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has been adopted by the European Joint Aviation Authorities as the basis of aeromedical risk assessment.
The 1% rule cannot apply to solo pilot flying in public transport operations, because it is derived from
two pilot operations and the availability of a second pilot to take over in the event of one pilot becoming
incapacitated. However, the 1% rule has also been applied to the private pilot population by some States,
on a pragmatic basis, such that a private pilot who develops a medical problem may be permitted to
continue to fly as a solo pilot if his risk of an incapacitation is 1% per annum or less. This acceptance of
an increased risk of incapacitation in a private pilot seems reasonable since the overall level of safety
demanded of private operations is less that that of commercial operations and it would therefore be out of
place to demand a professional pilot medical standard for private pilot operations.
The “1% rule” provides a rational, objective method of assessing the fitness of applicants. However, other
limits of acceptable incapacitation risk, such as 2% per annum, have been suggested. The important point
is that States should endeavour to define objective fitness criteria to encourage consistency in decisionmaking
and to assist in improving global harmonization of medical standards.
Causes of incapacitation
A dramatic form of pilot incapacitation, although not necessarily its most hazardous, is death in the
cockpit. A survey (1993 - 1998) of flight crew incapacitation on United States scheduled airlines recorded
five deaths in the cockpit, all owing to cardiovascular diseases. The youngest pilot was 48 years of age
ICAO Preliminary Unedited Version — October 2008 I-3-4
when he died. No case resulted in aircraft damage or operational incident. It should be noted that ICAO
introduced the requirement for incapacitation training in two-pilot operations in the 1970s and this has
undoubtedly reduced the risk to flight safety from pilot incapacitation.
Incapacitations from self-limiting illness may be less dramatic but are considerably more frequent. In two
studies of airline pilots, in 1968 and again in 1988, more than 3000 airline pilots completed an
anonymous questionnaire survey including questions about whether they had ever experienced an
incapacitation during a flight. In both studies, which revealed remarkably consistent results, about 30%
answered “yes”. However, only about 4% considered their incapacitation a direct threat to flight safety. In
both studies the most frequently cited cause of incapacitation was acute gastroenteritis (see Table 1).
Table 1. Causes of incapacitation in airline pilots, in order of frequency.
(Adapted from Buley, 1969; Green and James, 1991)
1. Uncontrollable bowel action (21%) and “other”
gastrointestinal symptoms (54%)
75%
2. Earache/blocked ear 8%
3. Faintness/general weakness 7%
4. Headache, including migraine 6%
5. Vertigo/disorientation 4%
As can be seen, most of these incapacitations are caused by gastrointestinal upsets which are usually
impossible to predict. Whilst they may represent little more than varying degrees of discomfort and
inconvenience, they can also be completely incapacitating. Here is an example taken from a pilot’s report:
Trip was normal up to time of incident. Approximately half-way between LAS and LAX, 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.
Trip landed safety at LAX with First Officer . . . at the controls. An ambulance was requested by the crew...
I was taken to the Daniel Freeman Hospital in LAX where . . . (I was given) . . . a diagnosis of
gastroenteritis. I think that spells food poisoning in our language. After some medication I felt wonderfully
relieved and was released from the hospital.
Fortunately, gastroenteritis rarely occurs so suddenly as to prevent a planned handover of control, thereby
minimizing the flight safety risk.
Pilot incapacitation is clearly both a traditional aeromedical problem and a straightforward training
problem. As long ago as 1970, a past Chief of ICAO’s Aviation Medicine Section, wrote:
“. . . It is suggested that acknowledgement of pilot on-duty incapacitation . . . as a permanent part of the air
transport industry scene in the foreseeable future constitutes a constructive rather than a defeatist medical
position. Further, it appears essential that the design, management, operational, training, and licensing
disciplines should recognize that pilot incapacitation must be given due weight . . . in the overall judgement
　
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