Hypoxia For Flight Crews

Hypoxia (OGHFA BN) | SKYbrary Aviation Safety 5/9/22, 16:40
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Hypoxia (OGHFA BN) Article
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Background OGHFA
Category:
Hypoxia is a state of oxygen deficiency in the body
sufficient to impair functions of the brain and other organs.
Flight
Because of the nature of flight, flight crews are much more Content
Safety
likely to suffer from hypoxia than “normal” people. Knowing source:
Foundation
what to look for and how to react to resolve the situation is
essential to maintain flight safety. This Briefing Note
Content
defines hypoxia and describes the symptoms and EUROCONTROL
control:
performance decrements that can result from it. It is
important for flight crews to understand the warning signs
of hypoxia and how the human body responds to reduced
levels of oxygen. Also included are some techniques that
can help a flight crew member defend against the effects
of hypoxia.
Introduction
Hypoxia from exposure to altitude is due entirely to the

reduced barometric pressures encountered at higher
altitudes. The concentration of oxygen in the atmosphere
does not change as altitude increases; rather it stays
constant at about 21%. Because of the decrease in
barometric pressure, however, there is less atmosphere (air)
at higher altitudes, which results in less available oxygen.
The first hypoxia-related casualties were reported in 1878
https://skybrary.aero/articles/hypoxia-oghfa-bn Page 1 of 14
by Paul Bert as balloonists traveled high into the

atmosphere. Despite technological advances in aviation,
hypoxia still occurs today.
Hypoxia can occur quickly, and the body’s ability to adapt

to a low-oxygen condition is poor when the onset is fast.
Flight crews must be well-informed of the causes and
consequences of hypoxia in flight and know how to protect
themselves from such conditions.
Stages of Hypoxia
In aeronautics, hypoxia typically results from a

decompression or lack of pressurisation of the aircraft
cabin. Hypoxia occurs within a few minutes if the cabin
pressure altitude rises to between 5,000-6,000 m (about
16,000 - 20,000 ft). Acute hypoxia is characterised by
impaired cognitive performance and sometimes a loss of
consciousness.
If there is a cabin rupture or other cabin depressurisation

that occurs extremely quickly, hypoxia can occur within a
few seconds, especially if cabin pressure altitude is higher
than 7,500 m (about 25,000 ft). This sudden onset hypoxia
is termed fulminant hypoxia. At high altitudes, loss of
consciousness occurs within a few seconds without any
warning symptom. A “normal” person generally feels
nothing prior to loss of consciousness and will be unable to
recall the incident.
If the loss of cabin pressure can be resolved quickly, the

crew can regain consciousness within 20 seconds. A person
will, however, experience painful earaches due to rapid
descent or emergency repressurisation.
Acute hypoxia is the term classically used to describe the

different temporary clinical effects of hypoxia on cognitive
performance, behaviour, mood and the senses. Hypoxia is
particularly dangerous because its signs and symptoms do
not usually cause discomfort or pain. The onset of
symptoms is insidious, and tolerance can vary both among
individuals and on a daily basis for any particular person.
The effects of hypoxia begin immediately upon exposure to
any altitude above sea level. Below 3,500 m (about 11,000

ft), the performance decrements are minimal and normally
go unnoticed. Decreased night vision and drowsiness are
usually the only detectable issues at low altitudes.
Hypoxia can be recognised from both objective (i.e.,

capable of being perceived by an observer) and subjective
(i.e., perceived by the pilot only) symptoms. Objective signs
include increased rate and depth of breathing, tachycardia,
cyanosis (blue coloured lips and nails), mental confusion,
anger, euphoria, poor judgment, loss of muscle
coordination, slouching and loss of consciousness.
Behavioural changes may be noted by the hypoxic
individual, as well as by the observer. The subjective
symptoms include breathlessness, apprehension,
headache, dizziness, fatigue, nausea, hot and cold flashes,
blurred vision, tunnel vision, tingling, and numbness.
The Four Stages of Hypoxia
Hypoxia can be classified into four stages based on altitude

and the associated performance decrements and
physiological symptoms.
Indifferent Stage, 0 - 1,500 m (0 - 5,000 ft)

No physiological responses or performance decrements
related to hypoxia are typically observed between these
altitudes for a person in good health.
Complete Compensatory Stage, 1,500 - 3,500

m (5,000 - 11,400 ft)
Visual sensitivity at night is decreased by 10 percent at
1,500 m (5,000 ft) and by 30 percent at 3,000 m (10,000 ft).
Performance of new tasks may be impaired due to
memory issues. The nervous system, however, is able to
maintain its primary functions and performance, for the
most part, is unaffected.
Partial Compensatory Stage, 3,500 - 6,000 m

(11,400 - 20,000 ft)
Between these altitudes, a drastic increase in breathing is
needed to maintain proper cardiovascular function.
Nervous system functioning begins to degrade, but there

can also be great individual variability in the symptoms for
a given altitude.
Cognitive disturbances are typical at these altitudes. They

are characterised by two main components:
1. Loss of self-monitoring and cognitive feedback

2. Difficulty in thinking
The absence of self-monitoring makes it impossible for an

individual to recognise whether his or her actions are
hazardous. This, combined with slow thinking, can be
extremely dangerous. Many times fixation occurs or there is
a tendency to repeat an action without realising that the
action was just completed moments before. Judgment
becomes extremely poor and physical movement becomes
uncoordinated.
A pilot often will have trouble concentrating or may have

difficulty reading instruments. Delayed and/or imprecise
communications may result. Frequently, alterations in a
pilot’s voice are the first signs that something is wrong. An
example is when a pilot attempts to deliver altitude
information to the controller, but there is a noticeable delay
and the pilot has a lazy, dull tone to his or her voice. Many
potential accidents have been prevented when a controller
recognises these symptoms and notifies the pilot of the
need to take corrective action.
Such situations demonstrate the importance of knowing

the symptoms of hypoxia and the correct actions that must
be taken to resolve the situation. In a case such as the one
described above, it is important that the controller use
strong instructions to the pilot to take corrective action.
Because the crew may already be impaired by hypoxia,
they may have to be convinced that there actually is a
problem.
Effects of hypoxia on behaviour and mood

Sometimes a pilot receives instructions but is unable to
properly perform the mental or physical tasks needed to
perform the required actions. Figure 1 (below) shows how a
simple mental task becomes very difficult at high altitudes.

A person was asked to do a simple arithmetic task in an
altitude chamber. The altitude level was set at 6,000 m
(20,000 ft). The test consisted of counting backwards from
1,000 by increments of two. Almost immediately, the
subject made a large calculation error (went from 990 to
888), and writing was impaired to the point where it was
almost illegible. The subject was able to recover a few
seconds after receiving oxygen.
Figure 1: Simple arithmetic task in altitude chamber (6,000

m,; 20,000 ft); [1]
It is difficult to predict at what altitude behavioural
disturbances will occur and how long a person must be

exposed to a particular altitude before the onset of a
disturbance. Experiences may differ for the same pilot on
different days. Thus, it is nearly impossible for a pilot to
know exactly how his or her body will respond under
certain conditions.
Mood disturbances are generally extreme and can include

deep sorrow, uncontrollable laughing, nervous exhaustion,
attacks of aggressiveness and antisocial actions.
Sometimes a crew may appear to be drunk, and fighting
between crew members may occur. In most instances, only
breathing more oxygen will resolve the situation.
Sometimes a crew will enter a deep depressive state and

will experience a complete lack of will to conduct a task.
The crew may still be able to analyse the situation, but they
are unable to mount any practical response to it. “Nothing
can be done” is a frequent comment by a pilot who is
unable to act appropriately. Other times, a crew may react
with a behaviour that is the exact opposite of the behaviour
that should be implemented. For example, there have
been cases of crews intentionally depressurising the cabin
when there was a failure of the oxygen system.
The end of a hypoxia-involved crisis is usually very evident.

It often ends with a euphoric phase. This is often reported
in debriefings of military pilots who will sometimes submit
themselves to hypoxia intentionally. Some cases of
addiction to hypoxia and the euphoric state it can induce
have been reported among military pilots.
Sensory decrements
Vision is the first of the senses to be affected by a lack of
oxygen. This is especially true of night vision, which may
be affected as low as 1,500 m (5,000 ft) of altitude. Color
vision starts to deteriorate between 1,500-3,000 m (5,000
- 10,000 ft). At higher altitudes, the ocular muscles
become weakened and uncoordinated. The range of
accommodation is decreased which causes blurring of
near vision and subsequently difficulty in carrying out
near-vision-related tasks. Above 5,000 m (10,000 ft) of
altitude, the visual disturbances are more severe as

reaction time and responses to visual stimuli becoming
sluggish. Accommodation and convergence are
weakened and cause double vision. All problems,
however, can usually be reversed by the use of oxygen or
a return to sea level.
Hearing is particularly resistant to hypoxia which is one
reason many crew members have been saved from near
tragedy. Radio is the best way to communicate with a
pilot suffering from acute hypoxia. Simple orders from
pilots in other planes, controllers, or flight engineers have
been used to guide pilots to safety.
Critical Stage, above 5,500 m (18,000 ft)

Above this altitude, complete incapacitation can occur with
little or no warning. All senses fail, and a pilot will become
unconscious within a very short period of time. No stimuli
such as the radio will be able to help a pilot suffering from
hypoxia, especially fulminant hypoxia, above 5,500 meters
(18,000 feet).
Time of useful consciousness (effective

performance time)
Time of Useful Consciousness is defined as the amount of
time an individual is able to perform proper corrective or
protective actions under hypoxia in flight. This definition
explains why it is more useful to talk about effective
performance time (EPT) rather than time of useful
consciousness.
It is difficult to estimate universal values for EPT due to

individual variability influenced by endurance, experience,
physical exercise and the situation under which exposure
to high altitude has occurred. Two factors are crucial: the
proportion of O2 in the inspired gas prior to the
decompression and the level of metabolic activity at the
time of decompression. Approximated values of time of
Feedback
useful consciousness under air or O2 breathing, and for

these two conditions at rest or under moderate physical
exercise are shown in Table 1.
Table 1: Time of useful consciousness[2]

Figure 2 emphasises the deleterious effect of rapid
decompression at high altitude on EPT.
At the optimal level of cabin altitude of 2,500 m (8,000 ft),

the pressure of O2 in the lungs and in the pulmonary
vessels (PAO2 and PvO2, respectively) are equal to 96 and
40 hPa, such that O2 will flow from the lungs to the blood.
Upon rapid decompression at 12,000 m (39,000 ft),
PAO2 plummets so drastically and so quickly that it
becomes lower than PvO2. As a result, there is an
immediate reversal of oxygen flow from the blood to the
lung within four to five seconds following the
decompression. This depletes the blood’s oxygen reserve
and reduces the EPT at rest by up to 50 percent. Loss of
consciousness usually occurs within 10 seconds. However,
loss of consciousness does not mean that breathing will
stop. If a pilot puts the O2 mask on his face within the 5
seconds following the decompression, the lung pressure in
O2 increases to an effective value (80 hPa) and as result,
recovery from hypoxia occurs within seconds.
Two operational consequences result from this

phenomenon:
1. When a transport aircraft flies above 7,600 m (25,000 ft),

the rapidness of loss of consciousness makes it
mandatory to provide the crew an O2 device that can be
fitted on the face within five seconds. In case of cabin
decompression, putting the mask on the face becomes
an immediate and time critical emergency. It is
mandatory that the crew be effectively trained with the
procedures for donning the mask effectively. Crews must
be conditioned to apply this procedure by reflex prior to

taking any other action.
2. The threat of large variations in PAO2 following a
decompression supports the delivery of a gas enriched in
O2 into the cockpit in case of decompression when flying
above 2,500 m (8,000 ft). If the inhaled air contains at
least 40 percent additional oxygen, PAO2 will generally
remain within proper limits when between 2,500 - 12,000
m (8,000 - 39,000 ft). FAR 121.33e in the U.S. requires that
above 25,000 feet (7,600 m) one of the two pilots always
be fitted with an O2 mask. If the O2 mask is of the quick-
fitting type, it is required to be worn only above 41,000 ft
(12,500 m).
PAC
hPa
mmHg
96
72
80
60
40 P,Oat8,000ft
30
Figure 2: Evolution of the lung pressure in O2 (PAO2)
30seconds
following
22a rapid decompression. The O2 mask is put on the
16.55 seconds[3]
face within Possible
15 Lossofconsciousness
Preventing
12 Hypoxia
PAO2<P,O,
There are two methods for preventing hypoxia. One
method involves increasing barometric pressure to a
minimal value such that the concentration of oxygen is
Omaskputontheface
sufficient to prevent hypoxia from occurring. This is
generally done by pressurising the aircraft cabin. The other
Decompressionfrom8,000to39,000feet(753to197hPa"
method is to increase the breathable oxygen in a system
through the use of an O2 device. This is usually
accomplished by having a pilot wear an oxygen mask. It is
also possible to combine the methods to provide greater
assurance that hypoxia is prevented.
Cabin pressurisation
Pressurisation keeps the cabin barometric pressure (PBc) at
a value higher than the barometric pressure (PBz)
corresponding to the flight level. The inner-outer pressure
difference is generated by the difference between the
incoming and outgoing air flows.
What is controlled is either the cabin pressure or the inner-

outer pressure difference. Figure 3 demonstrates the
relationship between barometric pressure and altitude and
how pressurisation affects this relationship. In the initial
part of the ascent, the cabin pressure equals the outer
pressure, meaning that pressurisation is not triggered. In
the second part of the ascent, the pressurisation device
works to keep a constant cabin pressure. In the last part of
the ascent, the pressurisation device works to keep a
constant pressure difference, allowing pressure to decrease
so long as a constant difference between the cabin
pressure and outside pressure is maintained.
Pressurizationat
constantAP
Pressurization
atconstant
cabinpressure
Figure 3: Cabin pressurisation during the ascent of the

7' Absenceof
aircraft[3]
pressurization Barometri
Because aircraft pressurisation is effectively controlled by
on-board systems, crew and passengers can travel at high pressure
altitudes safely and in comfort. Supplemental oxygen
Pi
devices are usually not required, and everyone is free to 1013hPa
move about the cabin unhampered by oxygen masks or
760mmHe
other equipment.
As required in FAR and JAR 25, §841 concerning civilian

transport aircraft, hypoxia is prevented by maintaining a
cabin altitude below 8,000 feet (2,500 meters) in normal
flight conditions and below 15,000 feet (4,500 meters) in
case of “reasonably” likely conditions of failure; the main
components of the pressurisation device must be at least
redundant. Supplemental oxygen is required only when
cabin pressurisation fails.
Supplemental oxygenation
O2 devices are used in emergencies involving
pressurisation failure or the presence of smoke or fumes. In
normal night flying conditions, it can also be advantageous
for a pilot to use supplemental oxygen, especially in final
approach in order to overcome the impairment of
nocturnal vision normally experienced at 2,500 meters
(8,000 feet) of cabin pressure altitude.
FAR 121 prescribes the use of O2 devices as a function of

altitude (§327 to 337). Its key points are as follows:
Supplemental O2 is mandatory for all pilots in the range

of flight levels 100-120, except if the flight at this altitude
lasts less than 30 minutes; above FL 120, the use of
supplemental O2 is mandated without condition.
O2 must be available for at least 10 percent of the
passengers in the range of FL80-FL120, except if the flight
at this altitude lasts less than 30 minutes; same demand
for at least 30 percent of the passengers between FL120
and FL140. O2 delivery for all passengers above FL150.
So far, there is no corresponding JAR requirement.
Above 12,200 m (40,000 ft), 100 percent oxygen must be

breathed with additional pressure to achieve adequate
oxygenation to prevent hypoxia. This is termed Positive
Pressure Breathing (PPB). The level of positive pressure is
generated by the O2 device as a function of the altitude
level required to maintain PAO2 at the minimal value that
will allow a pilot to perform flight-saving procedures within
a few minutes. In other words, positive pressure is equal to
the difference between the environmental barometric
pressure and the needed lung pressure (196 hPa) allowing
PAO2 to be kept at 80 hPa.
Technique for pressure breathing

During PPB, breathing patterns are inverted as inspiration
becomes passive and easy and expiration becomes active
and difficult. As a result, breathing must be consciously
controlled to avoid hyperventilation. Practice is required to
become accustomed to this reversed breathing pattern.
The best technique for PPB is as follows:
Establish mental discipline to control breathing

When inhaling, maintain a conscious tension of the
respiratory muscles (diaphragm and abdominal muscles).
Control the expansion of the thorax through muscle
tension. As inhalation progresses, steadily decrease
muscle tension to allow progressive lung inflation
Pause when the desired lung inflation has occurred
When ready to exhale, positively increase muscle tension
for a steady, smooth exhalation
Pause and breathe at a rate slower than normal.
Summary of key points
Hypoxia remains a concern for all individuals involved in

flight safety.
Hypoxia is dangerous because it impairs cognitive and
physical performance, sometimes without the flight crew
realising that anything is wrong.
There is no way for physiological adaptation to hypoxia in
the aeronautical environment when there is a rapid
decrease in barometric and lung pressure.

Protection against hypoxia is mandatory. The main
protection tool is the pressurisation of the cabin. In case
of cabin pressurisation failure, supplemental oxygen is
required, according to some international mandates.
Pilots must be aware of issues related to hypoxia and
must be trained to wear and breathe through an
O2 mask.
Above FL 400 and in case of pressurisation failure, O2 is
delivered to the pilots with a positive pressure. A pilot
must be trained as to the proper technique for positive
pressure breathing.
Cross-References
The following Briefing Notes and Checklists complement

the above issues:
Stress and Stress Management

Well-Being
Lifestyle and Adverse Performance Effects
References
1. ^ Marotte (H.).- L’hypoxie. In: Physiologie aéronautique.

Editions S.E.E.S., Lognes, France, 2004, pp. 27-50. (from Dr
Henri Marotte, personal documentation)
2. ^ Sheffield (P.) ; Heimbach (R.D.).- Respiratory physiology.-
In: Fundamentals of Aerospace Medicine, DeHart (R.)
eds., Lea and Febiger, Philadelphia, 1985, pp. 91-102
3. ^ a b Marotte (H.), Toureé (C.), Clère (J-M.), Vieillefond (H.).-
Rapid decompression of a transport aircraft cabin:
protection against hypoxia. Aviat. Space Environ Med,
1990, 28(111), pp. 201-203.
Aviation medicine.- Ernsting (J.) ; Nicholson (A.) ; Rainford

(DJ) eds., 3rd ed., Butterworth-Heinemann, Oxford, 1999.
Hackworth (C.A.) ; Peterson (L.M.) ; Jack (D.J.), Williams
(C.A.), Hodges (B.E.).- Examining hypoxia: a survey of
pilots’ experiences and perspectives on altitude training.
Report DOT/FAA/AM-03/10, 2003.
Related Articles
Hypoxia
Category:
OGHFA, Crew Actions and Behaviours, Human
Factors
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Hypoxia (OGHFA BN) | SKYbrary Aviation Safety 5/9/22, 16:40

PORTALS BROWSERS THEMES TUTORIALS

Home » Portals » Human Performance » OGHFA

Hypoxia (OGHFA BN) Article

Hypoxia from exposure to altitude is due entirely to the

The first hypoxia-related casualties were reported in 1878

by Paul Bert as balloonists traveled high into the

Hypoxia can occur quickly, and the body’s ability to adapt

In aeronautics, hypoxia typically results from a

If there is a cabin rupture or other cabin depressurisation

If the loss of cabin pressure can be resolved quickly, the

Acute hypoxia is the term classically used to describe the

The effects of hypoxia begin immediately upon exposure to

any altitude above sea level. Below 3,500 m (about 11,000

Hypoxia can be recognised from both objective (i.e.,

The Four Stages of Hypoxia

Hypoxia can be classified into four stages based on altitude

Indifferent Stage, 0 - 1,500 m (0 - 5,000 ft)

Complete Compensatory Stage, 1,500 - 3,500

Partial Compensatory Stage, 3,500 - 6,000 m

Nervous system functioning begins to degrade, but there

Cognitive disturbances are typical at these altitudes. They

1. Loss of self-monitoring and cognitive feedback

The absence of self-monitoring makes it impossible for an

A pilot often will have trouble concentrating or may have

Such situations demonstrate the importance of knowing

Effects of hypoxia on behaviour and mood

simple mental task becomes very difficult at high altitudes.

Figure 1: Simple arithmetic task in altitude chamber (6,000

disturbances will occur and how long a person must be

Mood disturbances are generally extreme and can include

Sometimes a crew will enter a deep depressive state and

The end of a hypoxia-involved crisis is usually very evident.

altitude, the visual disturbances are more severe as

Critical Stage, above 5,500 m (18,000 ft)

Time of useful consciousness (effective

It is difficult to estimate universal values for EPT due to

useful consciousness under air or O2 breathing, and for

Table 1: Time of useful consciousness[2]

At the optimal level of cabin altitude of 2,500 m (8,000 ft),

Two operational consequences result from this

1. When a transport aircraft flies above 7,600 m (25,000 ft),

be conditioned to apply this procedure by reflex prior to

What is controlled is either the cabin pressure or the inner-

Figure 3: Cabin pressurisation during the ascent of the

As required in FAR and JAR 25, §841 concerning civilian

FAR 121 prescribes the use of O2 devices as a function of

Supplemental O2 is mandatory for all pilots in the range

So far, there is no corresponding JAR requirement.

Above 12,200 m (40,000 ft), 100 percent oxygen must be

Technique for pressure breathing

The best technique for PPB is as follows:

Establish mental discipline to control breathing

Summary of key points

Hypoxia remains a concern for all individuals involved in

decrease in barometric and lung pressure.

The following Briefing Notes and Checklists complement

Stress and Stress Management

1. ^ Marotte (H.).- L’hypoxie. In: Physiologie aéronautique.

Aviation medicine.- Ernsting (J.) ; Nicholson (A.) ; Rainford

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