-manual-2013.pdf.
K17577_C042.indd 657
Further reading  657
MacDonald RD, O’Donnell C, Allan GM, et al. Interfacility
transport of patients with decompression illness:
literature review and consensus statement. Prehospital
Emergency Care 2006; 10(4): 482–7.
Stephenson J. C. Pathophysiology, treatment and aero-
medical retrieval of SCUBA-related DCI [online].
Journal of Military and Veterans Health 2009; 17(3):
10–9.
17/11/2015 16:20
K17577_C042.indd 658 17/11/2015 16:20
 43
Patient transfer: The critically ill

NEIL MCGUIRE

Team composition 660 General conduct of transfer by air 668

Equipment 661 References 669
Critical illness 662

The requirement to transfer ever increasingly unwell
patients has necessitated major advances in patient trans-
fer. This has been driven by the dramatic increase in the
survival of the war wounded with major injuries seen in
recent conflicts. The advances are particularly noteworthy
in the aviation environment, which has always presented
serious challenges. Patients who have received injuries
which, in the past, would have been seen as most demand-
ing and requiring a high level of escort (Table  43.1), have
more recently been treated in different ways to allow
less intervention and a reduction in the level of supervi-
sion (e.g. the use of peripheral and neuro-axial blockade,
advanced chest drainage systems and vacuum wound
dressings). Likewise, patients once deemed too unwell to be
moved from their bed space within a hospital, have regu-
larly been safely transferred by air over extended times-
cales and great distances (Figure 43.1).
The models for casualty evacuation have also evolved
during this period alongside more traditional approaches.
It has been possible to project critical care into the pre-
hospital environment and this, as an integral part of the
whole evacuation chain, is believed to have helped lead
to the increased numbers of expected survivors from
major trauma. Models of predicted survival have evolved
to reflect this. Trunkey (1983) (Figure  43.2) shows a tri-
modal distribution of death following trauma, but more
recently Gunst et al. demonstrated the trends towards a
bimodal distribution. The proposal in the previous edi-
tion of this book that high-quality care at the outset of
injury or illness gave the optimal survival has been con-
firmed by recent experience. The distribution of military
deaths has become to all intents and purposes unimodal
(Figure 43.3). This is despite injury patterns so severe that
they defy normally used trauma severity classifications
such as the Injury Severity Score (ISS), Trauma Injury
Severity Score (TRISS), and Revised Trauma Score (RTS).
Only one death has occurred during transfer of sick and
wounded by Royal Air Force Medical Service Aeromed

Table 43.1  North American Treaty Organization (NATO) classification of dependency

Dependency
1 (High dependency)
2 (Medium dependency)
3 (Low dependency)
4 (Minimal dependency)
Requirement
Intensive support, for example, patients requiring ventilation, monitoring of central venous
pressure and cardiac monitoring. They may be unconscious or under general anaesthesia
Patients who, although not requiring intensive support, require frequent monitoring and
their condition may deteriorate enroute. For example, patients who have a combination of
oxygen administration, one or more intravenous infusion and multiple drains or catheters
Patients whose condition is not expected to deteriorate enroute but who require nursing
care of, for example simple oxygen therapy, an intravenous infusion, or a urinary catheter
Patients who do not require nursing attention enroute but who might need assistance with
mobility or bodily functions

659

K17577_C043.indd 659 17/11/2015 16:21

 660  Patient transfer: The critically ill
Figure 43.1  Critical care in the air: strategic critical care air support team, Boeing C-17 Globemaster.
% Casualty death
Minutes Hours Days/weeks
Figure 43.2  Trimodal distribution of death.
From Trunkey DD. Trauma. Scientific American 1983;
249: 20–7.
Service and Critical Care Air Support Teams (CCAST)
since they were formed in the late 1990s; this is despite
the transfer of thousands of Aeromed and hundreds of
critically ill patients.
Even though there have been advances in treatment and
equipment, the main principles of care remain the same.
Patient transfers should never be undertaken lightly and
whenever they occur, care must be patient focussed. All
aspects of the transfer are derived from this focus, whether
it is the accompanying personnel, equipment or logistic
considerations. It is vital to understand that the transfer
normally commences as soon as the patient leaves their
initial place of safety. This is where they would normally
have fixed and constant access to utilities (gases, power),
and to immediate comprehensive assistance. Transfer only
ends when these are again available. In some circumstances
exceptions may occur and these are discussed below.
K17577_C043.indd 660
TEAM COMPOSITION
Attendant medical and nursing personnel must be trained
in critical care (i.e. intensive care, including a high level of
airway skills such as derived from anaesthesia training)
and be current in its practice. In addition they should have
had specific training related to patient transfers. The back-
grounds of personnel used currently vary between nations,
but the principles remain the same.
In Europe, military teams are generally made up of
intensive care trained doctors and ICU nurses, with the
appropriate logistic support for the team (Roedig 2006).
In the UK, the Royal Air Force Critical Care Air Support
Teams are composed of intensive care trained anaesthetists
and intensive care nurses. They are accompanied by a flight
nursing attendant, who deals with the internal configura-
tion of the aircraft required for the patient, documentation
and aircraft way bills, and a technician (also known as a
medical and dental servicing [MDSS] technician) who is
responsible for gases and electrical safety and the servicing
and maintenance of the equipment.
In the US model, doctors are largely from an intensive
care background, but other specialties have been used.
All of these doctors have undergone aviation medicine
training and are designated as flight surgeons. Teams
also include intensive care nurses and respiratory techni-
cians, the latter being responsible for respiratory equip-
ment including ventilators. In other systems (e.g. REGA,
Swiss Air Ambulance), the critical care nurse will also be a
nurse anaesthetist.
17/11/2015 16:21

250
200
Number of deaths 150
100
50
0
<10 10–29
Time from injury to death (minutes)
Figure 43.3  UK military experience; unimodal distribution of death.
Defence Medical Services Research 2001–2013.
Depending on the nature of the patient’s condition,
the number of critical care trained attendants may vary.
Patients with spinal injuries, for example, will require addi-
tional personnel to allow for ‘log rolling’ when attending to
pressure area care. The additional personnel do not need to
be doctors or nurses, but they must be trained and com-
petent in patient handling. The team must possess the cor-
rect skill mix and a full understanding of and experience
with the demanding aeromedical repatriations of critically
ill patients. The importance of these attributes cannot be
overemphasized, because they provide for many of the safe-
guards to protect the patient.
A properly constituted experienced team almost instinc-
tively understands the issues, works closely together and
has a high level of situational awareness. This latter quality
is paramount in anticipating and reducing the occurrence
of clinical incidents. The team, in looking after each other
and appreciating risk, in turn are protecting the patient
from harm.
In an ICU, for example, the usual care provider is the
ICU nurse because he or she has the greatest understand-
ing of the minute-to-minute situation of the patient. This
is because they are normally constantly in attendance. The
physician has the clinical overview and influences treat-
ment direction, and in conjunction with the nurse and other
members of the multidisciplinary team, delivers complete
care to the patient. Within this partnership either party is
able to influence patient care. For example if a nurse is not
content with treatment or a clinical situation she is free to
comment constructively in the best interest of the patient.
Nurses are independent practitioners responsible for their
own actions regardless of who else is in attendance. This is
important because it allows for proper patient advocacy and
aids in the reduction of risk to the patient.
The selection of team members is potentially different for
each phase of the transfer. Short transfers by rotary wing,
K17577_C043.indd 661
Equipment 661
30–59 60–120 121–240 >240
or by road, to fixed wing aircraft can be achieved by the
minimum of a critical care Aeromed physician and a criti-
cal care Aeromed nurse. For the longer, fixed wing flights,
technical support and additional logistic personnel should
be included (Figure 43.4).
EQUIPMENT
Providing critical care during transfers requires extremely
capable equipment to ensure patient safety. Technological
advances in electronics and computer processors have led to
the availability of more capable and reliable equipment, but
careful selection is necessary to ensure it is fit for the aviation
environment. This demands not only robustness and features
such as the ability to use multiple power supplies (the most
common cause of critical incidents during transfer is bat-
tery failure [Thames Valley Critical Care Network Working
Party Transfer Surveys 2003 and 2004, unpublished data]),
but also survivability in the electromagnetic environment
of modern aviation. Similarly it is essential that equipment
does not interfere with avionics and that they do not present
an aircraft safety issue. Thorough testing and a meticulous
regime of clearance and certification for use in the air are
required to avoid potentially serious hazards.
Ventilators
Ventilators used for transfer must be able to emulate almost
all of the modes used in a fixed ICU facility to ensure con-
tinuity of care. These include modes such as volume control
and pressure controlled ventilation, positive end expiratory
pressure and continuous positive airways pressure. The abil-
ity to vary the inspiratory to expiratory ratio should also
be possible. As a general principle, ventilators should have
low power requirements and oxygen consumption, and they
should be able to use a variety of power supplies. Appropriate
17/11/2015 16:21
 662  Patient transfer: The critically ill
Figure 43.4  Multiple patient transfer by tactical critical care air support team, Lockheed C-130 Hercules.
alarms are essential and should be easily visible and loud
enough to be  heard. This can pose real challenges in the
combat environment, where there may be restrictions on
ambient lighting. Also many of the military transport air-
craft used in the tactical role have little or no consideration
given to the needs of a critical care team in their cargo areas.
Monitors
All parameters required to ensure continuity of care should
be monitored. In addition to monitoring, it is essential to
be able to carry out certain point-of-care testing such as
12-lead ECG and blood gas analysis. It is logical to assume
that if monitoring to a particular standard is required in
a fixed facility, then it should at least be maintained if not
enhanced in the hazardous and more demanding transfer
environment. The use of multifunction equipment with
wireless capability and smart batteries is increasingly prev-
alent and has many patient safety advantages. These have
marked advantages in terms of weight and space saving.
Monitors must at least meet minimal standards as set by
professional bodies (The Association of Anaesthetists of
Great Britain and Ireland 2006, 2007, 2009; Whitely et al.
2011), but for most patients these requirements should be
exceeded in the hostile air environment.
Other equipment
A variety of other equipment will be carried to support the
patient depending on their needs. The most commonly used
are in Table 43.2.
K17577_C043.indd 662
Specialist equipment
It is now possible to transfer patients requiring highly spe-
cialist care due to advances in technology. These include
intracranial pressure monitoring, renal replacement ther-
apy, extracorporeal carbon dioxide removal and extra-
corporeal membrane oxygenation. These monitoring and
support capabilities require an even higher level of team
training and competence.
Disposable equipment
A considerable array of disposable equipment is also
required to support the patient. This type of equipment has
greatly simplified infection control and aids in the rapid
replenishment of supplies. This does, however, have to be
balanced by difficulties of continuity of supply when oper-
ating in isolated locations and issues of disposal of waste
generated in the confines of the transfer environment.
There are other considerations related to support equip-
ment, such as power supplies, oxygen, stretchers, etc. that
must be taken into account, but these cannot be fully dealt
with here.
CRITICAL ILLNESS
Complex support for critically ill patients is necessary
because of the underlying processes in critical illness.
Systemic inflammatory response syndrome (SIRS), sep-
sis and coagulation disorders are all accompaniments to
multiple organ dysfunction and failure. These problems
17/11/2015 16:21
 Critical illness  663

Table 43.2  Supporting equipment for critical care transfers

Equipment Comment
Syringe pumps and volumetric May be life vital equipment if they are delivering drugs directly supporting the
pumps circulation
Suction apparatus Portable, high flow capability and able to collect fluid waste in a manner that protects
staff and is safely disposable
Blood analysis Blood gas, electrolyte, glucose, lactate and other blood analysis is at the heart of
critical care. Assessment of arterial oxygen, carbon dioxide, bicarbonate pH, glucose
and potassium, etc. should be carried out at least every hour during transfer as a
routine. This should also be undertaken if any changes are made to ventilation,
including change of ventilator, or if the patient’s clinical condition changes
Peripheral nerve stimulators Assess neuromuscular junction function when using neuromuscular junction blocking
drugs. This allows for more exact control and helps to avoid the physiological
consequences of under or over dosage
Pacemakers Usually life vital. Required to be highly reliable with extended battery life. The
indication of battery depletion must be timely and the brief act of changing the
battery must not interrupt function

are difficult enough to treat in the fixed hospital environ-
ment and present even greater challenges in the transfer and
aviation environment.
To understand this better, each of the organ systems
will be considered in turn to allow an understanding of the
problems that could be encountered.
The thorax
RESPIRATORY SYSTEM
Gas exchange
In addition to the reduction in oxygen tension with increas-
ing altitude, there are other influences on gas exchange,
which include patient positioning, analgesic and sedative
drugs and different modes of positive pressure ventila-
tion. The supine position compromises functional residual
capacity that is aggravated by alteration in ventilation and
perfusion matching. In the case of routine anaesthesia, a
moderate increase in the inspired oxygen concentration
usually attenuates the effect on arterial oxygen tension, but
the situation is more complicated in the critically ill. This
is due to a combination of hypoventilation, impaired dif-
fusion, ventilation perfusion mismatching, physiological
shunt and abnormalities in oxygen delivery and utilization.
These in turn are aggravated by changes in body tempera-
ture, pH and acid base balance. The extent of the effect will
vary according to the pathophysiological process being
experience by the patient at the time.
Pneumothorax
Air-containing cavities within the lung, bullae, post-sur-
gery or air leaks from trauma can all lead to pneumothorax.
Expanding air in the pleura or pericardium may lead to the
conversion of a simple pneumothorax or pneumopericar-
dium to a tension pneumothorax or pneumopericardium,
both of which are life threatening. Expansion of mediasti-
nal air may also lead to air tracking into the pleura and the
formation of pneumothoraces and or pneumopericardium.
Patients with rib fractures are at increased risk of pneumo-
thorax and haemopneumothorax. They also are very likely
to have ventilation and perfusion mismatching due to pul-
monary contusion. In view of this blood gases should be
checked even in spontaneously breathing patients as they
may be hypoxic even at sea level.
Airway management
If the airway is (or is likely to be) compromised, intuba-
tion should be undertaken under controlled circumstances
before any attempt at transfer. During induction, cardio-
vascular instability is common and can be life threatening.
Following the procedure the patient should be established
on ventilation, arterial blood gases checked, and a chest
X-ray performed. In the absence of X-ray capability, a
skilled operator may be able to detect the presence of a
pneumothorax with ultrasound, but the risk of not detect-
ing one remains high in the author’s opinion. Patients who
have been burned around their airway require particular
attention, because oedema, while not initially present, may
develop quickly and rapidly become life threatening. It may
also preclude intubation, and oedema of the neck may also
preclude direct access to the trachea.
Patients who are already intubated should have their endo-
tracheal tube checked and a chest X-ray performed to deter-
mine tube position and the current state of the lung fields. The
absence of a visible pneumothorax on X-ray does not preclude
the presence of one, and in the case of reasonable suspicion a
tube thoracostomy should be performed. Endotracheal tube
cuff pressures should be checked and monitored during flight.
The previous recommendation of filling the cuff with saline is
no longer supported (Dirven 2002).
Tube thoracostomies that have been placed for drainage
of air, blood or fluids should remain in situ. They should be
on free drainage and not clamped at any stage, remaining
dependent at all time. Systems that do not require fluid to

K17577_C043.indd 663 17/11/2015 16:21

 664  Patient transfer: The critically ill
function and have anti-reflux capability are preferred. The
use of the Heimlich-type valves incorporated in the system
or certain types of emergency chest drainage systems, as
used in acute trauma, may be a patient safety hazard. They
may become blocked, leading to tension pneumothorax that
may be difficult to detect or distinguish from other causes of
sudden deterioration. Emergency drainage bags, often used
with these devices, may be open-vented and are prone to
spill, presenting a biohazard.
During transfers the presence of an endotracheal tube
may lead to adverse ventilatory and cardiovascular effects.
Increasing sedation and, if required, adding neuromuscular
blockade may reduce the impact of these effects but add to
the likelihood of complications from overjudicious use. The
poor performance of many transfer ventilators increases
the need for these interventions. Patients recovering from
critical illness and being weaned from ventilatory support
can be set back by many days by using inferior ventilators,
which require the use of such drugs.
To reduce the likelihood of compromising recovery, a
tracheostomy may be considered, because this goes some
way to reduce the airway issues associated with oral endo-
tracheal intubation. Patients with a newly formed trache-
ostomy should not normally be transferred until the risk of
immediate post procedure haemorrhage has passed (at least
24  hours) and preferably when a tract has begun to form.
This is because if a newly provided tracheostomy is dis-
placed, regaining control of the airway may be impossible,
particularly if it was performed for upper airway obstruc-
tion. Even if the upper airway is clear, patients have died
during the attempt to provide an airway even in the con-
trolled environment of an ICU. For established tracheos-
tomy the same checks as for an endotracheal tube should
be performed.
Alternately, an ICU-level ventilator will reduce the effects
of intubation. Ideally this level of ventilation should be
provided for all critical care patients. Ventilation for these
patients is more complex and should not be approached as if
the patient has normal lungs and is simply being ventilated
for routine surgery.
In principle, transfer ventilation should at least emulate
that which the patient was receiving in the hospital. ICU
ventilators provide modes such as positive end expiratory
pressure, pressure control, inverse inspiration : expiration
ratios, etc., which compensate for changes in compliance.
Appropriate alarms and back-up systems are essential.
When transferring from one ventilator to another, patients
should be stabilized and arterial blood gases checked to
ensure there has been no deterioration. This should be done
even if the settings are similar to make allowance for indi-
vidual ventilator performance.
Patients with severe pulmonary damage, such as those
suffering from blast lung or influenza, may be profoundly
compromised and conventional ventilation may be inad-
equate even in a fixed facility. It is now possible to provide
advanced support with extracorporeal carbon dioxide
removal (ECCOR) (Baker et  al. 2012) or extracorporeal
K17577_C043.indd 664
membrane oxygenation (ECMO). The former has become
much less complex and can effectively be undertaken using
venovenous cannulae. The evidence base for survival ben-
efit has not been established for ECCOR. There is evidence
for survival benefit ECMO in children, but little in adults
(Hung et  al. 2012). Transporting patients with arteriove-
nous ECCOR is the most straightforward as no pumps are
required. Pumped venovenous ECCOR and ECMO (Cannon
et al. 2011) are highly complex and require even more spe-
cialized teams to undertake the transfer of these already high
risk patients.
CARDIOVASCULAR SYSTEM
Fluid balance and blood pressure
To attenuate the effects of flight the circulation must be opti-
mally filled and supported. In the critically ill patient, fluid
balance must be finely tuned due to factors such as continu-
ing fluid loss, intermittent positive pressure ventilation and
positive end expiratory pressure, oxygenation, renal impair-
ment and cardiovascular performance. If the cardiovascu-
lar system is not optimized the effects of acceleration and
deceleration during travel can be life threatening.
Vasoactive drugs having inotropic and vasopressor
actions may already be being used to treat the patient, but
may need to be started or augmented to allow safe transfer.
If there is potential for instability, drugs to support the cir-
culation should be attached and ready. These drugs may be
considered life vital, because sudden interruption in their
administration may result in severe cardiovascular insta-
bility or cardiac arrest. Vasoactive drugs require admin-
istration via the central venous route and this must also
be available. This also provides for monitoring of central
venous pressure to aid cardiovascular monitoring.
Patients particularly at risk are those with severe SIRS,
sepsis, multiple organ failure, major trauma or burns.
Patients with spinal cord injury are a special case and are
discussed below. To ensure that changes related to fluid bal-
ance may be monitored and appropriate drugs can be given,
adequate access to the circulation must be available.
In trauma where major blood loss has occurred and may
be continuing, blood and blood products may be required
to be administered during transfer and so appropriate man-
agement and storage of these is necessary.
Cardiac function
Changes in acid–base balance, electrolyte disturbance
and the inflammatory substances released in critical ill-
ness impair myocardial contractility. Any arrhythmias will
compound these effects. Monitoring and correcting acid–
base balance, arterial blood gases and electrolytes, particu-
larly potassium and magnesium, will do much to attenuate
these problems.
Following acute coronary syndromes and myocardial
infarction, the myocardium may be extremely irritable lead-
ing to arrhythmias and even cardiac arrest. Cardiac failure
and cardiogenic shock may also complicate the picture. All
17/11/2015 16:21

attempts to optimize patients should be made before trans-
fer is contemplated and most advise not to transfer within
the first 48 hours of such events.
The situation may be further complicated by preparing
to move the patient leading to increased intrinsic sympa-
thomimetic activity. This may mask the inadequate filling
and vagal influences. In some this may lead to damaging
tachycardia and hypertension. In others the opposite occurs,
with acute vagal stimulation from, for example, moving the
patient’s head when they are intubated. Adjuvant therapy
with sedation, analgesia or neuromuscular blockade given
to reduce the effects of transfer may precipitate bradycardia
and acute vasodilatation in the cardiovascularly compro-
mised patient and need to be used with caution.
Patients who require acute mechanical cardiovascu-
lar support can be transferred using intra-aortic balloon
pumps. While this has been undertaken by paramedics in
the US (Sinclair & Werman 2009), these were short journeys
(39.9 ± 26.1 minutes) and it is recommended that a special-
ist team be constituted for extended travel. Transportation
of patients with temporary ventricular assist devices is also
possible (Potapov et al. 2004) but again requires the use of
specially constituted teams familiar with the devices as well
as the transfer environment.
The abdomen
GUT MOTILITY
Patients who are post trauma, post-surgery, on certain
drugs or who are critically ill from whatever cause, are likely
to have impaired gastric motility. Delayed gastric emptying
will result in raised gastric volume and may lead to nau-
sea, vomiting, regurgitation or electrolyte disturbances.
Passive regurgitation in the unconscious critically ill patient
will lead to pulmonary aspiration and the risk of chemical
pneumonitis and pulmonary sepsis. Acute gastric dilatation
is also a serious complication and adds impaired respiratory
function to the list of problems that may be encountered.
AIR TRAPPING AND INTRA-ABDOMINAL PRESSURE
Surgery in the peritoneal cavity initially leaves residual air
trapped after closure. If this expands it may cause pain and
in large amounts may lead to a rise in intra-abdominal pres-
sure and a degree of intra-abdominal hypertension. Air or
other gases within the lumen of the bowel also expand, giv-
ing rise to pain and discomfort, and put anastomotic suture
lines at risk. Ileus or deranged bowel motility, common in
acute phases of critical illness and during the course of criti-
cal illness, may also lead to raised intra-abdominal pressure
and intra-abdominal hypertension, de novo. Expanding gas
will exacerbate this problem.
Intra-abdominal hypertension interferes with intra-
abdominal organ function as well as respiratory and car-
diovascular function. Renal function may be impaired,
with a rise in creatinine and urea. The kidneys are particu-
larly at risk in critical illness and the additional insult of
K17577_C043.indd 665
Critical illness  665
intra-abdominal hypertension may precipitate renal failure.
The liver is also vulnerable and deranged hepatic function
may occur.
Supporting the gastrointestinal tract is achieved by ini-
tial drainage, early feeding, optimizing fluid balance, gas
exchange and improving perfusion generally. The place-
ment of a nasogastric drainage tube should be the usual
requirement for Aeromed transfers of the critically ill.
Decompressing the stomach of gas and fluid reduces the
potential effects discussed above. Feeding should be stopped
a number of hours before transfer to reduce the likelihood of
reflux. The use of prokinetic drugs such as metoclopramide
or erythromycin may be considered. Nasogastric or orogas-
tric tubes should be aspirated and then placed on free drain-
age, while remaining dependant. As drainage bags expand
they should be regularly decompressed.
MANAGEMENT OF FEEDING/GASTROINTESTINAL
HAEMORRHAGE PROPHYLAXIS AND ILEUS
In order to reduce the incidence of upper gastrointestinal
tract haemorrhage over the period of cessation of feeding
or in patients who are not fed, H2  receptor blocking drugs
or proton pump inhibitors should be used. For long trans-
fers, feeding may be recommenced at the discretion of
the attending physician, but the risk of aspiration is high
(Turner & Ruth 2008).
If there has been intra-abdominal surgery and or bowel
surgery without sufficient time to allow anastomoses to
heal and ileus to settle, sea level cabin altitude should be
requested. If there is ileus from medical causes, with a risk
of perforation or acute uncontrollable haemorrhage, trans-
fer should be delayed until this has resolved by either thera-
peutic or surgical means.
HEPATIC FUNCTION
Hepatic dysfunction may be primary, due to ingestion of
drugs or infection. In the critically ill, changes in blood
flow, the presence of toxins and drugs in the circulation
and the direct effects of infective agents may compromise
hepatic function. Also, increased intra-abdominal pressure
(intra-abdominal compartment syndrome) due to ileus or
haematoma may compromise hepatic function indirectly by
impairing perfusion.
Impaired hepatocyte function increases the potential for
coagulopathy and for altered metabolism of drugs. In prac-
tice mildly deranged hepatic function is of little significance
during transfer. However, in acute hepatic failure even
short distance ground transfer may be extremely hazardous
owing to the circulatory and neurological effects associated
with the condition. Transfer to enable the patient to receive
hepatic transplantation may be justified and the attendant
risk accepted.
Blood glucose, circulatory optimization, coagulation
and neurological status need to be monitored and treated
carefully. Patients with cerebral oedema are particularly at
risk and should have intracranial pressure measurement.
17/11/2015 16:21
 666  Patient transfer: The critically ill
RENAL FUNCTION
Reduced blood flow to and within the kidney occurs in the
critically ill. It is caused by systemic hypotension and the
non-specific effects of sepsis. Intrinsic renal damage may
result from and be aggravated by hypoxia and the nephro-
toxic effects of drugs. Usually a combination of factors is
involved and they may result in impaired renal function
and even renal failure.
Impaired renal function may also be due to existing renal
disease that may or may not have been previously identified.
The goal in the critically ill is to maintain function and where
it is impaired or lost, replace it. In the modern critical care
environment acute renal failure is not an individual cause of
mortality and renal replacement is routinely available.
Patients who are inadequately treated may be subject to
changes in electrolytes during the transfer that will compro-
mise their safety. If this occurs there are limited therapeu-
tic options and the patient may suffer irreversible cardiac
dysfunction. Temporizing treatments with sodium bicar-
bonate, calcium salts, glucose and insulin or ion exchange
resins have a limited role.
Renal replacement is provided to control fluid balance,
control acid-base balance and electrolytes. In the air trans-
fer environment it is now possible to provide renal replace-
ment, but this is a further level of complexity and should
only be used by well trained and experienced teams.
Patients who have the physio-biochemical derangements
associated with renal impairment should have renal replace-
ment prior to transfer, with a short period of stabilization
post treatment. Even if the measured parameters are accept-
able, treatment in the immediate period before transfer is
advisable in patients who are known to be dependent on this
therapy. If this is not available locally, renal support could
be provided by the Aeromed team with portable equipment.
Urinary catheters need to be checked to ensure there is
free drainage and urine output should be measured hourly
as in the intensive care.
Central nervous system
THE HEAD
The major goal in the management of cerebral injury is to
reduce the incidence of preventable secondary brain injury
by the avoidance of hypoxia, the normalization of arterial
carbon dioxide and the maintenance of cerebral perfusion
pressure. Cerebral perfusion pressure is dependent on the
mean arterial blood pressure, the central venous pressure
and the intracranial pressure.
Head injury leading to altered level of consciousness is
assessed by using the Glasgow Coma Scale. Restless unco-
operative patients are difficult to manage and may be a
danger to themselves and even to the aircraft. It is tempt-
ing to sedate such patients to manage them, but this risks
reducing the level of consciousness further and is associated
with hypoventilation. Hypoventilation will initially lead to
hypercarbia and then to hypoxia. Hypercarbia increases
K17577_C043.indd 666
intracranial pressure that may be critical for the already
injured brain. Hypoxia will also lead to further neurologi-
cal injury. To avoid this, the airway must be maintained and
ventilation controlled if necessary.
Any expanding air in the cerebrospinal fluid or in the
skull may raise intracranial pressure. This is of particular
significance when the normal compensatory mechanisms
for finely adjusting the intracranial pressure are already
compromised. Normally, autoregulatory mechanisms
adjust blood flow when there are changes in arterial car-
bon dioxide, arterial blood pressure and central venous
pressure. Cerebrospinal fluid production and absorption
is also closely controlled. In serious head injury or where a
large space-occupying lesion is present, some or all of these
mechanisms may be disrupted globally or regionally in the
brain. A sudden increase in volume caused by the presence
of expanding air may precipitate further neurological dam-
age or acute cardiovascular instability.
Patients with a Glasgow Coma Scale of eight or less
should be intubated and ventilated (AAGBI Guidelines
2009) (care for the cervical spine should also be routinely
practiced where trauma has occurred). This will require the
correct use of drugs to induce anaesthesia, and the proce-
dure must be carried out by a physician who is experienced
and capable of intubating head-injured patients. This is
because vasodilatation caused by induction agents may lead
to hypotension and cerebral hypoperfusion. Conversely,
intubation may lead to a marked sympathetic stimulation
and a marked increase in intracranial pressure.
SPINAL INJURY
The lower cervical spine and the junction between thoracic
spine and lumbar spine are the most common sites of injury.
Spinal fractures and dislocations lead to disturbances of not
only sensory and motor, but also, significantly for transfer,
autonomic function.
Injuries to the cervical and upper thoracic region lead to
cardiovascular instability due to loss of cardio-accelerator
nerve output and vasomotor tone. Below T5 the sympathetic
innervation of the myocardium is preserved. Ventilation
is also affected, as is bronchomotor tone. These effects are
much greater than is normally appreciated (Table  43.3).
Ileus, urinary retention, gastric ulceration and haemor-
rhage may also occur in the early period. These patients
have a markedly increased risk of deep venous thrombosis.
Later post injury, general nutrition issues and pressure areas
are a problem.
All critically ill patients, but especially those with a spi-
nal injury, require meticulous skin care. Particular attention
must be directed towards areas prone to pressure. Regular
inspection and turning needs to be undertaken to avoid
pressure sores developing. This important task requires ade-
quate numbers of trained personnel and the space to under-
take it. Standard operating procedures should include this
important aspect of care and how it is to be accomplished.
Injury of the thoracic spine due to trauma is likely to be
complicated by other thoracic injury, including pulmonary
17/11/2015 16:21
 Critical illness  667

Table 43.3  Effects of spinal cord dysfunction

Position Cardiovascular Bronchial Tone Ventilation

High cervical Bradycardia, hypotension, Variable tone, potential Failure of ventilation, requires immediate
for bronchospasm intervention
Mid cervical Bradycardia, hypotension Variable tone, potential Paradoxical ventilation, reduced functional
for bronchospasm residual capacity, inability to cough
Low cervical Bradycardia, hypotension Variable tone, potential Hypoventilation, sputum retention,
for bronchospasm deterioration of ventilation likely after
initial period
Upper thoracic Bradycardia, hypotension Loss of intercostals, peripheral diaphragm,
hypoventilation, cough reduced, sputum
retention
Lower thoracic Hypotension Loss of abdominal wall tone, reduced cough

contusion as discussed above. This adds to the problems of
secretion retention and the potential to develop pulmonary
sepsis. Adequate, preferably closed system, suction apparatus
is essential to reduce the effects of bronchial plugging which
can lead to rapid desaturation. It must also however, be remem-
bered that patients with unopposed vagal influence, due to
high spinal cord injury, may be prone to profound bradycardia
or even asystole when subjected to endobronchial suctioning.
Burns and trauma
Patients who have been injured due to burns or trauma may
develop a SIRS profile. It is unpredictable who will develop
this complication which may carry a genetic predisposition.
Some who have received what might be considered a rela-
tively minor injury may be affected whereas others who are
severely injured may not.
Following limb trauma, compartment syndromes must
be excluded. Fasciotomies must be undertaken pre-transfer.
Fractures need to be adequately stabilized, preferably with
a rigid fixation device. This is particularly important where
there is any question of vascular compromise. In the case of
serious pelvic fracture, where there is risk of further haem-
orrhage, external fixation is also essential.
Patients with burns present special challenges due to
potential for airway problems (see above), anaemia, initial
and continuing high volume loss of fluids, electrolytes and
albumin loss. They may also need escharotomy of limbs and
chest to allow adequate circulation peripherally and ventila-
tion where there are circumferential deep burns. Sepsis is a
high risk and leaking dressings present a biohazard.
Diving
Critically ill patients from diving accidents who have been
inadequately treated or divers who have had other problems
requiring air evacuation are at risk of nitrogen bubble for-
mation and the attendant cardiovascular, respiratory, neu-
rological and locomotor complications. Initial evacuation
from the scene of an accident by rotary wing presents a haz-
ard, due to lack of cabin pressurization even if 100 per cent
oxygen is being administered.
Subsequent movement by air should ideally be only
undertaken when treatment by recompression has been
completed according to the appropriate decompression
tables and when deemed safe by appropriate expert opin-
ion. If this cannot be achieved options include using a por-
table recompression chamber or sea level cabin altitude
with oxygen therapy. The latter option is not ideal as there
are hazards of 100  per cent oxygen logistically and dam-
age to the alveolar mucosa may occur. The risks of transfer
before definitive treatment may be justified to gain access
to a hyperbaric facility if it is to mitigate further damage.
These decisions should be made with the input of experts in
diving medicine.
Therapeutics
If at all possible, patients should remain on the drug treat-
ment that has been established before transfer. This will nor-
mally include analgesia, sedation and prophylaxis for deep
venous thrombosis. It will also likely include antimicrobials
and vasoactive drugs according to the patient’s needs.
If drugs are changed just before transfer there may be
serious consequences such as severe cardiovascular insta-
bility. Drugs should therefore only be added to facilitate
transfer, and any changes to drugs should be studied over
a sufficient period of time to properly judge the effect of
those changes.
Patients may be on a therapeutic regimen that is not
normally used by the transfer team, but the similarity of
the drug effects can usually be read across and they can be
safely maintained on the drugs from the transferring facil-
ity. Adequate supplies of drugs to cover the transfer and all
foreseeable eventualities should be carried by the transfer
team. This includes oxygen.
Temperature control
Avoiding hypothermia and if possible hyperthermia is an
important goal. Sedation and neuromuscular blockade
disrupt normal temperature control mechanisms. This
is accentuated in critical illness where normal metabolic
processes are compromised. Some patients will become

K17577_C043.indd 667 17/11/2015 16:21

 668  Patient transfer: The critically ill
Figure 43.5  A patient securely packaged for transfer.
hypothermic (core temperature below 35°C), whereas others
in hot climates may become pyrexial. This situation is con-
fused by changes occurring during ventilation, the admin-
istration of intravenous fluids, from evaporation from fluid
loss in haemorrhage post trauma or burns and exposure to
the environment.
Effects on drug metabolism are probably of low sig-
nificance in the context of aeromedical evacuation.
Hypothermia can affect cardiovascular function and can
lead to life-threatening arrhythmias. It also interferes
with clotting and can almost inhibit it altogether with
obvious consequences.
GENERAL CONDUCT OF TRANSFER BY AIR
When all of the above have been considered and any poten-
tial for optimization has been exploited, the patient is ready
to be transferred. This begins with transfer onto the portable
equipment before the movement of the patient is actually
contemplated. Once this has been successful and a period
of observation has passed to ensure no adverse effects have
occurred, the patient may be moved.
The general considerations of any patient transfer are
similar. They include careful preparation, meticulous atten-
tion to detail and, as already stated, patient-focussed care.
If a patient is to be moved they should arrive at their des-
tination in at least as good condition as when they set off,
if not better, and if they have deteriorated this should be as
a result of their underlying condition and not as a result of
the transfer.
The patient should be packaged in such a way as to allow
access to them and all of the required equipment, but at the
same time they and the equipment should be adequately
restrained to comply with relevant regulations (Figure 43.5).
This packaging should also allow for proper pressure area
K17577_C043.indd 668
care, which includes changes in position and inspection at
appropriate intervals.
At all times during the journey the monitors and indi-
cators of correct equipment function must be visible to the
operators. This presents challenges for the military aviation
environment, but the problems are not insurmountable as
infrared friendly and dimmable displays are available. So
that continuous monitoring of these parameters is under-
taken in the constantly changing environment, at any
one time there should be a designated individual with the
required skills in interpretation observing them.
Patient consent
As part of the risk assessment, before a patient is trans-
ferred consideration must be given to the patient’s actual
or perceived wishes. In England and Wales the principles
of consent, patient capacity and who is legally able to give
consent when the patient lacks capacity are contained in the
Guidance from the General Medical Council (2013) and the
Mental Capacity Act 2005. If the patient is able to appre-
ciate what is proposed they must be consulted, potential
risks explained in a way that they can understand and their
wishes respected.
If the patient lacks capacity and it is at all possible, rela-
tives should be consulted if they have a view on what the
patient might wish. They cannot, however, decide what
should be done unless they have been legally appointed
to do so. Patients who lack capacity are further protected
in law in that regardless of who makes decisions on their
behalf this should be based in their best interest. Best inter-
est is discussed in the Mental Capacity Act 2005, and may
be determined by a court in some cases. It should also be
noted that a physician is not obliged to offer treatments that
they would regard as not in the patient best interest, such as
if it is believed that a transfer was clinically inappropriate.
17/11/2015 16:21

SUMMARY
●● The necessity to move ever more critically ill
patients has increased hugely over the past few
years, and with this capability in military practice
has developed immeasurably. This has required
the rapid evolution of the skills, training and
expertise needed to accomplish these highly
complex missions. What has not changed is the
requirement for meticulous planning by per-
sonnel currently taking care of the critically ill,
who have the ability to accurately assess patients
and then move them using that skill, experience
and expertise.
●● Missions, as has always been the case, must be
properly resourced and have robust logistical sup-
port. Equipment has to be specifically designed
for transfers and must be able to emulate that
of the fixed environment. It must be thoroughly
tested to ensure compatibility with the air envi-
ronment and to be able to survive and function
correctly in that environment.
●● It is now possible to successfully transfer patients
by air who are at the extreme ranges of physi-
ological tolerance and allow patients such as the
critically ill and war wounded access to the high-
est level of care in their home country.
REFERENCES
Baker A, Richardson D, Craig D. Extracorporeal carbon
dioxide removal (ECCO2R) in respiratory failure: an
overview, and where next? Journal of the Intensive
Care Society 2012; 13: 232–7.
Cannon JW, Zonies DH, Benfield RJ, Elster EA, Wanek SM.
Advanced en-route critical care during combat opera-
tions. Bulletin of the American College of Surgeons
2011; 96: 21–9.
Dirven PJA. Minimal Sealing Pressures of Endotracheal
Tube Cuffs Filled with Saline in a Model of the Airway.
Presented at AIRMED 2002 World Congress, 17–20
September 2002, Interlaken, Switzerland.
General Medical Council. Good Medical Practice. London:
General Medical Council, 2013. Available from http://
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www.gmc-uk.org/guidance/good_medical_practice.
asp. Accessed 24 Feb 2015.
Gunst M, Ghaemmaghami V, Gruszecki A, Urban J,
Frankel H, Shafi S. Changing epidemiology of trauma
deaths leads to a bimodal distribution. Proceedings
(Baylor University. Medical Center) 2010; 23: 349–54.
Hung M, Vuylsteke A, Valchanov K. Extracorporeal
membrane oxygenation: coming to an ICU near you.
Journal of the Intensive Care Society 2012; 13: 31–8.
Potapov EV, Merkle F, Güttel A, et al. Transcontinental
transport of a patient with an AbioMed BVS 5000
BVAD Annals of Thoracic Surgery 2004; 77: 1428–30.
Roedig E. Aeromedical Evacuation. Available from http://
www.transfair.fr/casestudies/AE-roedig.pdf. Accessed
24 Feb 2015.
Sinclair TD, Werman HA. Transfer of patients dependent
on an intra-aortic balloon pump using critical care
services. Air Medical Journal 2009; 28: 40–6.
The Association of Anaesthetists of Great Britain and
Ireland. AAGBI Safety Guidelines: Interhospital
Transfer. London: The Association of Anaesthetists
of Great Britain and Ireland; February 2009. Available
from http://www.aagbi.org/sites/default/files/interhos-
pital09.pdf. Accessed 24 Feb 2015.
The Association of Anaesthetists of Great Britain and
Ireland. Recommendations for the Safe Transfer of
Patients with Brain Injury. London: The Association of
Anaesthetists of Great Britain and Ireland; May 2006.
Available from http://www.aagbi.org/sites/default/
files/braininjury.pdf. Accessed 24 Feb 2015.
The Association of Anaesthetists of Great Britain and
Ireland. Recommendations for Standards of Monitoring
During Anaesthesia and Recovery, 4th edn. London:
The Association of Anaesthetists of Great Britain and
Ireland; March 2007. Available from http://www.aagbi.
org/sites/default/files/standardsofmonitoring07.pdf.
Accessed 24 Feb 2015.
Trunkey DD Trauma. Scientific American 1983; 249: 20–7.
Turner S, Ruth M. Critical Care Air Support Teams. In
Neilsen JN: NATO HFM-157. Proceedings of the
Human Factors and Medicine Specialist Meeting on
Medical Challenges in the Evacuation Chain. Seigburg,
Germany: Dec 2–3, 2008.
Whitely S, Macartney I, Mark J, Barratt H, Binks R.
Guidelines for the Transport of the Critically Adult,
3rd edn. London: The Intensive Care Society; 2011.
17/11/2015 16:21
K17577_C043.indd 670 17/11/2015 16:21
 Part     IV
Operational Aviation Medicine

44 Pilot selection and training 673

Robert Bor, Carina Eriksen and Margaret Oakes
45 Crew resource management 685
Revised by Stephen R. Jarvis
46 Air traffic control 697
John Roberts
47 Errors and accidents 707
Sarah Harris
48 The flight deck and cockpit 723
Michael Bagshaw
49 In-flight communications 737
Graham M. Rood and Susan H. James
50 Noise 747
Graham M. Rood and Susan H. James
51 Aircrew and cosmic radiation 769
Robert Hunter
52 Motion sickness 781
Alan J. Benson and J.R. Rollin Stott
53 Passenger safety in civil aviation 797
Revised by Nigel Dowdall
54 Rotary wing operation by land and sea 805
Mark S. Adams
55 Uninhabited aerial vehicles 815
Dale Daborn
56 Aircraft hygiene 825
Michael J. Kelly
57 Accident investigation and aviation pathology 831
Matthew E. Lewis and Graeme Maidment

K17577_C044.indd 671 17/11/2015 16:22

K17577_C044.indd 672 17/11/2015 16:22

Pilot selection and training
ROBERT BOR, CARINA ERIKSEN AND MARGARET OAKES
Introduction 673
History and benefits of pilot selection 674
An overview of pilot selection 675
Psychology and medicine in pilot selection 675
Elements of the selection process 676
Ethical use of tests in pilot selection 678
Psychometric ability testing 679
Personality 680
INTRODUCTION
This chapter provides a practical guide to the information
and skills necessary for aviation medical professionals to
understand and contribute to the psychological aspects of
selecting and training pilots. Effective pilot selection and
training continue throughout a pilot’s career and play a fun-
damental part in the safety, efficiency, cost base and public
image of any aviation-based organization. Aviation medical
professionals are particularly well qualified to make valu-
able contributions to effective pilot selection. The major
focus of this chapter is therefore the design and implemen-
tation of selection procedures. Medical staff are perhaps
less likely to be asked to take part in pilot training but may
find themselves asked for advice or intervention when pilots
encounter difficulties in training. The final sections of this
chapter therefore present modern psychological models of
learning and outline appropriate ways of managing pilot
anxiety about training and testing.
Any military or civilian organization which recruits
pilots will be aware that, even without formal advertising,
they will frequently be overwhelmed with applications or
enquiries from more than enough applicants who will be
‘good enough’ in that they have the technical qualifications
and experience to do the job. The role of a well-designed
recruitment system is therefore to rule out applicants who
are not suitable and to select individuals most likely to
K17577_C044.indd 673
44
Work sampling 681
The selection process 681
Pilot training 682
Learning theory 682
Conclusion 683
Referenes 684
Further reading 684
perform well in the organization assessing them, assuming
they are even actively recruiting. However, recruitment and
selection are not precise sciences. The reader who is famil-
iar with the selection of medical students, for example, will
probably recall successful candidates who failed their final
medical exams and, by contrast, candidates who appeared
weak at selection but became qualified and respected doc-
tors; similar results can be found from pilot selection.
Research and literature which examines pilot selection
generally focuses on the selection of candidates for intensive
and expensive training courses: initial military training or
sponsored civilian training. Selection procedures are most
often assessed in terms of the proportion of successful can-
didates who pass that expensive initial training. While it is
vital that pilot candidates do complete their initial train-
ing, selection procedures also need to identify those most
likely to meet the longer-term requirements of the organi-
zation recruiting them. These requirements might include
consistency with the organization’s values, lifestyle, career
structure and culture, suitability for non-flying duties or
potential to contribute to other aspects of the organization
or undertake leadership roles.
Pilot selection and retention is an ongoing process
throughout an individual’s career as it is applied to select for
promotion to command, higher military rank and training
and management roles. It is also used to select pilots moving
between civilian organizations and from military to civilian
673
17/11/2015 16:22
 674  Pilot selection and training
employment. It therefore places significant demands on indi-
viduals and demands significant resources of organizations.
The sections in this chapter which consider pilot selec-
tion start with an overview of the background and context
of pilot selection. This is important to anyone involved
in designing or implementing pilot selection procedures
because it is that context which enables the selection team to
understand what they are aiming to achieve. Later sections
of this chapter describe the most commonly used elements
of selection processes. The information in these sections
will enable the reader to identify, source and evaluate poten-
tial assessment tools and to interpret and apply the data pro-
duced in using them. The final section on selection examines
the way in which the knowledge and skills described can be
implemented as an effective selection process.
Training is another process which continues throughout
a pilot’s career. While it is most obviously the domain of
specialist training personnel, medical staff can provide sig-
nificant and valued support to trainers and students when
they encounter difficulties. The sections of this chapter
which examine pilot training will equip the reader with the
knowledge to provide that support. The focus is the appli-
cation of modern theory and practice to training pilots in
technical and non-technical skills.
Overall, this chapter provides the necessary knowledge
to support medical staff in playing an active role in pilot
selection and training. It describes the context and back-
ground to both processes and examines practice and theory
relevant to medical staff.
HISTORY AND BENEFITS OF PILOT
SELECTION
Pilot selection has grown in sophistication and importance
with the development of aviation, from the earliest days of
the Wright brothers. Given the paucity of flying machines
and the unregulated and partially developed nature of com-
mercial aviation operations then, there were certainly no
rigorous selection processes. Interestingly, prior to the First
World War, pilots were selected on the basis of their ability
to ride a horse. Although this now seems a quaint and even
laughable criterion it was not without merit, the assump-
tion being that if a man was able to control a horse at speed
and while carrying weaponry, he was able to multitask and
conceptualize phenomena in three dimensions (Anderson
1919). It is not surprising, therefore, that many of the pilots
chosen to operate the early aircraft were cavalry officers.
There were very few female flyers in the early days of fly-
ing (although of course there were some famous women
pioneers in powered flight and the first commercial female
pilot flew an airmail plane in 1918), and even now women
form only a small percentage (6 per cent) of the total pilot
population. However, in the modern cockpit, traditional
female skills such as sloping level rather than hierarchical
management, teamworking and concentration when still
young, and multitasking are important, whereas sustained
physical strength is no longer particularly required. Given
K17577_C044.indd 674
all this, and the growing shortage of pilots due to increas-
ing air travel and the approaching block retirement of many
older pilots, it is likely that female candidates for pilot jobs
will increase significantly in number as they are encouraged
by airlines, and even the military air forces, perhaps with
greater flexibility in work and career patterns.
The outbreak of the First World War demanded a more
rigorous, efficient and effective method for pilot selection.
In those early days, suitability was essentially determined
by on-the-job testing or a rudimentary form of job sampling
assessment. Aspiring pilots might be put into an aircraft and
required to operate parts of the flight with a co-pilot and,
depending on performance, this might determine whether
or not they were selected. Very basic flight simulators were
developed for this purpose near the beginning of the war
(from 1915, along the lines of a 1909  prototype) which,
although bearing little resemblance to the experience of
actual flight, were at least a first step in the right direction.
It was not until the outbreak of the Second World War that
pilot selection, particularly for the military, became a spe-
cialization in its own right. It became necessary to select
suitable pilots for a variety of operations. By this time, avia-
tion had evolved to encompass a wide range of very different
roles for aircraft, and therefore demanded specialist skills
and attributes among pilots. Military operations included
operating fighters, transport, bombers and reconnaissance
aircraft. Scarce resources also needed to provide pilots who
were unlikely to be combatants but would rather be ferry-
ing or delivering valuable and scarce aircraft. Efficient and
effective methods were needed in order to ensure the right
choice of person for pilot training to function well in each
specialist role with the minimum of training. Early pilot
assessment was mainly conducted by the military. The mili-
tary’s sponsorship of research and test assessment centres,
developed under critical need conditions, set the tone for
pilot selection for many years to come – and arguably still
influences pilot selection today.
Today, pilots recruited into the airline industry in many
respects bear little resemblance to their predecessors from
the early days of powered and controlled flight. Not only are
the majority of pilots in employment serving within com-
mercial aviation as opposed to military, but the tasks they
are required to perform are, in most respects, completely
different. The modern flight deck is typically a place of auto-
matic pilot systems, screens and digital readouts rather than
of physical levers and mechanical instruments. It demands
advanced computer skills, as well as the traditional skills of
co-ordination and spatial awareness.
Pilots are increasingly selected not only for their flying
ability, but also for how they fit within an organization or
company. Their ability to work within the culture of the
organization is valued as highly as their flying record and
piloting skills. An organization may aim to recruit pilots
who will operate best as part of a complex team in heavy
military or civilian aircraft. Alternatively, the organiza-
tion might need pilots who function well on their own,
perhaps in military fighters or smaller civilian aircraft. It
17/11/2015 16:22

would be unusual for an individual to be equally suited to
both roles. Many pilots progress through the ranks from ab
initio training, and therefore may leave school, college or
university and start their flying career under sponsorship
by a commercial airline right from the start, rather than
transferring from the military. Selection of candidates for
sponsorship must aim not only to select those who will suc-
ceed in training and fit the sponsoring organization, it must
also identify candidates with the potential for promotion,
command, training and management roles.
Recent developments in technology have increased the
range of roles for which pilots may be selected. The control
of unmanned aerial vehicles (UAV), for example demands
the ability to fly and navigate, but the tools used to do this
are significantly different to those typically found even in
the most modern flight decks. A single flight may be con-
ducted by a series of different pilots using remote sensing
displays in two dimensions.
Decision making is entirely different for UAV pilots. In
UAVs, for example, safety based decisions are entirely driven
by responsibility or employment demands as opposed to
the desire for personal safety. Regular pilots are in full and
immediate control of their craft and decisions. UAV pilots
are supported by ‘mission control’ support staff. Selection
for UAV pilots must take account of these requirements.
Selection of aircrew would be merely an academic issue
were it not for the fact that there is considerable risk, both
financially and in terms of time commitment, inherent in the
decision to accept someone for pilot training. In the United
States Air Force, for example, the cost of failure in a candi-
date for pilot training is around $100,000. Approximately a
quarter of those initially selected do not succeed in becom-
ing qualified pilots, and the annual cost of this failure rate to
the USAF is close to $50,000,000. A false positive in candi-
date selection (the mistaken choice of a candidate for a pilot
training programme) is not only financially detrimental
(National Audit Office, 2000), but also impacts negatively in
terms of other resources, and even morale within the train-
ing cohort. The importance of selection is therefore self-evi-
dent and, much as with the selection of medical students, it
is crucial that the right choice is made from the outset and
the various losses associated with attrition minimized.
AN OVERVIEW OF PILOT SELECTION
In most organizations, certainly those which have a strong
focus on their workforce, people are arguably the most
important resource. Without good and safe pilots, no
amount of advanced or specialist equipment will lead to a
more competitive, effective – or even functioning – airline
or air force.
In one sense, the process of selection is intuitive; it is
much like the selection of medical students. It would be
most unlikely that a medical school would select students
solely on the basis of their application or personal state-
ment. Admission tutors are interested in the potential stu-
dent’s background, motivation and what their referees have
K17577_C044.indd 675
Psychology and medicine in pilot selection  675
to say about them. Then, assuming all is well after these have
been perused and scrutinized, the next stage is to meet in
person candidates who have been shortlisted.
Selecting commercial and military pilots is the same sort
of process, but the requirements differ depending on the
nature of the operations they will be required to undertake.
For example, bush pilots who have to handle travellers’ bag-
gage manually and who fly small aircraft in and out of chal-
lenging landing spots and who have no physical barriers
between themselves and their passengers need very differ-
ent skills to those who work in search-and-rescue, for mili-
tary, transport or combat operations, and to those who fly
commercially. Or, of course, to those who operate UAVs for
which there is and will be an increasing need. Organizations
may also offer very different career paths. For example, in
some sectors it may be normal and appropriate for pilots
to be employed for only a short period of time and for the
employment to be a stepping stone to another stage of their
career. In other settings, this would prove very costly to the
employing organization and pilots who quickly move on
would be disruptive, costly and unwelcome.
The process of selection therefore starts with the detailed
analysis of the role for which candidates are being selected
and that role’s future demands (potential for promotion) to
define a job description. This forms the basis of the person
specification which is the standard against which applicants
should be assessed. Hunter and Burke (1995) provide an
extensive description of how to do this. A person specifi-
cation might define necessary (education, qualifications,
flying experience) and desirable (interest in a specific orga-
nization, fit to culture) characteristics. The role of the selec-
tion process is to eliminate candidates who do not have the
necessary characteristics or qualifications and to identify
those who exhibit the highest levels of desirable characteris-
tics. Of course, the aim is to do this with minimum cost and
maximum efficacy. No small challenge!
PSYCHOLOGY AND MEDICINE IN PILOT
SELECTION
The involvement and expertise of psychologists and medical
professionals in this selection process has arisen mainly due
to the large number of applications which have to be pro-
cessed, as well as in recognition of their unique skills and
experience relevant to pilot selection.
Psychological assessment specifically helps to reduce
the chances of false positives in crew selection, whereby
unsuitable aircrew may slip through the net, which may
incur considerable cost and expense to the aviation orga-
nization. However, as long as humans are involved in the
selection process and humans are sought to operate air-
craft, there will arguably always be some level of impreci-
sion in the selection process. This in itself is not necessarily
a problem or inherently a bad thing, as all the evidence from
published literature shows that crew selection in the airline
industry, for the military, and for other flight operations is
largely carried out safely, effectively, efficiently and mostly
17/11/2015 16:22
 676  Pilot selection and training
with the desired outcome being achieved. The role of the
medical examiner is vital in order to ensure that the candi-
date meets the medical requirements of the country’s crew
licensing authority, as well as those of the employing carrier
or military.
Our experience of aircrew selection is such that we do
not advocate a ‘one-size-fits-all’ approach to screening and
selection. The notion that all pilots do the same job and
psychologically resemble one another with regard to their
personalities or skills is spurious; different pilot types are
required for different tasks in a range of organizations.
Selecting the right person for the job will depend on:
●● The ethos of the airline, carrier or military authority.
●● The type of equipment to be operated.
●● The routes and scope of operations.
●● Whether the flight purpose is passenger transportation,
military, cargo, search-and-rescue, or executive.
ELEMENTS OF THE SELECTION PROCESS
The full selection process normally includes most or all of
the following stages:
●● Advertising.
●● Pre-screening.
●● Developing an hypothesis.
●● Reading references.
●● Assessing the curriculum vitae.
●● Shortlisting of candidates for testing and interview.
●● Testing the candidate.
●● Interviewing.
●● Decision-making.
The following paragraphs provide an outline of each stage.
Advertising
It is essential that the advertisement is clear about what
is required for the job concerned and who is likely best to
meet these requirements. Whilst it is illegal to discriminate
unfairly against any particular type of applicant, certainly
in most western countries and in Europe especially, it would
be nonsensical to advertise for pilots generally when a par-
ticular type of pilot is required. If a rotary wing pilot is
needed for search-and-rescue operations, this must be made
clear or the pool of applicants will be unfiltered and the
whole exercise will become time-consuming and expensive.
Ensuring that the advertisement is clear is the first stage in
the selection process.
Pre-screening
However clear the criteria in the advertising, some appli-
cants will put in an application regardless of these. The role
of pre-screening is to check qualifications, experience and
characteristics which can be reliably demonstrated without
K17577_C044.indd 676
individual testing or interviewing against the person specifi-
cation. Essentially, the aim is to screen out candidates who do
not match the parts of the person specification which can be
checked using written or electronic applications as quickly and
inexpensively as possible. This ensures that only candidates
who are likely to match the necessary elements of the person
specification are invited to more expensive assessment stages.
Pre-screening can include several steps and the first is
often an application letter or cover letter. Requiring this
is useful as it gives the first window into the thinking of
the applicant and their attitude towards selection and/or
towards the organization which is the potential employer.
Whether the letter is handwritten or typed, on personal
stationery or on printed letterhead, the extent to which the
applicant has taken care (or otherwise) to personalise their
application, how much care has been taken in the formula-
tion and presentation of the letter, its length and compre-
hensiveness, all provide valuable pointers to the personality
of the candidate. It is important that selectors at this pre-
screening stage read through applications with care and
apply not only common sense, but also some detective abili-
ties, as well as making a basic assessment of the psychologi-
cal presentation (on paper) of the applicant.
An application form also allows the filtering process to
be standardized so that applicants can be more readily com-
pared initially. Some organizations require a photograph of
the applicant, although this is usually simply to ensure that
the person who comes through the door is the person about
whom the information on the application was given and
checked. The applicant should also be asked to provide the
necessary evidence of qualifications and career history, such
as photocopies of relevant documents. At this stage, refer-
ences are typically sought.
Developing an hypothesis
After having considered all the applications and made
judgements as to the extent to which various criteria have
been met (for example, number of flying hours, type rat-
ings, previous experience), it is then possible to generate
some hypotheses about a given individual. Is there a pat-
tern of changing jobs? Does it appear that they are unable
to settle down in their work or their personal life? Is this
person being over-inclusive about their qualifications as
a means of boosting their profile, but without much sub-
stance to validate this? Hypothesizing in this way enables
the rank-ordering of applications at this stage so as to deter-
mine who are likely to be the most suitable candidates to
shortlist for interview.
Reading references
It has been argued that references are not as important in
staff selection as they once were, but it is undeniable that
they provide some level of information which can prove
useful. Since it is unlikely that a candidate will put forward
a negative reference, whether it be from school, college or
17/11/2015 16:22

previous employer, it will at the very least confirm that oth-
ers in positions of responsibility actually know the candi-
date. A hard look at precisely who has been approached to
provide references – and who not – can be illuminating.
For example, if the current or immediate past employer
has not provided a reference, this might signal a discordant
relationship between the candidate and their employer and
this should be checked. Many organizations make a prac-
tice of telephoning referees to check that they have actually
written the reference concerned, as a form of due diligence,
whilst a few others go as far as employing investigators who
approach referees as a starting point to establishing that
what a potential candidate has stated is actually true.
Assessing the curriculum vitae
Aviation medical examiners should not be surprised if a
pilot applicant’s curriculum vitae (CV) is short, perhaps no
longer than a single page. Unlike a medical or academic CV,
the inverse applies with respect to length because with pilots
there is a tendency to précis or condense information rather
than to elaborate. This does not necessarily signal low levels
of experience or a paucity of intellectual functioning; it may
simply be stylistic and reflect good organizational skills. A
CV should be looked at both in terms of content and process.
Process reflects the general layout and organization of the
document. With experience, it is possible quickly to identify
gaps in a CV, such as periods of unemployment which are
not accounted for, or exaggeration of role levels or job titles
which might signal a tendency towards self-aggrandisement
or plain dishonesty.
The CV provides basic personal details of the applicant,
as well as a history of their education, training and career
history. It may also include information about hobbies and
interests and seemingly unrelated qualifications, such as
an HGV licence, or former membership of a military cadet
organization which may be a useful indicator in those apply-
ing for military aviation roles. A CV should be informative
and provide sufficient factual information, with small areas
of detail, so that those undertaking selection can gain a
clearer understanding of an applicant’s achievements and
potential gaps. It does not matter if a CV covers the same
ground as information required by the application form –
this can provide a useful double-check.
Shortlisting of candidates for testing or
interview
Further hypothesizing can be undertaken at the point when
a CV, application form, references and covering letter have
all been received, scrutinized and checked. It is now time
to draw up a shortlist of candidates suitable for testing or
interview. Up to this stage, the selection process has not
involved any face-to-face meetings with candidates and, in
some organizations where there are large numbers of appli-
cants for any job, this is obviously a good use of time and
resources as meeting every applicant would be a Herculean
K17577_C044.indd 677
Elements of the selection process  677
task. However, it is necessarily the case that some potentially
good candidates will be lost at this stage of the process (this
is designated as a ‘false negative outcome’, where a poten-
tially excellent applicant is overlooked on account of his
or her application). Nonetheless, this loss must be weighed
against the resources which would be needed within the
organization to interview every candidate.
Testing the candidate
Having shortlisted candidates, there may now be a require-
ment for them to undertake certain psychological tests, as
we discuss elsewhere in this chapter, as well as completing
simulation tasks to a greater or lesser extent (if not in a flight
simulator, then paper- or computer-based activities such as
tracking, planning, spatial awareness and reaction times,
for example). All such tests provide another dimension of
information about the candidate’s skills, proficiency and
potential in various areas to that provided by either a writ-
ten account of them or an assessment by an interviewer.
A further part of the selection at this stage might be
having the candidate undertake a medical examination,
given the obvious requirements for medical fitness which
pilots must meet. It is a sad fact that some pilots who are
outstanding with regard to their aviation skills are none-
theless proven to be medically unsuitable, perhaps having
a history of a particular medical problem or such problem
being revealed during the course of a medical examination.
Medical examiners may find that selection medicals define
higher standards of fitness than the regulator demands for
medical certification. Airlines and military organizations
rightly want to ensure that pilots they invest in are likely to
be fit to work until retirement age.
Interviewing
Interviews should be conducted by at least two people so as to
ensure that one can observe and take notes, while the other
is engaged in the questioning. There are many books on how
to conduct an interview, but almost all of these highlight
the value of the face-to-face interview as an opportunity to
engage with the applicant person-to-person. It is a useful
context in which to assess how the candidate approaches the
interview (do they see it as important and formal, a casual
event to be fitted in with more important activities in their
daily life, or have a different, perhaps unexpected, approach
entirely?), how they deal with a stressful situation, and it is
revealing of the candidate’s personality. Over-confidence
or over-submissiveness, inappropriate responses, a sense of
entitlement, or perhaps an indication given by their non-
verbal communication that all is not well, can make it clear
that a candidate is unsuitable despite their apparent suitabil-
ity on paper. An interview is also a context in which a mini
mental state assessment can be undertaken. This is highly
important in the selection of pilots, given the levels of attri-
tion during training due to mental health factors. However,
these might be overlooked during interview due to the ‘halo
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 678  Pilot selection and training
effect’ of the candidate’s otherwise excellent performance or
suitability in other areas of the selection process.
It is important for interviewers to remember that dur-
ing the selection process – and this is particularly true of the
face-to-face interview – they are representing the employ-
ing organization in which they serve, and the candidates are
at this stage still outsiders to the organization. An organiza-
tion which deals with people with courtesy and consideration
gives a good impression which will soon spread. One of pilots’
biggest complaints about selection processes is the negative
experience they have in the course of interviews. A failure
to provide feedback to candidates (particularly unsuccessful
ones) can be damaging to the reputation of an organization.
Furthermore, it may leave potentially suitable candidates who
may have wished to reapply at a later stage when some defi-
ciency (for example, insufficient work experience) has been
remedied, disenchanted and therefore unwilling to do so.
In some organizations, repeat interviews are conducted
with different members of staff, and the findings of the
respective interview teams are then graded and pooled at
a further selection meeting. This allows candidates to be
assessed and observed in different contexts, their responses,
validity and reliability to be checked, and any undue bias to
be highlighted and examined.
Interviewers need to take great care about what ques-
tions are asked during the interview. For example, it is
inappropriate (and illegal) to ask a candidate if she is plan-
ning to have a family and/or how soon she is going to do
this. Questions should be decided in advance (and perhaps
checked by in-house lawyers), which will ensure that inap-
propriate and/or illegal questioning is avoided. Preparing
questions in advance also means that all candidates are
asked the same questions, thereby allowing for compari-
son between them. However, more probing and expanding
questions can be raised ad hoc as the need arises during the
course of the interview.
Decision-making
This time- and resource-consuming process of pre-screen-
ing and shortlisting candidates up to this stage will begin to
show results.
The final stage of the selection process is not focused
on the candidates, but has to do with the selection process
itself. Those involved in selection must consider, continu-
ously, whether the process has been effective and whether it
is working. The only way to determine this is whether those
selected have proved historically, and are proving now, to be
suitable for the organization and for the role for which they
were selected, and whether or not they stay with the orga-
nization for a sufficiently long period to provide a return on
the investment made in their selection and training.
ETHICAL USE OF TESTS IN PILOT SELECTION
Most people approach job interviews and selection pro-
cesses with a measure of trepidation, perhaps perceiving the
K17577_C044.indd 678
process as unfair and discriminatory. In essence, the second
part of this perception contains some truth, as obviously
those conducting the selection process are in fact seeking to
discriminate between different candidates in order to deter-
mine those who will make good pilots. However, some of
the negative perception of candidates around selection may
well be ameliorated by their being offered specific feedback
on their personal performance. Some can be provided with
the assurance that their performance was satisfactory, with
an explanation of the respect in which another candidate
was better fitted to the requirements of the employing com-
pany or military organization.
Prior to any assessment being undertaken, a candidate
should:
●● Be informed in good time of the venue, where and to
whom they should report.
●● Have a clear understanding of the amount of time they
will need to allocate and the nature of the tests they will
be required to complete, to reduce unnecessary anxiety.
●● Be given any instructions or advice specific to the
testing process and centre; for example dress code,
necessary documentation to be provided, parking and
refreshment arrangements.
●● Be advised whether or not studying or other specific
advance preparation is required of them. In reality,
many candidates undertake some form of simulated
assessment or similar to prepare and familiarize them-
selves with the types of selection methods now used.
It goes without saying that the testing centre should give a
clear impression to the candidate of the potential employer’s
business, nature and relationship with employees.
Most candidates are likely to be nervous and apprehen-
sive about the assessment, and it is important that they are
put at ease as soon as possible on arrival. While some forms
of assessment might, at times during the process, seek to
increase candidates’ stress levels to see how they react under
such conditions, it may well be counterproductive to start
the assessment process in this way without first establishing
the candidate’s normal behaviour and some level of rapport.
Those charged with the responsibility of meeting and greet-
ing candidates should ensure that they are welcoming and
encouraging, showing a personal interest in the candidate
and seeking to put them at ease. Informal conversations
may also reveal more about the personality and attitudes of
individual attitudes.
Essential considerations for the assessment process are:
●● That care is taken to ensure that the actual testing room
is quiet, comfortable, adequately lit, well ventilated, and
is generally a clean and well-managed space.
●● That tests are introduced clearly and systematically and
in the same way to each group of candidates.
●● That there is a consistent response to candidates who
struggle with answering a question or completing
a task.
17/11/2015 16:22

Professional bodies involved in the development and prac-
tice of psychological testing, such as the British Psychological
Society (www.bps.org.uk), require that records are kept of
candidates attending for testing. These usually include hard
or digital copies of tests and each individual candidate’s
responses so that they can be checked at any later stage for
drafting and/or clerical errors. These records also, as is the
case with clinical records, constitute legal documents.
It should be noted here that completed questionnaires
and other assessment records should never be left unse-
cured where they might be seen or accessed by unauthor-
ised people. Such records are a matter of legal privacy as
they obviously constitute personal data in law (for example
under the Data Protection Act 1998). This consideration
apart, however, obviously assessment results hold insights
into personal psychology and, as such, are not for general
viewing any more than are medical notes.
Psychological testing has advanced considerably since
the early days of psychometrics in the late nineteenth and
early twentieth centuries – interestingly, a period which
coincides with the early days of powered flight. It is of
course important to choose the right tests for measuring
performance relevant to neophyte pilots.
Psychological testing is not a pure science, and it is not
without its limitations. One of the most important limi-
tations is the way in which tests are administered, and
the fairness or bias shown by the test administrator. It is
highly important that candidates who attend for testing
are treated with respect and are also, at the end of the
process, provided with feedback about their performance,
particularly if they have not been successful. This is so
that they may gain insight into and understanding of their
abilities and limitations. It will also concomitantly improve
the image of the recruiting organization and of the use
of psychometrics.
PSYCHOMETRIC ABILITY TESTING
Psychometric testing can be computerized or administered
as the more old-fashioned pencil-and-paper testing struc-
tured as multiple choice questions. However, in either form
the test process should be overseen by staff who are familiar
with and trained in the administration and interpretation
of such testing. Some aviation companies use an external
organization to administer and oversee psychometric test-
ing, whereas others may use their own human resources
department or an occupational psychologist to design and
deliver the tests. When using psychometric tests, an airline
will first need to decide which tests best identify the quali-
ties defined in the person specification.
Selection tests should satisfy the criteria of reliability and
validity (Rust & Golumbok 2008). Reliability refers to the
consistency of the measure provided by the test, while valid-
ity reflects the degree to which a test is able to measure what
it is supposed to measure. It is important to note that a test
can be valid even if it is not reliable and reliable even if it is
not valid.
K17577_C044.indd 679
Psychometric ability testing  679
The main measures used to assess test reliability are:
●● Test–retest reliability: measures the correlation of
results from the same test administered to the same
people after a time interval.
●● Equivalent-form reliability (also known as parallel
form reliability): measures the administration of two or
more tests, using the same or different testing elements
in a different sequence and measuring the same objec-
tives, the results from the different versions then being
correlated in order to evaluate the consistency of results
across the different versions.
●● Internal consistency: this measures whether each item
under each category is measuring the same thing, albeit
at differing levels.
The main measures used to assess test validity are:
●● Face validity (also known as surface validity): measures
whether the test appears to measure what it is supposed
to measure.
●● Content validity: measures the match between test
questions and the content or subject area they are
intended to assess.
●● Predictive validity: measures how well a test predicts
future performance, measured historically. An impor-
tant purpose of the pilot recruitment process is to select
candidates who have a good chance of passing the
training course. Predictive validity is therefore a vital
component of pilot testing as it can help aviation train-
ers select those who are predicted to do well during the
training course.
●● Concurrent validity: measures how well a particular
test correlates with previously validated tests.
There are generic attributes which any organization might
demand of pilots. Qualified candidates might be assessed
in terms of licences and ratings held and flying experience.
They might also be assessed on their performance in simu-
lator tasks. The person specification for inexperienced can-
didates for pilot training might define high levels of spatial
awareness and good reaction times. However, there may
also be unique and specific skills and aptitudes required for
particular operations. If a pilot is being selected for com-
mercial aviation a different skill set will be needed from that
required from a military pilot; single-crew flying demands
different skills from those needed for multi-crew services.
Tests administered to prospective military and com-
mercial aircrew typically include a battery of subtests, such
as is found in the Micropat (Microcomputerised Personnel
Aptitude Test), which is a PC-based test developed in the
UK covering non-verbal intelligence, mechanical aptitude,
comprehension of basic flying instruments, stick and rud-
der tracking, velocity control tracking and dynamic per-
ceptual tracking. The BAT (Basic Attributes Test) developed
in the United States has five tests that measure psychomo-
tor coordination, short-term memory and attitude toward
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 680  Pilot selection and training
risk-taking. The specific tests cover two-hand coordination,
complex coordination, item recognition, time sharing and
activities interest inventory. The TASKOMAT (developed in
the Netherlands) (Boer 1995) and ASA (another used in the
United States) are two further examples of the computer-
ized battery-type tests. All of the tests assess similar abilities
or potential, but in different ways.
PERSONALITY
In the context of selection, personality is an assessment of
the way in which an individual is most likely to behave in
the role for which they have applied. A completely accu-
rate and reliable description of an individual’s personality
would therefore be a significant contribution to selecting
pilot candidates most likely to behave in ways appropriate
to that role. It is, however, essential that anyone involved in
selection processes understands the limitations to the pre-
dictive power of the personality assessments they use. They
should never be used in isolation to make selection deci-
sions. They can, however, make a valuable contribution to
identifying differences between technically able candidates
which may make them more or less appropriate for selection
for a specific pilot role.
There are a number of useful models of personality
which support a range of psychometric personality assess-
ments. The majority aim to define a number of personality
traits which describe the behaviours an individual is most
likely to employ. Personality traits are long-term character-
istics that describe preferences; they do not have absolute
predictive validity. For example, a pilot candidate assessed
as conscientious may behave that way most of the time, but
there may be situations where they become hurried or lose
concentration. Typical models use two to 16 factors. We will
present one of the most commonly used in assessment, the
Big Five model (Rust & Golumbok, 2008).
The Big Five model
Based on extensive search of the literature which examines
psychological models of personality, Rust and Golombok
present a model which proposes that an individual’s per-
sonality may be described in terms of five factors which are
substantially independent:
●● Extraversion/introversion: individuals who score
highly for extraversion will generally prefer to work
with others or in a team. Those who score highly for
introversion will prefer to work independently.
●● Tough/tender mindedness: individuals who are
assessed as being tough-minded are more likely to con-
fidently make tough decisions. Tender-minded candi-
dates are more likely to prefer a co-operative approach
to decision-making.
●● Conformity: candidates with high levels of conformity
are likely to feel comfortable with established values and
to prefer traditional ways of doing things. Those with
K17577_C044.indd 680
low levels of conformity will prefer to seek out new ways
of doing things.
●● Neuroticism: those with high levels of neuroticism
will be more able to identify emotions in others and to
exhibit nervous behaviour. Candidates with low levels
of neuroticism will be more able to behave confidently
under stressful conditions but may lack caution and
sensitivity to other’s emotions.
●● Conscientiousness: individuals with high levels of con-
scientiousness may become engrossed in small details
as they prefer to work with care and attention to detail.
They will often excel at mundane repetitive tasks. Those
with lower levels of conscientiousness will prefer to
focus on the ‘big picture’ and will have less patience for
routine tasks.
The Big Five model suggests that any individual may be
ranked on each of these five personality traits and that these
rankings will give an accurate prediction of an individual’s
preferred behaviour. For example, a tough-minded extravert
who scores highly on conformity and lower for neuroticism
and conscientiousness will generally prefer to work in a team
and feel confident making tough decisions. They will typi-
cally follow standard operating procedures and cope well in
stressful situations, often showing an appreciation of tactical
or strategic considerations. They may, however, be seen as
insensitive to others and struggle to focus on repetition or
detail for long periods of time. No personality assessment,
however, can accurately predict an individual’s behaviour in
every situation. For example, it is perfectly possible that the
individual just described might sometimes behave in ways
which demonstrate an ability to empathize with others.
Alternatively, their tendency to prefer working in a team may
lead them to deviate from established procedures if others do
so. Personality only assesses the way in which an individual
will generally behave or prefers to behave. It cannot predict
every action a candidate may take at work.
WHAT PERSONALITY TRAITS SHOULD PILOT
SELECTION EXAMINE?
Again, we return to the need for selection processes to iden-
tify the candidates most likely to be the best fit for the recruit-
ing organization. Typically, the literature (Hunter & Burke
1995; Smallwood 2000) suggests that pilots should be extra-
verted, conscientious, potential leaders with stable person-
ality traits. Your organization may, however, have slightly
different requirements. If you have access to historical selec-
tion data which include personality assessment, time spent
evaluating the range of personality traits most evident in
experienced pilots who are known to be a ‘good fit’ will be
invaluable. Another, although somewhat resource-consum-
ing, approach would be to complete personality assessments
with the existing pilot population and identify the traits
most evident in well-performing experienced employees.
Overall, personality assessment is perhaps best used as a fil-
ter to exclude candidates who demonstrate extreme or rigid
personality traits undesirable in pilots. A civilian airline, for
17/11/2015 16:22

example, might decide to exclude candidates with extreme
levels of introversion and neuroticism or particularly low
levels of conformity and conscientiousness.
Methods of personality assessment
Personality may be assessed on the basis of questionnaires
completed by the candidates themselves, colleagues, subor-
dinates and managers or a combination of those. It may also
be assessed at interview. Typically, pilot selection processes
use self-report questionnaires and ask interviewers to com-
ment on their assessment of candidates’ personality as one
aspect of selection interviews.
Personality assessments which use self-report and assess-
ment by others are available from test publishers. Those which
have been suitably evaluated for validity and reliability will
only be available for purchase and use to assessors who are
qualified in their use. Registers of tests and authorised tes-
ters in the UK are available through the British Psychological
Society website (www.psychtesting.org.uk). Choosing person-
ality assessments to use as part of a selection process should be
done in conjunction with a qualified assessor and the infor-
mation available from the test publisher. As with psychomet-
ric ability testing, choosing a test to use should consider:
●● Model: what personality traits are being assessed and
to which model of personality do these relate? How are
these traits relevant to pilot candidates? What range of
scores for each trait would indicate appropriate candi-
dates for this organization?
●● Validity: what level of validity has the test demonstrated
in relevant adult populations and ideally among pilots?
●● Reliability: what levels of predictive and test–retest
reliability has been demonstrated, ideally among similar
pilot populations?
Many selection interviews aim to encompass an assessment
of a candidate’s personality. Aviation medical professionals
may be directly involved in interview panels and they are
also well positioned to evaluate a candidate’s personality
during the course of a selection medical. The following fac-
tors may give some indication of the way in which a candi-
date will generally behave in a professional context:
●● Non-verbal indications: do they maintain appropriate
eye contact and use appropriate open body language
(occasional nervous mannerisms might be appropriate,
continuously closed body language and avoidance of
any eye contact or maintaining a fixed stare are prob-
ably not)? Are they professionally presented and appro-
priately groomed? Do they frequently seem embarrassed
or flustered? If facing a panel of interviewers, how do
they split their attention between members of the panel?
●● Use of language: do they respond with open and appro-
priate answers to questions (interview nerves mean that
many good candidates will stumble over some answers
or occasionally ask you to repeat questions, but only
K17577_C044.indd 681
The selection process  681
responding ‘Yes’ or ‘No’ to open questions may not be
appropriate)? Do they use an appropriate tone of voice
and professional language?
WORK SAMPLING
One well-established predictor of performance in a techni-
cal role is work sampling where candidates are required to
demonstrate their ability to perform tasks related to the role
for which they are applying. When selecting trained and
experienced pilots, work sampling, in the form of exercises
in an aircraft or simulator can be a useful check of a can-
didate’s proficiency. Work sampling for inexperienced pilot
candidates is more challenging and generally reverts to psy-
chometric testing of cognitive and psychomotor abilities. In
both cases, technical proficiency is a necessary but not suf-
ficient requirement for success at application. It is absolutely
essential that pilots should be able to fly to the required stan-
dard or be likely to pass initial training. There will always be
more than sufficient candidates who can do this. Recruiting
organizations need a broader range of assessment to differ-
entiate between candidates who are good enough and select
those who are the best fit. Medical personnel are unlikely
to be obviously involved in tests of technical proficiency.
However, they are ideally placed to assess candidates’ per-
ception of their performance. In interviews and medical
assessments, a candidate’s response to questions such as,
‘How did your simulator exercise go?’ can provide a useful
insight to personality, confidence and self-awareness.
THE SELECTION PROCESS
As we illustrated at the beginning of this chapter, any orga-
nization recruiting pilots will need to process large numbers
of applications, often aiming to recruit only a small number
of pilots. The cost of sophisticated work sampling tests and
interviews is such that it makes sense to use less expensive
filters first. Most selection processes therefore start with
written or online application forms which may include self-
reported medical and health questionnaires. An ethical and
effective recruitment process will define the standards and
criteria required for applications to be accepted for the next
stage of the process before assessment starts. This might
include levels of education, flying experience, health and fit-
ness. Each application can then be compared to the required
standard and will be successful at that stage if it meets all
criteria. Psychometric, psychomotor, medical and personal-
ity testing are again most ethically and effectively employed
in the same way – screening candidates against predeter-
mined criteria based on the person and job specification.
Simulator and flight tests and interviews are opportuni-
ties to differentiate between candidates who all have a high
probability of being technically proficient. To be ethical and
effective, an organization should be clear about the qualities
it values in its pilots when defining a person and job specifi-
cation and recruit those who best match those criteria.
17/11/2015 16:22
 682  Pilot selection and training
PILOT TRAINING
Training is another process which continues throughout a
pilot’s career and may often be associated with significant
levels of anxiety. All training is overseen by national and
international regulators and is almost without exception
associated with academic exams and practical skills tests.
Civilian and military initial training and testing must be
completed and passed in order to gain initial qualifications.
The exact details will vary by regulator, but will typically
require completing a certain amount of academic, flight
and simulator training and a challenging set of written
examinations and practical skills tests in order to acquire
a pilot’s licence.
For professional pilots, there will generally also be addi-
tional training and testing to gain and demonstrate com-
petence in their specific professional role. This might be a
type rating on a specific civilian aircraft or a qualification
for a particular military role, such as search and rescue.
Initial training and qualification must be passed in order
to gain employment as a professional pilot. Each pilot must
then meet the local regulator’s requirements for recent
experience and periodic testing in order to maintain their
qualifications and continue in employment. In the UK,
for example, civilian airline pilots must pass two simula-
tor tests, a passenger flight observed by an examiner and
a medical every year. Not only is training demanding in its
own right, continuing testing and examining can be per-
ceived as threatening a pilot’s career and livelihood.
The aviation medical professional will quickly become
aware that many of the pilots who attend for medical
renewals and especially with medical problems which may
threaten their ability to hold a licence to fly will be signifi-
cantly anxious. As civilian pilots in particular are increas-
ingly flying beyond the historically established retirement
age of 55 and are therefore more likely to encounter physi-
ological challenges in meeting medical requirements, this
will become a more frequent occurrence.
The aviation medical professional may be called upon
when pilots encounter difficulties in completing training or
passing tests and examinations. The sections which follow
support an understanding of learning theory and guidance
on managing anxiety. The aim is to equip medical profes-
sionals to support pilots and training departments when
they encounter difficulties.
LEARNING THEORY
The challenge for anyone who is involved in pilot selection
and training is to understand how people learn and how
that knowledge (or learning) is applied to the environment.
To begin to understand this process, we may first need to
consider a fundamental question: How do people learn?
There are several theories that set out to describe learning,
some of which are more modern than others. This section
will focus on behavioural, cognitive and psychomotor theo-
ries of learning. These theories generally agree that learning
K17577_C044.indd 682
is relatively permanent and is the result of past experiences.
They differ in the extent to which they explain overt changes
in behaviour (for example, gaining the skill to manually fly
an aircraft) or more covert cognitive changes (for example,
understanding how an aircraft system works or how to
become an effective team member). These may reflect differ-
ent types of learning or different aspects of the same learning
process. It is worth noting that there are additional factors
that may influence learning, such as fatigue, motivation to
learn, anxiety, stress or physical health issues to mention a
few. A person, whether a pilot or a teacher, does not exist in
isolation and it is therefore plausible to assume that their
learning can also be influenced by their current environ-
ment, past experiences as well as individual characteristics.
Behavioural learning theories
Behavioural learning theories are founded on the propo-
sition that past experience will influence future behav-
iour. The most famous models are Pavlov’s Classical
Conditioning and Skinner’s Operant Conditioning, both
developed from extensive observation and investigation of
animal behaviour.
In classical conditioning, Pavlov observed that present-
ing a stimulus (food) produced a certain response in dogs
(salivation). He then introduced a second stimulus (a bell)
after the first stimulus (food) which seemed to produce the
same response. By repeatedly presenting the bell after the
food, Pavlov discovered that the dogs eventually produced
salivation at the sound of the bell alone. Later research dem-
onstrated that, to an extent, humans learn some behaviours
in similar ways. This explains the role of repetition in train-
ing; practising the response to a particular stimulus (clear-
ance to take off, a checklist or emergency drill) conditions
the correct response (taking off, completing the checklist or
drill).
OPERANT/INSTRUMENTAL CONDITIONING
Operant conditioning is different to classical conditioning
because it assumes that reinforcement (reward) depends
upon the proper response. Skinner used a form of a puzzle
box to demonstrate this using rats. If, for example, a rat is
presented with something pleasurable such as food when
pressing the lever, the behaviour is strengthened (positive
reinforcement). The behaviour is weakened by, for example,
presenting the rat with something painful, such as deliver-
ing electric shock when pressing the lever. In pilot training,
the desired behaviour is reinforced by the reward of instruc-
tor’s praise or silencing the emergency signal. Skinner’s
theories also highlight the potential dangers in using pun-
ishment in training; punishment may become associated
with the instructor rather than the unwanted behaviour
and induce fear rather than the desired behaviour.
Conditioning theories explain a significant proportion
of learning, especially the role of repetition and reinforce-
ment. They are insufficient, however, to explain the role of
cognition and reflection in successful pilot training.
17/11/2015 16:22

Cognitive theories
Modern psychological theories of learning propose a cycle
of behaviour and cognition which operate sequentially and
continuously. This is illustrated in Figure 44.1.
Most pilot training begins with an experience such
as trying a new skill after an instructor demonstrates or
encountering a new piece of knowledge in a lesson or text
book. For learning to be effective, the next step is to reflect
on that experience to consider what can be learnt. This then
results in a conceptualisation of how new knowledge might
be used (understanding how a hydraulic system works or
how one might fly more accurately next time). This in turn
enables active experimentation (being able to answer an
exam question on hydraulic systems or operate the system
in the aircraft or flying more smoothly). If a trainee pilot
were to repeat the cycle in Figure  44.1, for example, they
might find that abrupt movements on the controls at their
first attempt made flying level very difficult. They might
reflect on that and decide to use smaller movements next
time and experience a smoother flight at their next attempt.
MANAGING ANXIETY ABOUT TRAINING AND
TESTING
Given that pilots must continuously pass various written
examinations, skills tests and medical assessments in order
to continue in their career, it is not surprising that they may
report significant levels of anxiety related to training and
testing. This is when medical staff may be called upon to
help. In cases of severe and incapacitating anxiety, the most
appropriate course of action is likely to be a referral to a
qualified psychologist, ideally with a background in avia-
tion. In less severe cases, the anxious pilot may benefit from
self-help books based on recognised psychological mod-
els or even computer-based cognitive behavioural therapy
which may be available through their medical practitioner.
The approach of both will be similar and will aim to manage
the physical sensations of anxiety and anxious cognitions.
4. Active 1. Have an
experimentation experience (Try
(Try doing it to fly straight
differently) and level)
3. Conceptualise 2. Reflect (How
well did I do?
(What should I
What went
do differently
next time?) right/wrong?)
Figure 44.1  Modern learning cycle based on Kolb (1984)
K17577_C044.indd 683
Conclusion 683
There is a short list of appropriate resources under Further
Reading below. Guidance on managing physical sensations
of anxiety will typically cover:
●● Managing rest and exercise (it can often be helpful to
point out that one night’s broken sleep worrying about
a test is unlikely to significantly affect performance if
anxiety is actively managed).
●● Relaxation and controlled breathing exercises.
●● Calming activities, such as walking, reading or listening
to music.
Guidance on reducing anxious cognitions might include:
●● Identifying and challenging anxious thoughts.
●● Helping to find balanced alternatives to cognitive dis-
tortions, such as catastrophic thinking, i.e. predicting
the worst possible outcome (the thought ‘if I fail I will
lose my job/licence’).
●● Planning thorough preparation or practice for each test
to counter thoughts such as ‘I can’t do this’ or ‘I don’t
know enough’.
●● Using positive distractions, such as enjoyable activities
not related to flying.
CONCLUSION
Pilots undergo continuous selection and training through-
out their careers and aviation medical professionals are well
positioned to support both processes. In doing so, they can
make a valuable contribution to the culture, cost base and
safety of organizations with which they work.
SUMMARY
●● Pilot selection is not a precise science, though mod-
ern recruitment methods can considerably reduce
the risk of hiring unsuitable candidates, which can
come at significant cost to the organization.
●● Selection and retention of pilots is an ongoing
process throughout the individual’s career and
their suitability for and ‘fit’ within the organiza-
tion is arguably as relevant as their proficiency
and skills in flying.
●● The introduction of controls for the piloting of
UAVs has opened up a new domain for AMEs
involved in pilot selection and crew licensing.
●● The process of pilot selection starts with a job
specification, and progresses through to sys-
tematic screening, short-listing, assessment and
hypothesis-testing at interview, before a decision
is reached.
●● When used appropriately and ethically, psycho-
metric tests play a useful role in personality assess-
ment and aptitude testing for pilot selection.
17/11/2015 16:22
 684  Pilot selection and training
REFERENCES
Anderson HG. The Medical and Surgical Aspects of
Aviation. London: Oxford University Press, 1919.
Boer LC. Taskomat: evaluation of a computerized test bat-
tery. International Journal of Selection and Assessment
1995; 3: 105–14.
Hunter DR, Burke EF. Handbook of Pilot Selection.
Aldershot: Ashgate, 1995.
Kolb DA. Experiential Learning Experience as a Source of
Learning and Development. New Jersey: Prentice Hall,
1984.
National Audit Office. Training New Pilots. London: NAO,
2000.
Rust J, Golumbok S. Modern Psychometrics, 3rd edn.
London: Routledge, 2008.
Smallwood T. The Airline Training Pilot, 2nd edn.
Aldershot: Ashgate, 2000.
FURTHER READING
Bor R, Hubbard T. Aviation Mental Health. Aldershot:
Ashgate.
K17577_C044.indd 684
Fearfighter. Computer Based Cognitive Behavioural
Therapy. Available from www.fearfighter.com.
Goodman L, McBride DK, Owens JM, Wherry RJ. The
Identification of Processes Underlying the Skilled
Aviator. In: Jensen RS (ed). Proceedings of the Second
Symposium on Aviation Psychology. Columbus, OH:
Ohio State University, 1983: 541–6.
Hope T, Butler G. Manage Your Mind. London: Oxford
University Press, 2007.
Hunter DR, Burke EF. Computer-based selection testing
in the Royal Air Force. Behaviour Research Methods,
Instruments and Computers 1987; 19: 2–5.
Hunter DR, Burke EF. An Annotated Bibliography of the
Aircrew Selection Literature. Research Report 1575.
Alexandria, VA: US Army Research Institute, 1990.
Hunter DR, Burke EF. Handbook of Pilot Selection.
Aldershot: Avebury Aviation, 1995.
Kennerley H. Overcoming Anxiety. London: Robinson,
1997.
Stammers RB, Patrick J. The Psychology of Training.
London: Methuen, 1975.
17/11/2015 16:22

Crew resource management
Revised by STEPHEN R. JARVIS
The origins of crew resource management 685
The development of crew resource management 686
The aims and requirements of crew resource
management 686
Crew resource management syllabi and training 687
THE ORIGINS OF CREW RESOURCE
MANAGEMENT
The original aim of crew resource management (CRM) was
to reduce flight crew error (Helmreich et al. 1999).
The application of human sciences to aviation (in order to
avoid error) was firmly established well before CRM train-
ing was conceived. Work in the 1940s and 1950s by scientists
such as Norman Mackworth, Paul Fitts, Alphonse Chapanis
and John Flanagan helped to establish the idea that aviation
design and practice should consider human capability and
limitations. The improvements generated during this clas-
sic period of human-centred work are still apparent today
and undoubtedly form a first line of defence against human
error. A classic example of that work is the placement and
shapes of undercarriage and flap levers, intended to reduce
confusion and subsequent human error slips. Although
established over 70 years ago it can still be seen in all mod-
ern air transport aircraft. As well as design principle, areas
focusing on ‘the person’ such as selection and training also
benefited from an increased use of human science research
and human-engineering (the practice of applying human
sciences such as psychology and physiology to operational
environments, now more widely known as human factors).
Early uses of this approach often focused on human traits
and characteristics. Early work by John Flanagan attempted,
through qualitative methods, to discover the characteris-
tics and behaviours typical of unsuccessful pilot trainees,
with a view to improving selection (Flanagan 1954). Hence,
human-centred approaches were used to improve aviation
K17577_C045.indd 685
45
Background to crew resource management content 687
Assessing crew resource management skills 692
Crew resource management effectiveness 693
References 694
safety and reduce error, long before the implementation of
CRM training.
Crew resource management training took the same idea
into pilot training by attempting to teach ‘non-technical’
principles, such as those derived from social psychology,
to the operators themselves (i.e. pilots) so that they could
then modify and improve their own behaviour and per-
formance in the interests of safety and error avoidance.
Whereas technical skills (handling ability, use of systems,
navigation, etc.) had always been recognized as essential,
non-technical skills such as communicating effectively
and leading a small team were not formally taught prior to
CRM training.
In the 1970s, further convincing data emerged from the
newly implemented cockpit voice recorders (CVR) that indi-
cated the extent to which non-technical elements (human
error) were contributing to air accidents. These data, along
with various analyses of accident causation (e.g. Ruffle-Smith
1979) led to a conference called Resource Management on
the Flight Deck, held in the US in 1979. Research presented
concluded that the majority of pilot-related errors were due
to failures of interpersonal skills, communications, decision
making, and leadership (Cooper et al. 1980).
One highly influential accident was the loss of a United
Airlines DC8 at Portland in 1978. Analysis by the National
Transportation Safety Board (1979) cited the captain’s fail-
ure to accept input from other flight crew members, as well
as their lack of assertiveness. Driven by these accident find-
ings (which relied heavily on the CVR data) as well as the
conference conclusions, United Airlines set up the very
685
17/11/2015 16:23
 686  Crew resource management
first comprehensive CRM course in 1981  (see Helmreich
et al. 1999).
In modern times, research has consistently cited human
error and ‘poor CRM’ (under a variety of labels) as being the
major cause of accidents. Wiegmann and Shappell (1999)
concluded that over 75 per cent of specific US Navy aviation
mishaps were partly or fully attributable to human error;
70  per cent of which were associated with aircrew human
factors, and over half containing at least one CRM failure.
Von Thaden and Steelman (2005) found that 27 per cent of
Part 121 accidents were directly attributed to a breakdown
in CRM. As research continues to show a high involvement
of human error and CRM in accidents and incidents, CRM
and human factors training continue to be seen as key ways
of tackling the problem.
THE DEVELOPMENT OF CREW RESOURCE
MANAGEMENT
The first CRM courses focused on the types of areas that
were uncovered by CVR analysis such as communication,
leadership and interpersonal skills. The CVR could only
uncover factors that could be conveyed and implied by
sounds, usually in the form of verbal communication. This
meant that most of the issues that emerged were within the
domain of social psychology and group dynamics, and so
early courses were often developed and run by people with
psychology or management training. Because of this, other
ideas from these domains (e.g. personality traits and leader-
ship styles) were brought into the training. These were not
always met with universal approval from flight crews.
A common focus in early CRM courses was to address
the perceived authoritarian role of captains in the flight
deck. Several high profile accidents (such as the 1979 United
Airlines DC8 accident and the 1977 KLM/Pan Am Tenerife
747 runway collision) had suggested, in hindsight, that had
the junior flight crew members been more assertive, or the
captain less authoritative, then the accident could have been
avoided because those crew members had a more accurate
picture of the situation than the captain. Hence there was an
effort to use CRM training to try to reduce this problem by
using group dynamics and management principles. Some
captains had trouble accepting such ideas.
Since the introduction, CRM has moved and changed
in many different ways. Some commentators consider
that CRM has ‘evolved’ through definable generations; for
example Helmreich et  al. (1999) discuss five generations
of CRM training. This may be true in mature parts of the
industry in some countries, but an industry-wide global pic-
ture is more difficult to define. It is certainly true that CRM
has expanded in a variety of different ways over the last
30 years, and a number of approaches have been attempted
and repeated with varying levels of success. However, some
aspects of change were universal. During the 1980s ‘cockpit
resource management’ became ‘crew resource management’
as team building became more prominent and crewmem-
bers other than pilots were included as part of that ‘team’.
K17577_C045.indd 686
There is an argument to say that this practice made it more
difficult to embed CRM in flight operations.
Over the 30 year history of CRM, recognition increased
that many human-related issues remained hidden from
the CVR but were nevertheless very important (e.g. mode
awareness, monitoring, vigilance and fatigue). As recogni-
tion and research of wider accident factors increased, CRM
training widened to encompass more of these elements (e.g.
situational awareness, individual decision making, fatigue,
workload and stress management). In this way, CRM train-
ing gradually took on a larger remit, covering areas such as
wider cognitive ‘skills’, error prevention, accident theory,
culture, stress and fatigue management.
In the late 1990s, Helmreich introduced the idea of threat
and error management (TEM) as a new way forward for CRM
training. TEM widens CRM to encompass all threats to the
operation (not just errors). It uses accident theory based on
the work of James Reason (see Reason 1990) to train crews
to avoid threats and errors as well as trap or mitigate them
if they occur, before accidents happen. Many airlines have
since included this idea as part of their CRM training.
THE AIMS AND REQUIREMENTS OF CREW
RESOURCE MANAGEMENT
The general aim of CRM training has been consistent over
three decades, and remains as it began: to help prevent
human-related factors causing aircraft accidents. However,
the various ways to achieve this overall aim expanded and
changed, along with ideas of what CRM training should
constitute. The current objectives of CRM training are
defined in CAP 737 (UK CAA 2006) as follows:
●● To enhance crew and management awareness of human
factors that could cause or exacerbate incidents which
affect the safe conduct of air operations.
●● To enhance knowledge of human factors and develop
CRM skills and attitudes that when applied appropri-
ately could extricate an aircraft operation from incipient
accidents and incidents whether perpetrated by techni-
cal or human factor failings.
●● To use CRM knowledge, skills and attitudes to conduct
and manage aircraft operations, and fully integrate
these techniques throughout every facet of the organiza-
tion culture, so as to prevent the onset of incidents and
potential accidents.
●● To use these skills to integrate commercially efficient
aircraft operations with safety.
●● To improve the working environment for crews and all
those associated with aircraft operations.
●● To enhance the prevention and management of crew error.
From its conception in the 1980s, CRM training was man-
dated through regulation. The need for recurrent as well as
initial training was recognized.
The UK Civil Aviation Authority (CAA) went a stage
further than other national regulators by implementing an
17/11/2015 16:23

accreditation scheme for CRM trainers, requiring anyone
wishing to teach CRM to flight crew to be accredited as a
CRM instructor (CRMI) by the CAA. CRM instructors were
assessed by a CRM instructor examiner while delivering a
real course. As well as prerequisite experience and qualifica-
tions in the technical domain, anyone wishing to receive a
CRM instructor accreditation had to demonstrate that:
●● They had the knowledge specified for their relevant role,
and could role-model best CRM practice.
●● They had the necessary instructional skills.
●● They were able to assess non-technical skills
where required.
●● They were able to facilitate a constructive debrief (UK
CAA 2013; Standards Document 29, version 5, p 7).
The UK accreditation system was recently disbanded
because there is now European-wide standardization under
the European Aviation Safety Agency.
CREW RESOURCE MANAGEMENT
SYLLABI AND TRAINING
Although CRM training has been mandatory in the avia-
tion industry since 1995, regulation still only expresses
CRM in terms of high-level concepts. Specific content has
never been standardized. This has enabled considerable
freedom and interpretation, and consequently there is enor-
mous variety in the types of material taught on courses and
in the quality of the courses themselves. The expansion and
variations of CRM training mean that it is difficult to be
clear about what CRM looks like today.
In 2003 it was noted that CRM was taught using a vari-
ety of methods, including lectures, practical exercises, role
play, case studies and accident re-enactments on videotape
(O’Connor & Flin 2003). Apart from use of newer technol-
ogy such as computer presentations and movie files, this
has not changed how CRM is delivered in the classroom.
However, some airlines have made attempts to deliver CRM
in smaller packages during recurrent simulator details, by
discussions and small presentations during briefings and
training. There is no research on the success of such work,
but it does align with a general intention to integrate CRM
into technical training, which has been a recognized expec-
tation from the very earliest days of CRM (Helmreich 1999).
In terms of content, the syllabi of most courses have
changed little in the last 15 years, and most address aspects
of communication and teamwork, situational awareness,
decision making, leadership and stress (Flin & Martin 2001;
O’Connor and Flin 2003; Hatlestad 2005).
CAP 737  (UK CAA 2006, p4) lists the required course
content for flight crews as:
●● Human error and reliability, error chain, error preven-
tion and detection.
●● Company safety culture, SOPs, organizational factors.
●● Stress, stress management, fatigue and vigilance.
K17577_C045.indd 687
Background to crew resource management content  687
●● Information acquisition and processing, situational
awareness workload management.
●● Decision making.
●● Communication and coordination inside and outside
the cockpit.
●● Leadership and team behaviour synergy.
●● Automation, philosophy of the use of automation (if
relevant to the type).
●● Specific type related differences.
●● Case-based studies.
Strictly in terms of requirements there is no further obliga-
tion (in terms of detailed content) and consequently a large
variety of content exists in CRM courses. However, more
guidance can be obtained from the European Aviation
Safety Agency.
There is no direct reference to TEM in the UK require-
ments, but the general nature of the syllabus means that
individual organizations can choose to include it.
One further complication is the considerable disagree-
ment between academics and authors on the meaning and
validity of the terms that the regulation treats as being
firmly defined, such as situational awareness, workload
and even human error. Course designers attempting to
perform deep research into such concepts (e.g. for poten-
tial course material) can find the higher-level literature
(research, academic and scientific) problematic. Rather
than finding deeper explanation of such concepts, they
will discover that the literature often argues against the
use of the CRM concepts that they are familiar with, and
even whether such concepts are real. However, industry
is understandably hungry for CRM progression and solu-
tions to solve human error, but it moves faster than the
scientific and academic underpinning. At worst this leads
to a vicious circle whereby industry only accepts ideas that
are most easily used and accepted, as opposed to those that
are the most supportable, and this can widen the problem
still further.
BACKGROUND TO CREW RESOURCE
MANAGEMENT CONTENT
Early CRM focused on crew interaction and dynamics, in
line with CVR findings. CRM content was drawn from the
area of social psychology, particularly the psychology of
small groups and teams, group decision-making processes,
and management/leadership research.
Clearly there are benefits derived from having more than
one crewmember on the flight deck. Apart from the safety
of redundancy, there is more resource available to deal with
emergencies and high workload situations. Additionally,
there is a greater pool of experience from which to draw, and
the potential for a greater number of ideas to be generated,
and so theoretically the right solution to a problem should
be more likely to emerge in a crew than an individual. This
has always been accepted by the industry, and indeed there
is no evidence that it is untrue.
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 688  Crew resource management
However, when things work as expected on a flight deck,
no incident or accident is generated, and so no data is cap-
tured about why things worked properly. For this reason it
is very important that CRM training not assume that acci-
dents are a normal sample of all flights, so it should not
attempt to make changes to the way pilots act based solely
on what went wrong in accidents. For example, accidents
have occurred after captains failed to heed advice of other
crewmembers, but that does not support CRM content that
implies that captains must never reject the advice of other
crewmembers. The balance is crucial if CRM training is to
be accepted and useful.
Group psychology
Despite the benefits created by having several people on a
flight deck, there are dangers associated with how groups
behave and how individuals become influenced by others
around them (known as ‘conformity’ or ‘social influence’).
This is within the wider domain of social psychology. A key
point with social influence is that people may be unaware
that others have influenced them, and hence teaching about
this subject in CRM is important in terms of raising aware-
ness in order that crews can mitigate the effects, even if the
CRM training by itself does not achieve this end.
The dangers come from two types of influence: norma-
tive and informational. Normative influence is where indi-
vidual behaviour, decisions or actions are driven by the
perceived expectations of others (even where the individual
disagrees with them), whereas informational influence is
where individuals allow themselves to be informed by oth-
ers. The fundamental difference is that normative influences
change people’s behaviour without affecting what they
really believe, whereas informational influence changes
what people think and believe.
Informational influence is most apparent where individ-
uals doubt their own judgement. An early example of infor-
mational influence was demonstrated by Sherif (1936) in
experiments on the ‘autokinetic’ effect, an illusion whereby
a stationary spot of light in an otherwise dark room appears
to move randomly. Participants were asked to estimate the
amount of movement individually and then in groups of
three. Sherif found that the group judgements converged
and participants conformed to these norms even when they
were subsequently tested individually.
Small groups, such as flight deck crews, when faced with
unfamiliar and ambiguous circumstances may converge on
a false interpretation of evidence. This can be subtle or even
occur tacitly; for example, when crew members do not show
their concerns it can be interpreted by other crew members
as the situation being alright, and so those crew members
in turn do not seek further evidence. CRM training has
attempted to make crews aware of these sorts of issues.
Normative influence was classically demonstrated by
Asch (1951, 1956). Each participant in the experiment
was one of a group asked individually to assess the length
of lines against a set of reference lines. The participant
K17577_C045.indd 688
responded verbally after hearing a number of others give
their responses, unaware that the other ‘participants’ were
in fact confederates of the experimenter. On some occa-
sions, the confederates all gave the same incorrect response
prior to the participant’s response. Participants differed in
the extent to which they yielded to this social pressure (i.e.
copied the response of the majority, despite it being wrong)
but overall about one-third of the responses conformed to
the group’s clearly erroneous judgement. When the incor-
rect responses of the confederate group were not unani-
mous (e.g. one confederate giving the correct answer), the
conformity effect was reduced greatly. Group size was found
to determine the likelihood of conformity. A single confed-
erate was unable to influence the participant’s behaviour,
but conformity increased with confederate groups of up to
three or four individuals.
Research has also shown that individuals are slower to
express opinions when they are in a minority (Bassili 2003),
and that this effect increases as a function of the difference
between the sizes of the majority and the minority.
Bond and Smith (1996) performed a meta-analysis of
studies using line judgement tasks similar to that reported
by Asch. The results indicated that conformity in US stud-
ies had declined since the 1950s, and cross-cultural com-
parisons revealed that conformity was related to a country’s
‘individualism–collectivism’ (i.e. the extent to which its
population tends to favour individual or group solutions to
problems).
Normative influence is relevant to the aviation context,
where many situations can arise in which crews feel the urge
to satisfy passengers, other crew members, other aircraft or
air traffic controllers due to normative, rather than opera-
tional, reasons. CRM courses often facilitate discussions to
allow examples to emerge from the audience members that
are specifically relevant to the operational environment.
A particularly well-researched type of conformity is
called obedience, where individuals comply with the expec-
tations of perceived authority figures. This type of compli-
ance is normal and usually helpful in most societies (e.g.
in schools, workplaces, families, etc.). However, it has been
shown that the power of authority figures and the ease with
which they are accepted, can produce inappropriate and
dangerous behaviour in professional contexts.
The classic work by Milgram in the 1960s (Milgram
1974) demonstrated the ease with which individuals can be
induced to obey authority. Milgram’s experiments induced
participants (in the role of ‘teachers’) to administer lethal
electric shocks to others (‘learners’) as a consequence of
answering memory questions wrongly. The learners were
stooges, and no electric shocks were administered in reality,
but the ‘teachers’ were unaware of that until the experiment
ended. Many varieties of the experiment were tried, and the
results consistently showed that normal individuals would
often obey authority even when the requests are contrary to
their own judgement or conscience.
Milgram’s results were all based on work performed
in the laboratory using subjects who were unfamiliar to
17/11/2015 16:23

the environment and task. Any direct inference to the
domain of professional aviation would therefore be unsup-
portable. However Hofling et  al. (1966) showed a simi-
lar effect within a valid (real-world) professional context.
They discovered that nurses obeyed telephone instructions
from an unknown doctor to administer an overdose of an
unknown drug without the proper paperwork, within a real
working environment.
Strikingly, for both Milgram’s and Hofling’s research,
most experts (scientific and domain) asked to predict the
results beforehand had anticipated no such effect. This illus-
trates the important point that social psychological effects
are generally underestimated or not recognized, and so one
aspect of CRM training has been to try to bring awareness
of such effects to professional practitioners.
Such concepts are clearly relevant to the flight deck,
where there is often a marked ‘cockpit authority gradient’
(Edwards 1975). A number of accidents have suggested
that a junior first officer yielded to an experienced captain,
despite having recognized a dangerous situation unknown
to the captain.
Anderson et al. (2001) noted the importance of the com-
mand structure on the flight deck. The captain, whether
acting in the role of pilot flying or pilot not flying, has
responsibility for major decisions. However, other crew
members play a significant role in monitoring the progress
of the flight and must be prepared to challenge questionable
decisions. They may fail to do so if the cockpit authority gra-
dient is too steep. Conversely, a cockpit authority gradient
that is too flat may imply weak leadership, with all its inher-
ent risks. A major contribution of CRM training is to pro-
vide guidance on optimizing the cockpit authority gradient.
Social psychology as applied to the flight deck provided
the basis of much early CRM training, and is still taught in
CRM today.
Personality
The term ‘personality’ refers to enduring predispositions to
behave in particular ways. These predispositions, or traits,
can be distinguished from more transient moods, or states.
Early CRM training focused heavily on pilot personality,
much of it borrowed from management training. However
this focus has lessened considerably in modern times. One
reason is undoubtedly that pilots were uncomfortable with
the implication that their personalities might make them
more or less prone to accidents.
Although there is some evidence relating personality to
accidents, it is not overwhelming. Nevertheless, Robertson
and Clarke (2002) reported a meta-analysis of personality
and accidents in high-risk occupations and found them to
be associated with personality traits such as openness, low
agreeableness and low conscientiousness. However, Cellar
et  al. (2000) found only limited evidence that agreeable-
ness was associated negatively with vehicular accidents,
and Salgado (2002) was unable to demonstrate a reliable
association between any factors and accident rates. Levine
K17577_C045.indd 689
Background to crew resource management content  689
et  al. (1976), in a study of accident involvement in the US
Navy, found that those with a history of accident involve-
ment were more adventurous and risk-taking. Sanders et al.
(1976), in an attempt to cross-validate earlier findings that
three factors from the Cattell 16PF (personality factors) per-
sonality test were predictive of pilot-error accident involve-
ment, reported that ‘individual differences in personality
characteristics of the aviators prevent consistent identifica-
tion of traits associated with pilot-error groups’. Although
there does appear to be some association between personal-
ity and accidents, it is unlikely that a single ‘accident-prone’
personality exists (Sümer 2003; Farmer 1984).
Leadership
Effective leadership was another area that initially featured
heavily in CRM courses but is seen less nowadays.
Early ideas on leadership psychology focused on the sim-
ple trait approach (i.e. leaders were born with certain traits
that made them effective leaders). It was soon recognized
that such traits were only effective given the right situations,
and also that the traits themselves were less important than
the behaviour exhibited. By the time CRM became com-
mon in the 1990s, the situational-behavioural approach was
generally accepted, whereby effective leadership was a com-
bination of the leaders’ behaviour and the situation.
There is usually said to be two types of leadership behav-
iour: task-oriented behaviour (that concerned with goal
achievement) and socioemotionally oriented behaviour,
which seeks to maintain the group satisfaction (Bales 1950;
Cartwright & Zander 1968). It is generally held that a bal-
ance of the two elements is most effective, and the best bal-
ance will depend upon the situation. For example in a flight
deck emergency, an autocratic, task-oriented approach is
likely to be more effective.
Decision making
Classical approaches to decision making assume that indi-
viduals weigh up all possible courses of action and select
the one that is most appropriate. Thus, the individual is
assumed to perform a series of activities such as identifying
the problem, generating alternatives, assessing the advan-
tages and disadvantages of each, choosing a solution, and
testing its effectiveness. This idea has long been challenged
however, particularly for everyday decision-making tasks,
or those taken under pressure. Herbert Simon coined the
term ‘bounded rationality’ in the 1950s, expressing the view
that human’s ability to act in such logical and rational ways
is severely limited (Simon 1957).
It is now widely recognized that real-life decision mak-
ing in dynamic time-critical environments where infor-
mation may be ambiguous or lacking does not conform
to rational, exhaustive processes. Such naturalistic deci-
sion making is particularly applicable to experts who
draw upon a considerable amount of past experience. In
Klein’s (1989, 1998) recognition-primed decision model, for
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 690  Crew resource management
example, the expert matches the current situation to simi-
lar past experiences, selecting an adequate course of action
rather than exhaustively comparing all possible solutions
and selecting the one that is optimal. There is growing
interest in naturalistic decision making within aviation,
since aircrew activities, particularly in emergencies, are
performed under adverse conditions appropriate to the
naturalistic approach. However, although the principles of
naturalistic decision making have received support in the
literature, they are not yet sufficiently mature to form the
basis of aircrew training.
Despite the descriptions of naturalistic decision-making
processes, it is still often held that greater amounts of option
generation and consideration will result in more effective
decisions. Modern CRM courses often refer to the need to
generate as many options as possible to solve a problem,
although there is little ‘real-world’ research evidence to
suggest that this will lead to more effective outcomes than
using naturalistic methods in most situations. It is likely
that certain situations (particularly where plenty of time is
available) might benefit from this approach, whereas more
urgent problems would benefit from naturalistic or proce-
duralized approaches, which have the advantage of free-
ing up crew capacity and workload. Indeed this has been
reflected in some modern CRM programmes, whereby
crews are taught to assess the time available before choosing
a decision method.
Communication
Research on communication has uncovered the characteris-
tics of effective flight crews. It has been reported, for exam-
ple, that crews that engage in more frequent operational
communications and exchange of information commit
fewer errors and distribute workload more evenly during
critical phases of flight (Foushee & Manos 1981).
Communication can be made more effective in a number
of ways (Huey & Wickens 1993), such as standardizing and
restricting vocabulary, using short messages, and present-
ing redundant information (e.g. both visual and auditory).
The number of pilots’ requests for full or partial repeats
of air traffic controllers’ taxi instructions increases with
complexity, as do errors in read-back, and longer message
lengths can overload the pilot’s working memory (Morrow
& Rodvold 1993; Morrow et al. 1993). Errors in communi-
cation were starkly revealed in a study by Rantanen and
Kokayeff (2002), in which experienced pilots listened to
taped air traffic control clearances and copied them down
on to paper. The authors reported ‘astonishingly poor per-
formance’ on this task. Errors of commission were much
more frequent than errors of omission and were influenced
strongly by habit and past experience. The errors typically
made by pilots during communication with air traffic con-
trollers are the use of non-standard phraseology, trunca-
tion of read-back, failure to issue read-back, and failure to
request clarification when appropriate (Spence 1992; Prinzo
& Britton 1993).
K17577_C045.indd 690
Jensen and Biegelski (1989) summarized the communi-
cation skills that should be nurtured by CRM training:
●● Enquiry: Crew members may be reluctant to seek clari-
fication, lest it call into question their professional skills
or hearing.
●● Advocacy: Aircrew members, even if they occupy a
relatively junior position, must be prepared to state their
beliefs.
●● Listening: Jensen and Biegelski emphasized that listen-
ing is a skill that must be learned.
●● Conflict resolution: When crew members express their
opinions and beliefs, conflicts are likely to emerge. They
must be taught how to resolve conflicts effectively, using
them to arrive at better solutions.
●● Critique: This is an important form of feedback that can
be used to improve a variety of flight deck skills.
Situational awareness
Initially, situational awareness (SA) was not part of CRM
training, but it has grown to become a key element over the
last 20 years. Endsley (1988) describes situational awareness
as the perception of the elements in the environment within
a volume of space and time (level 1), the comprehension of
their meaning (level 2) and the projection of their status in
the near future (level 3).
Research has attributed the majority of aircraft accidents
to ‘lack of SA’ (e.g. Durso & Gronlund 1999), including
74 per cent of accidents involving controlled flight into ter-
rain in the period 1978–92. However, such conclusions are
vigorously criticised by others in the academic community,
who dispute the value of situational awareness as a concept
(see Dekker 2005).
Nevertheless, situational awareness and team situational
awareness remain popular in modern CRM course content.
Prince (1998) provided a detailed framework for SA train-
ing, which included:
●● Discussion of the high frequency of SA-related incidents.
●● The CRM-related activities that support SA (leader-
ship, communication, preparation and planning,
adaptability).
●● Inferring SA from observable behaviours.
●● The role of team SA in accident prevention.
●● The conditions under which SA is likely to be compro-
mised (high workload, fatigue, equipment malfunction).
This framework still reflects the sort of approach taken to
SA in modern CRM courses. There is no industry or sci-
entific agreement on how a pilot should best achieve good
SA, avoid losing it or know when it is lost. The implied mes-
sage of CRM courses can appear to be that the pilot should
scan sources of data more thoroughly, particularly during
and after high workload and non-normal events. It can be
argued that such a message misses some essential points of
human cognition.
17/11/2015 16:23

From a scientific perspective, it has proved difficult
to measure SA in practice. Two of the most widely used
measures are the situational awareness global assessment
technique (SAGAT) and the situational awareness rating
technique (SART). SAGAT attempts to measure SA objec-
tively, freezing and blanking the operator’s displays and
presenting queries to test knowledge of the current state of
the system (e.g. location of other aircraft) (Endsley 1988).
SAGAT has been found to have good reliability and there is
evidence for its validity, such as significant correlation with
aircrew performance in a combat simulation (Endsley 2000).
However, SAGAT perhaps relies too heavily on memory as
an index of SA and does not appear to provide a means of
assessing the implicit (and non-verbalizable) knowledge
that is a characteristic of the highly skilled operator. SART
adopts a different approach, eliciting subjective ratings on
a number of scales related to demand for mental resources,
supply of resources, and understanding of the situation (e.g.
Selcon & Taylor 1990). Like SAGAT, SART has been found
to be related to aircrew performance (Selcon & Taylor 1990)
but is subject to the disadvantages associated with subjec-
tive techniques, including the effects of possible errors in
the individual’s mental model.
There is a question mark over the validity of all such
methods: can the results really be said to represent situ-
ational awareness? Furthermore, one can question whether
the tested elements are valid indicators of good situational
awareness (i.e. high scores would represent good perfor-
mance) or just the most convenient elements to measure.
Hence, situational awareness is a concept on which the
scientific community is undecided, not just in terms of the
extent to which it can be trained, but also how it can be mea-
sured/captured, and indeed whether it is a valid concept to
be applying to safety and accidents at all. Despite this, the
concept of SA is almost universally accepted and established
within the operational environment (e.g. CRM training).
Workload
Like situational awareness, there is considerable debate
around the concept of workload within the scientific and
academic communities. However, unlike for situational
awareness, the measurement of workload is well established
and it is generally accepted that individuals can recognize
and control their workloads to some extent (workload man-
agement). There is also wider acceptance of the underlying
theoretical concepts to workload. It is generally accepted
that there are different types of workload (for instance cog-
nitive, physical, temporal). Within CRM training there is
a general blurring of these, and workload is discussed as a
single concept most closely aligned with the academic defi-
nitions of cognitive workload (i.e. an idea of mental effort
and capacity required for tasks). It can be more useful and
practical to consider workload in such a way in order to
optimize tasks and equipment.
The flying task is characterized by the need to share
attention between several subtasks. In general terms, four
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Background to crew resource management content  691
types of task must be performed: aviation, navigation, com-
munication and systems management (Wickens 2002). Even
the highly skilled pilot may perform suboptimally under
conditions of high workload, such as dealing with an emer-
gency. With mastery of a task comes the development of
‘motor programmes’ and procedural memories, automated
behavioural routines that require little conscious atten-
tion (compare with the experienced car driver, who often
is unaware of routine actions such as changing gear). Many
everyday errors are the result of well-practised but inappro-
priate behaviour, or ‘actions not as planned’ (Reason 1990).
High workload, which reduces the opportunity to monitor
behaviour that has been delegated to the control of motor
programmes, makes such errors more likely. A further pos-
sible consequence of overload is an increase in attentional
selectivity (i.e. a focusing of attention on particular ele-
ments of the task). Such an effect has been demonstrated in
noisy environments, which, like overload, tend to increase
the individual’s level of arousal (Hockey 1970). Faced with
increased task demands, the operator may choose to act
quickly at the expense of accuracy or may even shed some
subtasks completely, with obvious implications for safety.
When faced with too much information, the human brain
is likely to focus down on what it feels is the most important
information only, and become blind to the rest. This is an
important coping mechanism, but can also lead to problems.
As Wickens (2002) has noted, high workload is also likely to
impair the pilot’s awareness of both the environment and
the state of the aircraft; hence, workload and situational
awareness are intimately related. However it should also be
noted that good situational awareness is often associated
with high workload, since it can take a great deal of con-
centration to maintain awareness in certain circumstances.
Training is a powerful method of managing workload.
Flying training attempts to automate skilled behaviour
as far as possible, producing ‘over-learning’ by continued
practice after proficiency has been achieved. The individual
may, therefore, have more spare capacity to deal with other
tasks (Farmer et  al. 2000). Personnel selection also offers
a means of ensuring that aircrew will be able to cope with
high task demands.
In the context of CRM, an important issue in workload
management is effective sharing of activities among the
crew members. As Huey and Wickens (1993) note, mainte-
nance of team performance under high workload requires
effective CRM, including sharing of information and coor-
dination of monitoring and task responsibilities.
Threat and error management
TEM has become an important part of CRM, and has argu-
ably replaced traditional CRM in some quarters. TEM
originated from a programme run at the University of
Texas in the mid-1990s, supported by the Federal Aviation
Administration and NASA.
The basis of TEM is that error should be normalized
(Helmreich et al. 1999, p8) and that this is communicated
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 692  Crew resource management
and understood by all crews in the airline. This means that
all levels of the organization accept that errors are inevita-
ble, and move to a position where they deal with this inevi-
tability, rather than attempting to eradicate it. This would
also apply for operational threats.
TEM training builds on this position, by training a mind-
set whereby crews actively look for potential threats and
errors in order to avoid adverse situations occurring, or trap
the issues if they happen. If, despite this, some errors or threats
still occur, then crews should mitigate their consequences.
Hence the essential framework of TEM is that opera-
tional threats and errors are avoided, trapped or mitigated.
ASSESSING CREW RESOURCE
MANAGEMENT SKILLS
In the very early years of CRM training there was little
systematic checking of CRM in practice, and no proper
agreement about what acceptable CRM usage would look
like. It was therefore difficult to assess whether individual
pilots exhibited acceptable standards of CRM. Any check-
ing that did occur was left to trainers’ judgement during
simulator or line checks. Hence the need for some sort of
standardized assessment and validation of CRM became an
important issue.
The first concept to evolve into a method of evaluating
CRM was a system of behavioural markers developed by
the University of Texas and NASA in the late 1980s, sup-
ported by the Federal Aviation Administration. All mod-
ern forms of CRM assessment followed from this system, by
using behavioural markers as the basis of CRM evaluation
and assessment.
In general, behavioural marker systems have their roots
in research methodologies used by social scientists to qual-
ify and even quantify observations of other peoples’ perfor-
mance and behaviours. In essence, such tools usually take
the form of a list of descriptions of potentially observable
behaviours that one would expect to see (or not to see) in
that given situation, such as on a sports field or in a wait-
ing room. The observer records each occasion that they feel
that they have observed one of the listed behaviours. Hence,
although the data will still be rooted in subjectivity, the tool
is an attempt to make observational analysis more consis-
tent across observers and over time. Hence, behavioural
marker systems do represent a genuine attempt to make
CRM skills assessable, measurable and comparable, as well
as to set recognizable standards for CRM usage.
The original University of Texas project became the Line
Operations Safety Audit (LOSA) programme, whereby
behavioural markers were incorporated into a line-oriented
checklist, which was used to collect and analyse data about
CRM and non-technical skills observations from many
airlines. After several refinements and validations, the use
of markers was deemed to be a valid method of assessing
CRM training in operational environments. The LOSA
markers were developed into a behavioural rating scale,
based around the threat and error management model. The
K17577_C045.indd 692
elements of the scale include areas such as SOP briefing,
Workload Management, Vigilance, evaluation of plans, and
inquiry. Examples of specific markers are:
●● Crew decisions and actions were openly analyzed.
●● Crew members not afraid to express a lack
of knowledge.
●● Aircraft position, settings, and crew actions were
verified.
Whereas the use of these LOSA behavioural markers is pre-
dominant in the US, many other systems have been devel-
oped and are in use in other areas of the world. There is no
way of knowing how many such systems exist. Some airlines
develop their own systems, as do academics.
The major behavioural marker system in Europe is called
NOTECHS (non-technical skills). It was developed between
1997 and 1998 by a consortium consisting of the Netherlands
National Aerospace Laboratory (NLR), German Aerospace
Centre (DLR), the French Institute of Aerospace Medicine
(IMASSA), and the University of Aberdeen (van Avermaete
1998).
NOTECHS was designed to minimize ambiguities in the
assessment of non-technical skills (Flin et al. 2008, p.304),
and as such is a much more detailed and comprehensive
set of markers than the LOSA rating scale. NOTECHS has
undergone reliability and validity testing and been reported
to have inter-rater reliability of up to 88 per cent (Flin et al.
2005). However, the scenarios used were developed specifi-
cally for the purpose and the raters had no concurrent tasks
or observations to perform in the way they would in the real
world. Nevertheless NOTECHS is one of the few marker
systems to be supported by scientific evidence.
The unadjusted NOTECHS framework is shown in
Table 45.1. It consists of four main categories; cooperation,
leadership and management, situational awareness and
decision making. Each of these is split into four elements,
making sixteen elements on which crews can be assessed on
a scale from very poor to very good. A number of example
behaviours are given for each element. (Table  45.1  shows
one for each element.)
One major difference between NOTECHS and previous
marker systems (including the University of Texas system) is
that NOTECHS includes both positive and negative exam-
ples of behaviour. The behaviour examples are intended to
be clear and directly observable and hence easy to identify.
There is little research on how NOTECHS is used in real-
ity, in the simulator or on the line.
Behavioural markers have been absorbed into regulation.
For example, the UK CAA stipulates that airlines must use
behavioural markers to assess and evaluate crews in terms of
their non-technical skills (UK CAA 2013). NOTECHS is the
only system named as being approved by the UK CAA (2013);
however, it is also made clear that any system can be used with
the approval of the authority, and indeed there are at least five
different behavioural marker systems used by UK airlines as
of 2013, including modified versions of NOTECHS.
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Table 45.1  The NOTECHS framework
Categories Elements
Cooperation Team building and maintaining
Considering others
Supporting others
Conflict solving
Leadership and Use of authority and assertiveness
managerial skills Maintaining standards
Planning and coordinating
Workload management
Situational awareness System awareness
Environmental awareness
Anticipation
Decision making Problem definition / diagnosis
Option generation
Risk assessment/option choice
Outcome review
From CAP 737, UK CAA (2006).
As well as being used for general data gathering (in the
case of the LOSA programme), behavioural marker systems
are used to assess the non-technical skills of individuals and
crews. For example, a training captain will fill in a behav-
ioural marker form such as NOTECHS while concurrently
performing a technical check such as an operator profi-
ciency check. At the end of the operator proficiency check,
the trainer will debrief the pilots on their use of CRM, using
observations based on the marker system. Under some avia-
tion authorities, pilots can be failed on their CRM skills
and such a failure can form part of an overall failure of the
technical check.
So despite having their roots in scientific observation
instruments, one major difference for the CRM behavioural
marker systems is that they are used to assess single crews.
In scientific studies such analysis usually gets aggregated
over a large sample of people in order to avoid sampling
error and observer bias. It follows that a potential weak-
ness of using behavioural marker systems in this way is the
variation in observational interpretations of the assessors.
Whereas scientists spend considerable amounts of time
making sure that individual observers are standardized
and judgements are triangulated, behavioural marker sys-
tems are often used by trainers who have been given very
little, or no standardization and hence there is a risk of wide
variation in outcomes. Nevertheless behavioural markers
represent a genuine attempt to objectify the assessment of
non-technical skills.
CREW RESOURCE MANAGEMENT
EFFECTIVENESS
Despite all the forms of CRM, the estimated proportion
of accidents caused by pilot factors remains high for all
K17577_C045.indd 693
Crew resource management effectiveness  693
Example behaviours
Establishes atmosphere for open communication and
participation
Takes condition of other crew members into account
Helps other crew members in demanding situation
Concentrates on what is right rather than who is right
Takes initiative to ensure involvement and task completion
Intervenes if task completion deviates from standards
Clearly states intentions and goals
Allocates enough time to complete tasks
Monitors and reports changes in system’s states
Collects information about the environment
Identifies possible future problems
Reviews causal factors with other crew members
States alternative courses of action
Asks other crew member for options
Considers and shares risks of alternative courses of action
Checks outcome against plan
types of aviation (Jarvis & Harris 2008, p 211). Many esti-
mates abound, but most studies quote accident propor-
tions of between 55  and 80  per cent as being attributable
to human cause. In commercial aviation, these percentages
rose throughout the last century as technical reliability
improved; hence it is more useful to suggest that technical
accident causes decreased markedly, whereas human causes
have not kept pace. Such figures cannot provide suffi-
cient evidence to support or dispel notions that CRM has
reduced accidents.
Research has attempted to establish the value of CRM
training. The difficulty for such research is the isolation
of variance. Since there is no way of constructing a valid
control measure (e.g. a random group of pilots who do not
get exposed to CRM training or ideas), results cannot be
indisputably linked to the CRM training. For instance, if
a measured improvement in safety coincides with a period
of CRM training, there is no way of proving to what extent
CRM training was responsible, if at all.
Salas et  al. (2001) looked at 58  published accounts and
concluded that it was impossible to determine whether
CRM achieved its ultimate goal of improving flight safety. It
has been claimed that CRM training reduced the incidence
of accidents involving human error by 81  per cent (Diehl
1991). However Wiegmann and Shappell (1999) found that
the incidence of CRM-related mishaps was comparable to
that observed before its introduction. Johnson (2000) drew
attention to accident reports in which prior participation
in CRM training had no observable effect on crew perfor-
mance. He attributed failures of CRM to factors such as
crew fatigue and the cockpit authority gradient and argued
that greater attention should be given to the underlying
causes of high workload, distraction and poor decision
making, rather than attempting to counteract their effects
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 694  Crew resource management
by means of CRM training. There is also evidence that CRM
has failed to ensure adherence to automation-related pro-
cedures (Helmreich et  al. 1996); that acceptance of CRM
deteriorates over time, even when recurrent training is pro-
vided (Helmreich & Taggart 1995); that a small proportion
of pilots consistently reject CRM concepts (Helmreich &
Wilhelm 1991; Helmreich & Merritt 2000); and that courses
originating in the USA are unsuitable for cultures that
discourage the questioning of the judgement of superiors
(Helmreich & Merritt 1998).
Recent research has claimed that CRM has considerable
cost benefits. Arthur et  al. (2011) produced a method of
utility analysis suitable for measuring the cost-effective-
ness of CRM training (in terms of CRM leading to fewer
accidents). The method calculated that CRM saves between
$293  million (best case) and $177  million (worst case).
However, the major factor in the equation was obtained
by asking seven subject matter experts (CRM/human fac-
tors trainers, facilitators or researchers) how many acci-
dents they thought CRM prevented in their airline. All
seven offered the opinion that that CRM did prevent acci-
dents, and the mean number of prevented accidents given
was fed into the equation. Hence although this research
appears to produce a hard quantitative figure for CRM
effectiveness, that figure is a direct expression of seven
people’s subjective opinions. Unfortunately such opinions
cannot be substantiated, and one might expect that indi-
viduals involved in CRM and human factors would give
such favourable opinions. Although the method provides
a genuine attempt to solve a very difficult problem, it faces
the same difficulties as all previous research when it comes
to assessing the value of CRM.
Science has still not developed a supportable way of
assessing the extent to which CRM training is effective.
Evidently however, the continued worldwide regulation
and participation in CRM in aviation, together with inter-
est shown in CRM from other safety critical industries,
suggest a general consensus that CRM training remains
worthwhile.
SUMMARY
●● CRM was established over 35 years ago as a way
to reduce aircraft accidents caused by human
error. Originally conceived as training aimed
only at pilots, CRM training is now given to
many other operational personnel.
●● Although now part of regulation, CRM training
takes a variety of forms. Topics include managing
human limitations and error, teamwork, opera-
tional threats, leadership, and many other aspects
of aircraft operation, often also referred to as
non-technical skills.
●● Pilots’ CRM is assessed using observations sup-
ported by behavioural marker systems.
K17577_C045.indd 694
ACKNOWLEDGEMENT
Revised and updated from the corresponding contribution
to the Fourth Edition written by Eric Farmer.
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Air traffic control
JOHN ROBERTS
Introduction 697
An overview of air traffic control 697
INTRODUCTION
The world of air traffic management is a dynamic and rap-
idly developing part of the aviation sector. New technolo-
gies are changing the way air traffic control is managed and
delivered. Personnel working in air traffic management will
need to adapt to these changes whilst continuing to provide
a safe service. The staff required to provide an air traffic ser-
vice work in numerous disciplines, including for example
specialist air traffic control engineers, human factors spe-
cialists as well as air traffic controllers. The medical exper-
tise to provide general work-based medical support for staff
falls under the specialization of occupational medicine.
However air traffic controllers themselves play an integral
part in the ‘regulated’ area of the aviation industry and the
medical considerations in delivering work-based care to
controllers comes under the specialization of aviation medi-
cine. Medical personnel who look after air traffic employees
need to have an understanding of the regulatory framework
in which they operate and to have a good knowledge of the
working environments, practices and the hazards which
may impact on their well-being. The first part of this chapter
will give an overview of air traffic control. It will consider
the early history of air traffic control and the development
of the relevant regulatory bodies. It will look in detail at
the working environments within air traffic management
and the resultant working practices that have developed to
deliver the service. The second part of this chapter will deal
with specific medical issues. It will discuss medical stan-
dards and common areas of medical concern within the
air traffic control industry and consider the future develop-
ments in the industry and how these may impact on those
working in air traffic control.
K17577_C046.indd 697
46
Medical aspects of air traffic control 701
References 706
AN OVERVIEW OF AIR TRAFFIC CONTROL
The birth of air traffic control
Following the first powered flight by Orville Wright on 17th
December 1903 there was a steady growth in the numbers
of people and aircraft taking to the air. However early avia-
tion was a dangerous business. Navigation devices were
limited to magnetic compasses. Pilots flew at low level to be
able to navigate by roads and railways. Accidents were com-
mon place. As air travel increased it was realized that some
method of controlling aircraft was necessary, especially at
airports. In 1921, Croydon Airport London was the first air-
port in the world to introduce a flag waving system to advise
pilots when it was safe to land. This can be thought of as the
first instance of air traffic control.
History of the development of air traffic
control regulation
The early 20th century saw a gradual increase in the num-
bers of aircraft, flights and nations becoming involved in
aviation. The need to standardize and coordinate was rec-
ognized early with the International Commission for Air
Navigation holding its first convention in Berlin in 1903 with
eight nations attending. The second conference three years
later was attended by 27  countries. On 7th December
1944, 52 countries signed the Convention on International
Civil Aviation (known as the Chicago Convention) which
eventually led to the formation of the International Civil
Aviation Organization (ICAO) on 4th April 1947. Later
that year ICAO became an agency of the United Nations.
ICAOs role is to lay down the principles and techniques of
697
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 698  Air traffic control
international air navigation to ensure the safe and orderly
development of air transport internationally. As of 10th
November 2011  there were 191  member nations (http://
www.icao.int/MemberStates/Member%20States.English.
pdf). Each signatory’s national aviation authority must
adhere to the standards laid down by ICAO as a minimum,
but they may choose to use more stringent regulations if it
is felt appropriate.
Work on developing standards, practices and procedures
for air traffic control started in October 1945  but it took
until May 1950  for Annex 11  the International Standards
and Recommended Practices – Air Traffic Services to be
adopted by the Council, which then became effective on 1st
October 1950 (ICAO 2001). Annex 11 states that the objec-
tives of the air traffic services shall be to:
1. Prevent collisions between aircraft.
2. Prevent collisions between aircraft on the manoeuvring
area and obstructions on that area.
3. Expedite and maintain an orderly flow of air traffic.
4. Provide advice and information useful for the safe and
efficient conduct of flights.
5. Notify appropriate organizations regarding aircraft in
need of search and rescue aid, and assist such organiza-
tions as required.
Basic principles of air traffic control
The main objective of an air traffic control service is to
prevent collisions between aircraft. The airspace in a geo-
graphical area where air traffic services are being provided
is deemed to be controlled and aircraft in controlled air-
space must obey the instructions of the air traffic control
provider. To prevent collisions, aircraft flying in controlled
airspace are allocated a pocket of airspace into which no
other aircraft is allowed to enter. This principle is known as
separation. Aircraft must be vertically, horizontally and lat-
erally separated. In general, aircraft flying at altitudes from
sea level to 29 000 ft should come no closer vertically than
1000 ft. Above 29 000 ft this is increased to 2000 ft except
in airspace where reduced vertical separation minima
(RVSM) can be applied. The degree of lateral and horizon-
tal separation is governed by the accuracy of information
on the precise location of the aircraft and the speed of the
aircraft in that operating area. Where the information is
very accurate, such as in a geographical area with good
radar coverage, aircraft are usually separated five miles
laterally and horizontally. Nearing airports where aircraft
speeds are lower this is often reduced to three miles sepa-
ration. In regions without radar coverage, the position of
the aircraft may be determined by radio reports from pilots
based on dead reckoning, internal navigation aids and bea-
cons. In such areas aircraft may have 60 miles of lateral sep-
aration and be separated by 10 minutes of flying time if on
the same trail.
RVSM applies in certain areas where radar coverage is
good and aircraft have modern altimeters allowing them to
K17577_C046.indd 698
fly with reduced vertical separation, such as 1000  ft verti-
cal separation above 29 000 ft over most of North and South
America, Europe, North Africa and Southeast Asia.
Becoming an air traffic controller
The route to becoming an air traffic controller varies from
nation to nation but entry requirements for training are
fairly similar. The individual must have the right to work
in that country and there is often a level of basic academic
qualification. As the role demands the ability to handle
complex information, have excellent spatial awareness and
problem solving, it is usual to have specific selection tests.
A medical assessment is required and there is a require-
ment for proficiency in the English language. There may
be a requirement to pass a security investigation and some
nations may set a maximum age limit. There are usually two
stages to qualifying as an air traffic controller. Initial train-
ing covers the basics of aviation law, navigation, meteorol-
ogy and air traffic control disciplines. This may be offered by
employing organizations, or through independent air traffic
control colleges, but any training courses must be approved
by the national regulator. During initial training candidates
may be streamed towards the air traffic discipline for which
they appear to have a particular aptitude. Once initial train-
ing is completed to a satisfactory standard they are issued a
student air traffic controllers licence. The student control-
lers may then be assigned to units where they receive spe-
cific training directly relevant to their proposed future role.
Depending on the type and complexity of eventual job role
the training may last from several months to up to 4–5 years.
Training is only completed when the controller has been
assessed, usually with a practical and verbal examination,
and achieves a standard that is acceptable to the regulator. It
is at this point that they become validated air traffic control-
lers and are issued a full air traffic controllers licence. Some
national authorities require controllers to undergo special
training to ensure they can deal with unusual events that
they are unlikely to see in their day-to-day duties. In the
UK this is known as TRUCE training (Training in Unusual
Circumstances and Aircraft Emergencies) and controllers
must undergo TRUCE training annually.
It is the controller’s responsibility to ensure they main-
tain the validity of their licence. This includes ensuring that
any ratings or unit competencies as well as the medical cer-
tificate remain valid, although many employing organiza-
tions will also have processes in place to ensure that their
controllers maintain a valid licence.
Provision of air traffic control service
At the most basic level air traffic control can be thought of
as ground based controllers directing aircraft on the ground
and through controlled airspace, making use of radio, data
link and radar information. Controllers use their skills of
spatial awareness, problem solving and visual scanning to
build a picture of all the aircraft in their area of control and
17/11/2015 16:23

take information from these aircrafts headings, heights and
speeds, as well as the desired routing of all the aircraft. They
must be able to predict where separation between aircraft
may be lost and must make interventions such as turn-
ing, climbing or descending aircraft to ensure separation is
maintained between all aircraft at all times. Even in today’s
computerized and digital information world the controller
remains a key component of the air traffic control system.
Controllers, usually known as air traffic control officers or
air traffic control specialists, usually work in one or more
of three disciplines: area control, approach control or
aerodrome control.
AREA CONTROL
Area controllers are responsible for controlling aircraft
at higher altitudes and on established routes (en route)
between airport approaches and departures. En route air-
space is divided up into 3D blocks or sectors, the dimen-
sions of which are well defined and depend on the numbers
of aircraft and the complexity of the traffic that regularly
uses that area. Each sector has its own unique radio fre-
quency to allow the pilot and controller to communicate.
Area controllers may be qualified to control aircraft in all
the centres sectors, but in area centres with multiple and
highly complex sectors this is impractical, and in such areas
controllers may only hold validations for one or two sectors.
Most nations will have at least one area control centre; there
are about 250 area control centres world-wide. Area centre
controllers use radar information to monitor the progress
of flights in their sectors, ensuring that separation minima
are maintained at all times. Where an area centre airspace
is beyond ground based radar coverage then procedural
Figure 46.1  Area control centre.
K17577_C046.indd 699
An overview of air traffic control  699
control methods are used to maintain separation minima.
Area controllers usually hand on their traffic to another
area sector or to an approach controller. Area control cen-
tres may be located at airports but are often situated well
away from them and in the case of the larger centres may
have several hundred controllers working in that location
(Figure 46.1).
APPROACH CONTROL
Approach controllers typically direct aircraft approaching,
departing or overflying within 30–50 miles of a designated
airport. Often known as Terminal Control or TRACON
(Terminal Radar Approach Control) in the US, the area
covered by a controller depends on the density and com-
plexity of the local air traffic. Where there are many airports
in close proximity the approach function may be consoli-
dated into a terminal approach centre, such as the London
terminal control centre, which covers London’s five major
airports with coverage up to 20 000 ft and out to 100 miles.
As with area centres, the busier terminal control centres
may split their airspace into several sectors with controllers
holding validations for one or two sectors. Terminal con-
trollers hand their traffic over to other terminal sectors, area
sectors or a tower controller and are responsible for ensur-
ing that aircraft are at an appropriate altitude for hand over
or set at a suitable rate for landing. Approach control is often
collocated at the airport but may be collocated with an area
control centre.
AERODROME CONTROL
The primary means of controlling aircraft in the immedi-
ate airport setting is visual observation from the air traffic
17/11/2015 16:23
 700  Air traffic control
control tower’s visual control room (VCR) (Figure  46.2).
Aerodrome or tower controllers are responsible for the safe
and efficient movement of aircraft and vehicles on the oper-
ating areas (runways, taxiways, holding areas and stands)
and aircraft typically within 5–10 miles depending on local
procedures. Busier airports may also use radar to assist
with the control of arriving and departing aircraft as well
as using surface movement radar for aircraft on taxiways
and runways. Controllers in busy airports may be assigned
differing roles. Ground movement control (GMC) is respon-
sible for the safe movement of aircraft and vehicles on all the
operational areas such as taxiways, holding areas and run-
ways. This can be a very demanding role especially in air-
ports with a high density of aircraft and complex taxiways
and crossing points. Local or air controllers are responsible
for aircraft arriving and departing on the active runways.
Close cooperation between local, ground and approach
controllers is essential to ensure safe and efficient move-
ment of aircraft. Clearance or delivery controllers plan and
give clearance for the departure times of aircraft off their
stands to ensure that the traffic is presented to the GMC in
the most efficient manner.
Work patterns
The work of an air traffic controller can demand very high
levels of spatial awareness, concentration, visual scanning
and problem solving. It is essential that controllers have
regular breaks to prevent fatigue and to avoid overloading
individuals. ICAO are currently working on developing
Standards and Recommended Practices for air navigation
service providers and national regulators similar to those
already in place for pilots. However many nations may
already have a scheme in place such, as the UK’s Scheme
Figure 46.2  Air traffic control tower’s visual control room.
K17577_C046.indd 700
for the Regulation of Air Traffic Controllers’ Hours
(SRATCOH) (CAA Safety Regulation Group 2013). For
example, STRATCOH defines what constitutes operational
duty, breaks in operational duty, night duties and limits on
night duties, what is classed as an early start and limits on
the number of early starts. However as aviation is a 24 hours
a day 365 days a year activity then there may be a require-
ment to provide a 24 hours a day air traffic control service
depending on local area demands. In order to satisfy this
requirement, air traffic service providers must ensure that
there are sufficient numbers of suitably qualified controllers
on duty to meet the air traffic demands. In such instances
it is common practice for controllers to work a shift pat-
tern and depending on the employing organization the
pattern may vary. Some organizations allow controllers to
follow unique individual patterns whilst others have their
controllers assigned to watches with a predictable rotat-
ing shift pattern. Such a pattern could be two early starts
(0630–1400 hrs) followed by two late starts (1300–2300 hrs)
and then two nights (2200–0700 hrs) followed by a sleep day
and three days off.
Controller workloads
The workload of controllers will vary depending on their
role. Some aerodrome controllers may work at relatively less
busy airports with 10s–100s of movements per day whilst
busy international airports may see over 1000 movements
a day. That is not to say that the quieter airports are nec-
essarily less demanding. Busier airports tend to have more
controllers, may deal only with experienced commercial
pilots who are familiar with the airport, and with airlines
that fly regular and well planned schedules. Whereas qui-
eter airports may have fewer movements, there may be
17/11/2015 16:23

added complications in dealing with that traffic, as such
airports may have a mix of commercial and general aviation
and possibly rotary wing aircraft. Area and terminal con-
trollers tend to control sectors of airspace, with some sec-
tors covering a much larger geographical area than others.
Sector dimensions are usually dependent on the numbers
and complexity of the air traffic in that area. Therefore, a
sector where all aircraft are on established trails and fly-
ing at fixed altitude will cover a geographical area far larger
than a sector in which aircraft are turning and climbing or
descending. Controllers may have up to 10 aircraft on their
frequency at any one time.
Workload also depends on the time of day. Within
Europe and around most airports there tends to be a high
level of activity in the early morning and then again in
the late afternoon and early evening. Night-time tends to
be quieter but this is not always the case. Aircraft leaving
the US in the evening and heading for early morning arriv-
als in Europe cause a peak of traffic for the North Atlantic
Oceanic Controllers during the very early hours of the
morning. Another significant factor affecting workload is
weather conditions. Thunderstorms often cause aircraft to
deviate from planned routes causing controllers extra work-
load to ensure separation minima are maintained.
In periods of high work load the controller may feel that
they are becoming overloaded and unable to handle the
number of aircraft in their sector or area of responsibil-
ity. If this occurs then extra controllers can be called upon
to help, and this is commonly known as splitting the sec-
tor or position. Such an example is when two controllers
are called upon to do ground movement controller duties
instead of the usual one. Conversely, when there are quiet
periods two or more sectors may be combined to use one
radio frequency under the control of a single controller, this
is often termed band-boxing the sectors. However, it must
be remembered that high traffic demands are not the only
workload factor that may impact on flight safety. Periods of
relative quiet especially after a high intensity period is often
the time where mistakes could be made. This is not due to
boredom but may result from a relaxation and lack of con-
centration following an intense period of work.
Teamwork in air traffic control
Controllers rarely work in isolation. Collaborative work-
ing is essential. Controllers work alongside each other, and
interface with controllers on adjoining sectors, supervisors
and planners. Whilst for several decades pilots have been
trained in crew resource management to ensure increased
effectiveness of crew coordination and management of the
flight deck (Kanki et  al. 2010), a similar concept has only
been more recently introduced for controllers. Known as
team resource management, it uses human factors prin-
ciples to ensure effective collaboration and team working
amongst controllers (Wolding et  al. 2005). Selection tests
often try to assess candidates to see if they can work suc-
cessfully as part of a team and how they communicate with
K17577_C046.indd 701
Medical aspects of air traffic control  701
others. Personality traits or conditions that may have an
adverse effect on team work or interpersonal communica-
tion need to be considered at selection as these may rule out
candidates as being suitable to become a controller.
MEDICAL ASPECTS OF AIR TRAFFIC
CONTROL
Medical standards
To ensure air traffic controllers are physically and psycho-
logically fit to undertake their duties they are subject to
strict medical regulation. The aim of medical regulation is
to reduce the likelihood of sudden or subtle incapacitation
of the controller leading to a risk to flight safety. Controllers
are subject to very similar medical standards as commer-
cial pilots and in general the same 1  per cent rule applies
(Mitchell and Evans 2004). This means that a controller
would be denied a medical certificate if their risk of a medi-
cal incapacitation was deemed to be greater than 1 per cent
per year. Overarching standards are detailed in the ICAO
Manual of Civil Aviation Medicine (2012). However,
nations may use their own more stringent standards, for
example within Europe the European Class 3 Requirements
(2006) apply.
Medical assessment of air traffic controllers can only be
carried out by suitably qualified physicians. The Eurocontrol
document, for example, states that ‘Class 3  Assessment
Qualification Training, including practical work, for physi-
cians responsible for medical examinations of ATCOs and
student ATCOs should include the following topics – avia-
tion rules and regulations, medical subjects, psychology, ATC
related topics including; organization and structure of ATC
and international organizations, familiarization with ATC
working positions and tasks, aviation psychology relevant
to ATC, human factors in ATC including TRM, current &
future systems in ATC. Training should include the possibility
to gain some experience in ATC simulation’.
In Europe, initial controller medical assessments are
normally carried out by the National Regulatory Authority
medical examiners appointed to the Authority’s Aero
Medical Section (AMS) or by medical examiners at desig-
nated and approved aeromedical centres (AMC). Renewal
or revalidation medicals can be carried out by designated
and authorized medical examiners (AME). When a control-
ler has satisfied the medical examiner that they have met
the medical standards, they are issued with a medical cer-
tificate which is proof of their fit status. The medical cer-
tificate forms part of the controller’s licence and the licence
is only valid with a valid medical certificate. Under the
European requirements medicals have a periodicity of two
years under the age of 40 and are needed each year there-
after, but the periodicity may vary in other nations. Whilst
the exact content of the renewal medicals may vary from
nation to nation depending on the controllers’ age, the ini-
tial medical is generally similar. It normally consists of a
17/11/2015 16:23
 702  Air traffic control
physical examination by the authorized physician, detailed
eyesight assessment including colour vision, a resting ECG,
audiogram, spirometry, urine testing and a blood test. Any
medical condition with a significant risk of sudden inca-
pacitation, which significantly interferes with the ability to
assimilate visual and auditory information, and which can
impact on spatial awareness, communication, processing of
information and problem solving may be incompatible with
holding a medical certificate.
Once assessed as fit it is the controllers’ responsibility to
maintain his medical validity and to notify the appropriate
authority if they are aware of any condition or treatment
that is likely to cause a decrease in medical fitness that may
impact on flight safety. If a controller develops a medical
condition or commences treatment that may be incompat-
ible with the standards required to hold a medical certificate
they must notify the National Regulatory Authority or an
AME. If the condition or treatment is likely to be of a tem-
porary nature it may be necessary to make the controller
temporary unfit (TU) for operational duties and procedures
should be in place to ensure the controller is formally noti-
fied that they can no longer exercise the privileges of their
licence. As the acceptable level of risk for medical problems
impacting on the controllers’ ability to perform the role
safely is lower than other non-regulated work purposes
then the TU controller may be fit to perform other duties
that do not involve the requirement to hold a valid medical.
Should the condition change or improve to an extent where
they may be considered as being fit to perform their duties, a
controller must have their medical reinstated by the regula-
tory authority before they can return to operational duties,
and again a formal procedure should be in place to notify
the controller that they are once again able to exercise the
privileges of their licence.
Stress
It is widely thought by the public, occupational physicians
and Hollywood film-makers that air traffic control is one
of the most stressful occupations. However, whilst it is gen-
erally accepted that there can be periods of intense activ-
ity requiring high levels of attention, concentration and
problem solving, with controllers experiencing ‘an adrena-
line rush’, a study by Farmer et al. (1990) suggests that the
role of an air traffic controller is not inherently stressful.
Controllers are specially selected, carefully regulated and
very well trained to handle the situations they deal with day
to day. Working practices are in place to prevent overload.
Any particularly stressful events tend to be short lived and
are usually resolved successfully. Controllers often state that
once they unplug their headsets the stress goes – they rarely
take it home with them.
Of course controllers can and do suffer from stress but
it is very unusual for the stressors to be limited to factors
within the operational duties. Controllers are exposed to
similar stressors as the general population in terms of per-
sonal, family, financial and other such factors. As stress can
K17577_C046.indd 702
limit a controllers’ capacity to handle complex information
and thus impact on their ability to perform their role well, it
is essential that controllers, their supervisors and managers
are taught to recognize the signs of stress and what to do if
they feel a problem is developing. Warning signs may be irri-
tability, sleeplessness (especially early waking), tiredness, a
lack of energy, poor decision making, poor concentration,
overeating or poor appetite, and an increase in smoking or
alcohol consumption. Employing organizations should have
a procedure in place to detect and help deal with the early
signs of stress. This may need to include an education pro-
gramme and a process for individuals to discuss their con-
cerns and be given help, support and treatment options as
necessary. Part of any education programme must include
the acceptance of stress as a real and legitimate concern and
to give individuals the confidence to deal with stress rather
than attributing it to a character flaw and hence driving it
underground without addressing the issues.
Employing organizations should also be aware of the
potential impact their actions may have on individuals, for
example in how they manage change programmes.
Any major work change such as a physical move of work
location or major change in working practices should be
carefully managed to lessen the impact on the effected indi-
viduals. Time and effort spent on how change is managed
carefully is never wasted.
If a controller feels their capacity to cope at work has
been compromised, then it may be necessary to temporar-
ily suspend their licence to give them time to address their
issues without having to cope with any additional work
pressure. Often just vocalizing their concerns to an AME
may help, but there may be a role for counselling or other
support. Controllers are often reluctant to consider medica-
tion such as SSRIs as these may impact on their ability to
control. Many controllers feel that work is their relief from
stress and work may be the one area in which they are in
control. However, if there is any suggestion that their abil-
ity to work may be compromised then they should be made
TU, until matters begin to resolve and a fit assessment can
be considered.
Fatigue
The potential for fatigue to be a major risk factor to flight
safety in aviation is well recognized. Despite controllers not
being exposed to long haul flights and changes of time zones
as are pilots, controllers may have to work changing shift
patterns and periods of intense mental workload. A com-
prehensive overview of the impact of fatigue in ATC has
been carried out by Mitchell et al. (2010).
Fatigue can be thought of as a subjective feeling of wea-
riness that can result from prolonged physical or mental
workload. Whilst fatigue can occur in any profession, in
air traffic control where human decision making plays such
a vital role it is a particularly important issue as increas-
ing fatigue can lead to impaired performance which can
impact on flight safety. It is therefore essential that air traffic
17/11/2015 16:23

controllers are aware of the potential risks and what can be
done to manage these risks. There are three types of fatigue
that may impact on air traffic controllers.
MENTAL FATIGUE
Mental fatigue can be defined as a subjective feeling brought
about by prolonged mental activity which results in a reduced
capacity for further work and poor accomplishment. The
signs and symptoms of mental fatigue may include feelings
of tiredness and sleepiness, a slowing or inability to make
decisions, poor judgement and carelessness, reduced abil-
ity to detect errors, yawning, irritability and moodiness. All
these can lead to serious risks in the operational role of the
controller with slower decisions being made, getting behind
on tasks, tunnelling of attention and failing to see the whole
picture, poor judgement and an inability to spot errors in
their own or others’ work.
PHYSICAL FATIGUE
Physical fatigue can be thought of as a temporary loss of
strength or energy and can be caused by intense physical
exercise or by maintaining a fixed posture. The signs and
symptoms of physical fatigue are tired aching muscles, feel-
ings of physical exhaustion and tiredness and the need to sit
or lie down. The risks from physical fatigue are poor con-
centration and distraction caused by the need to rest.
VISUAL FATIGUE
Visual fatigue or asthenopia is a condition which arises
from excessive demands on visual function. Rapid and pre-
cise eye movements make heavy demands on visual percep-
tion and will increase visual fatigue. Signs and symptoms of
visual fatigue are pain, irritation of a burning type sensa-
tion in or around the eye, reddening and watering of the
eyes, difficulty focussing, diplopia and headaches. The risks
from visual fatigue may include reduced speed of percep-
tion, poor vigilance and a tendency to misread things and
poor hand eye coordination.
ORGANIZATIONAL COUNTERMEASURES FOR
FATIGUE
Fatigue can be a very real problem for air traffic controllers
as demonstrated by the news stories of 2011 in the US of con-
trollers being asleep whilst on duty. Controllers and their
employing organizations have a duty to ensure that fatigue
levels are monitored and managed appropriately. Education
and communication are key components of addressing
fatigue issues. As well as ensuring that controller work pat-
terns conform to accepted guidelines for down time and
rest breaks, the employer can put in place other measures
to lessen fatigue. Consideration should be given to optimiz-
ing the workplace to increase alertness by means such as
adjusting lighting levels to ensure the operating areas are
reasonably bright, but not so bright as to induce problems
with glare and ensuring the ambient temperature and ven-
tilation are suitable and not too warm or stuffy. Supervisors
should try to ensure that controllers are given some variety
K17577_C046.indd 703
Medical aspects of air traffic control  703
in their tasks and should check for signs of fatigue in their
staff. They should also ensure that breaks are taken and used
appropriately for rest.
INDIVIDUAL COUNTERMEASURES FOR FATIGUE
Individual controllers should be made aware of the signs
and symptoms of fatigue and how these may impact on
their ability to perform their role safely. They should also
be advised how to lessen the impact of factors that may
lead to fatigue. Such measures may be considered under the
following headings.
General countermeasures
Controllers should attempt to adapt their life style to take
into account work patterns, especially shift and night work.
They should ensure adequate time to plan their work activi-
ties and how these may impact on life away from work.
They should try and maintain a healthy diet, remain well
hydrated and take regular exercise. They should make
friends and family aware of their work patterns to ensure
a compromise can be achieved around social events if at all
possible. Controllers should make good use of their time
away from work to rest and recover and if they have second-
ary employment should ensure this does not impact on their
primary role.
Sleep countermeasures
Controllers should be realistic in their sleep demands; most
people require about 7–8 hours sleep in a 24 hour period.
Controllers should be made aware of good sleep hygiene
practices. They should try and sleep in a quiet, cool, dark
room that is clean and uncluttered, without TVs or comput-
ers. Caffeine and alcohol are best avoided within 4–6 hours
of sleep and exercise or a heavy meal should be avoided
within 2–3  hours of sleep. A relaxing pre-sleep routine
should be developed to prevent becoming engrossed in an
activity that may lead to pre-sleep time arousal. If difficulty
is found with dropping off to sleep for more than 30 min-
utes then it may be advisable to get up and engage in a non-
stimulating activity such as reading a (non-exciting) book
or doing jigsaw puzzles. In such cases as soon as the indi-
vidual begins to feel sleepy they should return to bed and
try to drop off to sleep again.
Utilizing rest-breaks at work
Controllers should make good use of the compulsory or any
other rest breaks in the working day as these are designed to
allow recovery from the mental, visual and physical fatigue
that may result from their role. As controllers are usually
involved with screen work they should not use their breaks
for work related non-operational tasks. Indeed even computer
based tasks for personal use such as surfing the net or checking
emails are best avoided. Ideally breaks should allow control-
lers to engage in conversation with colleagues, or other restful
activities such as reading, listening to music or taking a short
stroll. It is particularly important to avoid computer based
activities in the last 10–15 minutes of a rest period.
17/11/2015 16:23
 704  Air traffic control
Visual countermeasures
It is vital that controllers have regular eye examinations
to ensure that any correction, if required, is optimized for
their role. Staring at screens for extended periods of time
is known to reduce the blink rate and cause eye strain.
Controllers are advised to make sure they spend time away
from screens in their breaks and make an effort to spend
time looking at distant objects when it is safe to do so.
Medication in air traffic control
To ensure flight safety is not compromised, controllers must
not provide an operational air traffic control service whilst
under the possible influence of any psychoactive substances.
Most nations will have specific legislation prohibiting control-
lers from working in a medically certified role whilst under the
influence of alcohol or illegal drugs, but pharmacological sub-
stances whether prescribed or bought over the counter may
also have a very significant effect on controller performance
and have a detrimental impact on flight safety. If controllers
have any doubt about their ability to work whilst taking medi-
cation, or if the medication may impact on their ability to work
safely, they must seek advice from an AME, an Aero Medical
Centre, or the National Regulatory Authority. There may be
subtle differences between nations in the groups of medica-
tions deemed safe for controllers to take whilst delivering an
air traffic control service. AMEs who look after controllers
must make themselves fully aware of the national require-
ments via their National Regulatory Authority.
All controllers should be personally aware of their respon-
sibilities with regard to maintaining their fitness to control.
If they are prescribed medication or decide to take over the
counter medication, they must be sure that it will not be
likely to cause incapacitation or impairment. Often control-
lers request a list of medications that may impair their abil-
ity to work. It is important that they realize that there is no
definitive list as new medications may not yet be listed and
cannot be assumed therefore to be safe. Medication may
have differing effects at differing doses, and often the condi-
tion leading to the need to prescribe may have an impact
on ability to work over and above that of the medication.
In general, simple analgesia such as paracetamol, aspirin
or non-steroidal anti-inflammatory agents are usually safe,
but if there is any doubt controllers must seek the advice of
an AME.
To ensure controllers are aware of their responsibilities
with regard to medication it is recommended that student
controllers receive instruction in this area and that employ-
ing organizations have an on-going education programme
to reinforce this information. National regulators may
choose to have reminders of these responsibilities printed
on or associated with the medical certificate.
Age, cognitive ability and controlling
With the increase in life expectancy being seen in
many countries and many nations now adopting anti
K17577_C046.indd 704
age-discrimination policies, it is possible that controllers in
such nations may choose to work until an older age or be
significantly older when commencing air traffic controller
training. Many nations have a maximum age cut off point at
which a candidate can commence controller training. There
is wide agreement that cognitive ability for certain tasks
declines with age. Studies in the aviation sector have shown
a decreased accuracy of aviation tasks with age (Taylor et al.
2005); whilst studies have shown a negative relationship
between the age of controllers and both training success
and ratings of job performance (Heil 1999), there is also evi-
dence that controllers can use their experience on the job
to compensate for any age-related cognitive decline (Numes
and Kramer 2009). Where entry into controller training
age limits do not apply, it is important that selection tests
are appropriate and as realistic to the task of controlling as
possible to ensure that only suitable candidates are accepted
into training based on predicted ability.
It must also be remembered that whilst cognitive ability
declines with age, the risk of medical conditions develop-
ing which may lead to an increased chance of incapacitation
increases with age. There is often a requirement for addi-
tional medical investigations, such as the UK’s requirement
for controllers to have a stress ECG once they reach 65 years
of age and four-yearly thereafter (CAA 2009). In reality
the intense nature of the controllers’ role makes it very
unusual for them to work past 65  years of age, especially
in very busy airports or on busy sectors in area or terminal
control centres.
Vision
A vast amount of information required to perform the role
of controller is received visually. Controllers may work in
a range of very challenging visual environments, with a
requirement to look in detail at screens for extended peri-
ods of time. These screens may be at a range of focal lengths
depending on the role and local ergonomic set up. It is also
common practice for controllers acting as instructors or
examiners to have to stand behind students, but they still
need to be able to see the screens that the student is working
from. This adds an unusual additional focal length which
may not be ideal for looking at a screen. The background
lighting conditions in VCRs may change from very bright
on sunny days to low lighting levels at night. Night duties
may also require controllers to look for aircraft movements
around the airfield against a background of considerable
light pollution.
It is for all these reasons that there are regulatory visual
standards for controllers and vision that falls below these
standards is incompatible with holding a valid medical.
Detailed eye examinations are required and correction
may be worn if acceptable but national standards may vary
in terms of the amount and type of correction permitted.
AMEs must be familiar with acceptable standards. Often
controllers with visual acuities within the regulatory stan-
dards may choose to wear correction to ensure that their
17/11/2015 16:23

vision is optimized for their specific role. Controllers should
be advised to take measurements of the various eye to screen
distances at their work places to help enable opticians or
optometrists to decide on the best correction.
Controllers are expected to have normal colour vision
and studies have shown that colour defective vision leads
to errors in air traffic control tasks (Mertens and Milburn
1996). With the greater use of computer screens for data
display, and the greater use of colours in displays, it is essen-
tial that regulators are aware of new technologies being
deployed within the air traffic control industry to ensure
that the standards set for colour vision are matched to the
demands of the role.
Hearing standards
As well as visual input, controllers rely heavily on audi-
tory information and normal hearing is required to be able
to perform their tasks successfully. Radio transmissions
between the ground and aircraft are usually conducted via
headsets worn by the controllers. It is essential that control-
lers have good hearing in the speech frequencies and regu-
lators set standards for hearing loss usually in the ranges of
500, 1000, 2000 and 3000 Hz. Hearing must be good bilater-
ally as it is common practice for transmissions from aircraft
to be channelled into one side of the headset and telephone
and other voice communications to be channelled into the
other. Alternatively, controllers often work with one side of
the headset over the ear to receive the radio transmissions,
leaving the other ear open to receive telephone instructions
or to listen to colleagues and supervisors.
Some national regulators will allow some flexibility
in hearing standards. A functional hearing test may be
required to assess if, despite falling outside limits from an
audiogram, the controller is still able to hear all instruc-
tions issued to them in the course of their normal duties.
If all instructions are heard accurately and the decrease in
hearing does not impact on their ability to perform their
duties they may still be able to be assessed as fit and main-
tain a medical certificate. Clearly if controllers are miss-
ing vital instructions they must be assessed as unfit. Some
regulatory authorities are now permitting controllers to
work with digital hearing aids. Each case must be care-
fully investigated and functional hearing tests performed to
ensure that the hearing aid allows the controller to hear all
instructions and that it does not have any adverse effect on
safety. Any hearing aids that are being considered for use
in the operational environment should be checked by air
traffic engineers to ensure there is no interference with any
operational equipment.
Shiftwork
As the provision of an air traffic control service can be a
24 hours a day, 365 days a year commitment, it is not unsur-
prising that controllers are often shift workers. Depending
on regulations and on the employing organizations work
K17577_C046.indd 705
Medical aspects of air traffic control  705
patterns may vary hugely. Some controllers way work basic
office type hours, some work individual patterns, others
work a wide range of differing patterns whilst often con-
trollers form part of a ‘watch’ where all the watch members
work the same repeating patterns. As such it is common for
controllers to be shift workers and to be expected to work
night shifts. The negative effects of shift work and night
shifts are well recognized (Harrington 2001). Fatigue issues
have already been discussed. It appears that controllers
may find it more difficult to recover from night duties with
increasing age. Employing organizations should try and
ensure that the operational demands for the provision of a
service are managed in a way to cause as little disruption to
controllers as possible. However, whilst the negative effects
of shift work are often quoted, it must be remembered that
controllers often enjoy shift work, allowing them more days
off and to be away from work when most of the rest of the
working population is at work.
Effects of future developments in air traffic
control
With the ever increasing sophistication of technology and
increasing computer power, the role technology plays in
air traffic control will only increase. At present technology
presents controllers with information and they use their
skills and knowledge to predict possible losses of separa-
tion and to give instructions to aircraft as interventions
to provide solutions to allow aircraft to remain separated.
New systems are already in place in some nations where the
technology is now predicting possible losses of separation,
allowing controllers to check the effectiveness of their solu-
tions, thus allowing the controller to choose the best solu-
tion. This all serves to give the controllers extra capacity
and to handle more traffic. However there are concerns as
continued development and reliance on technology may be
seen as deskilling controllers and changing their role from
being one of intervention to one of monitoring. It is pos-
sible that this shift of emphasis may lead to a different skill
set requirement and may require new tests and recruitment
checks to ensure appropriate skills matching to the new
type of roles. As previously discussed the new technologies
represent considerable change and current controllers may
well have change averse personalities. Changes in equip-
ment and working practices may be resisted, especially by
older controllers who may find it difficult to change their
way of working. It is vital that employing organizations
engage with their controllers early on in the change process
to allow for a smooth transition of technologies and mini-
mum stressful impact on the controllers.
Future medical regulation of controllers
Most of the current medical standards applied to control-
lers, such as the 1 per cent rule, have their origin in the pilot
community. There is a growing realization that these stan-
dards may not be appropriate for controllers. The 1 per cent
17/11/2015 16:23
 706  Air traffic control
rule came about following Chapman’s work in 1984  and
applies to the acceptable level of risk in pilots that a con-
dition may lead to sudden incapacitation (Chapman 1984).
Similar standards apply to controllers, despite the work
environment being very different. Although controllers too
have high workloads, periods of intense activity and are
subject to fatigue, there are many instances where another
controller could take over from them if they were to col-
lapse or feel themselves becoming unwell whilst on duty.
Research by Girgis et  al. (2012) has shown that in certain
ATC environments such as centres, aviation safety may not
necessarily be compromised by the sudden incapacitation
of a controller, if another controller can take over within
120  seconds. This could mean that medical standards for
controllers may be too rigid resulting in some controllers
with certain medical conditions being excluded from opera-
tional duties due to safety concerns when the evidence may
not support this. It is an area for further research as control-
lers are expensive to train and should not be excluded unless
their health is a real risk to aviation safety.
SUMMARY
●● For AMEs to be able to offer air traffic controllers
a suitable level of medical support they must have
an understanding of the basic principles of air
traffic control including the work environments
in which the controllers operate.
●● Regulatory medical standards that apply to con-
trollers may have subtle variations compared to
pilots and may vary from nation to nation. AMEs
must familiarize themselves with the relevant
national requirements.
●● Fatigue is a major issue affecting controllers
and AMEs must be aware of the risk and of
fatigue countermeasures.
●● Increasing sophistication of computers will lead to
an increasing role of technology in controller deci-
sion making. The skills required in future control-
lers may be different from those required today.
●● Regulatory medical standards that apply to con-
trollers may need revision in the future to take
account of the changing work role and evidence
based assessment of risks to flight safety.
REFERENCES
CAA Guidance UK. European Class 3 Medical Certification
of Air Traffic Controllers. September 2009.
CAA Safety Regulation Group. CAP 670 Air Traffic Service
Safety Requirements. April 2013.
Chapman P. The consequences of in-flight incapacitation
in civil aviation. Aviation, Space, and Environmental
Medicine 1984; 55(6) 497–500.
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Eurocontrol. Available from: http://www.eurocontrol.
int/sites/default/files/content/documents/nm/safety/
requirements-for-european-class-3-medical-certifica-
tion-of-atcos.pdf.
Farmer EW, Belyavin AJ, Berry A, et al. Stress in ATC
1: Survey of NATS Controllers. Report no. 689.
Farnborough: RAF Institute of Aviation Medicine,
1990.
Girgis MMR , Mitchel SJ, Chase V. ATCO Medical
Standards – Deriving Incapacitation Standards from
Simulation Data and Modelling. Paper presented at
ASMA Annual Scientific Meeting, Atlanta, May 2012.
Harrington JM. Health effects of shift work and extended
hours of work. Occupational and Environmental
Medicine 2001; 58: 68–72.
Heil MC. Air Traffic Control Specialist Age and Cognitive
Test Performance. DOT/FAA/AM-99/23. Washington,
DC: Office of Aviation Medicine, 1999.
*ICAO. Air Traffic Services. Annex 11 to the Convention on
International Civil Aviation, 13th edn. Montreal: ICAO,
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Kanki B, Helmreich R, Anca J (eds). Crew Resource
Management, 2nd edn. Oxford: Academic Press, 2010:
ix–xi.
Manual of Civil Aviation Medicine – ICAO. Doc 8984
AN/895 3rd edn. 2012.
Member States ICAO. Available from: http://www.icao.
int/MemberStates/Member%20States.English.pdf.
Accessed 04 Dec 2013.
Mertens HW, Milburn N J. Performance of color-depen-
dant air traffic control tasks as a function of color
vision deficiency. Aviation, Space, and Environmental
Medicine. 1996; 67(10): 919–27.
Mitchell LS, Megan A, Kaminski GM, et al. Human
Performance and Fatigue Research for Controllers.
Mitre Technical Report MTR 100316. Bedford, MA: The
Mitre Corporation, 2010.
Mitchell SJ, Evans AD. Flight safety and medical inca-
pacitation risk of airline pilots. Aviation, Space, and
Environmental Medicine 2004; 75(3): 260–8.
Numes A, Kramer AF. Experience-based mitigation of
age-related performance declines: evidence from air
traffic control. Journal of Experimental Psychology:
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Taylor JL, O’Hara R, Mumenthaler MS, et al. Cognitive
ability, expertise, and age differences in following
air traffic control instructions. Psychology and Aging
2005; 20(1): 117–33.
Wolding M, Van Damme D, Patterson I, Henrigues P. Team
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* Requirements for European Class 3 Medical Certification of Air
Traffic Controllers.
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Errors and accidents
SARAH HARRIS
Introduction 707
The route to an accident 707
Understanding ‘error’ 710
Investigating error 714
Operational accidents – special cases 718
INTRODUCTION
Although there have been many developments in aviation,
such as improvements to technology, regulations, policies
and training, aviation continues to operate with inherent
risks and hazards, including the risk of human error. This
is often due to:
1. Accepted risks and hazards.
a. Cost. It would be too costly to eliminate them,
accounting for the initial mitigation and mainte-
nance of that mitigation.
b. Performance. It would be operationally ineffective
to eliminate them. For example, eliminating the risk
of a mid-air collision may mean operating with only
one aircraft in an airspace sector at any one time.
c. Feasibility. It may not be possible to eliminate them.
For example, exiting an aircraft on the evacuation
slide may always carry a risk of injury.
Aviation organizations therefore attempt to mitigate risk
levels but within cost, performance and feasibility limita-
tions. Other variables will also play a role, such as domestic
and international regulations, task objectives, time at risk,
the likelihood of the hazard and the potential severity of
any consequences.
2. Uncontrolled risks and hazards.
a. Mitigation error. The risk of certain hazards may
have been miscalculated and, as a result, mitigation
is absent or insufficient.
K17577_C047.indd 707
47
Reaction, resilience and prevention 720
The role of aviation medicine 720
References 722
Further reading 722
b. Maintenance of mitigations. Correctly implemented
mitigations may not be maintained. For example,
there may be deviations from training standards or
procedures over time.
c. Changes to the operational baseline. Developments in
the organization, such as changes to operating require-
ments, personnel, equipment or environments, can
increase the risk of existing hazards or introduce new
ones. Such changes can be overlooked or there can be a
delay in the organization’s response to such changes.
Consequently, there are accepted and uncontrolled risks in
most aviation activities. This chapter addresses this realistic
hazard/risk residue and how it may contribute to accidents.
It also discusses special aviation cases, resilience and pre-
vention and the role of aviation medicine.
THE ROUTE TO AN ACCIDENT
As a result of the hazard/risk residue, accidents still occur.
However, there has been a move away from focusing on oper-
ator error in such accidents to a more realistic and holistic
view of the accident sequence. This trend towards consider-
ing all aspects of the accident sequence has produced many
theoretical models. How you consider the accident sequence
will depend on which of these models you use. Three models
have been used here to provide a broad understanding.
1. Swiss cheese model – Reason (1997). One of the most
influential developments in a holistic view of an accident
sequence came from Reason’s Swiss cheese model. In this
707
17/11/2015 16:27
 708  Errors and accidents
model, factors from the organization and supervisory
level (termed latent failures) through to the front-end air-
crew level (termed active failures), may contribute to the
accident sequence. Each level represents a slice of cheese
and each hazard represents a hole in that slice. With each
slice lined up, there is scope for the holes in the cheese
to also line up, creating a clear path to an accident. This
model is illustrated in Figure 47.1.
2 . Human factors analysis and classification system
(HFACS) – Wiegman and Shappell (2003). HFACS
was subsequently developed as a more comprehensive
framework for analysing and classifying the human
factors in an accident. HFACS, building on the Swiss
cheese model, classifies factors into organizational influ-
ences, unsafe supervision, preconditions for unsafe acts
(latent failures) and unsafe acts (active failures).
3. Accident route matrix (ARM) – Harris (2011). The UK
Royal Air Force Centre of Aviation Medicine (RAF
CAM) subsequently developed the ARM as a human
factors investigation tool. The ARM builds on the
concepts from (1) and (2) and classifies factors at the
organization, supervisory, task, equipment, environ-
ment and aircrew level as either unsafe conditions or
unsafe actions. As the ARM was developed as an avia-
tion investigation tool, it has a typical aviation timeline
and hazard management sequence as follows:
Figure 47.1  Reason’s (1997) Swiss cheese model.
Figure 47.2  Typical aviation timeline.
K17577_C047.indd 708
a. Aviation timeline. The first part of the timeline
includes all conditions and actions that occurred
prior to the day of the accident. These are termed
entry conditions. The second part refers to all
conditions and actions that occurred on the day
of the accident. This includes the initial readi-
ness stage (from the start of the aircrew’s shift
through to take-off), the inflight stage and even-
tually the post-flight stage. It is within the latter
two stages that the accident typically occurs. A
modified timeline, taken from Harris (2011) and
Revell, Harris and Cutler (2014), is illustrated in
Figure 47.2.
b. Hazard management sequence. This sequence
breaks down the accident into four typical aviation
accident stages – the hazard on-set itself and the
subsequent recovery, escape and survival responses.
The latter two stages may occur in any order or
simultaneously. The hazard management sequence
is preceded by a pre-hazard stage and followed by
a rescue stage, to complete the accident sequence.
It is important to consider all these stages in an
accident sequence.
A modified example of the hazard management sequence,
taken from Harris (2011), is given in Figure 47.3.
17/11/2015 16:27
 The route to an accident  709

Hazard Recovery Hazard Escape

identification/ initiation irrecoverable initiation
diagnosis

Pre-hazard Hazard Recovery Escape Survival Rescue

events onset response response response

Recognition
of situation?

Figure 47.3  Hazard management sequence.

Modified from Harris (2011).

The ARM maps conditions and actions onto the avia-
tion timeline and hazard management sequence to create
an accident matrix. This matrix helps understand how and
when each factor contributed to the accident. A modified
example of the matrix, taken from Harris (2011), is given
in Figure  47.4. Examples of applying the matrix to actual
air accidents are provided in the Investigating error section.
This matrix illustrates that an accident can start to develop
as far back as the entry conditions. This may be years or days
prior to the actual event. It may also start within one or many
of the conditions or actions listed down the left-hand side. If
any of the entry conditions are unsafe and there are insuf-
ficient defences to capture such hazards, the effect may go on
to influence the readiness stage. If any of the readiness condi-
tions are unsafe and there are insufficient defences, the effect
may go on to influence the inflight stage. This means the crew
could take off with an accident sequence already in progress.
If a hazard on-set then occurs in flight, the crew will have to
rely on a timely and effective recovery response. If this does
not occur, the crew will then have to rely on timely and effec-
tive escape and survival responses. If this does not occur, the
crew may not escape or survive the accident without injury.

Climate, policy, Planned for operational On-task changes to Potential point

ORG

processes, procurement requirements task requirements of impact/

accident

Culture, training, currency, Authorisation and

Superv

Flight/formation captaincy
supervision, procedures out-brief

Typical number/type of Planned for tasks and

Task

Actual tasks and margin for error

tasks, margin for error margin for error

Typical aircraft, Accepted equipment

Equip

Actual equipment serviceability

equipment, clothing and serviceability

Typical conditions, Planned for conditions Actual internal and external environmental
Enviro

perceived threat level and threat level conditions and perceived threat level

Typical performance,
Aircrew
actions

Planning, briefing, Actual actions and unsafe actions (errors)

behaviours, learning, rest,
pre-flight checks
exercise, eating, drinking
Hazard Recovery Escape Survival
onset
response response response
conditions
Aircrew

Typical mental and social

On-the day task, crew
readiness, personal Actual unsafe aircrew conditions
and personal readiness
conditions

Entry conditions Readiness In-flight Post-flight

Figure 47.4  Accident route matrix (ARM).

Modified from Harris (2011).

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 710  Errors and accidents
Inadequate defences
Potential
Hazard
accident onset
trajectory
Entry conditions Readiness
Figure 47.5  Inadequate defences along the aviation timeline.
Figure  47.5  illustrates how the accident trajectory can
progress if defences are inadequate at the various points
along the aviation timeline. However, an accident may take
many different forms. It may only start during the readiness
stage, it may occur during takeoff or it may not occur until
landing or shutting down.
RAF CAM currently uses the ARM for UK military
human factors air accident investigations, where it is applied
to each relevant group of aviation personnel as required.
RAF CAM also uses the ARM as an accident prevention
tool, which is discussed further in the Reaction, resilience
and prevention section.
As the ARM includes typical aviation conditions and
actions, as well as a typical timeline and hazard manage-
ment sequence, it will be used as a reference model for
the rest of this chapter. However, the Energy Institute,
London (2008) Guidance on Investigating and Analysing
Human and Organizational Factors Aspects of Incidents
and Accidents provides a comprehensive overview of other
human error accident analysis tools.
UNDERSTANDING ‘ERROR’
Aircrew error traditionally refers to the unsafe action that
either initiated the hazard on-set or prevented the recov-
ery from that hazard. Consequently, aircrew error is often
thought to have ‘caused’ the accident. However, Figures
47.4 and 47.5 illustrate that an accident route encompasses
many more factors and stages other than these discrete
actions. Should an aeromedical doctor be asked to assist in
an investigation, they will need to be cognisant of these other
factors. This section addresses these factors in more detail.
What factors are important?
In any accident sequence there are three types of factors:
1. Unsafe factors. This includes any conditions or actions
that increased the likelihood of the hazard on-set or
decreased the success likelihood of the recovery, egress
or survival responses.
2. Potential factors. This includes any conditions or actions
that could have contributed to, or increased the severity
of, the accident sequence.
3. Safe factors (defences). This includes any conditions or
actions that decreased the severity of the accident or
K17577_C047.indd 710
Unsuccessful Unsuccessful Risk to
recovery escape survival
In-flight Post-flight
increased the success likelihood of the recovery, egress
or survival responses.
In reality, it is often the unsafe factors in (1) that are the
point of focus. For this reason, the rest of this chapter will
refer to unsafe factors for a matter of simplicity. However,
the aeromedical doctor may wish to consider all three types
of factors for aeromedical related events, should time and
finances permit.
Understanding conditions and actions
Generally, it is thought that unsafe actions occur as a result
of preceding unsafe conditions. However, it is over simplis-
tic to assume that an accident chain of events would equate
to an unsafe condition > unsafe action > accident. In reality,
one or several unsafe conditions may lead to one or several
unsafe actions, which in turn may create further unsafe con-
ditions and further unsafe actions. Further, there is likely
to be a complex interaction between each unsafe condition
and each unsafe action, which may occur over several weeks
prior to the accident and involve many different aviation
personnel. The ARM in Figure 47.4 represents this complex-
ity by using arrows vertically and then horizontally.
Unsafe conditions
Unsafe conditions include any condition that had the poten-
tial to negatively affect performance or survivability. This
section briefly describes some of the most likely unsafe con-
ditions as illustrated in Figure 47.4.
1. Organization level. Unsafe conditions at the organi-
zation level may include a climate that places more
emphasis on performance than safety, a culture that
results in fear of reprisal, processes that are hard to
achieve or procurement of equipment or selection of
personnel that are not fit for purpose.
2. Supervision/local level. Due to variations in aircraft,
aircraft role or airfield conditions, individual local units
may be influenced by specific operational, training, pro-
cedural or supervision requirements. This means each
unit within an organization may experience different
unsafe conditions. At the entry conditions stage, unsafe
local conditions may include insufficient on-the-job
training, currency or supervision, inconsistent or hard
17/11/2015 16:27

to follow local procedures or a local risk-taking culture.
At the readiness and in-flight stages this may include
insufficient flight authorisation and captaincy.
3. Task level. Unsafe tasking may include too many or too
few tasks, tasks with an unsafe margin for error or tasks
that were inappropriately matched to the personnel
or equipment.
4. Equipment level. This may include a lack of equipment
or confusing, unusable or unserviceable equipment or
protective clothing.
5. Environment level. This may include poor weather,
high-risk terrain, a perceived threat to life, obstructions,
loose articles, insufficient space or lighting or excessive
heat, cold, noise or vibration.
6. Aircrew level. The ARM in Figure 47.4 represents three
aircrew condition categories:
a. Mental readiness. Mental readiness is acquired
through training and experience at the entry condi-
tions stage, through planning, briefing and check-
ing activities at the readiness stage and through
on-task knowledge and situation awareness at the
inflight stage. Unsafe mental readiness is having
insufficient or incorrect knowledge or skill to per-
form the required tasks correctly and on time, with
the required equipment, in the required environ-
ment, with other required personnel.
b. Social readiness. This represents the working
relationships a pilot may have with other personnel,
including the quality of communication, teamwork
and leadership. Unsafe social readiness may include
personality clashes, authoritarian leadership or
poor communication.
c. Personal conditions:
⚫⚫ Physical conditions. This includes any pre-exist-
ing injuries, disabilities or size, weight, height,
vision, hearing or fitness limitations at the entry
conditions stage, any on-the-day injuries at the
readiness stage and any accident-related injuries
in-flight or post-flight.
Note: Accident-related injuries such as burns
or head, eye and impact injuries could provide
valuable information on the accident environ-
ment, the performance of any survivability
equipment and the survivability performance of
the aircrew, such as whether they were wearing
a helmet or restraint system.
⚫⚫ Physiological conditions. This includes any ill-
ness, fatigue, poor nutrition or hydration, use
of medication, drugs or alcohol or any accident-
related conditions such as disorientation,
hypoxia or thermal stress.
●● Psychological conditions. At the entry condi-
tions stage this may include insufficient psy-
chological readiness for flight and survivability,
unsafe attitudes, motivations or expectations,
over-familiarity and complacency, long-term
stress or overload or poor general well-being.
K17577_C047.indd 711
Understanding ‘error’  711
Specific inflight conditions may include exces-
sive workload or stress. As stress can reduce
working memory performance and workload
can impair the pilot’s ability to hear auditory
messages or alarms (Wickens and Hollands
1999), both may specifically affect the pilot’s
ability to identify the hazard and perform a
successful recovery response. Specific accident-
related conditions may also include panic and
paralysis, denial and inactivity (not taking any
action), over-activity (doing everything other
than the correct action), low morale or apathy
(Leach 1994).
Unsafe conditions at (1) and (2) are likely to affect the
conditions in (3) to (5). Unsafe conditions at (1) to (5) may
in turn affect the aircrew conditions in (6). For example, an
unsafe operating culture may encourage risk-taking, unsafe
tasking may encourage complacency, high workload, stress
or fatigue, unsafe equipment or clothing may encourage
incorrect mental models, workarounds or a lack of use and
an unsafe environment may reduce visibility, audibility and
physical reach and increase conditions such as workload,
stress, fatigue, thermal stress, noise-induced hearing loss
or vibration-related vision and motor control impairments.
Unsafe aircrew conditions at (6) may then go on to affect
aircrew actions.
Unsafe actions
There are many different technical ways of describing
human error. How you view and analyse error may depend
on which of these descriptions you choose to use. This sec-
tion presents error according to some of the most commonly
used technical terms. However, for ease of detecting and
understanding a potential error in an accident sequence,
this section also presents error based on a simplistic five-
step performance sequence.
1. Technical terms. Reason (1997) and Reason (2008) clas-
sifies errors into skill, rule and knowledge-based errors
and violations. These are now common terms used
in investigations.
a. Skill-based errors – slips and lapses. Once a practised
task is learned and mastered, the pilot can perform
it automatically without much conscious effort.
However, although skilled tasks eventually become
‘automatic’, they still require periodic monitoring
as they remain vulnerable to error. If the individual
does not periodically monitor their skilled actions,
slips and lapses may occur. Slips are when the pilot
intends to perform the correct action but due to
distraction, strong habit intrusions or similarities
with other contexts or tasks, they actually execute
another. Slips are usually considered attention-based
errors. Lapses are when the pilot forgets to perform a
planned action due to interruptions or incorrect use
17/11/2015 16:27
 712  Errors and accidents

of priming cues such as checklists. Lapses are usually
considered memory-based errors.
b. Rule-based mistakes. Rule-based performance may
be performed automatically or with some conscious
effort. It relies on pre-learned if/then rules and is
used to supplement the pilot’s skills in (a). Rule-
based mistakes may occur due to insufficient train-
ing and currency, inappropriate procedures, poor
context cues that may initiate the wrong if-then rule
or poor habits and workarounds that result in the
pilot applying unsafe rules.
c. Knowledge-based mistakes. Knowledge-based
performance has a high dependency on working
memory and attention and for this reason, it is often
reserved for when the pilot’s skills in (a) and rule
use in (b) are no longer sufficient. As knowledge-
based performance relies so heavily on working
memory and attention, knowledge-based mistakes
occur when there is a breakdown in these resources,
such as loss of concentration or failure to retain or
update scenario information.
d. Violations. Violations are intentional deviations
from regulations or procedures. Violations can
be routine, where they are part of the operating
norm, or exceptional, where they are unique and
not generally accepted. Individuals usually commit
violations when the preferred action is quicker or
easier to achieve than the correct one.
Other common terms used in error analysis include:
e. Mode errors. Mode errors occur when the pilot
misunderstands the mode the equipment is in. This
may be due to poor training, poor procedures or
poor user interface, all of which may result in an
incorrect mental model of the system or equipment.
f. Communication errors. Communication errors
may include mishearing air traffic control, failing to
communicate a change of plan or misunderstand-
ing the meaning of an instruction. Communication
errors may occur due to aircrew conditions such as
hearing impairments, social conditions such as poor
teamwork, equipment conditions such as inaudible
or unreadable messages or environment conditions
issues such as background noise.
g. Perceptual errors. Perceptual errors usually include
visual or vestibular errors and illusions. Perceptual
errors may occur due to external factors such as
low visibility or loss of horizon, insufficient train-
ing or aircrew factors such as cognitive processing
or physiological limitations. Perceptual errors are
discussed further in Step 2 in the next section.
h. Decision errors. Decision errors occur when select-
ing a planned course of action. The pilot may use
rules (b) or knowledge (c) to reach a decision.
2. Application in an accident. Table 47.1 includes a simple
five-step performance sequence to illustrate where
errors may occur. Although the sequence is from step
1 to step 5, in reality a performance sequence may occur
Table 47.1  Simple performance sequence with common
potential errors
Performance sequence
What the pilot
was trying to do Potential errors or unsafe events
Step 1. Detect Unaware had to scan information
information or cues
equipment Forgot to scan information cues
status (typical ‘lapse’)
Incorrectly scanned cues (typical
‘slip’)
Tried but could not see, hear or feel
information
Step 2. Perceive/ Cues not acknowledged
recognize status Misperceived cues (typical
of information perceptual error)
Step 3. Did not understand information/
Understand cues
information Misunderstood information/cues
(typical mode error)
Step 4. Decide Wanted to but could not decide
No decision
Incorrect / unsafe decision (typical
decision error)
Step 5. Take Wanted to but could not act
action No action
Forgot to act (typical ‘lapse’)
Incorrect/unsafe action (typical ‘slip’)
Accidental action
in parallel with other sequences, it may be continuous –
restarting at step 1 to monitor actions from step 5 – or it
may only be partially completed.
a. Step 1: Detection
●● Information not scanned. A rule-based mistake
may occur where the pilot is unaware a scan
was required at that time. This may be due
to poor supervision, training or procedures.
A skill-based lapse may also occur, where the
pilot forgets to scan the information, pos-
sibly due to poor currency, interruptions
or distractions.
●● Unsafe scan. Visual scans of the internal (cock-
pit) and external environment require trained
patterns of head and eye movement to miti-
gate the fact that peripheral vision may detect
movement but miss detail; direct line of sight
may detect detail but is relatively narrow; and
workload can tunnel the already narrow field
of view. Further, airframe structures may also
obstruct the field of view. However, the pilot
may unintentionally perform a scan incorrectly
or intentionally perform a modified scan as
part of a violation, both of which may result in
information being missed.

K17577_C047.indd 712 17/11/2015 16:27


Unsuccessful scan. Even with a correct scan,
●●
the pilot may be unable to detect the informa-
tion due to visual, auditory or reach restrictions,
such as obstructions, bulky clothing, unread-
able displays, inaudible sounds or messages or
physical impairments to the eyes, ears or hands.
This is not an error as such but still considered
an unsafe event.
b. Step 2: Perception and recognition. Even if there was
sensory input at step 1, the following may occur:
●● Information not perceived. Examples may
include missing an alarm or the proximity of
another aircraft, even though the alarm was
audible and the pilot was looking right at the
aircraft. These errors may be affected by high
workload, stress, fatigue or interrupted atten-
tion. They may also be influenced by expecta-
tion, such as a pilot failing to perceive an air
proximity threat, as they did not expect it to
be there.
●● Misperception. Examples may include mishear-
ing messages, misreading display parameters
or misperceiving visual and vestibular cues.
Misperception may occur as a result of insuf-
ficient training, visual or vestibular illusions or
pilot experience and expectation, such as a pilot
reading the landing gear as down even when it
was up. Misperception may ultimately result in
the pilot misjudging height, speed, distance, rate
of descent or orientation.
For further information on visual and vestibular errors
the reader should refer to the Optics and vision and Spatial
orientation in flight chapters.
c. Step 3: Understanding. Even if the information was
correctly perceived, the following may occur:
●● Information not understood. Examples may
include seeing a warning or hearing a message
that doesn’t make any sense. This may be due to
insufficient training, currency, inflight readiness
or social factors such as poor leadership and
communication style. For passengers, this may
be due to unclear in-flight emergency instruc-
tions or briefings.
●● Information misunderstood. Examples may
include misunderstanding equipment status
or modes (a mode error), procedures, check-
lists or verbal commands. These errors may
also be due to training, experience, social
factors or the quality of the procedures and
equipment themselves.
Errors in steps 1 to 3 may result in misleading informa-
tion being fed into step 4, such as the pilot identifying a
hazard that did not exist or missing or underestimating a
hazard that did exist.
K17577_C047.indd 713
Understanding ‘error’  713
d. Step 4: Decision. Even if the information was under-
stood, the following may occur:
●● Wanted to but couldn’t decide. There may be
insufficient time to make a decision. This is not an
error, as such, but still considered an unsafe event.
●● No decision. The pilot may find it difficult to
make a decision even if sufficient time was
available. This may be due to cognitive condi-
tions such as trying to use knowledge-based
performance, or accident-related conditions
such as stress, panic or denial (see ‘Aircrew
Psychological conditions’).
●● Unsafe decision. This may be due to incorrect
rule-based or knowledge-based performance,
accident-related conditions such as stress or an
intentional violation due to inappropriate prac-
tices and operating culture.
Errors in step 4  may result in an unsafe plan of action
for step 5.
e. Step 5: Action. Even if a correct decision was made,
the following may occur:
●● Wanted to but could not act. There may be
insufficient time to act or there may be reach
restrictions such as obstructions or bulky
clothing, unserviceable equipment or accident-
related injuries that prevent the action from
occurring. This is not an error, as such, but still
considered an unsafe event.
●● No action. The pilot may fail to act even if suf-
ficient time was available. This may be due to
accident-related conditions such as panic paral-
ysis, inactivity or over-activity (see ‘Aircrew
psychological conditions’).
●● Forgot to act. A skill-based lapse may occur
where the pilot forgets to act, possibly due to
interruptions or distractions. This often occurs
when there is a delay between planning the
action (step 4) and executing the action (step 5).
●● Unsafe action. The pilot may not have sufficient
skill to execute the action correctly, such as
trying to land in hazardous conditions with an
asymmetric engine failure. This is likely to be
due to insufficient training, currency and experi-
ence or inappropriate and unachievable tasking.
Alternatively, the pilot may start the planned
action but a skill-based slip occurs due to atten-
tion interruptions and a different less safe action
is performed instead. The pilot may also intend
to perform a less safe action as part of a violation.
●● Accidental action. The pilot may accidentally
knock a switch or control due to unmonitored
movement, bulky clothing, a lack of space
or switches and controls that protrude, are
unguarded and on route to other switches or
controls that the pilot intended to operate.
17/11/2015 16:27
 714  Errors and accidents

Errors or delays in a performance sequence may not only INVESTIGATING ERROR

initiate a hazard on-set but may also affect hazard identifica-
tion and the quality and timing of any recovery response (see
Figure 47.3). They may even limit a recovery response, forcing
the aircrew to move to escape and survival responses instead.
Note: Although it is usually only the ‘on-the-day’ errors
that are of interest during an accident, errors that occurred
in the entry conditions stage are of equal importance.
Previous typical performance sequences, along with any
corresponding singular or habitual errors, will provide
background information to why the on-the-day conditions
and actions occurred.
If the aeromedical doctor is asked to assist in an investi-
gation they may use any accident analysis model to guide
them. However, many accident analysis models are often
more useful for post-investigation classification. The ARM
may be more useful for investigating as it provides an avia-
tion and accident timeline, which should help organise both
data collection and analysis. This section therefore uses the
ARM to work through two air accident examples to pro-
vide the reader with an understanding of how to approach
investigations.

WORKED EXAMPLE 1: UK SERVICE INQUIRY (SI) – PUMA 2011 (SERVICE INQUIRY

GOV.UK, 2013)
Shortly after takeoff a Puma’s main rotor gear box (MRGB) cowling panel detached in flight, impacting the main and
tail rotor blades, which significantly affected aircraft handling. The crew performed an emergency landing, upon
which the aircraft rolled, injuring the crew and catastrophically damaging the aircraft.
Note: The ARM was used to investigate the human factors in this accident. However, the results have been simpli-
fied for the purpose of this example. The full SI report is available online at: www.gov.uk/government/collections/
service-inquiry-si.

The aeromedical doctor may use some or all of the follow-
ing guidance from the ARM to investigate the ocurrence:
1. Initial investigation – on-the-day perishable data. The
aeromedical doctor should first concentrate on collect-
ing perishable on-the-day accident data as follows:
a. Inflight/accident stage (right-hand side of the
ARM). Start by ascertaining the key pre-accident
inflight events (or ground events if not inflight).
Then ascertain the key accident events. Try to
organize data into the pre-hazard, hazard on-set,
recovery, escape and survival response stages and
rescue stage if possible (see Figure 47.3) and divide
data into conditions and actions.

WORKED EXAMPLE 1: ACCIDENT

Pre-hazard inflight. Unknown to the crew, one unsafe condition existed:

1. Equipment – the MRGB cowling was not secure.

Hazard on-set. The MRGB cowling detached and impacted the main and tail rotor blades.
Unsafe conditions included:
1. Equipment – damaged blades, difficult to handle controls and excessive vibration.
2. Aircrew (condition) – sudden and unexpected increased workload.

Recovery response. The crew elected to land as soon as possible. Considering the sudden on-set of the hazard and
workload, handling actions were reasonable.
Escape and survival. The aircraft landed heavy and rolled. Unsafe actions and conditions included:

1. Aircrew (non-action) – the handling pilot (HP) was flying the controls and the non-handling pilot (NHP) was follow-
ing through, limiting brace action ability.
2. Equipment – insufficient energy absorbing seats.
3. Aircrew (condition) – injury, exacerbated by (1) and (2).
Rescue. No significant events reported.

b. Readiness stage (middle of the ARM). To now injury, on-the-day social readiness, such as team
understand the background to the accident events, compositions and relationships and on-the-day
check on-the-day readiness. Check on-the-day mental readiness, such as the crew’s knowledge,
personal readiness, such as tiredness, sickness or experience and whether the task was suitably

K17577_C047.indd 714 17/11/2015 16:27

 Investigating error  715

planned for, briefed and authorized. Then check match between the task requirements, the crew’s
overall task readiness, such as whether the task combined readiness, the equipment, clothing
was reliably and safely achievable considering the and environment.

WORKED EXAMPLE 1: READINESS

Readiness. The Puma crew planned to conduct an initial training sortie (sortie 1), land at another military base to
refuel and change HP/Captain, conduct a further training sortie (sortie 2) and then return to base. The crew, there-
fore, had two readiness stages.
Initial readiness – pre sortie 1. By initial takeoff the following unsafe condition existed:

1. Aircrew (condition) – incorrect understanding of after flight servicing (AFS) procedures.

Second readiness – pre sortie 2. As the crew prepared to depart for the second part of the sortie (following
a refuel and Captaincy changeover), there was a requirement to open the MRGB cowling to inspect a fluid level.
Although the crew reported re-securing the cowling, the cowling was not secure. Evidence indicated the following
probably occurred:

1. Aircrew (slip) – the crew did not secure the cowling correctly – influenced by:
●● Distraction – another crewmember was present during the securing process, which may have distracted the

crewmember securing the cowling, increasing the risk of error.

●● Overconfidence the crew reported being very experienced in securing the cowling, which may have made

them vulnerable to low arousal, complacency and thus error.

2. Aircrew – the crew did not check the cowling correctly – influenced by:
●● Aircrew (condition) – poor technical readiness at initial crew-in (see pre-sortie 1).

●● Aircrew (mistake) – the crew did not therefore follow the correct ‘checking’ rules.

●● Aircrew (mistake) – the crew did perform checks but these were conducted by the two crewmembers involved

in the securing process, of which one may have been vulnerable to expectation bias and thus error.
●● Aircrew (lapse) – the supervisory step of approving the secured cowling was unintentionally omitted from the

Captain’s external checks due to interruption.

●● Aircrew (lapse) – the pre-sortie brief was omitted, thus the checks were not discussed.

●● Aircrew (condition) – each crewmember assumed the others’ check was sufficient.

●● Aircrew (condition) – the HP/Captain had just come into role, thus his new task focus may have influenced his

wider awareness.

Note: It may prove difficult to detect unsafe condi-
tions and actions as aircrew may not have recognized and
reported them, they may not wish to disclose them or they
may have memory recall distortions. Further, some con-
ditions such as poor visibility, spatial disorientation and
smoke, may be highly transitory and have perished by the
time the investigation starts. Consequently, (a) and (b) may
have to be performed in parallel, over several weeks, with
reliance on interviews with other crewmembers and more
objective evidence, such as meteorological, engineering or
medical reports, aircraft data recorder outputs, video foot-
age or air traffic control evidence for support.
2. Follow-up investigation – entry conditions (left-
hand side of the ARM). Finally, to understand the
background to the events in (1), ascertain any relevant
preceding entry conditions. This is generally considered
less perishable data.
  Check for any relevant organizational policies, any
supervision or operating practices, any procedures,
any climate or culture or any equipment or clothing
procurement or design issues, which may have influ-
enced events. Also check the typical operating charac-
teristics of the crew, such as what flights they typically
flew, what equipment and clothing they typically used,
what environment they typically operated in, what their
typical roles and habits were and what their typical
health and fitness was like. Specifically check whether
any pre-existing aircrew conditions were recognized
and whether they fell within the organization’s required
training, currency, medical or fitness standards.
An assessment should then be made as to whether
these standards were sufficient in light of the specific
accident events.

K17577_C047.indd 715 17/11/2015 16:27

 716  Errors and accidents

WORKED EXAMPLE 1: ENTRY CONDITIONS

The following preceding entry conditions influenced the events in (1):

1. Organization – securing and checking technique training and procedures were ambiguous.

2. Supervision – insufficient AFS knowledge had not been rectified.
3. Equipment – cowling lock design made them look and feel locked even when they were not.
4. Equipment – there was no cockpit warning to indicate the cowling was not secured.
5. Aircrew – the crew were experienced in securing and checking the cowling.
6. Aircrew – the HP was an inexperienced Captain.

And:

7. Organization – there was no formal policy for NHP brace position options.

8. Equipment – there were insufficient energy-absorbing seats.

The Puma worked example in (1) and (2) is summarized in the ARM in Figure 47.6.

Lack of brace position

ORG

policy for NHP

Hazard onset Point of impact
Ambiguous training Captain’s
and procedures focus
No cowling
Superv

Failure to rectify AFS

knowledge check (lapse)
No pre-sortie
Captaincy
inexperience brief (lapse)
Task

No cockpit warning
Cowling not Heavy impact
Misleading lock design Cowling and roll
Equip

secured detaches
Insufficient energy
absorbing seats
Enviro

Insufficient
Cowling checks
opened
Aircrew
actions

(mistake)
Previous cowling Two crew Insufficient Recovery Escape and
locking habits when locking locking response: survival:
(mistake) (slip) land ASAP no brace
conditions
Aircrew

Knowledge of cowling Misled Distraction, confidence, Workload Injury

locking task readiness check bias, assumption

Entry conditions Readiness 1 Readiness 2 Flight Post-flight

(sortie 1) (sortie 2) (Sortie 2)

Figure 47.6  Puma UK service inquiry (SI), 2011.

Modified accident route matrix (ARM) from Harris (2011).

Although not contributory factors in the accident, other potential unsafe actions and conditions were noted. These are
often of equal value in safety lessons learned.

K17577_C047.indd 716 17/11/2015 16:27

 Investigating error  717

WORKED EXAMPLE 1: POTENTIAL UNSAFE ACTIONS AND CONDITIONS

Accident point (escape and survival):

1. Environment – orientation of the wreckage (on the side), which could have affected egress.
2. Equipment – loose ladder and load pole, which could have affected egress.
3. Aircrew (lapse) – personal beacon left in the wreckage, which could have affected rescue.

Readiness:

1. Aircrew (routine violation) – the ladder was not secured properly pre-flight.
2. Equipment – the load pole was secured but within poorly designed stowage.
3. Equipment – a personal beacon was stowed as it was not integrated with the AEA.

Entry conditions:

1. Supervision – the unsafe practice of not securing ladders, had not been rectified.
2. Equipment – poor ladder stowage increased probability of a routine violation.
3. Equipment – poor load pole stowage increased probability of a loose article.
4. Equipment – procurement of non-integrated personal beacons.

3. Analysis. Now try to ascertain key accident character-
istics, such as whether any relevant decisions or actions
in (1) and (2) were correct, justified, in an appropri-
ate order or timeframe, intended and recognized
(Harris 2011). Then assess the relationship between
the factors in (1) and (2), preferably with the help of
human factors experts. Analysis should be continual,
as results will typically lead to further evidence
collection requirements.
4. Advice. Offer aeromedical advice as appropriate.
5. Classification. Ideally, classify the results for presenta-
tion, computer entry and trend analysis. This can be
achieved using any preferred accident model.

Another example of applying the ARM to an aircraft accident is as follows:

WORKED EXAMPLE 2: NATIONAL TRANSPORT SAFETY BOARD – EUROCOPTER 2011

(NTSB.GOV, 2013)
An emergency medical services helicopter was en route to an airfield to refuel when it impacted the ground at a high
rate of descent, with low rotor power and a low fuel state. Evidence indicated that the pilot did not follow company
standard operating procedures for a low fuel state, he commenced a leg of the mission with insufficient fuel, he was
distracted due to texting, fatigued and failed to execute a sufficient recovery response. All crew, and the patient,
were killed.
Note: The results of this investigation have been simplified for the purpose of this example. The full NTSB report is
available on-line at: www.ntsb.gov/investigations/summary/AAR1302.html.

The Eurocopter worked example is summarized in the ARM in Figure 47.7.

K17577_C047.indd 717 17/11/2015 16:27

 718  Errors and accidents

Specific scenario not

ORG practiced in simulator Hazard onset Point of impact

Lack of policy for

reporting low fuel state
Superv
Task
Equip

Insufficient equipment Insufficient High rate of

readiness: Low fuel fuel, low descent, impact
power
Enviro

Low fuel state

not reported
Decision to proceed Recovery response:
Aircrew
actions

with low fuel state failure to enter

autorotation
Personal Low fuel procedures
texting not followed
conditions
Aircrew

Distraction Escape and

survival:
Fatigue no survivors

Entry conditions Readiness Flight Post-flight

Figure 47.7  NTSB Eurocopter report, 2011.

Modified accident route matrix (ARM) from Harris (2011).

OPERATIONAL ACCIDENTS – SPECIAL a. Supervision. Supervisors may have remained at the

CASES
There are some aviation activities that are worth a special
mention in terms of error and accidents. Although some of
these activities are often safer due to additional mitigations
such as specialist training, highly skilled and experienced
aircrew and detailed planning, they may also increase the
risk of unsafe conditions.
1. Deployments. A deployment refers to the temporary
transfer of one or more aircrew to an unfamiliar or less
familiar environment. On such occasions, the following
may apply:
home base where they intend to supervise remotely,
a minority may have deployed with the crew or the
crew may have to rely on local supervisors. There
may also be unfamiliar or less familiar local pro-
cedures and shift changes, possibly moving from a
9–5 to a 12-hour shift or nights.
b. Task. Tasks may be of higher workload than
normal, especially if the deployment is short with
specific objectives. The crew may also be placed
under more pressure, which may include perfor-
mance pressure if the deployment is an important
step in the individual’s career. For military person-
nel deployed to an operational theatre, there may

K17577_C047.indd 718 17/11/2015 16:27


also be political, fuel, landing, enemy action, risk to
life and medical evacuation task pressures.
c. Equipment. There may be a dedicated deployed
engineering team, reliance on local engineers, one
or two flight engineers or no engineering sup-
port at all. There may also be less equipment and
parts available.
d. Environment. The crew may be unfamiliar or less
familiar with the local environment, which could
include a change in air traffic control, traffic density,
circuits, landing cues and runway dimensions.
There may also be language barriers, specifically
with local air traffic controllers, or time zone and
climate changes, both of which the crew may not be
acclimatized to.
Further, it may not be possible to have access to a
healthy nutritious diet, quiet, dark and private accom-
modation, suitable washing facilities, Internet or tele-
phone services.
As a result of (a) to (d), the following may also apply:
e. Aircrew level. The crew may not have suffi-
cient knowledge and skill to operate in the new
environment and/or they may develop unsafe
personal conditions such as fatigue, stress or
general poor wellbeing. They may also develop
unsafe task related conditions such as task focus
and risk-taking, which may include pushing the
limits with flying hours, fuel and aircraft ser-
viceability. Risk-taking is especially likely if the
individual is deployed to an established location
where risk-taking is the ‘norm’, if the individual
is unaware of the risks and there is insufficient
independent supervision.
2. Combat. Combat flying carries a high risk of hazards
due to the operational pressures, operating 12- or
24-hour on-call shifts, the risk to life and the poten-
tial unpredictability of combat scenarios, which may
include reacting at short notice, peaks and troughs of
workload if the response involves a long transit followed
by intense combat or rescue manoeuvres and landing
at unfamiliar high-risk destinations in unfavourable
environmental conditions. Combat crews can, therefore,
be vulnerable to unsafe conditions such as risk-taking,
stress, fatigue and poor wellbeing, especially if they
are deployed and/or colleagues are injured or killed in
action. Further, due to cultural or gender factors, such
issues may not be openly discussed and may fester as
a result.
3. Emergency response teams. Emergency response
crews may include search and rescue, medical evacu-
ation or quick reaction response and may also carry a
high risk of hazards due to similar factors listed in (2).
Consequently, they may also be vulnerable to unsafe
conditions such as risk-taking, stress and fatigue, espe-
cially if they are also deployed.
4. Display teams. Unlike combat and emergency response
teams, display flight profiles are planned and rehearsed
K17577_C047.indd 719
Operational accidents – special cases  719
and typically conducted during the day. However,
display personnel may still be required to land at
multiple airfields, they may experience public display
pressures and they may be exposed to task pressures
if their routine is tightly timed and reliant on weather,
cloud bases or other display aircraft. Workload may
also occur in peaks and troughs if the display involves a
long transit followed by intense aerobatic manoeuvres.
Consequently, display teams can also be vulnerable to
unsafe conditions such as risk-taking, stress and fatigue,
especially if they are also deployed.
5. Interoperability. Some crews may operate different
aircraft types, such as rotary, fixed wing, multi-engine
or light aircraft, or different variants of the same
aircraft type. This may be due to professional require-
ments alone or a mixture of professional and personal
flying. Regardless, multi-aircraft flying may become
an unsafe condition if the aircrafts have different but
similar equipment or procedures, if they have differ-
ent levels of training and currency or if one is flown
significantly more than the other. In these situations,
aircrew become vulnerable to mistakenly operating
one aircraft or system as if it was the other or being
dependent on equipment or handling capabilities that
only exist in the other aircraft type. This may specifi-
cally occur in the presence of stress or extreme high or
low workload; a condition often termed ‘reverting to
type’.
6. Uninhabited air vehicles. Some aviation tasks involve
operating the aircraft from a remote base many miles
from the aircraft itself. Although remote piloting may
still involve aviation responsibilities such as captaincy,
use of aviation procedures and checklists, execution of
takeoffs, landings and circuit management, communi-
cation with air traffic controllers and aviation-related
fuel, serviceability and environmental pressures, opera-
tors may not be trained aircrew. Specifically, opera-
tors may not be afforded the same level of training,
emergency or simulator practise, restrictions on flying
hours or welfare support as aircrew, despite the aviation
responsibilities. Further, remote piloting does not have
the benefit of the visual and tactile feedback afforded to
in-cockpit crews, making operation potentially more
difficult. These factors could lead to unsafe conditions
such as insufficient skill, insufficient situation aware-
ness, stress and fatigue, especially if the crews are also
deployed and/or in a combat role.
For more details about uninhabited air vehicles the
reader should refer to the Uninhabited air vehicles chapter.
There are unique risks and hazards associated with many
other aircraft roles. For example, taxi and shuttle services
may be more vulnerable to complacency due to route over-
familiarity or high workload due to frequent takeoffs and
landings and test flights may be more vulnerable to risk-
taking due to the high risk nature of testing unproven sys-
tems. It is important, therefore, for the aeromedical doctor
17/11/2015 16:27
 720  Errors and accidents
to consider the unique risks and hazards associated with
each aircraft role.
REACTION, RESILIENCE AND
PREVENTION
Although it is preferable that all required defences have
been implemented prior to the operation of each aircraft
type, in reality, this does not occur. As aviation organi-
zations and military units grow and adapt in response to
changes around them, aviation risks and hazards also
evolve. It is, therefore, important that an organization con-
tinues to monitor its defences throughout any changes.
Although there are many examples of defence monitor-
ing strategies in the aviation industry, such as risk analy-
sis, simulator assessments and telemetry monitoring, this
section highlights three specific approaches that involve
aviation medicine.
1. Incident reporting. A traditional but rather reactive
way to respond to unsafe events is to collect and docu-
ment incident reports. This activity may range from
recording individual incidents to analysis of wider
trends. It is preferable that aeromedical doctors are
involved in this process to monitor aviation medicine
related events, such as unsafe operation of oxygen sys-
tems or episodes of disorientation. However, it should
be noted that incident reporting alone is not sufficient to
monitor unsafe events, including those related to avia-
tion medicine. Many unsafe events can go unreported if
they were not detected, if there is a fear of reprisal, if the
individual did not know how to report it or if they did
not have access to reporting tools.
2. Resilience engineering. Resilience engineering is
a relatively new field that promotes adaptation as a
key approach to safety. The Resilience Engineering
Association website (2013) states that resilience engi-
neering is ‘a way to enhance the ability of organiza-
tions to create processes that are robust yet flexible
and adaptive, to monitor and revise risk models and to
use resources proactively in the face of disruptions or
ongoing production and economic pressures’. Reason
(2008) in his chapter ‘Achieving resilience’, highlights
that it is the human’s ability to adapt and change to
circumstances that promotes resilience, rather than
consistency and invariability. The field of aviation
medicine would therefore need to implement adap-
tive and responsive aviation medicine programmes
if it is to achieve resilience and respond to ongoing
organizational changes.
3. Operational events analysis. RAF CAM also use the
ARM as a basis for preventative operational investiga-
tions, known as operational events analysis (OEA) – see
Harris (2011) and Revell, Harris and Cutler (2014).
These operational investigations involve one or two
aviation medicine related investigators deploying to and
integrating with an aviation unit, which may occur at
K17577_C047.indd 720
a home base or in an operational theatre. Integration
involves sleeping in the same accommodation, eating
in the same locations, working the same shift patterns
and shadowing a representative sample of personnel and
flights. The objective of an OEA is to use the structure
and content of the ARM, along with accident knowl-
edge and experience, to assess whether any observed
or reported event has the potential to result in a hazard
on-set. If it does, an assessment is also made as to how
well the personnel are likely to recover from such a
hazard (recovery response) and, if necessary, whether
they are likely to execute successful escape and survival
responses. Results are then fed back to the unit as a
‘heads-up’ to the possible risks and hazards they may
be carrying.
A more detailed overview of the role of aviation medi-
cine in the management of error and accidents is provided
in the next section.
THE ROLE OF AVIATION MEDICINE
This chapter has highlighted several areas where aviation
medicine can play a significant role in both reducing and
responding to unsafe conditions and actions. The roles that
have been discussed so far include:
1. Reaction, resilience and prevention. This includes
management of aeromedical-related incident reports,
aeromedical resilience engineering programmes and
preventative investigations, such as use of OEAs.
Managing incident reports and integrating preventa-
tive programmes into aeromedical practices will not
only help reduce accidents but will also help mitigate
hazards as and when they arise, such as implement-
ing updates to training programmes or the design of
survival equipment.
Note: To deliver resilient aeromedical programmes
the aeromedical doctor may need to have regular con-
tact with front-line personnel and tailor their support
according to specific aviation roles, as discussed in the
Operational accidents – special cases section.
2. Pathology and investigation support. The aeromedical
doctor may be asked to assist with the understanding of
and/or the investigation of aeromedical-related events,
as described in the Investigating error section. The
aeromedical doctor may work with human factors and
engineering experts, manufacturers and local opera-
tional personnel. In the case of fatalities, they may also
liaise with the assigned pathologist. Further details on
aeromedical investigations are provided in the Accident
investigation and aviation pathology chapter.
However, aviation medicine can also contribute to reduc-
ing unsafe conditions and actions by formulating, imple-
menting and monitoring aeromedical policies and
procedures concerning:
17/11/2015 16:27
 The role of aviation medicine  721

3. Selection. This includes aircrew selection requirements
to ensure those selected are appropriate for the aviation
role. This may involve documenting the anthropomet-
ric, weight, vision, hearing and fitness for flight require-
ments. Selecting appropriate personnel will ensure
appropriate baseline aircrew conditions.
4. Training. This includes policies that stipulate the type
of aviation medicine subjects taught, the frequency
of such training and the delivery. Appropriate avia-
tion medicine subjects are listed throughout this text.
Training should not only prevent unsafe conditions but
if an aeromedical hazard on-set occurs, it should also
improve the likelihood of hazard identification and an
appropriate recovery response.
5. Equipment. This includes the research of and procure-
ment of appropriate aeromedical equipment and cloth-
ing, such as ejection seats and head, eye, ear, hypoxia,
acceleration (restraints), thermal, smoke, drowning and
rescue protection. Input may also include associated
operating and maintenance procedures. Appropriate
equipment, clothing and procedures will improve the
likelihood of successful escape and survival responses.
6. Operations. This includes advising aviation units on
appropriate tasking, shift work patterns and operat-
ing environments for relevant personnel. Appropriate
operations will help minimize unsafe conditions in the
entry conditions stage, such as stress, fatigue and low
morale and will help reduce inappropriate planning and
tasking in the readiness stage.
7. Medical supervision. This includes monitoring for
any change in physical, physiological or psychological
condition (from the baseline in (3)), which may affect
performance or survivability. Unmanaged physical
changes, such as injuries or excessive weight gain, could
reduce the likelihood of a successful escape response.
Unmanaged physiological and psychological changes,
such as fatigue or low morale, could generally increase
the likelihood of a hazard on-set and reduce the likeli-
hood of timely responses.
Figure 47.8 summarizes the role of aviation medicine in
error management, accident prevention and response using
a modified ARM (Harris 2011).

Aeromedical policy, Feedback into aeromedical

ORG

processes, procurement system

Superv

Aeromedical training,
Incident reporting or accident investigation support
currency, supervision

Monitoring of typical
Task

Assessment of task demands

task demands

Escape and survival

Equip

Assessment of equipment and clothing performance

equipment and clothing
Enviro

Monitoring of typical
Assessment of operating environment
working environments

Monitoring of behaviours
Aircrew
actions

Assessment of unsafe actions

that may affect conditions
or performance
Hazard Recovery Escape Survival
onset response response response
conditions

Monitoring of changes
Aircrew

Monitoring of changes
to typical on-the-day Assessment of aircrew conditions
to conditions
readiness levels

Entry conditions Readiness In-flight Post-flight

Figure 47.8  Accident route matrix (ARM) and the role of aviation medicine.
Modified from Harris (2011).

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 722  Errors and accidents
SUMMARY
This chapter has addressed the reason there are still
hazards and risks in aviation, the typical route to an
aviation accident, understanding and investigating
error, operational special cases, reaction, resilience
and prevention and the role of aviation medicine.
Six key points from this chapter include:
●● Aviation continues to operate with inherent risks
and hazards, including the risk of human error.
As aviation organizations and military units grow
and adapt in response to changes around them,
this inevitably affects the aviation risks involved. It
is therefore important the organization continues
to monitor its defences throughout these changes.
●● There has been a move away from focusing on
operator error in accidents, to a more holistic
view that considers the relationship between
unsafe conditions and actions at the organization,
supervisory, task, equipment, environment and
aircrew level.
●● The accident chain of events may include a long
complex sequence of interactions between unsafe
conditions and actions. Further, some unsafe
conditions and actions may have occurred many
months before the day of the accident.
●● It is important to consider recovery, escape and
survival responses, as well as the initial hazard
on-set.
●● There are unique risks and hazards associated
with each aircraft role.
●● Aviation medicine can play a significant role in
both reducing unsafe conditions and actions and
responding to them should they occur.
REFERENCES
Harris S. Human Factors Investigation Methodology.
[Online.] International Symposium on Aviation
Psychology, 2011. Available from: www.wright.edu/
isap.
Leach J. Survival Psychology. Basingstoke, UK: Macmillan,
1994.
K17577_C047.indd 722
NTSB.gov. NTSB Aircraft Accident Report AAR-13-02 into
the Accident Involving Eurocopter AS350 B2 on 26
Aug 2011. [Online.] Available from www.ntsb.gov/
investigations/summary/AAR1302.html. Accessed
14 Jan 2014.
Reason J. Managing the Risks of Organizational Accidents.
Farnham, UK: Ashgate, 1997.
Reason J. The Human Contribution: Unsafe Acts,
Accidents and Heroic Recoveries. Farnham, UK:
Ashgate, 2008.
Resilience Engineering Association. About Resilience
Engineering. [Online.] Available from www.resilience-
engineering-association.org. Accessed 20 Aug 2013.
Revell S, Harris S, Cutler V. A preventative approach to
identifying and addressing flight safety human factors
issues. [Online.] Proceedings European Association for
Aviation Psychology, 2014. Available from http://www.
eaap.net/library/2562/conference-proceedings.html.
Service Inquiry – gov.uk. Service Inquiry Report into the
Accident involving Puma XW211 on 5 Jul 2011. [Online.]
Available from www.gov.uk/government/collections/
service-inquiry-si. Accessed 25 Nov 2013.
Wickens C, Hollands JG. Stress and Human Error.
In: Wickens C, Hollands JG (eds). Engineering
Psychology and Human Performance, 3rd edn. Upper
Saddle River, NJ: Prentice Hall, 1999.
Wiegmann DA, Shappell SA. Human Error Approach
to Aviation Accident Analysis: The Human Factors
Analysis and Classification System. Farnham, UK:
Ashgate, 2003.
FURTHER READING
Energy Institute. Guidance on Investigating and Analysing
Human and Organizational Factors Aspects of
Incidents and Accidents. London: Energy Institute,
2008.
European Association for Aviation Psychology, 2013
[Online]. Available from: www.eaap.net.
Hancock PA, Szalma JL. Human Factors in Defence:
Performance Under Stress. Farnham, UK: Ashgate,
2008.
International Society of Air Safety Investigators, 2013.
[Online]. Available from: www.isasi.org.
Reason J. Human Error. Cambridge: Cambridge University
Press, 1990.
17/11/2015 16:27

The flight deck and cockpit
MICHAEL BAGSHAW
Introduction 723
Definitions 723
Role of flight crew 723
Aircraft controls 725
Flight deck design 725
Multifunction instrument displays 730
Head up displays (HUDs) 731
Visual enhancement 732
INTRODUCTION
The navigation and operation of an aircraft is executed by
the crew members from the flight deck or cockpit. The sys-
tems to operate engines and aerodynamic control surfaces
govern the progress of the aircraft on the ground and in
flight, while the instrumentation provides information on
direction, speed, altitude and orientation, as well as infor-
mation for the management of the flight such as navigation,
fuel, warning systems, etc.
This chapter deals with the operation of the aircraft,
particularly the interface between the flight crew mem-
bers and the aircraft instrumentation and operating sys-
tems. The psychological aspects of personality, behaviour
and interaction between crew members (e.g. crew resource
management) and of life support equipment and personal
protection are considered elsewhere (q.v.).
DEFINITIONS
When the crew are normally unable to leave their seats
during the course of a flight, the aircrew compartment is
usually referred to as the cockpit. This encompasses primar-
ily, but not exclusively, military fast jet aircraft, helicopters
and trainers where the crew may require personal life sup-
port equipment and/or be restrained in an armoured or
ejection seat.
K17577_C048.indd 723
48
Situational awareness 733
Automation 733
Advantages of automation 735
Disadvantages of automation 735
Automation complacency 735
Conclusion 735
References 736
The aircraft flight deck, on the other hand, describes the
compartment housing the crew where they may leave their
seats during flight and do not require personal life support
equipment during normal operations. This applies gener-
ally, but not only, to civilian aircraft and military transports.
The terms aircrew and flight crew are interchangeable,
military crew members usually being known as ‘aircrew’
whereas ‘flight crew’ generally refers to civilian crew mem-
bers. In the USA, this term can also include flight attendants
working in the passenger cabin, but in Europe it is usually
exclusive to flight deck technical crew (pilots and flight
engineers).
ROLE OF FLIGHT CREW
Although there are similarities in the basic flying skills of
military, commercial airline and general aviation flight
crew members, the tasks or roles can be very different.
It is axiomatic that selection and training of these differ-
ent groups should differ, although the basic fundamentals
are similar.
Within these groups there are subdivisions of operation.
Military aviation includes for example:
●● Basic and advanced flying training.
●● Interdiction and ground attack.
●● Airborne interception.
723
17/11/2015 16:28
 724  The flight deck and cockpit
●● Close air support.
●● Tactical and strategic airlift and transport.
●● Maritime fleet defence and attack.
●● Air to air refuelling.
●● Casualty evacuation.
●● Airborne early warning and electronic countermeasures.
●● Photo-reconnaissance.
●● Air-sea rescue.
●● Antisubmarine warfare.
The design of aircraft is optimized for the role, although,
whenever possible, a multi-role function is incorporated in
the design and development (e.g. air-to-air refuelling tankers
can act as transport aircraft, battlefield support helicopters
may be used for casualty evacuation, light aircraft can be used
for police or military surveillance or for training). However,
the basic concepts of aircraft control and flight instrumen-
tation are similar whatever the role of the aircraft, and they
evolve throughout their service leading to modifications and
changes to cockpit instrumentation and equipment.
Just as the aircraft is optimized for a particular role or
roles, so military crew members are selected and trained for
particular specialist areas, after generic basic flying train-
ing. The prime operational grouping is between rotary
and fixed wing, with further selection within those groups
(e.g. support/transport/maritime/fast jet). Crew members
are initially selected according to aptitude (q.v.), and ser-
vice requirements, for employment as pilots, navigators,
weapon system operators, radar operators, fighter control-
lers, flight engineers or loadmasters. Although the captain
of the aircraft is usually a pilot, but by no means exclusively
(particularly in maritime and early warning operations),
there is no hierarchy of skill or knowledge. Some aircraft,
chiefly fast jets, are operated by a single pilot, whereas oth-
ers, such as long-range transport, refuelling and airborne
early warning, require a larger crew complement. It is usual
for military crews to be ‘constituted’, which means that
they train and operate together and gain an understand-
ing of individual personalities and foibles, so enhancing
operational effectiveness.
In the military single-seat and two-seat role, crews oper-
ate within a squadron environment and fly together in tacti-
cal formations. Although not flying in the same cockpit or
flight deck, the development of mutual understanding and
trust between individual pilots enhances operational effec-
tiveness in the same way as for constituted crews.
In two-seat combat aircraft, the crew of pilot and naviga-
tor/weapons system operator is usually constituted.
Military aviation takes place in a dynamic strategic and
tactical environment, with a need for ongoing situational
analysis and appropriate reaction. The environment may be
hostile as a result of climate and/or enemy activity, and the
aircraft is very much a vehicle to achieve a particular mili-
tary objective. The operation of the aircraft, its equipment
and (if appropriate) its weapon system should make mini-
mal demands on the crew so they can concentrate on the
tactical scenario to complete the task safely and effectively.
K17577_C048.indd 724
Cockpit and flight deck design should follow this maxim,
but this ideal is not always achieved.
In airline operation, the driving force is commercial
pressure. The aim is to carry as many passengers and as
much freight as possible, in safety and at the cheapest fare
compatible with providing adequate revenue and meeting
passenger service expectations. The revenue must cover the
costs of the operation, including direct operating costs such
as fuel, airports, navigation, maintenance and staff, as well
as providing a margin for future investment and an ade-
quate return on investment for the shareholders.
In the middle of the twentieth century, the flight crew
of a long-range commercial airliner or transport aircraft
included two pilots, a flight navigator, a flight engineer and a
radio operator. By the beginning of the twenty-first century,
the crew generally consisted only of two pilots, the roles of
navigator, radio operator and, more recently, the flight engi-
neer, having been supplanted by technology.
The task of the crew on a flight deck is to work together
safely and effectively. This is influenced by the role or job of
the individual crew members, the status and experience of
the individuals, and their personalities (q.v.).
The reason for having more than one pilot on the flight
deck of an airliner or transport aircraft is to reduce work-
load by task sharing, to produce consensus decision making,
and to ensure cross-checking of actions to minimize error
and enhance safe operation through active monitoring.
The role of the pilot will depend upon whether he or she
is nominated handling pilot for the particular sector of the
flight. The captain retains command and ultimate responsi-
bility for the conduct of the flight, but duties are shared. In
general, the handling pilot (‘pilot flying’ or PF) is concerned
with the physical control of the aircraft, while the non-
handling pilot (‘pilot non-flying’ or PNF) is responsible for
communication with air traffic control, actioning checklist
items, inputting data to the flight management system and
monitoring the actions of the handling pilot. Monitoring is
a complex task requiring vigilance and active participation
in the flying task, and is a core piloting skill. The term MP
(monitoring pilot) is synonymous with the term PNF. It is
common practice for these roles to alternate between the
pilots on consecutive flight sectors.
The monitoring role can be demanding, particularly if
the non-handling pilot is junior or less experienced than
the handling pilot. There has to be an understanding and
acceptance by both pilots that it is entirely in order for the
non-handling pilot to question the actions of the other
and, if necessary, take over control. This aspect is explored
in more detail in the chapter dealing with crew resource
management.
For long-range military logistics and transport opera-
tions and for ultra-long-haul commercial flights, it is com-
mon to carry additional flight crew members to allow
periods of rest during the cruise. In the commercial opera-
tion, these are referred to as the ‘heavy crew’.
It is the task of airline management to control the long-
term risks of the company as a whole and the task of flight
17/11/2015 16:28

crew to control short-term risks encountered on individual
flights to achieve a safe and efficient operation. The coordi-
nation of these two is achieved partly by the development
and use of standard operating procedures (SOPs). These
SOPs marry the needs of the particular operator with the
checklists and standard drills issued by the aircraft man-
ufacturer, and also incorporate the requirements of the
appropriate regulatory authority such as the Civil Aviation
Authority (CAA), Federal Aviation Administration (FAA)
or European Aviation Safety Agency (EASA). In large air-
line companies, it is the case that individual crew members
rarely fly together on a regular basis and, indeed, may never
have met before a particular flight, so it is essential that they
all follow and understand the SOP for any given operation
or phase of flight. The crew interface with the cockpit and
flight deck instrumentation forms part of the critical path-
way for consistent use of SOPs. SOPs are equally essential in
military operations to ensure safety and efficiency.
The term general aviation encompasses those flying
activities other than military or commercial operations,
including fixed wing and rotary (helicopter) aircraft.
Gliding, micro-light and ultra-light flying activities are gen-
erally not classified as general aviation, but are categories in
their own right and are not considered in this chapter.
General aviation includes a whole spectrum of fixed and
rotary wing aircraft, from single-seat light aircraft with
little or no instrumentation up to business jets with flight
decks as sophisticated as any found in a commercial air-
liner. Similarly, the qualifications of general aviation pilots
range from a basic National Private Pilot Licence through
to an Airline Transport Pilot Licence, with a wide range
of experience.
Civilian flying training, private recreational flying,
sports flying, air ambulance and police support flying
and corporate aviation are all considered to be ‘general
aviation’ activity.
Single pilot operation is common in general aviation,
particularly in light aircraft and light helicopters.
AIRCRAFT CONTROLS
The flight path of a fixed wing aircraft is determined by the
aerodynamic control surfaces. In basic form, the elevators
control movement in pitch, ailerons control roll (also con-
trolled by spoilers in high performance aircraft) and the
rudder controls motion in yaw. Deflection of the elevators,
ailerons and spoilers is controlled by movement of the con-
trol column or control wheel or side-stick, and the rudder
by movement of the foot pedals.
In smaller aircraft, control surface deflection is effected
via direct cable or rod links from the cockpit controls.
However, in larger and high performance aircraft, deflection
is achieved by servo actuators which respond to hydraulic or
electrical signals derived from cockpit control deflection or
autopilot guidance.
Engine thrust is managed by the power lever(s). In
a jet engine, this is a function of the speed of rotation of
K17577_C048.indd 725
Flight deck design  725
the engine which, in turn, is influenced by fuel flow. In a
propeller-driven aircraft, power is delivered as a function
of the speed of engine rotation and the pitch angle of the
propeller blades, controlled by the throttle and the propeller
pitch levers. In a piston-engined aircraft, the fuel/air mix-
ture ratio is also manually controlled to take account of air
density being a function of altitude.
Modern aircraft incorporate sophisticated engine man-
agement systems (such as fully automatic digital engine
control [FADEC]) where automation can simplify engine
control for the different phases of flight.
The flying controls of a helicopter are different. The flight
path is determined by a combination of the power delivered
by the rotor and the effective angle of attack presented to the
relative airflow by the rotor disc. The tendency of a single-
rotor helicopter to rotate opposite to the motion of the rotor
disc is counteracted by sideways thrust produced by the tail
rotor; in a twin-rotor helicopter, this is achieved by counter-
rotation of the two rotor discs.
The collective lever changes the lift on the aircraft by
altering the blade pitch and, hence, the angle of attack of
the disc as a whole, i.e. collectively. An increase in the angle
of attack results in increased drag and requires a linked
increase in power to the rotor to maintain a constant rotor
speed (rotor rpm). Conventionally, the collective lever is
operated by the pilot’s left hand and is the prime control for
the vertical flight dimension.
Control of the horizontal flight direction is effected by
the cyclic stick in the pilot’s right hand, which varies the
blade angle of attack as it rotates, i.e. cyclically, to create dif-
ferential lift either laterally or fore/aft, thus rolling or pitch-
ing the aircraft.
The power delivered to the tail rotor, and thus motion in
yaw, is controlled via the pedals.
Any change in deflection to one of the controls requires
a compensatory adjustment to the input of the other two
controls. Thus, flying a helicopter requires a high degree of
cognition and physical coordination.
Unless specifically designed otherwise (e.g. an agile high
performance fighter or light aerobatic competition aircraft),
most fixed-wing aircraft are inherently stable in flight. The
aircraft will usually continue on a given flight path until a
control input modifies this. However, a helicopter is inher-
ently unstable requiring constant control input from the
pilot (which may be assisted by automation in modern
sophisticated helicopters).
FLIGHT DECK DESIGN
The design of the flight deck or cockpit is necessarily a com-
promise between economics, the need to accommodate
the range of flight crew shapes and sizes, and the position-
ing of instruments and controls for optimum functional
reach without compromising lookout and the operation of
the aircraft.
The layout of the flight deck is designed to suit a popu-
lation falling between the 5  per cent confidence limit for
17/11/2015 16:28
 726  The flight deck and cockpit
females and the 95 per cent limit for males, for key static,
dynamic and contour measurements (see elsewhere for con-
sideration of anthropometry). For a military aircraft, the
design will be influenced by the population demography
of the sponsoring country. However, civilian aircraft are
designed for worldwide sales and some compromise is nec-
essary to take account of the fact that different populations
throughout the world are of different physical stature.
The key reference point on the flight deck for the safe and
efficient operation of the aircraft is the ‘eye datum point’ or
‘design eye position’. When the pilot adjusts his or her seat
to achieve this point, there should be optimum vision of
controls and instrumentation and external reference with-
out the need for excessive head movement. Sitting below the
eye datum point decreases downward vision over the air-
craft nose and on the final stages of the landing approach
sight of the runway undershoot may be lost. It is also essen-
tial that full deflection of all the flight controls, including
rudder and toe-operated brake pedals, is possible when
strapped into the seat.
Instrumentation
To operate any type of aircraft safely and efficiently, the pilot
needs to control its progress through the air from the point
of departure to the destination. In the early days of flying,
aircraft were flown in sight of the Earth’s surface and dura-
tion of flight was relatively short within a limited aircraft
Figure 48.1  BE2b cockpit.
K17577_C048.indd 726
performance envelope. Orientation was provided by visual
cues from the ground, the horizon and the sky.
Figure 48.1 shows the cockpit of the Royal Aircraft Factory
B.E.2b, which served as a light bomber and reconnaissance
aircraft in the early months of the First World War (1914–
1918). The very basic cockpit arrangement includes a throttle
and a map case at the left, a simple control column and an
instrument panel housing an air speed indicator, engine rev-
olution counter and an altimeter. The pilot maintained ori-
entation and navigated by reference to external visual cues.
Even at the end of the First World War, when the Vickers
Vimy was introduced by the Royal Air Force as the first pur-
pose-built heavy bomber, the cockpit was cramped and had
only basic instruments. Reference to Figure 48.2 confirms
what a great feat of airmanship was achieved by Alcock
and Brown in 1919 when they completed the first crossing
of the Atlantic Ocean in this aircraft without the benefit of
sophisticated instrumentation.
With the continuing development of both military and
civil aviation, aircraft flew faster, further and higher and out
of sight of the surface. The properties of the gyroscope were
utilized to develop the artificial horizon, which assisted
the pilot to determine orientation when flying ‘blind’ in
cloud or at night. Application of the laws of gyro dynam-
ics also enabled the development of the turn indicator and
the gyrocompass.
Properties of the atmosphere and the physics of aerody-
namics were utilized in the design of altimeters, airspeed
Figure 48.2  Vickers Vimy cockpit.
17/11/2015 16:28

indicators and vertical speed indicators and compasses
became more sensitive and sophisticated. Development of
electronics and microprocessors has led to great advances
in flight deck instrumentation and technology.
A major problem in the provision of information to assist
orientation is that the aircraft flies in a four-dimensional
environment (the fourth dimension being time), whereas it
is possible to display information only in two dimensions.
Figure  48.3  shows an artificial horizon (also known
as a gyro horizon or attitude gyro; it is known as an atti-
tude indicator when the instrument face is calibrated with
degrees of pitch). The heart of the instrument is a horizon-
tally-mounted gyroscope which maintains position while
the aircraft (and the instrument case) moves around it.
The artificial horizon line is attached to the gyroscope, and
this will always represent the real horizon when the instru-
ment is operating correctly. The fixed model in the centre
Figure 48.3  Artificial horizon.
Figure 48.4  Instruments showing aircraft in stalled descent.
K17577_C048.indd 727
Flight deck design  727
represents the aircraft, and this moves with respect to the
artificial horizon in the same way as the real aircraft moves
in respect to the real horizon. (Russian aircraft instrument
display works in the opposite sense, with the aircraft symbol
moving around the fixed horizon line). However, the instru-
ment only indicates the position of the aircraft relative to
the horizon, a concept known as the aircraft attitude. It does
not indicate whether the aircraft is climbing, descending,
turning or is in level flight, although it does give an accurate
representation of bank angle.
The only way to confirm what the aircraft is actually
doing is to cross-refer to other instruments. This process
is referred to as ‘scanning’ the instrument panel, and the
pilot learns techniques of selective scanning according to
the phase of flight.
Thus, with an indicated high nose attitude, the aircraft
might be in a climb, might be descending or could be main-
taining level flight.
Figure  48.4  shows the instrument panel of an aircraft
descending with a high nose attitude. The attitude indicator
would suggest that the aircraft is climbing, whereas cross
reference to the vertical speed indicator shows a descent
which is confirmed by the altimeter indicating a reduction
in altitude (‘unwinding’).
To maintain straight and level flight at a constant air-
speed, using the aircraft controls, the pilot selects the appro-
priate attitude on the artificial horizon (or attitude indicator)
and then scans the altimeter to ensure that the aircraft is
not climbing or descending, the turn instrument to ensure
that the aircraft is not turning, the compass to ensure that
the desired heading is being maintained, and the airspeed
indicator to ensure that the appropriate speed is being flown,
returning to the artificial horizon after each scan. Any devia-
tion from the desired parameter(s) requires a control input
and a continuation of the instrument scanning process.
17/11/2015 16:28
 728  The flight deck and cockpit
Thus, a simple feedback loop is established, involving visual
perception, cognitive processing and motor output.
In the early stages of flying training, the emphasis is on
the development of motor skills and simple judgement mak-
ing. The development of more complex judgement occurs as
experience is gained because motor skills are developed by
handling items which can be seen, felt and moved, whereas
cognitive judgement and decision making is more abstract,
using intelligence, awareness and experience.
Cognitive judgement is the end result of perceiving a
situation via the sensory system or memory. The situation is
then assessed using the hierarchical order of the brain and a
plan of action is decided. In doing this, the pilot uses knowl-
edge gained from previous experience to evaluate the plan
based on information perceived.
The development of motor memory proceeds from the
basic cognitive phase to the associative phase, when events
and procedures become linked with past experience involv-
ing some conscious thought process. Finally, the automatic
phase is reached when no conscious thought is required. The
acquisition of skill in this manner allows mental processing
capacity to be freed for other tasks, such as maintenance of
situational awareness, and the scanning process occurs at a
lower conscious level.
During periods of high workload, or if the pilot is under
stress, mental capacity may be reduced and the instrument
scanning process can break down as a result of failure of
the automatic phase, leading to loss of situational awareness
(see below).
During the Second World War (1939–1945) attempts
were made to simplify the scanning process and improve
Figure 48.5  Instrument panel development.
K17577_C048.indd 728
the display of information within the cockpit. In the Royal
Air Force, a standard instrument layout was adopted in
which the main performance instruments were arranged in
a ‘T’ shape with the artificial horizon being placed in a cen-
tral position. This standard ‘T’ was subsequently adopted
throughout the western world.
Figure  48.5  shows the development of the instrument
panel up to 1963, with a notable similarity between the
Hawker Hurricane panel of 1940  and the Hawker Hunter
panel of 1956. Although the instrument designs and dis-
plays have changed slightly, the basic ‘T’ remains. With the
introduction of higher performance aircraft in the 1960s,
attempts were made to improve instrument displays to
reduce the amount of scanning required and to overcome
the limitations of two-dimensional representation of the
four-dimensional situation. The 1963  Lightning panel in
Figure 48.5 shows the strip display of airspeed and a hori-
zontal situation indicator; however, the attitude indicator is
still the most prominent instrument.
Interpretation of strip displays compared with conventional
dials takes a higher stage of mental processing and it is more
difficult to derive rates of change. They are still sometimes
used for display of engine parameters and, in improved form,
for the display of altitude and speed in modern electronic flight
instrument displays. However, to overcome the difficulty in
interpreting rate of change, modern strip speed displays incor-
porate an arrow to indicate the trend of speed change.
Strip displays of engine parameters in the Boeing 747-
400  are seen in Figure  48.6, and can be compared with
the conventional circular engine instruments of the
C130 Hercules in Figure 48.7.
17/11/2015 16:28

Altimetry
The altimeter is effectively an aneroid barometer calibrated
to read in feet (or metres in aircraft manufactured in Russia
and Eastern Europe) rather than hectopascals (hp), milli-
bars (mb) or inches of mercury (in Hg) (note that values of
hp are numerically identical to mb). It is calibrated for the
ICAO standard atmosphere (q.v.) and an adjustment knob
allows correction for local pressure, indicated on a sub-scale
on the instrument display.
Figure 48.6  Boeing 747-400 flight deck.
Figure 48.7  C130 Hercules instrument panel.
K17577_C048.indd 729
Flight deck design  729
Altitude is defined as the elevation above mean sea level.
Since atmospheric pressure varies at the surface of the Earth,
a forecast is made of the pressure (hp or in Hg) in a given
geographical area for the next hour, and this is referred to
as the QNH (the Q code is a vestige of the early days in avia-
tion when information was transmitted in Morse code by
telegraphy). Thus, altitude is measured with reference to
the QNH datum and is a measure of the vertical distance
(in feet or metres) of an aircraft above mean sea  level.
17/11/2015 16:28
 730  The flight deck and cockpit
(In the USA, this is defined as ‘true altitude’, whereas ‘abso-
lute altitude’ is the elevation above terrain).
In aviation, height is a measure of the vertical distance
of an aircraft above the airfield elevation. The atmospheric
pressure is forecast at the airfield datum and this is referred
to as the QFE. Thus, an aircraft altimeter set to this datum
will indicate zero on the ground at the airfield, and not the
altitude above mean sea level (unless the airfield happens to
be at sea level).
Because of the continuously changing atmospheric pres-
sure, and because at any one time the pressure varies at
different points on the Earth’s surface, the standard atmo-
spheric pressure (1013.2  hp or 29.92  in Hg) is used as the
datum pressure for en route flying above a certain altitude.
This altitude is referred to as the transition altitude above
which vertical elevation is referred to as a flight level (FL).
The flight level is stated in three digits, representing hun-
dreds of feet.
Thus, FL290 means that the aircraft altimeter indicates
29 000 feet above the standard pressure datum of 1013.2 hp,
and ensures that appropriate vertical separation can be
maintained between all aircraft flying in the vicinity which
will also be using the standard atmosphere datum. It does
not necessarily mean that the aircraft is flying at an altitude
of 29 000 feet above sea level (unless the surface atmospheric
pressure at that point happens to be 1013 hp).
On descent to the aerodrome, the datum is changed from
the standard setting to the appropriate QNH at the transi-
tion level. This ensures terrain clearance by the descending
aircraft, and allows an accurate approach profile to be flown
to the runway.
The three-needle display altimeter (Figure 48.8) is easily
misinterpreted, and the potential for fatal error is enhanced
by the fact that the needle indicating tens of thousands of
feet is smaller than that indicating thousands, which in turn
is smaller than that indicating hundreds of feet (the altitude
Figure 48.8  Three-needle altimeter.
K17577_C048.indd 730
indicated in Figure  48.8  is 9640  feet, or just over FL96  as
the datum is set as 1013  hp; a quick glance at the instru-
ment might lead to an erroneous reading of 19 640 feet with
implications for safe terrain clearance).
Modern altimeters have a digital display plus a single
needle indicating hundreds of feet, giving the advantages of
both display types (Figure 48.9).
Studies comparing the three-pointer altimeter display
with a digital display show a difficulty factor of 3:1  and
an error rate of 20 per cent over the digital (Campbell and
Bagshaw 2002). Although a small change in value is best
displayed on a digital instrument, rate of change is best per-
ceived on an analogue instrument (quantitative informa-
tion is better suited to a digital display, while qualitative/
comparative/rate information is more suited to an analogue
display).
MULTIFUNCTION INSTRUMENT DISPLAYS
The development of modern cathode ray tubes and liquid
crystal displays, requiring relatively little electrical power
and developing less heat than the earlier electronic instru-
ments, enabled rapid advances to be made in multifunc-
tional instrument displays.
Figure 48.10  shows an example of an early cathode ray
tube which brings together the functional performance
instruments within a single display. Care is required to
interpret the information from the clutter.
The flight decks shown in Figures 48.11 and 48.12 indi-
cate how progress has been made in improving the clarity
of displayed information. However, the dominant feature
of these flight decks is the number of keyboards and input
devices. Pilots have to learn to adjust their workloads to a
level which maintains a certain amount of intellectual activ-
ity and keeps them in the automation loop. Programming
the system is time-consuming and the pilot needs to know
how to do the simple things in real time. All temporal sense
can be lost when an individual becomes absorbed in pro-
gramming a system.
Figure 48.9  Digital altimeter.
17/11/2015 16:28

Figure 48.10  Electronic instrument display.
Figure 48.11  Boeing 787 flight deck.
Figure 48.12  Airbus A350 flight deck, showing head up display units.
K17577_C048.indd 731
Head up displays (HUDs)  731
Human error will always occur and this applies as
much in programming the system as in the other activities
involved in operating the aircraft. Hence, the importance of
a minimum two-crew operation, whereby one monitors the
actions of the other.
It is not only modern airliners which have such sophis-
ticated cockpits. Figure  48.13  shows the cockpit of the
Augusta/Westland EH 101  Merlin helicopter. Essential
flight information is presented on six multifunction display
screens, with back-up analogue instruments available in
case of electronic display failure.
HEAD UP DISPLAYS (HUDS)
When involved in reading and interpreting the instrument
displays, the pilot is looking inside the aircraft at the instru-
ment panel with head down and eyes focused at the panel
distance. It takes time for the gaze to be shifted to the exter-
nal world seen through the windscreen, moving the head
up and refocusing the eyes at infinity. This can be critical
in an air combat situation or when delivering a weapon
onto a target. It can also degrade flight safety when flying
an instrument approach to a runway in poor visibility and
a low cloud base, having to look up to visually acquire the
runway at the instrument minimum descent height in the
final stage of the approach.
HUDs were originally developed for military combat
aircraft, but are increasingly being used in corporate and
commercial aircraft.
Computer-generated information is projected on to a
transparent screen in front of the windshield which appears
to the pilot to be superimposed at infinity on the external
visual scene. The information duplicates that from the flight
instruments, as well as navigation and weapon systems
(where applicable). Although reducing the need for head
down scanning, the symbology can be complex and the
17/11/2015 16:28
 732  The flight deck and cockpit
operation of the HUD control system makes demands on
cognitive processing, taking up mental processing capacity.
Figures 48.10  and 48.11  show HUD units incorporated
into the flight decks of the Boeing 787  and Airbus A350.
Figure 48.14 shows the range of symbology used in a typical
military HUD.
Rather than projecting the image on to a fixed screen, the
next stage in military combat aircraft and helicopters was for
the information to be projected on to the helmet visor giv-
ing a helmet-mounted display (HMD) (Figure 48.15). This
has the advantage of the information being visible wherever
Figure 48.13  EH101 Merlin flight deck.
Heading scale
Flight director
cross
Velocity vector
Airspeed scale
G-meter
Figure 48.14  F15 Head up display symbology.
K17577_C048.indd 732
the pilot is looking, which can aid weapon aiming and tacti-
cal awareness, but the design has to take account of weight,
symbology and image contrast. Again, there is the consider-
ation of complexity of interpretation and operation.
VISUAL ENHANCEMENT
When flying at night or in cloud, the pilot relies on infor-
mation derived from the aircraft instrumentation, gen-
erally using external visual cues for takeoff and landing.
Automatic ‘blind’ landings are now routine in airline and
Pitch ladder
Waterline
Altitude scale
Steerpoint
information
17/11/2015 16:28

Figure 48.15  F35 Helmet mounted display.
transport operations, although the problem in very low vis-
ibility remains of guidance on the ground once the landing
is complete. The development of infrared and laser technol-
ogy has allowed the pilot to ‘see’ in the dark or poor visibil-
ity and to visually acquire a target. Modern combat aircraft
incorporate forward-looking infrared sensors, which super-
impose the generated visual scene on the HUD. However,
the pilot needs to cognitively process the image to translate
the two-dimensional representation into four-dimensional
situational awareness.
Visual enhancement can also be achieved by the use
of night-vision scintillation tubes, in the form of helmet
mounted goggles. Initially developed for use by military
helicopter crews, night-vision goggles (NVGs) are now rou-
tinely used by the crew members of a range of military and
civil aircraft. Their use requires special training in the inter-
pretation of the perceived image, particularly with respect
to judgement of depth and rate of relative closure between
the aircraft and other objects. Because of the spectral sensi-
tivity of the scintillation tubes, the cockpit lighting has to be
adapted for use with NVGs.
SITUATIONAL AWARENESS
Situational awareness is the state of knowing where the air-
craft is, where it has been and where it is going in terms of
the four dimensions of flight. Loss of situational awareness
is a major causal factor in accidents associated with human
error. It can be defined as the perception of the elements
in an environment within a volume of time and space, the
comprehension of their meaning, and the projection of their
status in the near future.
In practical terms, it is a state of mind encompassing
a dynamic mental model of relevant aspects of the ‘real’
world. It is created and maintained by cognitive and physi-
cal activity, and requires dynamic awareness of the operat-
ing environment, the aircraft modes, and the state of the
aircraft technical systems. The mental model is formed
from perception, comprehension and projection to enable
an active goal to be achieved.
When perception (and the mental model) matches real-
ity, the crew member is situationally aware. This requires
cognitive processing of the two-dimensional information
on attitude, altitude, speed and time to give the four-dimen-
sional picture, as well as continuing awareness of the prog-
ress of the navigational and operational plan.
K17577_C048.indd 733
Automation 733
AUTOMATION
The military tactical environment has become extremely
complex, with large amounts of rapidly changing infor-
mation to be processed and acted upon by the flight
crew. The demands on crew members are such that the
only way to operate efficiently is to use automation and
computer technology.
In civilian operations, a major driving force for tech-
nological development has been cost reduction; a micro-
processor is cheaper than a human crew member. It is also
more efficient at performing routine tasks, but only when
under the control of a human being. Similarly, the evolution
of electronic flight instrument displays has been driven as
much by the fact that a liquid crystal display is cheaper to
build and maintain than a complex analogue mechanical
instrument, as by the multifunctional capacity of the elec-
tronic display itself.
In themselves, these developments should not lead to
an increase in workload or error. However, the pilot now
has a range of functional tasks to perform and there are
fewer crew members to monitor and cross-check actions.
Commercial and military pressures require long working
hours, which can lead to fatigue (q.v.) and reduced vigilance
increasing the possibility of error.
Automation itself is not a new concept. Autopilots were
introduced before the Second World War (1939–1945) and
are now commonly found on most classes of aircraft, ranging
from relatively unsophisticated light aircraft to the highly
automated flight deck of the modern commercial airliner.
The technical complexities of modern aircraft, plus the ever
increasing complexity of the airspace in which all aircraft
operate, has increased demands on the flight crew and led
to a steady increase in mental workload, with a concomitant
reduction in the demands for physical motor skills.
As well as automating the navigation of the aircraft and
its actual control via the autopilot, another goal has been to
optimise flight performance and manage fuel consumption.
Continuously monitored and computer calculated throttle
settings and flight paths can achieve significant fuel savings
which have commercial and military benefits.
All pilots undergo initial training on basic light aircraft
or helicopters, utilizing simple control systems. When fly-
ing larger or more sophisticated aircraft, the perception
remains that the physical deflection of an appropriate cock-
pit control is causing the appropriate response, even though
the deflection has simply signalled the servo-motor system
to act. This applies whether the signal is generated by con-
trol input from the pilot or from programming the autopilot
or flight system.
The operation of the man-machine interface has become
more complex as the capabilities and capacity of the auto-
mated flight management system have evolved. From the
original suite of single-function switches and knobs, there is
now a range of multi-function keyboards and controls. The
following is an extract from the description of the autopilot
controls in a modern passenger airliner:
17/11/2015 16:28
 734  The flight deck and cockpit
The controls for the autopilot are mounted on
the flight control unit (FCU) above the instrument
panel. Fundamentally, the autopilot and auto
throttle attempt to acquire or maintain target
parameters determined either by manual inputs
from the handling pilot or by computations from
the flight management guidance system (FMGS).
When the target parameter is set by the FMGS,
the term ‘managed’ is used for the target param-
eter. When the target parameter is set by the
flight crew, the term ‘selected’ is used.
The altitude and speed selection controls can
be either pushed or pulled. When turned, the
altitude selector knob adjusts the target alti-
tude and when pushed, the same knob allows
the FMGS to ‘manage’ any intermediate altitude
constraints entered into a route. When pulled,
the altitude selector knob triggers an ‘open’
climb or descent. The term ‘open’ means that
any intermediate altitude control constraints
within the active route computed by the FGMS
are ignored. When in descent, it also means that
idle thrust is selected and airspeed controlled
by the elevators.
The speed selection control has compa-
rable functions. (UK Air Accident Investigation
Branch 2004)
This description illustrates the complexity and the
required depth of understanding of modern flight manage-
ment systems.
Different aircraft manufacturers have evolved differ-
ent philosophies in the development of automation. The
philosophies of two of the major western civilian aircraft
manufacturers are summarised as follows (Campbell and
Bagshaw 2002):
The Airbus philosophy
●● Automation must not reduce overall aircraft reliability
but should enhance aircraft and system safety, efficiency
and economy.
●● Automation must not lead the aircraft out of the safe
flight envelope, and it should be maintained within the
normal flight envelope.
●● Automation should allow the operator to use the safe
flight envelope to its full extent, should this be necessary
due to abnormal circumstances.
●● Within the normal flight envelope, the automation must
not work against operator inputs, except when abso-
lutely necessary for safety.
The Boeing philosophy
●● The pilot is the final authority for the operation of
the aircraft.
K17577_C048.indd 734
●● Both crew members are ultimately responsible for the
safe conduct of the flight.
●● The order of priority of flight crew tasks is safety, pas-
senger comfort, efficiency.
●● Design for crew operations is based on pilots’ past train-
ing and operational experience.
●● Systems must be designed to be error tolerant.
●● Hierarchy of design alternatives is simplicity, redun-
dancy, automation.
●● Automation is a tool to aid, not replace, the pilot.
●● Address fundamental human strengths, limitations and
individual differences for both normal and abnormal
operations.
●● Use new technologies and functional capabilities only
when they result in clear and distinct operational or effi-
ciency advantages and there is no adverse effect on the
human–machine interface.
It is recognized that there are advantages and disadvan-
tages to aspects of both these philosophies, but the products
of both manufacturers are in safe and efficient worldwide
service.
Advanced automation changes the nature of the human
factor considerations on the flight deck. The flight crew need
to remain effectively ‘in the loop’ as part of the system, so
the pilot–computer interface is crucial in keeping the pilots
informed of the system operation and conversely keeping
the computers informed of the condition and behaviour of
the flight crew.
Although automation significantly reduces pilot work-
load on one hand, new systems actually increase workload in
the areas of programming, understanding and monitoring.
Advantages of the human over a machine include:
●● Creativeness.
●● Innovation.
●● Aptitude to deal with novel situations.
Human qualities which cannot be replicated by automa-
tion include:
●● The capability of quickly grasping logical connections
in large complex quantities of data and filtering out the
meaningless data.
●● The ability to divide up memory into related
data segments.
●● The ability to identify errors when data is
presented graphically.
●● The possession of genuine flexibility in dealing with
unforeseen events.
The irony of automation is the paradox that automation
does much better than the pilot those things that a pilot
already knows how to do well. However, it does not know at
all how to do those things which the pilot would like to do
well (Bainbridge 1987).
17/11/2015 16:28

ADVANTAGES OF AUTOMATION
The major advantage of automation is the reduction in pilot
workload associated with the manual tasks of navigating
and flying and the associated cognitive processing. There is
high accuracy and reliability of the systems and, in general,
they are very cost effective. The use of multifunctional dis-
plays allows increased sophistication of information presen-
tation, enhancing accuracy, efficiency and the maintenance
of situational awareness.
DISADVANTAGES OF AUTOMATION
Although the workload associated with manually flying
and navigating the aircraft is reduced, the programming
and monitoring of the automated systems can signifi-
cantly increase workloads during critical phases of flight.
However, during long-range cruise, workload may fall to
such low levels that boredom occurs and arousal levels can
reduce significantly. This can influence performance, par-
ticularly of vigilance and monitoring tasks, and can reduce
job satisfaction.
Difficulties in designing an effective pilot/equipment inter-
face can relate to system opacity, autonomy and protection.
System opacity increases with technology and gives
poor mental representation of the underlying system func-
tion. It is based on the need-to-know principle in that the
display to the crew shows only a simple tree which hides a
forest of complexity. This is a great advantage for standard
operations, but can be a limitation when things go wrong
and the crew are unclear as to what can be done to resolve
the situation.
System autonomy means that the greater the technol-
ogy, the more the system is able to adapt to a given situation
without operator commands. This is particularly relevant in
the function of the autopilot which can initiate a chain of
events without direction from the pilot. This, again, is not a
problem during normal operation but, if the pilot workload
is high, they may be outside the loop.
System protection is a built-in function to prevent errors
from system malfunction. However, this can lead to the
crew deviating from standard operating procedures because
of fears that the system protection will lead the aircraft into
dangerous modes of flight.
It has been suggested that these three problems can be
resolved by increased training. However, adaptation is slow,
particularly when a pilot is transferring to fly an automated
aircraft from a conventional type, and the complexity of
automated systems takes long experience for full under-
standing to develop.
AUTOMATION COMPLACENCY
Automation has sometimes been seen as an end in itself,
rather than as a tool to enhance the aircraft operation.
Excessive reliance on automation can lead to automation
K17577_C048.indd 735
Conclusion 735
complacency, where situational monitoring and cross-
checking is reduced because of a belief in the infallibility
of the automatic system. The very reliability with which
automated systems normally perform can lead to overconfi-
dence and complacency.
An error during data input may not be picked up and
corrected at the time. Subsequent cross-checking of the
flight progress may reveal a disparity, but automation com-
placency may reinforce the hypothesis or mind-set that the
system ‘knows what it is doing’.
Alternatively, the belief in the system reliability may lead
to an absence of cross-checking and a breakdown in the
crew’s situational awareness.
Monitoring may become passive, whereby the inherent
belief in the automated system’s infallibility leads to the
crew member simply watching what it is doing, rather than
analysing and constantly checking. On the other hand, the
multifunctional capability of the automated cockpit can lead
to a narrowing of concentration on to one particular aspect.
This blinkered concentration leads to a breakdown in the
monitoring of the whole system. Finally, the complexity of
the automated system can lead to confusion and a loss of
situational awareness. It is essential for the crew to maintain
system mode awareness to remain in the automation loop.
Albert Einstein is credited with saying:
‘Computers are incredibly fast, accurate and
stupid.
Humans are incredibly slow, inaccurate and
brilliant.
Together, they are powerful beyond imagination.’
CONCLUSION
The cockpit or flight deck is a complex working environ-
ment. The practitioner of aviation medicine needs to under-
stand the human factors as well as gaining a basic knowledge
of the technology involved. There is no substitute for gain-
ing practical experience and every opportunity should be
taken to observe flight crew at work, either in the air or in
the flight simulator.
SUMMARY
●● The cockpit or flight deck is a complex working
environment.
●● Many traditional flight crew roles have been sup-
planted by technology, and basic aircraft flying
control skills are becoming secondary to system
management capacity.
●● Electronic multi-function displays are
replacing conventional mechanical instru-
mentation, but this presents challenges of
information interpretation.
17/11/2015 16:28
 736  The flight deck and cockpit

REFERENCES
●● An aircraft flies in a four-dimensional envi-
ronment but it is only possible to display flight Bainbridge L. Ironies of Automation. In: Rasmussen J
information in two dimensions, requiring (ed). New Technology and Human Error. London: John
cognitive processing by the crew to maintain Wiley, 1987.
situational awareness. Campbell RD, Bagshaw M. Human Performance and
●● Automation can be seen as an end in itself, rather Limitations in Aviation, 3rd edn. Oxford: Blackwell
than as a tool to enhance the aircraft operation. Science, 2002.
Excessive reliance on automation can lead to UK Air Accidents Investigation Branch. UK Air Accidents
automation complacency, where situational moni- Investigation Branch Bulletin 2004; December: EW/
toring and cross-checking is reduced because of a G2004/04/14.
belief in the infallibility of the automatic system.
●● Monitoring by the non-flying crew member may
become passive, whereby the inherent belief in
the automated system’s infallibility leads to the
crew member simply watching what it is doing,
rather than analysing and constantly checking.

K17577_C048.indd 736 17/11/2015 16:28


In-flight communication
GRAHAM M. ROOD AND SUSAN H. JAMES
Communication in aircraft 737
Physical nature of speech 739
Speech intelligibility 740
Reduction of cockpit noise 744
Historically, the primary form of communication in avia-
tion has been speech. Since the sender and receiver usually
are humans, speech has been a very effective medium. In
aviation, English is used as the international communicating
language, but there are a number of potential problems (e.g.
regional accents and non-native English-speakers) that can
affect the intelligibility of messages. This type of communi-
cation can be referred to as man-to-man communication.
With the increasing sophistication of radio and elec-
tronic systems, the ability of a machine to communicate
with the pilot, either through relaying a verbal message or
by using an auditory warning, became more commonplace,
with many of these systems supplementing or complement-
ing the visual warning systems. Often the audio warning
was used in a higher-urgency case (e.g. ground-proximity
warning system), when the likelihood of missing the visual-
only signal was an unacceptable probability. This is a form
of machine-to-man communication.
Currently, the final communication channel is from
human to machine, where a person uses speech to talk to
the machine, which ‘understands’ the contents of the mes-
sage and activates the avionic systems to act appropriately.
This requires sophisticated speech-recognition systems,
which, in the harsh world of the aircraft cockpit, have only
recently reached sufficient maturity to be incorporated in
operational aircraft.
In day-to-day life, communication between people is pre-
dominantly speech-based, but the use of non-verbal meth-
ods such as gesticulation and facial expression normally
provides added meaning and emphasis. In most aircraft,
however, the only possible form of communication between
K17577_C049.indd 737
49
Communication in civil aircraft 745
Currently acceptable figures for speech intelligibility 745
References 746
Further reading 746
crew may be speech: non-verbal methods of communica-
tion are not possible when military aircrew are physically
separated and dressed in flight-clothing assemblies. This
may represent a very significant loss.
COMMUNICATION IN AIRCRAFT
There are, effectively, two interface sites between the person
and the aircraft communications system:
●● Human output device (mouth, throat).
●● Human input device (ear).
The goal at both of these locations is to transduce the sig-
nal as faithfully as possible and to maximize the exclusion
of ambient noise. The acoustic merit of a mask or helmet
will depend on how well it performs these two functions.
Output from the person
Speech may be transduced from a pressure wave (speech)
signal into electrical signals by a microphone. In aviation,
the most common types of microphone are those incorpo-
rated in the oronasal oxygen mask (used in most fast jets),
noise-cancelling boom microphones (used in helicopters
and transport types) and, in special circumstances, throat
or bone-conduction microphones.
MASK-MOUNTED MICROPHONES
The acoustic attenuation properties of oxygen masks are
similar to those of flying helmets, i.e. poor at low frequencies
737
17/11/2015 16:28
 738  In-flight communication
but improving with rising frequency. Like most acoustic
systems, the mask system may have resonances, which are a
function of interactions between different parts of the mask
structure and which will reduce attenuation, sometimes to
the point of producing higher sound-pressure levels inside
the mask compared with outside. However, the speech sig-
nal-to-noise ratio is generally more than adequate to provide
good intelligibility at the mask-microphone output. Even in
the noisiest aircraft, the quality of the signal from a micro-
phone mounted in an oronasal mask is good. Nevertheless,
there may be cases of poor design in the impedance match-
ing of the microphone to the communication avionics and
other distortions that may be introduced downstream of the
mask, where aircrew can, often unjustly, put the blame for
inadequate communications on this piece of equipment.
NOISE-CANCELLING BOOM MICROPHONES
This form of microphone transduces speech very well and
generally performs its function perfectly satisfactorily. The
noise-cancelling properties are a function of frequency and
provide better cancelling properties at low frequencies than
at high frequencies. The quality of design and the type of con-
struction of these microphones affect their noise-rejection
properties. This enables some microphones to have noise
discrimination (or rejection) of up to 10 dB at 4 kHz, while
others have none. At lower frequencies, noise rejection can be
up to 30 dB, with a theoretical maximum of 45 dB at 100 Hz.
Owing to the low-frequency content of helicopter noise,
noise-cancelling boom microphones are well suited to this
type of vehicle and generally provide an acceptable solution
for noise reduction. However, in order for the microphone
to work efficiently, the microphone must be placed as close
as possible to the lips. Even minor movement away from the
lips, in the order of 2–3 mm, will significantly degrade the
speech signal-to-noise ratios.
THROAT MICROPHONES
A throat microphone is inherently less sensitive to airborne
noise and generally can provide a better signal-to-noise
ratio than a noise-cancelling microphone. However, the
overall frequency response is limited, and the microphone
output has a preponderance of low-frequency components,
which give good signal-to-noise ratios but do not contribute
significantly to high intelligibility.
The transducer of the throat microphone is pressed
against the pharynx and is sensitive to the powerful vibra-
tions that occur here in voiced phonemes (see below). If
one places the fingers on the larynx and says ‘aaaah’, these
vibrations can be felt clearly; however, if one says ‘sss’ or any
other unvoiced consonant, nothing will be felt. In a similar
way, the throat microphone does not respond to unvoiced
phonemes. Because of this, a throat microphone leaves
a lot of speech to be ‘filled in’ or inferred by the listener.
The throat microphone does, however, have excellent rejec-
tion of normal airborne sound, so what is lost in quality of
speech transduction may be gained in terms of noise rejec-
tion. This form of transducer was once commonly worn
K17577_C049.indd 738
in helicopters, where the rejection of noise is invaluable in
some situations (e.g. the winchman).
BONE-CONDUCTION MICROPHONES
Bone-conduction microphones pick up the speech vibra-
tion signals that are transmitted through the skull and jaw,
rather than as direct acoustic signals formed through the
vocal system. As such, they are generally poor in high-fre-
quency content and suffer from the same problems as throat
microphones. However, under some specialized applica-
tions, such as covert surveillance, they can be regarded as
suitable and effective transducers.
A further factor that affects speech signal-to-noise ratios
in all types of microphone is the normal variation in speech
output levels found in airborne and other communications.
Some people talk more quietly than others, and there is,
essentially, a Gaussian or normal distribution of speaker
levels. Since the noise levels at the input are essentially con-
stant in a given environment, louder speakers will produce
higher signal-to-noise levels than quieter speakers. Also, the
noise levels experienced at the ear have an effect on speaking
levels. As the noise levels at the ear increase, so the talking
levels increase; this phenomenon is known as the Lombard
effect. In most aircraft communication systems, because the
free-field pathway between the mouth and the ear, which
controls speech output levels, is occluded by a helmet or
headset, an artificial pathway is provided, feeding the
speech signal through the communication system back to
the ear. This is the side-tone signal, which can be adjusted to
control voice output levels in most communication systems.
Measurements made during experimental flights in
Royal Navy Merlin helicopters showed a variation in speech
signal-to-noise ratios between speakers of between 3 dB and
29 dB, and this is considered typical of operational flight.
Input to the person
In aviation, aircrew personnel normally wear a headset or
flying helmet that incorporates a communications system.
Some pre-Second World War systems used an acoustic tube
that fed directly to the ear of the aircrew, from one crew
member’s mouth direct to the crew member’s ear. This was
known as the Gosport tube. It worked, but not necessar-
ily well: in order to ‘turn up the volume’, one had to shout
louder. Some intermediate systems used a telephone with an
acoustic tube to feed the signal to the pilot’s ear (e.g. the
Second World War type C and the 1960s Mk2 series flight
helmets), but generally these were superseded by full elec-
trical communications, in which each aircrew member had
control of their input volume levels to the headset.
In principle, it should be possible to provide a satisfactory
signal-to-noise ratio at the ear simply by turning up the gain
of the communications system until the signal is loud enough
to hear above the ambient noise. Several factors make this
solution impractical. First, speech at or greater than 125 dB
causes discomfort and pain. Second, listening to speech at
sound-pressure levels even considerably less than 125 dB for
17/11/2015 16:28
 Physical nature of speech  739

any significant period of time poses a distinct threat of dam-
age to the hearing. Third, physiological changes take place
in the ear at high sound levels, and it is not clear that a given
signal-to-noise ratio at a high noise level would produce the
same intelligibility as that produced at more moderate levels.
It is undesirable to present speech at levels much in excess of
100 dB. If a 15-dB ratio is required, then the ambient noise at
the ear must not be greater than 85 dB. Thus, in general terms,
if the ambient sound-pressure level inside the aircraft cabin is
115 dB, then the helmet or headset should provide an attenua-
tion of at least 30 dB. By applying the same reasoning in more
detail across each frequency band, the amount of attenuation
required throughout the frequency spectrum may be defined.
The use of the helmet or headset to provide protection
against high noise levels is commonplace. This protection
allows speech and non-speech communications to be effec-
tive and the intelligibility of incoming messages to be at a
high enough level to be operationally acceptable.
PHYSICAL NATURE OF SPEECH
Speech sounds are not steady or continuous through time.
Although from a perceptual point of view speech is com-
posed of phonemes, these phonemes do not correspond pre-
cisely to any physical pattern of sound or to the letters used
in a word.
The word ‘meaty’ is written phonemically as /m/, /i/, /t/,
/i/. The pattern of sound associated with a given phoneme
depends on the age, sex and personal idiosyncrasies of the
speaker and the location of the phonemes in the word. The
/p/ in ‘spoon’ is physically very different from the /p/ in
‘pan’, and yet perceptually they are identical. The percep-
tual system is not, therefore, performing a simple decod-
ing of the incoming signal but is performing a complicated
pattern-recognition task in which many cues, including the
context in which the sound occurs, are being utilized.
Each sound consists of various combinations of different
frequencies. Some sounds, e.g. the ‘s’ in ‘sea’, contain almost
all the speech frequencies and approximate to white noise in
which all frequencies are represented equally. Vowels con-
sist of high-amplitude sounds. All vowels are voiced (i.e. the
larynx is used in their production) as are some consonants
(e.g. /b/). However, many consonants (e.g. /t/) are unvoiced
and are of lower amplitude than vowel sounds; this has
some consequence in the testing of equipment.
The energy content of speech is distributed widely. The
dynamic range of male speech varies from about 52 dB for
casual speech, to around 76 dB for loud speech, to 89 dB
for shouting. The corresponding female figures are some
2–3 dB lower during casual speech, increasing to some
5–7 dB lower at shouting levels. The frequency spectrum of
speech contains frequencies from around 100 Hz to above
10 kHz; however, the information content of speech is not
distributed equally or so widely, which is a matter of primary
importance in the design of communication systems. The
way in which the information content of speech is distrib-
uted can be seen from the weighting constants in the articu-
lation index (AI) calculation procedure (see Table 49.1); as

Table 49.1  Method of calculating the articulation index (AI) using the weighted and summed speech signal-to-noise ratios
to enable an AI figure to be determined

Calculation of articulation index

Signal-to-noise ratio (A)
Frequency (Hz) (dB) Weighting factor (B) Product (A × B)
200 0 0.0004 0
250 0 0.0010 0
315 5 0.0010 0.0050
400 10 0.0014 0.0140
500 16 0.0014 0.0224
630 14 0.0020 0.0280
800 15 0.0020 0.0300
1000 12 0.0024 0.0288
1250 6 0.0030 0.0180
1600 11 0.0037 0.0407
2000 16 0.0037 0.0592
2500 6 0.0034 0.0204
3150 11 0.0034 0.0374
4000 7 0.0024 0.0168
5000 2 0.0020 0.0040
AI = 0.3267
The speech signal-to-noise ratio is taken at the output from the microphone. This AI figure is then related to Figure 49.2, which gives the
level of intelligibility for particular types of text material (sentences, limited vocabularies, nonsense syllables, etc.)
Calculated intelligibility (from Figure 49.2):
AI = 0.33 = 85% intelligibility for sentences for first presentation to listeners = 94% intelligibility for sentences known to listeners

K17577_C049.indd 739 17/11/2015 16:28

 740  In-flight communication
an example, almost 73 per cent of the speech intelligibility
is contained in frequencies of 1 kHz and above, and only
27 per cent is in frequencies below 1 kHz. Most communi-
cation systems for aircraft are specified with a flat frequency
response from around 300 Hz to 3–4 kHz, with a gradual
roll-off outside these frequencies; generally, this is wide
enough to allow for good communication.
The amplitude of the speech often is not great enough for
good intelligibility in a noise environment. This is due to a
complicated phenomenon known as masking. For the pur-
poses of this chapter, it is sufficient to state that it is difficult
to comprehend quiet speech in a loud-noise environment.
Many types of physical distortion and clipping of speech
peaks can occur; in aircraft, various protective devices
and communication systems are used to protect and pre-
serve the speech. The effectiveness of these devices can be
assessed only in terms of intelligibility.
SPEECH INTELLIGIBILITY
In most aircraft, aircrew members use an intercommunica-
tion system (intercom) to talk to each other, partly because
noise levels may be high but mainly because normally the
crew members are physically separated, sometimes by the
length of the aircraft; this type of communication falls
under the heading of ‘aided communication’. Where crew
members are in close proximity, either on the flight deck
or where rear-crew systems operators are at a console, crew
may talk face-to-face rather than over the intercom – this is
known as ‘unaided communication’.
Aided communication
In order to be able to quantify reliably the transmission and
reception quality of a communication system, there are a
number of tests that allow adequate levels of repeatability
and a diagnostic capability. These have been developed over
the years and consist of either word lists, e.g. the Harvard
phonetically balanced (PB) list, or rhyming tests, e.g. the
modified rhyme test (MRT) and the diagnostic rhyme test
(DRT).
The most straightforward form of intelligibility test is
one in which a single word is read to a listener. The listener
writes down the word that they believe they have heard and
the response is marked for correctness. This is the funda-
mental method used in the Harvard PB word lists, against
which other tests are compared. The 50 word lists used in
the Harvard PB test are intended to have a phonetic consti-
tution similar to that of spoken English.
The Harvard PB word lists are, however, open to many
sorts of error and need practice. To counteract these diffi-
culties, intelligibility assessments can be made more easily
by means of one of the forms of rhyme test. In these tests,
the listener is provided with a multiple-choice answer sheet.
Thus, the response alternatives given to the stimulus word
‘hat’ might be ‘bat’, ‘cat’, ‘fat’, ‘rat’, ‘hat’ and ‘mat’, from
which the listener deletes the one that he or she hears. The
K17577_C049.indd 740
response list generally contains words varying in only one
phoneme from one another (in the example given here, a
consonant phoneme).
Consonant phonemes are generally used in such tests, as
vowel phonemes are, on the whole, louder and consequently
not affected so readily by poor signal-to-noise ratio (the dif-
ference in decibels between the level of the signal and that of
the masking signal).
In the USA, the test used most commonly for military
communication systems is the MRT. This test, like the PB
lists, consists of prepared lists of monosyllabic words. The
listener selects the word perceived from a list of six words
on a multiple-choice answer sheet. The difference between
the six words is in only one consonant, and the test is useful
for studying confusions between particular speech sounds.
It also has the significant benefit of requiring short training
times and lends itself to mechanized scoring. Other types
of distortion, such as that produced by overdriving an inad-
equate transducer, may require a vowel test; suitable tests
do exist.
A further type of two-choice intelligibility test is the
DRT. This uses two rhyming words, with the initial con-
sonants differing by a single attribute. The words in each
pair are chosen so that a particular attribute of speech is
present in one word but not in the other. Detailed analysis
of the responses will indicate which parameter of a com-
munication system will need to be improved. DRT tests are
important in the assessment of narrow-band digital speech
channels (secure speech transmissions), where plain speech
is encoded, transmitted in scrambled digital form and
decoded back into plain speech at the receiver’s end. The
DRT is used as the standard test for linear predictive cod-
ers (LPCs) in North Atlantic Treaty Organization (NATO)
standardization agreement (STANAG) 4198.
The intelligibility of a signal is affected not only by the
masking noise in which the signal is heard (Figure  49.1),
but also by the size of the vocabulary from which the sig-
nal is taken (e.g. digits compared with isolated words), the
100
Digits
80
Proportion correct (%)
60
Words in
40 sentences
Isolated words
20 Nonsense syllables
0
–18 –12 –6 0 6 12 18
Signal/noise ratio (dB)
Figure 49.1  Effect of the signal-to-noise ratio and the
nature of the signal on its intelligibility. The intelligibility
of the signal increases with signal-to-noise ratio, size of
the vocabulary employed, internal redundancy and con-
text of the signal.
17/11/2015 16:28

internal redundancy of the signal or words (e.g. totally non-
redundant nonsense syllables fare poorly) and the context
of the signal (e.g. isolated words compared with words in
sentences). Some speech is intelligible at negative signal-
to-noise ratios (i.e. when the average [long-term root mean
square] level of the speech is less than that of the noise). An
example may be drawn from Figure 49.1, where, at a signal-
to-noise ratio of –12 dB, digit intelligibility is around 55 per
cent, but for isolated words (where intelligent guesses are
not so productive), an increase of around 15 dB in the sig-
nal to a signal-to-noise ratio of +3 dB is required in order
to obtain a similar level of intelligibility. This is because the
level of speech varies in time, and for ‘very probable’ words
(drawn from a small vocabulary or where contextual infor-
mation is given) enough information is still present above
the ambient noise to provide the perceptual system with
data on which to base identification.
Because of the poor quality of many aircraft communi-
cations systems, the speech used in aircraft is fairly redun-
dant, so in any individual utterance, more speech sounds are
present than are necessary for the unambiguous detection
of a digit, letter or word. For example, instead of the letter
‘I’ (pronounced ‘eye’), which contains only two vowel pho-
nemes, the word ‘India’, which contains five phonemes, is
used, with a consequently higher probability of recognition.
However, the problem remains that any perceptual process
relies to a very large extent on the experience of the listener;
thus, if message A is probable but message B (which is acous-
tically similar) arrives, then B will be heard as A. This sort
of mishearing has often had serious consequences, but it is
best illustrated by the apocryphal story about the pilot who,
during the takeoff run, noticed that his co-pilot was looking
unhappy. ‘Cheer up!’ he said, whereupon the co-pilot lifted
the undercarriage (‘gear up’), to the general detriment of the
aircraft and particular embarrassment of the aircrew.
The final test of the quality of any communications sys-
tem must remain the intelligibility test. However, the incon-
venience of using large numbers of people to test systems
has led to the adoption of physical or objective methods of
assessment by calculation. We have noted that although
the energy of speech is distributed widely, the informa-
tion content is not, i.e. although there are a large number
of speech sounds in the part of the speech spectrum below,
say, 300 Hz, these do not contribute a great deal to the intel-
ligibility of the speech. It is generally correct to say that only
20 per cent of intelligibility is contained in 80 per cent of the
energy of speech – the vowel sounds – while 80 per cent of
the intelligibility is found in 20 per cent of the total energy
– the consonants. Large numbers of experiments have been
performed in an attempt to assess the relative contributions
of different parts of the spectrum to intelligibility. As a result
of these calculations, such as those presented in Table 49.1,
a predictive and calculable method of assessing probable
speech intelligibility has been developed. This method of
dividing the speech and noise spectrum into a number of
bands and assessing the contribution of each band to the
overall sum is the AI.
K17577_C049.indd 741
Speech intelligibility  741
Depending on the relative accuracy required, the over-
all spectrum can be divided into a greater or lesser number
of bands. Generally, it is preferable to use the larger num-
ber; in the example shown in Table  49.1, the spectrum is
split into 15 bands, each one-third of an octave wide. For a
smaller number of bands, octave bandwidths may be used.
The signal-to-noise level in each band is multiplied by its
weighting factor, which indicates its relative contribution
to the overall speech intelligibility, and the resultant fig-
ures are summed to give the AI figure. This figure is then
related to an intelligibility figure proper by use of the curves
shown in Figure 49.2, which is similar to the approach given
in Figure 49.1 in respect to changes in intelligibility due to
contextual information, redundancy, size of vocabulary, etc.
Thus, a measure of subjective intelligibility may be
obtained from direct physical measurement. The method
must, however, be used with care. It has only been validated
for male speech and it is subject to many caveats and qualifi-
cations, particularly if there is any trace of distortion in the
speech signal. This AI method is used with aided communi-
cation systems, i.e. using an air craft crew communication
system in conjunction with headsets or flying helmets.
A form of automated, more sophisticated AI is used in
the form of the speech transmission index (STI) or rapid
speech transmission index (RASTI). STI is similar to AI, in
that it determines specific signal-to-noise ratios in each fre-
quency band and then weights and combines them in order
to give an overall summed AI figure. In STI, however, the
signal-to-noise ratio in each band is determined from the
modulation transfer function in that band, which is con-
structed from an artificial input test signal (representative
of the temporal characteristics of running speech) and the
interfering noise. The subsequent modulation transfer func-
tion is used to give an equivalent signal-to-noise ratio, and
the weighted mean of these signal-to-noise ratios forms the
basis of STI. Like AI, the STI output figures vary between
0 and 1.
RASTI has a similar approach, using the measurement of
a modulation transfer function, but only two octave bands
are employed (500 Hz, 2 kHz), which allows a rapid evalua-
tion of STI within ten seconds.
All of these calculative methods are useful as they allow
a rapid rating of communication systems on a scale from
excellent to poor, but they are not yet sufficiently precise
in order to measure subtle but often important differ-
ences between systems in the way that MRT or DRT can.
Additionally, more recent developments that use signal-
processing techniques to remove ‘unwanted’ noise from a
noisy communication signal can introduce speech distor-
tions known as artefacts. Existing objective speech intelli-
gibility tests have been shown to be less appropriate for this
type of processed speech signal and newer techniques, such
as the short-term objective intelligibility measure (STOI),
provide a higher correlation with subjective based tests.
Both subjective testing (MRT, DRT, PB, etc.) and objec-
tive calculative approaches (AI, STI, RASTI, STOI etc.) have
their merits, and their use is based on the principle of the
17/11/2015 16:28
 742  In-flight communication

Test vocabulary
100
limited to

Percent of syllables, words, or sentences understood correctly

32 PB words
90 Sentences
Sentences
(first presentation
(known to
80 to listeners)
listeners)
PB words
70 (1000 different words)
Nonsense syllables
60 (1000 different syllables)
Rhyme tests
50
Test vocabulary limited
to 256 PB words
40

30

20

10

0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
Articulation index

Figure 49.2  Relationships between articulation index and intelligibility. These relationships vary with the type of material
and the skill of the talkers and listeners.

appropriate test for both the particular operational circum- The results of an octave analysis of noise levels on the
stances and any limitations in testing time or cost. flight deck of a jet transport aircraft were as follows:

Non-aided face-to-face communication Octave band 125 250 500 1000 2000 4000
(frequency, Hz)
In many aircraft and other vehicles, face-to-face commu-
Sound pressure 100 88 84 85 74 63
nication is necessary without resort to an aided (intercom)
(level, dB)
system. In this case, a simpler method called speech inter-
Speech interference level (dB) = (84 + 85 + 74)/3 = 81
ference level (SIL) is used to assess the suitability of the
noise environment for communication. In this method,
the cabin noise levels are measured in octave bands; the The particular problem is to assess whether a pilot can talk
three bands centred on 500, 1000 and 2000 Hz are summed to his or her co-pilot or engineer at a normal voice level
arithmetically and the average is taken. This average fig- while they are separated by a distance of 1.2 m.
ure is compared with a set of figures that will indicate Table 49.2 shows that at a separation distance of 1.2 m,
the level of communication possible. This method may the SIL would have to be 56 dB for normal speech effort,
be illustrated with the following example. It is useful to rising to 74 dB for a shouting voice. In this example, the
note that this method may be used over a wide range of pilot would be unable to talk to the crew, even using a
transportation vehicles (buses, cars, etc.) as well as in the shouting voice, and aided communications would be neces-
industrial environment. sary. The cabin noise levels would have to be reduced to a
Table 49.2  Speech interference levels (SIL) of steady continuous noises at which reliable communication is barely possible.
The values apply to male vocal effort and to a speaker and listener facing each other (subtract 5 dB for female voices)

Preferred speech interference level (dB)

Separation distance
(m) Normal effort Raised Very loud Shouting
0.15 74 80 86 92
0.3 68 74 80 86
0.6 62 68 74 80
1.2 56 62 68 74
1.8 52 58 64 70
3.7 46 52 58 64
Source: Beranek A (1971).

K17577_C049.indd 742 17/11/2015 16:28


level where an SIL of 56 dB could be obtained in order to
allow communication.
The American National Standards Institute (ANSI 1977)
specifies the SIL method for use in the USA. The European
approach is to use the preferred speech interference level
(PSIL) (International Organization for Standardization
(ISO) 1974), which is identical in method of calculation but
uses four octave bands centred on 500 Hz, 1 kHz, 2 kHz
and 4 kHz. The ANSI method quotes separation distances
between speakers ‘for just reliable communication’; the ISO
method is slightly more conservative, quoting differences
for ‘satisfactory conversation’. In practice, either method
will give satisfactory predictions in all but marginal cases.
Secure speech systems
There is a final class of communication system that can suf-
fer significantly from cockpit or aircraft environment noise,
and this occurs in secure speech systems. In such systems,
generally known as vocoder (voice-coder) systems, it is the
effects of the noise on the coding of the speech signal, rather
than the noise levels at the ear, that have the greatest effect on
speech intelligibility. Vocoder systems work by the aircrew
or operator speech from the normal oxygen mask micro-
phone for fast jets, and from the standard noise-cancelling
boom microphone for helicopters and transport/surveil-
lance aircraft, and the coding of the pressure waveform. The
waveform is then transmitted down the secure line or over
the radio links in secure code form to the listener, where the
waveform is decoded and then fed to the listener as clear
speech. If there is no noise (e.g. as in an office environment)
the system works well, as only the speech signal is encoded
as the pressure waveform and decoding decodes only the
correct signal. In a noisy environment, the encoded speech
signal contains an amount of contaminating noise. The
encoder does not have the capability to distinguish noise
from speech and, therefore, encodes the whole speech-
Band sound pressure level (dB re 20 µPa)
plus-noise signal. At the other end, the decoder treats this
whole contaminated signal as a speech signal only and tries
to make voicing sounds out of the whole signal, often with
peculiar effects on the speech signal, which renders it unin-
telligible. This is predominantly so at low speech signal-to-
noise ratios. Research into processing the speech signal at
source to improve the speech signal-to-noise ratios is pro-
viding a partial alleviation solution.
As noted earlier, it is NATO practice to use DRT to test
linear predictive coder secure speech systems.
Machine-to-man and man-to-machine
intelligibility
With regard to machine-to-man intelligibility, there are two
types of signal: speech and non-speech. Speech is in its usual
context, whether it is from recorded messages or from syn-
thesized speech devices. Non-speech in this context means
audio icons, such as a klaxon, horn or more sophisticated
auditory warning such as those used in Merlin helicopters.
K17577_C049.indd 743
Speech intelligibility  743
The speech signals, provided they are recorded, stored
and replayed such that speech degradation is minimized,
can be treated as a normal speech signal obeying the dic-
tates of normal intelligibility testing.
For non-speech signals, the required levels that must
be transmitted to the ear to ensure 100 per cent probabil-
ity of detection can be calculated. Figure  49.3  shows the
approach, using a Lynx helicopter noise spectrum, mea-
sured under a Royal Air Force (RAF) Mk 4 helmet as a basis
for the calculation. Other noise fields can be used, and cal-
culations have been used for Tornado GR4 and other fixed-
wing aircraft. From the noise levels at the ear, the auditory
masked threshold is calculated. At a level 15 dB above that
calculated threshold, a 100 per cent chance of detection of
a signal is ‘guaranteed’. Consequently, if a complex multi-
frequency signal has frequency components that fall on that
100 per cent boundary, then the signal will be detected and
the need to transmit auditory signals louder than necessary,
on the basis that louder is better, can be prevented. If the
signals are too loud, then the aircrew members are liable to
spend the initial periods of an emergency trying to mute or
cancel the signal; or if they let it continue, the high levels
may interfere with the necessary emergency communica-
tion between crew. In Figure 49.3, an upper limit is added
to the 100 per cent detection threshold in order to allow for
the different noise levels experienced over a range of aircrew
members’ ears due to the normal variation in fit of the flying
helmet and the different noise levels in different aircraft due
to the operational status (e.g. flying with the windows open
or the ramp down in a helicopter). Providing the frequency
100
90
80
70
60
Upper limit of
50 100% detection
band
40 100% detection
threshold
Calculated auditory
30
threshold
20
Cabin
noise
levels at
10 the ear
0
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Frequency (Hz)
Figure 49.3  Calculated pure-tone threshold and noise at
ear (10 Hz resolution) in the Lynx.
17/11/2015 16:28
 744  In-flight communication
content of the warning signals is kept within that band, the
listening task will have been optimized.
The use of man-to-machine communication has been
in the research area for some 25  years or more and only
recently has been incorporated into a production aircraft
(the RAF Typhoon). This system allows the aircrew to
speak directly to a machine; the machine recognizes the
speech and acts on the command. In its simplest form, this
is a method of switching by voice. The pilot can switch and
interrogate systems by talking to the machine. A simple
example of switching would be in selecting radio chan-
nels: instead of memorizing the radio frequency needed,
selecting the individual frequencies on the channel selec-
tor switch and then communicating, the pilot can say
‘Radio – Farnborough approach – go’ and communication
can be immediate. Similarly, the pilot can interrogate the
aircraft systems by saying ‘Check – bingo fuel – go’ and
the machine-to-man part of the system will tell the pilot
how much fuel is left (and the range available, if it is pro-
grammed into the system). The recognition rates are well
into the 98 per cent level, which makes it similar to manual
switching rates, and new algorithms are allowing close to
100  per cent recognition rates, even in the more extreme
cockpit environments.
REDUCTION OF COCKPIT NOISE
Speech intelligibility invariably increases as the noise lev-
els decrease, either from reduction in the working envi-
ronment or by protecting the ear from the noise. Chapter
50  discusses in more detail the role of the helmet or
headset in the reduction of cockpit and cabin noise lev-
els at the aircrew ear, but a brief discussion is included in
this chapter.
The primary purpose of any hearing protector is to pre-
vent noise reaching the cochlea and subsequent transmis-
sion of the nerve firings from the cochlear output to the
brain. In most cases, this can be achieved by occlusion of
the ear canal, which prevents noise reaching the eardrum
(tympanic membrane). This occlusion is achieved either
from a circumaural earshell or by using an earplug, or by
a combination of both. Most military earshells, as fitted to
a flying helmet or headset, usually contain a telephone that
allows communication with the aircrew from the intercom,
radio or aircraft warning systems. With a passive earplug of
the foam type (e.g. E-A-R®) or cylindrical plastic type (e.g.
V51-R), a telephone is absent and communication is not
possible, although specific versions (e.
Figure 49.1. In many aircraft, the noise levels are such that a
passive circumaural protector is effective enough to reduce
the noise levels in order to allow effective communication.
However, in higher-noise environments, passive attenua-
tion alone may not suffice.
In higher-noise environments, the use of active noise
reduction (ANR) can provide a useful reduction in noise
levels. Although these reductions are used primarily to
combat the risk of noise-induced hearing damage, the
noise reduction from ANR can also improve speech and
signal intelligibility.
In a series of experimental flying trials during an interna-
tional collaboration programme between the UK, the USA
and Australia, a number of helicopter sorties were flown and
a number of aspects of speech intelligibility investigated, all
related to the use of ANR. Four aspects were studied:
●● Direct speech intelligibility using PB word lists
and tested in accordance with military standard
(MIL-STD) 1472.
●● Subjective rating of communications clarity.
●● Subjective rating of the attentional demand required in
understanding the communications.
●● Subjective rating of the perceived intelligibility.
In flights with the Royal Australian Navy Seahawk S-70-B,
the PB word-list intelligibility improved from 83 per cent to
89 per cent. In the subjective ratings of clarity, attentional
demand and perceived intelligibility, the ANR ‘on’ case
improved all three to a statistically significant level. In a US
trial with an OH58D, a noisy helicopter, and the EH-60, a
surveillance helicopter, all the improvements in the ratings
of perception were highly significant (p < 0.002). Also, in
the OH58D, the experiments measuring the direct speech
intelligibility gains showed a 10 per cent improvement with
a better passive helmet earshell and a further four per cent
when using ANR. Thus, for speech intelligibility, the use
of better acoustic protection, either passive or active, will
improve communications. As the improvement is a direct
function of the speech signal-to-noise ratio, the simpler pas-
sive improvements can be utilized for the less noisy range
of aircraft; however, for noisier aircraft, active methods of
noise reduction may be required.
Similarly, for non-speech signals such as passive or active
sonar returns that are being interpreted by the sonar opera-
tor, reduced noise levels at the ear will increase the signal
intelligibility. In two classified helicopter trials on opera-