Pilot Incapacitation During Landing at VampulaAerodromeon24September2016

Investigationreport:L2016-01

2

SYNOPSIS

Pursuant to section 2 of the Safety InvestigationAct (525/2011), the Safety InvestigationAuthoritydecidedtoinvestigatetheaccidentwhichoccurredatTuulikki-Vampulaaerodromeon24September2016.KalleBrusi,MSc,wasappointedasteam leader fortheinvestigationgroup,accompaniedbyaeromedicalexaminerAdjunctProfessorAlpoVuorio,MD,PhD,andspecialist in forensicmedicineAnttiVirtanen,MD, as expertmembers of the investigationgroup.ChiefAirSafetyInvestigatorIsmoAaltonenactedasinvestigator-in-charge.

The investigation report presents the events before and after the accident. In addition, itaddressestheconductoftherescueoperationandanalysesthecontributingfactors.Finally,the report makes safety recommendations which, when implemented, could help avoidsimilaraccidentsoratleastmitigatetheirconsequences.

The objective of safety investigation is to increase safety and to prevent accidents andincidents and thedamage they cause. Safety investigationdoesnotapportion anypossibleblameor liability.Useofthereport forreasonsotherthan improvementofsafetyshouldbeavoided.

In accordance with the Safety Investigation Act (525/2011) the person conducting aninvestigationhastheright,fortheconductoftheinvestigation,toreceiveessentialinformationregarding the health of persons involved in the accident. This report examined the pilot’smedicalhistory indetail inorder toestablish thecause for thepilot’s incapacitation.Manysudden incapacitationsarecausedby cardiovasculardiseases,both ingeneralaviationandcommercial aviation. The investigation took into consideration that aeromedical decision-making followsuniformpractices in fitnessassessments following aheartattackasregardsprivateandcommercialpilotsandairtrafficcontrollers.

Those involved in the accident and the relevant supervisory authorities were given anopportunitytoprovidecommentsonthedraftfinalreport.Theircommentsweretakenintoconsiderationinfinalisingthereport.Asummaryofthecommentsisattheendofthereport.Thecommentsprovidedbyprivatepersonsarenotpublished.

Theinvestigationreport,includingitssummaryandappendices,ispublishedontheinternetpage of the Safety Investigation Authority at www.turvallisuustutkinta.fi (Finnish) andwww.sia.fi(English)

InvestigationL2016-01 Coverphoto:FinnishPolice;anindividualhasbeeneditedoutofthephoto.InvestigationReport7/2017ISBN:978-951-836-489-7(PDF)

3

TABLEOFCONTENTS

SYNOPSIS.......................................................................................................................................................................2

1 FACTUALINFORMATION...............................................................................................................................5

1.1 Historyoftheflight..................................................................................................................................5

1.2 Injuriestopersons...................................................................................................................................7

1.3 Damagetoaircraft....................................................................................................................................7

1.4 Otherdamage.............................................................................................................................................7

1.5 Personnelinformation............................................................................................................................7

1.6 Aircraftinformation.................................................................................................................................7

1.7 Meteorologicalinformation..................................................................................................................8

1.8 Aerodromeinformation.........................................................................................................................8

1.9 Rescueoperationandsurvivalaspects............................................................................................8

1.10 Medicalandpathologicalinformation.........................................................................................8

1.10.1 Thepilot’smedicalhistory...........................................................................................................9

1.11 Medicalcertification..........................................................................................................................12

1.11.1 Aeromedicalexamination...........................................................................................................12

1.11.2 Limitations........................................................................................................................................13

1.11.3 Medicalexaminationprotocol..................................................................................................13

1.11.4 Obligationsofthelicenceholder.............................................................................................14

1.11.5 Doctors’dutyofnotificationinaviation...............................................................................14

1.11.6 Doctors’dutyofnotificationinroadtraffic.........................................................................14

1.12 Incapacitation......................................................................................................................................15

1.13 Riskafterrecoveryfromheartattack........................................................................................15

1.14 Recoveringfromheartattackintermsofaeromedicaldecision-making....................16

1.14.1 InternationalCivilAviationOrganization(ICAO)guidelines.......................................16

1.14.2 TheaeromedicalguidelinesoftheEuropeanAviationSafetyAgency(EASA)......16

1.14.3 TheguidelinesoftheUKCivilAviationAuthority............................................................17

1.14.4 SpecialfeaturesintheguidelinesoftheAustralianCivilAviationSafetyAuthority(CASA).................................................................................................................................................17

1.14.5 SpecialfeaturesintheguidelinesoftheCanadianCivilAviationSafetyAuthority(TransportCanada)........................................................................................................................................17

1.14.6 Summaryofthespecialfeaturesininternationalguidelines.......................................18

1.15 Obstructivesleepapnoeaandcoronaryheartdisease........................................................18

4

1.16 TheroleoftheSafetyManagementSysteminaeromedicaldecision-making...........18

2 ANALYSIS............................................................................................................................................................20

2.1 Analysisoftheaccident........................................................................................................................20

2.1.1 Medicalcertifications...................................................................................................................20

2.1.2 Thefirstheartattack....................................................................................................................21

2.1.3 Thesecondheartattackandobstructivesleepapnoea..................................................21

2.1.4 Thethirdheartattack..................................................................................................................21

2.1.5 Thefourthheartattack................................................................................................................21

2.2 Coronaryheartdisease.........................................................................................................................21

2.3 Overallriskassessment........................................................................................................................22

2.4 Significanceofthedutyofnotification...........................................................................................22

2.5 Thepilot’shealthcare...........................................................................................................................22

2.6 Analysisoftherescueoperation.......................................................................................................23

3 CONCLUSIONS..................................................................................................................................................24

3.1 Findings......................................................................................................................................................24

3.2 Probablecauses.......................................................................................................................................26

4 SAFETYRECOMMENDATIONS...................................................................................................................27

4.1 Providinganinternationalprocessforariskassessmentafterheartattack..................27

4.2 Aeromedicalexaminers’competencybasedrecurrenttraining..........................................27

4.3 Doctors’nationaldutyofnotification.............................................................................................28

4.4 Safetyofgeneralaviationandsportaviation..............................................................................28

REFERENCES.............................................................................................................................................................30

SUMMARYOFTHECOMMENTSTOTHEDRAFTFINALREPORT........................................................31

Appendix1.AcciMappresentation

5

1 FACTUALINFORMATION

1.1 Historyoftheflight

TheaccidentoccurredonSaturday,24September2016tothepilotofaCessna172Naircraft,registration OH-COV. Prior to the accident flight the pilot flew the aircraft from Euraaerodrome inKauttua toTuulikki-Vampulaaerodrome inHuittinen.Thepilothad tohand-starttheenginebyswingingthepropellerbeforedepartingfromKauttua.Duringtheenginestartprocess thepilottook a15minutebreakand then tookoff forthe flightat11.47.Theflightlastedapproximately15minutes.

At12.21 thepilot tookoff fromTuulikki-Vampula aerodrome for a local flight.During theflightthepilotreportedthathewouldlandearlierthanplannedbecausehedidnotfeelwell.During the landing, a little before reaching runway 28, the aircraft almost collidedwith atrench.Thepassengerwarnedthepilotofthisandthepilotquicklycorrected thesituation.Followingthis,theaircraftdriftedtotherightandofftherunway(Figure1).Therightwingcollidedwithalightfixtureatthesideoftherunway.Thepilotagainsteeredtheaircraftbacktowards the runwayand applied thebrakes.At the taxiway intersection thepilot failed tosufficientlyturntheaircraft;asaresulttheaircraftwentdiagonallyacrossthetaxiwayintoaditchatlowspeed.Thishappenedat12.36.

Almostimmediatelyafterdeplaningthepilotcollapsedtotheground.Thepassengercalled112(theemergencynumber)at12.38.Thedoctorthatarrivedintheambulancepronouncedthepilotdeadat13.36.

6

Figure1.AerialphotoofVampulaaerodrome.The trackof the flightand the taxiingwasdrawnbyusingGPSdata.(Basemap:KTJ/MinistryofJustice/NationalLandSurveyofFinland)

1.

2.

3.

4.

5.

6.

AphotosequencetakenbyVampula’sCCTVcameras.Photos1and2showthelowapproach.Photo3shows the touchdown at the side of the runway. Photo 4 shows the correction back towards therunway.Photos 5and6show the taxiing into theditchat lowspeed. (Allrightsreserved:LeeviK.Laitinen)

7

1.2 Injuriestopersons

The pilot died as a result of the sudden attack.While the passengers did not sustain anyinjuries, one of them had a sudden attack during the course of the events and had to behospitalisedimmediatelyfollowingtheaccident.Hence,inaccordancewithICAOdefinitions,thepassengerwasseriouslyinjured1.

1.3 Damagetoaircraft

Theaircraftsustainedsignificantdamage.Nodetaileddamageassessmentwasmade.Amongotherthingstherightwing,thepropellerandtheenginemountweredamaged.

1.4 Otherdamage

Thelightfixtureatthesideoftherunwaybrokewhentherightwingcollidedwithitduringthelanding.

1.5 Personnelinformation

Thepilotwas65yearsold.HeheldaPrivatePilotLicencePPL(A)2.Therequiredratingfortheflightwasvalid.Therequiredclass2medicalcertificatehadexpiredon3October2015.TheLightAircraftPilotLicence(LAPL)medicalcertificatewasvaliduntil3October2016.Forthisreason,thepilotwasnotmedicallycertifiedforthisflight.Hehadflownaltogether19flightssince3October2015.

Table1.Thepilot’sflyingexperience

Flightexperience

Last24hours Last30days Last90days Total hours andlandings

Alltypes Approx30min2landings

Approx30min2landings

Approx2h20min10landings

498h30min501landings

1.6 Aircraftinformation

Theaircraftwasafour-seatCessna172N,designed forgeneralaviation.ItsregistrationwasOH-COVanditwasairworthy.

The aircraft was fitted with a recording GPS device. The recorded data were used inestablishing thehistoryof the accident flight. In addition, theprevious flight’s informationwasdeterminedfromtherecording.

1 ICAOAnnex13.Chapter1.Definitions2ThePPL(A)isaPrivatePilotLicenceforAeroplanes.

8

1.7 Meteorologicalinformation

From11.30 to12.30 the temperature variedbetween+9 °Cand+10 °C.Theweatherwascloudyornearlyovercast.Itdidnotrain.Themeasuredten-minuteaveragewindatKokemäkiwas3–4m/s,gustingto5–6.5m/s.Thewindswerenorth-westerly(300–320degrees).

1.8 Aerodromeinformation

Tuulikki-Vampulaaerodrome (EFVP) issituated inHuittinen.AerodromecoordinatesareN61°2'18.774"E22°35'35.176".

1.9 Rescueoperationandsurvivalaspects

Twophone callsweremade from theaccident site.The first callwas receivedby thePoriEmergencyResponseCentre(ERC)at12.38.DuringbothphonecallstheERCoperatorstriedtoestablishthesiteandthetypeoftheaccidentaswellasthenumberandconditionofthecasualties.Inaddition,thecallerwasrequestedtocontacttheERCagain,shouldthesituationchange.

The first alarm was given at 12.40, approximately 90 seconds from the beginning of theemergency call. The ERC, following its risk assessment of an “air accident,medium size”,launched a rescue operation.Thedispatched units included: theRescueChief, four rescueunits,aHEMShelicopter,anEMSphysicianinaMobileIntensiveCareUnit(MICU),theEMSSupervisor, fourEMS (ambulance) units and a BorderGuard helicopter.At 12.46 theERCreportedtheoccurrencetotheAeronauticalRescueCoordinationCentre(ARCC).

The first rescue unit arrived at the site at 12.51. Three rescue units and four EMS units,including theMobile IntensiveCareUnit,weredispatched all theway to the site.The firstambulancearrivedatthetarget12.56.Therescueunitsweretaskedtoprepareforinitialfireextinguishingandtopreventafirebyswitchingoffthemainpowerandshuttingoffthefuelsupply.Inaddition,thefuelthatleakedintotheditchwasremovedbyanoilabsorbentboom.Some rescue units had no task; they were standing by. The EMS units participated inprovidingmedicalcaretothepilotandincheckingtheconditionofthepassengers.TheEMSSupervisormanagedthesituationremotelyuntiltheEMSphysicianarrivedatthesite.

1.10 Medicalandpathologicalinformation

Pursuant to theSafety InvestigationAct (525/2011) theperson conductingan investigationhastheright,fortheconductoftheinvestigation,toreceiveessentialinformationregardingthehealthofpersonsinvolvedintheaccident.

9

1.10.1 Thepilot’smedicalhistory

Thepilothadhis firstaeromedicalexamination in1995and, following this,heheld avalidmedicalcertificatealmostwithoutinterruption.Priortotheaccidentthepilothadhadthreeheartattacks.

Figure2.Thepilot’sheartattacksandaeromedicalexaminationsshownonatime-scale.

Heartattackin2011

Thepilothadhis firstheartattack inMarch2011,at theageof59.Prior to thishehadnohistoryofheartdisease.Balloonangioplastywasperformed inthreedifferentplacesonthenarrowed left coronary artery; theywere then stented3.Following theprocedure thepilotreceived medication to halt the progress of coronary heart disease and was placed onanticoagulantsfor12months.Healsohadanechocardiogramexaminationduringtheperiodofhishospitalisation.

In a follow-upexamination inMay2011at thehospital thepilotwas reminded tovisit anaeromedical examiner (AME)before continuing to fly. InAugust2011 thepilotbookedanappointmentatanAME forthepurposeofobtainingaclass24medicalcertificate.TheAMErecommended that the certification be granted. The licensing authority handled theapplicationanddemanded,asadditionalinformation,thatcopiesofthemedicalrecords,the

3 Stentingmeansplacingadevicemadeofmetalmesh,inconjunctionwithballoonangioplasty,atthesiteofanarrowingcoronaryarterytokeepthearteryopen.

4 PrivatepilotmedicalcertificaterequirementsarebasedonEASAPartMEDregulations.Themedicalcertificateisvalidfor12monthsforpersonsolderthan50.

10

result of a stress echocardiogram5, a 24-hourECGmonitoring6 test and the cardiologist’s7evaluation be produced by October 2011. The licensing authority ordered the requiredmedicalrecordsstraightfromthehospital.Thepilotunderwenta24-hourHoltermonitortestin September.Additionally, inNovember he also underwent an exerciseECG examination8undermedications duringwhichno indications of oxygen deprivation in the heartmusclecould be found. The previously-required stress echocardiogram was not done. Followingthesetests,inMarch2012theAMErecommendedthatthemedicalcertificationbegranted.The licensingauthority issued themedicalcertificatewith thecondition that, inaddition tothe aeromedical examination, for the next medical examination the pilot would have toproducetheresultsofanexerciseECGtestandacardiologist’sevaluation.

InFebruary2013,beforethenextaeromedicalexamination,thepilotunderwentanexerciseECGunderhisregularmedications.Nosignsofoxygendeprivationintheheartmusclewerefound.The summary-partof the test results sufficed as the cardiologist’s evaluation. In anaeromedical examination in March 2013 the AME noted that the pilot’s health met therequirements for a medical certificate. The condition on which the certification could berevalidatedwasthat,inadditiontotheaeromedicalexamination,hewouldhavetoproducetheresultsofanexerciseECGandacardiologist’sevaluation.Thelicensingauthoritygrantedthemedicalcertificationwiththeabove-mentionedlimitation.

Heartattackin2013

The pilot had his second heart attack at the age of 62 in September 2013. This time thecoronaryarterywasadifferentonethantheoneaffectedin2011.Theheartattackoccurredapproximately seven months after having received medical certification. The narrowedbranchofthe leftcoronaryarterywastreatedwithangioplasty/stenting inoneplace.Whiletheearliercoronaryarterystents,putinplacein2011,werestillopen,clinicalmanifestationswere found across the entire wall of this coronary artery. During the hospitalisation anechocardiogramwasperformedonthepilot.Thetestrevealedaclearpostinfarctscar.Also,inthepost-mortemexaminationwidespreadfibrosisandfibroticscarringwasdiscoveredontheposteriorwallof the leftventricle.During thehospitalisation thepilotwasreminded tovisitanaeromedicalexaminer(AME)beforecontinuingtofly.

5 Anultrasoundscan,combinedwithanexercisetest.6 A24-hourelectrocardiogram(ECG).Atesttomonitortheelectricalactivityoftheheart,akaaHoltermonitortest,isused

todiagnosearrhythmias.The24-hourECGwillrevealwhetherthearrhythmiasareofasupraventricularorventricularnature.

7 Consultantspecialisedinheartdiseases.8 AnexerciseECGisdonewhencoronaryheartdiseaseissuspectedorwhenthebehaviourofsomearrhythmias,orlung

performance,isexamined.Duringthetesttheheartisstressedtothepointthatanypossiblenarrowingcoronaryarterieswillresultinoxygendeprivationintheheartmuscle(myocardialhypoxia).

11

Inearly2014 thepilotwasdiagnosedwithsevereobstructivesleepapnoea. Inresponse tothisContinuousPositiveAirwayPressure(CPAP)treatment9wasinitiated.

In July 2014 the pilot had an aeromedical examination. The AME had the results of theechocardiogram, done during the hospitalisation in 2013, and of the exercise ECG undermedications, performed inMay 2014. The AME granted themedical certification, but thelicensing authority did not revalidate it for the time being, due to the pilot being onanticoagulants.

Once the anticoagulant medication ended in October 2014, the pilot had yet anotheraeromedicalexamination.AtthistimetheAMEwasawareofthesleepapnoea,diagnosedinearly 2014. The AME granted the medical certification in October 2014 but the licensingauthority returned themedical certificationback to theAMEbecauseof technical reasons.Although, the medical certification was valid from October onwards. As part of theexaminationthepilotunderwenta24-hourHoltermonitortestinJanuary2015.Thepilotalsosawacardiologist.Onthebasisofthesetests,theAME finalisedthemedicalcertification inJanuary2015.ThelicensingauthoritycheckedtheAME’smedicalassessmentwithinthesamemonthbutdidnothavethecardiologist’sstatementortheresultofHoltermonitoring.

Heartattackin2015

ThepilothadhisthirdheartattackinlateJanuary2015attheageof63.Theheartattackwascausedbyblockage in theverysamecoronaryartery,whichhadbeen thecauseofthe firstheart attack. The narrowed branch of the left coronary artery was treated withangioplasty/stentinginoneplace.Inthepost-mortemexaminationfibroticscarlesionswerefoundon allwallsof the left ventricle.During thehospitalisationnomentionof thepilot’sflyinghobbywasmadeinhismedicalrecords.Thisinformation,however,wasmentionedintherecordsofhis twopreviousheartattackhospitalisations.Following theheartattackthepilot did not contact his AME or the licensing authority. In May 2015 the pilot flew aproficiency check flight to obtain revalidation for a SEP rating10. He continued to flyindependentlyinAugust2015.

AssociatedwiththetreatmentofillnessthepilotsawadoctorinSeptember2015.Atthetimeitcameupintheconversationthathis‘flyerdrivinglicence’wasstillvalidandthathewouldseetheAME inearly2016.During theSeptembervisit thedoctorwasconcernedabouttheeffectsof lowbloodpressure to thesafetyof flight.Thepilotrevisited thedoctor inMarch2016 for a follow-upassessmentandat that time thedoctorrecorded thathispilot licencewasvalidandthatthepilotshouldseetheAME inearlyOctober2016.Inmid-August2016thepilot saw adoctorbecausehewas feelingunwell,butno suspicionofheart symptomsaroseduringthevisit.

9 Moderateorsevereobstructivesleepapnoea(OSA)isprimarilytreatedwithaCPAP(ContinuousPositiveAirwayPressure)deviceusedduringsleep.

10 Single-enginepistonratingforaeroplanes.

12

Thedayoftheaccident

Onthedayoftheaccidentthepilotgotexceptionallyoutofbreathbecauseofhavingto‘handprop’theengine.After the final flighthe feltreally ill.TheEMSunitarrivedat thesiteand,judging by an electrocardiogram, it appeared that he was presently experiencing a heartattack.Thiswouldbehisfourthheartattackwithintheperiodoffiveandahalfyears.Despiteattemptstoresuscitatethepilot,hedied.

Post-mortemexaminations

During thepost-mortemexamination itwasnoted that thedeceasedhad suffered from anenlarged heart, which exhibited clinical manifestations in all three main branches of thecoronary arteries. There was severe atherosclerotic narrowing at the orifice of the rightcoronaryartery,andthepreviouslyinstalledmetalmeshstentsholdingopenthebranchesoftheleftcoronaryarterywerestilltobefound.Theclinicalmanifestationsinthebranchesoftheleftcoronaryarteryweremoderate,continuingallthewaytotheperipheryofthesmallcardiacarteries.Fibrotic lesionswere foundon themuscularwalloftheheart in theentirecoverage areaof allmain coronarybranches.Fibrotic scarswere extensivelynotedon theposteriorwalloftheleftventricle,theinterventricularseptumandtheanteriorwalloftheleftventricle.Ofthese,thelesionontheposteriorwalloftheleftventriclewasalreadydetectedinanechocardiogramin2013.Inadditiontotheoldfibroticlesions,manifestationssuggestingarecentmyocardialinfarctwerealsofound.

Forensictoxicologytestsadministeredonthesamplestaken fromthedeceasedrevealednoalcoholordrugs thataffect thecentralnervoussystemandwhichcouldhave impaired thesubject’sperformanceorjudgment.Thesamplescontainedtracesofamedicineprescribedtotreatthesymptomsofcoronaryarterydisease.

1.11 Medicalcertification

Applicantsfor,orholdersof,privatepilot,sailplaneandhot-airballoonlicencesmustholdatleastaclass2medicalcertificate.Class2medicalcertificationalsoincludestheprivilegesandvaliditiesofaLightAircraftPilotLicence(LAPL)medicalcertificate.

AnLAPLholderisallowedtoflyanaircraftwithamaximumtake-offmassoflessthan2000kg.AnLAPLmedicalcertification is sufficient foranLAPLholder.APPL licencerequires avalidclass2medicalcertification.APPLlicencedoesnotincludeanLAPLlicence.

BothLAPLandPPL licenceholdersareallowed to fly theCessna172N typeaircraft,whichwasinvolvedinthisaccident.

1.11.1 Aeromedicalexamination

PPL licenceholdersolder than50yearsofagemust takeannualaeromedicalexaminations.This assessment isdoneby an aeromedical examiner (AME).TheAMEassesses thepilot’sfitness for flying by using the European Aviation Safety Agency’s (EASA) Part-MED

13

aeromedicalregulationsasaguideline.Until2009theRegulationswereknownasJAR-FCL11.Forexample,theRegulationsdefineindetailthetestsonthebasisofwhichthepilot’sfitnessto fly isassessed followingaheartattack.Thepresentpost-heartattackassessmentcriteriaareidenticalwiththoseoftheJAR-FCL.

Duringanaeromedicalexaminationthepilotfillsinadetailedapplicationform.Togetherthepilotand theAMEcomplete theaeromedicalapplication formandconfirm the informationwith their signatures. Following this, the AME performs the examination which includes,amongother things,visionandhearing testsaswellasanevaluationof thesignificanceofpossible illnesses to themedical certificate.TheAMEmayrenewor revalidate themedicalcertificate,orlengthentheperiodofvalidity,onlyiftheapplicanthasproducedallpertinentpersonalhealthinformationaswellasothermedicalexaminationreportsandtestresults.

1.11.2 Limitations

Iftheapplicantdoesnotmeetalloftherequirements forthemedicalcertification,theAMEmustassesswhetheritispossibletograntthecertificationwithlimitations.Inthiscase,themedicalcertificateissuedbytheAMEwillincludealimitation,orlimitations.

Forexample,thecertificatemayincludeanoperationalsafetypilotlimitation(OSL)inwhichcasetheholderofthemedicalcertificatealwayshastoflywithsomeonewhoholdsapilot'slicence.ThereareonlyafewOSL-limitedpilotsinFinland.AnOPL-limitedpilotisnotallowedtotransportpassengers.TheAMEcanlimitthevalidityperiodofthemedicalcertificate(TMLlimitation),ororderanotherspecialrestrictionasspecified(SSL).

1.11.3 Medicalexaminationprotocol

Followinganaeromedicalexamination thepilotreceives a signedmedicalassessment.Thepresentpracticecameintoeffectinthespringof2013.Itconstitutestheexaminer’sdecisionon advising whether the person is fit, unfit or referred to the licensing authority, theAeromedical Centre (AeMC) or the AME as applicable. The AME can ask for any expertopinionsthatarerequired.AccordingtopresentpracticetheAME,asarule,takesthedecisionwhethertograntthemedicalcertification.

ThispracticeenteredintoforceatthesametimetheFinnishTransportSafetyAgency’sTrafficMedicineUnit introduced theEMPIC®FCL-M informationsystem inMay,2013.Thegoalofthesystem,amongotherthings,istosupportdecision-makingandthemanagementofthebigpicture.PreviouslytheAMEswouldreferthedecisiontograntthecertificatetothelicensingauthority,which,atthetime,usedthenationalinformationsystem.

11 TheJAR-FCLwerebasedontheregulationsoftheEuropeanJointAviationAuthorities(JAA).FollowingtheadoptionofRegulation(EC)No1592/2002,themainfunctionsoftheJAAwereabsorbedintotheEuropeanAviationSafetyAgency.

14

1.11.4 Obligationsofthelicenceholder

Licenceholdersmaynotusetheprivilegesof themedicalcertificate if theyknowthattheirstateofhealth is impaired.Moreover,holdersofmedicalcertificationmust,withoutunduedelay,contactanAMEoranAeroMedicalCentreiftheyhaveundergoneasurgicaloperationoraninvasiveprocedure.

1.11.5 Doctors’dutyofnotificationinaviation

WiththeexceptionofAMEs,Finnishdoctorsarenotrequiredtonotifyanydiagnosedchangeinthestateofapilot’shealththatjeopardisesflightsafety.However,pursuanttotheAviationAct, they are permitted to notify diagnosed changes in health or consult the aviationauthorities. Finland differs from, for example, Norwegian practice where all doctors arerequired to notify such cases. InNorway theobligation even extends to psychologists andopticians.Doctorshavehad thedutyofnotificationsince1982,and ithasbeenspecificallylaiddownintheNorwegianHealthPersonnelAct12.Theprovisionhasresultedinfiveannualnotifications,onaverage.Someofthecases,whichfallunderthiscategory,willprobablynotbenotified.Ontheotherhand,thetrainingprovidedtodoctorsregardingthescopeoftheactdidincreasethenumberofannuallynotifiedcases.

1.11.6 Doctors’dutyofnotificationinroadtraffic

Since2004Finnishdoctorshavehad theduty tonotify to theauthority that issuesdrivers’licences.Asof 1 January2016 thenotificationmustbemade to thepolice if thedriverhasbeendeterminedtobeunfittodrive forat leastsixmonths13.This legislationis foundedontheGovernmentResolutionrequiringimprovementsintheexchangeofinformationbetweendoctorsandtheauthorities.Aspartoftheprocess,preliminarystudiesweremadebeforethelegislation was enacted and, following this, reports have been published regarding theviabilityoftheActfromtheperspectivesofvariousactors.

WhentheActwasbeingdrafteddoctorsfearedthatthedutyofnotificationwouldnegativelyimpactthedoctor-patientrelationship,includingthepreservationoftrustinthatrelationship.Thisconcernhasnotcompletelygoneawayamongdoctors,evenafter theActentered intoforce.TheLINTUResearchProgramme14 forestablishingtheeffectsoftheActrevealedthatthenotificationsbeingmadebydoctorsonimpaireddrivingfitnesshaveincreased.However,theproblemisthatdrivinghealthrarelycomesupduringadoctorappointmentifthepurposeofthevisitisnotdirectlyassociatedwiththerighttodrive.

Thedutyofnotificationseems toworkwell,especially in thecaseofdriversolderthan65.Still, even then the majority of the notifications are made because of impaired mental

12 CorrespondencewithCivilAviationAuthority–NorwayinFebruary2017.13 FinnishTransportSafetyAgency.3February2016.Assessingfitnesstodrive:aguidefordoctors.14 Peräaho,M.,Laapotti,S.,Katila,A.,Hernetkoski,K.,(2012).“Doctor’sobligationtoinformthepolicewhenadriver’sfitness

todriveisimpaired:threeviewsonhowtheprocessworks.”.LINTUResearchProgramme.http://www.lintu.info/ILMO.pdf.Retrieved14.4.2017

15

functions.Thesystemdoesnotworkwellfordriversyoungerthan65yearsofageorforthosewithproblemsofsubstanceabuse.IntheLINTUResearchProgrammedoctorsbroughtupthelack of training on driving fitness assessment. The research also revealed clear variationamongdoctorsregardingtheirnotificationthreshold.

1.12 Incapacitation

Pilot incapacitation is the termused todescribe the sudden inabilityofpilots to carryouttheir normal duties. In general aviation incapacitation represents approximately 1.5% ofaccidents that result in fatalities15. Incapacitation can be partial or complete. In partialincapacitationthepilot’sfunctioningisimpairedbutdoesnotresultinatotallossofcontroloftheaircraft.Thecausemaybeapilot’slong-termillnesswhich,whenactivated,impairstheirability to function. Incapacitation can appear suddenly or gradually. An Australian studyfoundthatwheremedicalconditionsorincapacitationoccurred,themostcommoncause,50per cent of cases, was heart attack16. The study also stated that in 10 per cent of theincapacitationstheoutcomeoftheeventwasafatalaccident.Accordingtoarecentstudy,insixpercentofthefatalaccidentsinvolvingprivatepilotsbetween60–63yearsofageautopsyreportsfoundcausalassociationbetweenamajordiseaseandtheaccident17.

InBritain,professionalpilotshad36casesofincapacitationin200418.Halfoftheseoriginatedinthecirculatorysystemoftheheartorthebrain.Six incapacitationswerecausedbyacuteheartattacks.NowadaystheECCAIRSPortal(EuropeanCoordinationCentreforAccidentandIncidentReportingSystems)recurrentlyreceivesreportsofincapacitationsrelatedtocardiacevents.

1.13 Riskafterrecoveryfromheartattack

Eventhoughstentingtreatmentreducestheriskofrecurrence,theriskofanewheartattackisalwayspresent.Thehighestriskofrecurrenceisduringthefirstyearfollowingtherecoveryfromaheartattack.Evenaftersevenyears,theriskofaheartattackis2-3timeshigherthannormal.Approximatelyone insevenheartattacksurvivorshadanotherheartattackwithinsevenyears.Itisworthnotingthattheriskofrecurrencegrowswithage.Thetreatmentforrecoveringheartattackpatientsmustbeeffectivebecausetheyhaveahighriskofhavingaheartattackanddyingofit.19

15 Booze,C.F.,Pidkowicz,J.,Davis,A.,Bolding,F.(1981).“Postmortemcoronaryatherosclerosisfindingsingeneralaviationaccidentpilotfatalities:1975-77.”Aviation,SpaceandEnvironmentalMedicine,Vol.52,pp.24-27.

16 AustralianTransportSafetyBureau(2007).“Pilotincapacitation:analysisofmedicalconditionsaffectingpilotsinvolvedinaccidentsandincidents1January1975to31March2006.”AviationResearchandAnalysisReport–B2006/0170.

17 Vuorio,A.,Asmayawati.S.,Budowle,B.,etal.(2017).“GeneralAviationPilotsOver70YearsOld”.AerospaceMedicineandHumanPerformance.Vol88(2),pp.142–145.

18 Evans,S.,Radcliffe,S-A.(2012).“TheAnnualIncapacitationRateofCommercialPilots”.Aviation,SpaceandEnvironmentalMedicine,Vol83,pp.42-49.

19 Smolina,K.,Wright,L.,Rayner,M.,Goldacre,M.J.(2012).“Long-TermSurvivalandRecurrenceAfterAcuteMyocardialInfarctioninEngland,2004to2010.”.Circulation:CardiovascularQualityandOutcomes,Vol.5,pp.532-540.

16

1.14 Recoveringfromheartattackintermsofaeromedicaldecision-making

In addition to aeromedical regulationsmany countries have guidelines for the purpose ofmakingiteasiertoapplythelegislation.AeromedicalguidelinesexplainhowtheAME’sfitnessassessmentmusttakesomeonerecoveringfromaheartattackintoaccount.

1.14.1 InternationalCivilAviationOrganization(ICAO)guidelines

The ICAO’s Manual of Civil Aviation Medicine20 states that One of the major purposes ofmedicalexaminations…is toassess theprobabilityof amedicalcondition resulting in in-flightincapacitation. Based only on such an assessment can the authority objectively considercertification that is compatiblewithgenerallyaccepted flight safety standards…Themedicalexaminer is in many cases handicapped in making such an assessment, because adequatepredictive epidemiological data are not available for the condition itself or, if they are, theycannot be readily applied to the flight environment. This situation is, however, improving.Figuresfortheriskofafuturecardiaceventinanindividualrecoveringfromacommoncardiacproblem such asmyocardial infarction are available21.During the past thirty years severalaviation cardiology conferences have been held in Europe. The goal has been to improveaeromedicaldecision-makingwithregardtoheartdiseases.ICAOprovidesguidanceintermsofcardiacriskassessmentintheICAOManualofCivilAviationMedicine.

Inshort,itcanbesaidthatthemostrecentepidemiologicalevidenceregardingtheprognosesofmodern cardiology treatments, such as stenting,makes it possible to assess the risk ofrenewed cardiac events as regards recovering patients. This facilitates dividing pilots intodifferentriskcategories.

1.14.2 TheaeromedicalguidelinesoftheEuropeanAviationSafetyAgency(EASA)

Ingeneral,European countries complywithCommissionRegulation (EU)No1178/201122.TheEASA’sAcceptableMeansofCompliance(AMCPart-MEDandAMCPart-ATCO.MED)andthe (Finnish language) guidancematerial of the Finnish Transport Safety Agency’s TrafficMedicineUnitstatethefollowing:

At least6months from the ischaemicmyocardialevent, the following investigationsshouldbecompleted: an exercise ECG…an echocardiogram…a myocardial perfusion scan or stressechocardiogram…furtherinvestigationsmaybenecessary,amongotherthings,toassesstheriskofany significantarrhythmias. Inaddition, it isstated that thewholecoronaryvascular tree

20 ICAO.(2012).“ManualofCivilAviationMedicine”.Annex1,Chapter6–6.3.2.5.1.Doc89843rdedition.ISBN978-92-9231-959-5.

21 ICAO.(2012).“ManualofCivilAviationMedicine”.Part1.Chapter3.Medicalstandardsandpreventionofpilotincapacitation3.1.38–3.1.41.Doc89843rdedition.ISBN978-92-9231-959-5.

22 COMMISSIONREGULATION(EU)No1178/2011of3November2011layingdowntechnicalrequirementsandadministrativeproceduresrelatedtocivilaviationaircrewpursuanttoRegulation(EC)No216/2008oftheEuropeanParliamentandoftheCouncil.

17

shouldbeassessedassatisfactorybyacardiologist,andparticularattentionshouldbepaidtomultiplestenosesand/ormultiplerevascularisations23.

OnthebasisoftheRegulationandtheguidancematerial,thereisnodifferenceinclasses1,2and 3when being considered 6months after recovery from a heart attack for amedicalcertificatebuttheguidancematerialincludesfollow-uptobeperformedafter6monthsandthere are differences in procedures due to the specific needs of each type of medicalcertificate. Class 1 comprises both airline and commercial pilots and class 3 air trafficcontrollers.Nevertheless,therearedifferencesamongthetypesofmedicalcertificatewhenitcomestofollow-upafterrecoveryfromaheartattack.

1.14.3 TheguidelinesoftheUKCivilAviationAuthority

The UK Civil Aviation Authority has drawn an illustrative flowchart24 of the Europeanguidelines. Medical certification can be granted when all tests have been successfullycompleted.IftheapplicantpassesanexerciseECGtestbutnomyocardialperfusionimagingandechocardiogramhavebeendone,medicalcertificationcanbegrantedwithanoperationalsafetypilotlimitation.BritaincomplieswithEASARegulations.

1.14.4 SpecialfeaturesintheguidelinesoftheAustralianCivilAviationSafetyAuthority(CASA)

Theguidelinesremind theAME toassess theannualisedpercentageriskofrecurrenceandincapacitation.Also,itsaysthatcertificationwithpermanentsafetypilot(class2)restrictionmay be required. Additionally, the need for anticoagulation therapy should be assessed25.CASA’sAviationMedicalExaminer'sHandbookalsoincludesanapproachforaeromedicalriskassessment26.

1.14.5 SpecialfeaturesintheguidelinesoftheCanadianCivilAviationSafetyAuthority(TransportCanada)

Transport Canada provides that if a major coronary heart disease is located in the leftcoronaryartery, it is likely that theprognosisof thepilot’s coronaryheartdisease ispoor,evenfollowingtreatment.27

23 Revascularisation,i.e.restoringcirculationwithballoonangioplasty/stentingorcoronarybypasssurgery.24 CAAUK(2015)Class1/2certification-Coronaryarterydisease

https://www.caa.co.uk/WorkArea/DownloadAsset.aspx?id=4294973025.retrieved4.1.201725 CASACoronaryarterydisease–suspectedorconfirmed

http://services.casa.gov.au/avmed/guidelines/coronary_artery_sus_conf.asp.retrieved4.1.201726 CASAAviationMedicineHandbook12.4.http://services.casa.gov.au/avmed/dames/handbook/12.4.asp.Retrieved

4.1.201727 TransportCanada.HandbookforCivilAviationMedicalExaminers.TransportCanada.

https://www.tc.gc.ca/eng/civilaviation/publications/tp13312-2-cardiovascular-chapter1-2333.htm.Retrieved4.1.2017

18

Coronary heart disease is amulti-factor illness. The examination of individual risk factorsaloneshouldnotlullanyoneintoafalsesenseofsecurity.Theriskassessmentutilises,amongotherthings,theFraminghamcoronaryheartdiseaseriskscore.

1.14.6 Summaryofthespecialfeaturesininternationalguidelines

Ingeneral,itcanbesaidthatdifferentaviationauthoritiesrequirequitesimilartestsfortheiraeromedical follow-up assessments. The Australian regulations, especially, emphasise theoverall risk assessment.TheCanadian regulations remind that theprognosis of the pilot’scoronaryheartdisease,whenlocatedintheleftcoronaryartery,isunfavourable.

1.15 Obstructivesleepapnoeaandcoronaryheartdisease

Heartpatientsare2–3timesmorelikelytosufferfromobstructivesleepapnoea(OSA)thanthosethatdonothavecoronarydiseases,evenwhenthecommonfactorsareconsidered.TheEASA AMC Part-MED mentions that a person being examined for OSA must undergo asatisfactory cardiological evaluation before a fit assessmentmay be considered.UntreatedOSApatientshaveanincreasedrisktohaveaheartattackatnightorwhileasleepcomparedwithnon-OSAheartattackpatients28.ResearchshowsthattreatedOSAmayreducenight-timeoxygendeprivationintheheartmuscleandcoronaryheartdisease,atleastamongmen.Thisfinding, however is yet to be confirmed, pending sufficiently qualitative research on thesubject293031323334.Theresultsof awideclinical trialpublished in2016 found thatCPAPtreatmentdoesnotsignificantlyreducethelikelihoodofacardiovascularevent35.

1.16 The role of the Safety Management System in aeromedical decision-making

Decision-making processes and documentation constitute important areas of the SafetyManagementSystem(SMS).Aeromedicaldecision-makingprocessesarebasedonEASAPart-

28 Kuniyoshi.FH.,Garcia-Touchard.A.,Gami.AS.,etal.(2008).“Day-nightvariationofacutemyocardialinfarctioninobstructivesleepapnea”JournaloftheAmericanCollegeofCardiology,Vol52,pp.343-346.

29 Peled,N.,Edward,G.A.,Giora.P.,etal.(1999).“Nocturnalischemiceventsinpatientswithobstructivesleepapneasyndromeandischemicheartdisease”JournaloftheAmericanCollegeofCardiology,Vol34,pp.1744-1749.

30 Milleron,O.,Pillière,R.,Foucher,A.,deRoquefeuil,F.,etal.(2004).“Benefitsofobstructivesleepapnoeatreatmentincoronaryarterydisease:along-termfollow-upstudy”.EuropeanHeartJournal,Vol25,pp.728-734.

31 Marin,JM.,Carrizo,SJ.,Vicente,E.,etal.(2005).“Long-termcardiovascularoutcomesinmenwithobstructivesleepapnoea-hypopnoeawithorwithouttreatmentwithcontinuouspositiveairwaypressure:anobservationalstudy”.TheLancet,Vol365,pp.1046-1053.

32 Doherty,LS.,Kiely,JL.,Swan,V.,McNicholas,WT.,(2005).“Long-termeffectsofnasalcontinuouspositiveairwaypressuretherapyoncardiovascularoutcomesinsleepapneasyndrome”.Chest,Vol127,pp.2076-2084.

33 Somers,V.K.,White,D.P.,Amin,R.,etal.(2008).“SleepApneaandCardiovascularDisease”.Circulation,Vol118,p.1080-1111.

34 PulmonaryMedicine2013.Dx.doi.org/10.1155/2013/768064.DeTorres-Alba,F.,Gemma,D.,Armada-Romero,E.,etal.(2013).“ObstructiveSleepApneaandCoronaryArteryDisease:FromPathophysiologytoClinicalImplications”.PulmonaryMedicine,Vol2013,ArticleID768064,9pages.

35 McEvoy,RD.,AnticNA.,HeeleyE.,etal.(2016).“CPAPforPreventionofCardiovascularEventsinObstructiveSleepApnea”NewEnglandJournalofMedicine,Vol375,pp.919-931.

19

MEDregulations.TheSMSsystem36,orpartsof it,canbeapplied inmanagingaeromedicaldecision-makingprocesses.Then,itwillbepossibletostandardiseandclarifytheprocess,forexample,withthehelpofflowchartsandalgorithms3738.TheEuropeanSocietyofAerospaceMedicineisabouttoproposesuchanoperationalmodeltotheEASA39.In2015ESAMitwasproposedthatPart-MEDbeamendedtoincludeanalgorithm-baseddecision-makingtoolforassessing recovery fromheartattack37.Thepointofdeparture is apilot-orienteddecision-makingprocesswhichproceeds, stepby step,on thebasisof test results.The conclusionswould primarily be made by cardiologists that provide aeromedical assessments to thelicensingauthority.

Medicalriskassessmentisanintegralelementofsuccessfuldecision-making.Itisparticularlyimportant to be able to evaluate the overall risk of diseases and, consequently, make adecisiononafollow-upplan.Iftheriskisconsiderable,onemustconsiderlimitationsaspartofthe follow-upaction.Inthiscasethepilotbeingassessed iseitherabletocontinue flyingundersufficient limitationsor themedicalcertificate is temporarilyorcompletelyrevoked.TheAustralianaviationauthorityhasprovidedguidelinesforthisriskassessmentprocess.

36 FAASafetyManagementSystemBasis.https://www.faa.gov/about/initiatives/sms/explained/basis/.Retrieved15.2.2017.

37 Maire,R.,Muff,S.,(2015).“ProposalforachangeoftheEASA-Medical-RequirementswithintheAcceptableMeansofCompliance”.http://www.esam.aero/esam-papers/coronary-artery-disease.Retrieved15.2.2017.

38 Navathe,P.,Drane,M.,Preinter,C.(2014).“AeromedicalDecisionMaking:FromPrinciplestoPractice”.Aviation,SpaceandEnvironmentalMedicine,Vol85,pp.576-580.

39 Correspondence.RenéMairememberofESAMadvisoryboard.9.3.2017.

20

2 ANALYSIS

TheanalysisoftheaccidentusedtheAcciMap40model.TheoutlineoftheanalysisisbasedonanAcciMapdrawnbytheinvestigationgroup,includedinappendix1.

2.1 Analysisoftheaccident

2.1.1 Medicalcertifications

A PPL licence requires a class 2 medical certificate. An LAPL medical certificate isautomaticallyincludedinaclass2certificate.Whenitcomestothemedicalcertificationofthepilot,issuedin2015,hisclass2certificatewasvalidforoneyearandhisLAPLcertificatewasvalidfortwoyears.Judgingbyinterviewsandmedicaldocumentsitappearsthatthepilotdidnotintendtoflywithoutavalid,requiredmedicalcertificate.Onthebasisofdocumentsitcanbe assumed that he believed that the LAPLmedical certificate, togetherwith a valid PPLlicence,allowedhimtooperateaircraftwithamaximumtake-offmassoflessthan2000kg.

Amedicalcertificatecanbeissuedwithlimitationsiftheapplicantisnotregardedtopresentadangertothesafetyofflight.Forinstance,followingthefirstheartattackthepilothadthelimitationthat,inadditiontothenextaeromedicalexamination,hewouldhavetoproducetheresults of an exerciseECG and a cardiologist’s evaluation.Another limitation for a class 2certificate can include,amongother things,anOSL limitation,whichmeans that flying cancontinuewhenaccompaniedbyasafetypilot.

ConvertingaPPLlicencetoanLAPLlicenceisasimpleprocedurefollowingwhichtheLAPLmedical certificate applies. Nevertheless, when it comes to this accident, neither medicalcertificationwasvalidbecausethepilothadsufferedaheartattack,whichhefailedtoreporttoanaeromedicalexaminer.

NordidthepilotreportthechangesinhisstateofhealthtotheAMEwithoutunduedelay.Hebroughtthemupduringthemedicalexaminationswhenheneededtorevalidatethemedicalcertification.

40TheAcciMapmodel isusedtoanalyse factors thatcontributedtotheaccident,to findtheessentialconclusionsandtoprepareandtargetthekeysafetyrecommendations.

TheaccidentisdepictedatthebottomofanAcciMapasachainofevents.Therecogniseddecision-makingentitiesandotherrelevantactorsaremarkedontheleftaxis.Theanalysisoftheflowoftheeventsgoesfrombottomtotop.Thelowerpartofthepresentationillustratestheindividualaccidentunderanalysisandfromthereontheanalysisproceedstothebigpictureandsignificances,forexample,atthenationalorinternationallevel.

The analysis complieswith theAcciMappresentation andprovidesbackground information on individual textboxes,includingtheirmutualassociation.Theanalysisoftheauthorities’action,meantbytheSafetyInvestigationAct,isdoneseparatelyasrequired.

ThesourceoftheAcciMapmodel: J.Rasmussenand I.Svedung,2000,ProactiveRiskManagement inaDynamicSociety,SwedishRescueServicesAgency,Karlstad,Sweden.

21

2.1.2 Thefirstheartattack

Thesymptomsassociatedwithcoronaryheartdiseasehadappearedyearsearlier.Thepilothadhis firstheartattack inMarch2011at theageof59. Inconjunctionwith the follow-upfitness assessment the licensing authority first requested that all actions pursuant toRegulation(EC)No216/2008of theEuropeanParliamentandof theCouncilbecompleted.Nevertheless, theywerenotdelivered to theauthorityby theduedate.Following this, thepilotrevisitedtheAMEandthemedicalcertificationwasgrantedinMarch2012.AtthetimetheAMEdidnotrequireastressechocardiogramtestbecompleted.

2.1.3 Thesecondheartattackandobstructivesleepapnoea

ThepilothadhissecondheartattackinSeptember2013attheageof62.Inearly2014hewasdiagnosedwithobstructivesleepapnoea(OSA).HereceivedCPAPtreatmentforit.Accordingto the results of a recent,wide clinical trial, CPAP treatment does not reduce the risk ofrecurrenceofacardiaceventtothatofapersonrecoveringfromaheartattackwithnoOSA.

2.1.4 Thethirdheartattack

ThepilothadhisthirdheartattackinJanuary2015,inotherwordsalittleoverayearfromthesecondone.Hedidnotreport this to theAME.Even though thepilotassumed thathismedicalcertificatewasvalid,hisclass 2certificatewasnotvalid.Rather,hisLAPLmedicalcertificatewastechnicallyvalid.Still,anLAPLmedicalcertificationalonedoesnotsufficeforaPPLlicence.Evenso,thepilotshouldnothavebeenflyingbecause,followinghisthirdheartattack,nomedicalassessmenthadbeenmade.

2.1.5 Thefourthheartattack

The fourth, fatal,heartattackoccurredon24 September2016, a little less than twoyearsfromthethirdone.Approximatelyonemonthpriortothatthepilothadseenadoctorbecausehewasfeelingunwell,butnosignsofcardiologicalsymptomswerefoundintheexamination.

Thepilotwasalready feelingunwellearlierinthedaybeforetheaccident flight.Duringtheaccident flight thepilot’s functioning suddenlybecame impairedbecausehewas feeling ill.Forthisreasonhedecidedtoendtheflightearlierthanplanned.TheCCTVimagetakenattheaerodromeverifiesthedeteriorationofhisfunctioning.Alsotheinterviewsandtheflightpathanalysissupportthisview.

2.2 Coronaryheartdisease

Theheartattacksof2011,2013and2015occurredintheareasuppliedbytheleftcoronaryartery.TransportCanada’shandbookpaysparticularattentiontodiseaseintheleftcoronaryartery.

Coronary heart disease is a chronic disease. Treatments, such as revascularisation, canimprove itsprognosis.There is a follow-upperiod forgrantingmedicalcertificationafter a

22

heartattackaswellasadditionaltestingasperregulations.Onthebasisofthese,thefitnesstofly can be restored in full or with limitations, depending on if the future risk level ofincapacitationisconsideredtobelowenough.Theriskofarecurringheartattackgrowsaftereach heart attack. The evaluation tests presented in regulations improve the odds ofpredictingtheriskofafutureinfarct.Astressechocardiogramisoneofthetestsmentionedand,foritspart,improvesthechancesofdiagnosingasymptomaticoxygendeprivationintheheartmuscleafteraheartattack.

2.3 Overallriskassessment

Here, overall risk assessment means an evaluation, which takes into account differentillnessesaswellastheclinicaldeteriorationofadisease,suchasrecurringheartattacks.Onthebasisofthesetheexaminerwillcomprehensivelyassessthesubject’spresentandfuturefitness.

Documentsdonotrevealtowhichleveltheexaminerassessedthepilot’soverallriskfortheperiodof validityof themedical certification,whichwas granted in2015.The assessmentbecamemorechallengingafterthesecondheartattack.Atthattimetheriskfactorsthathadtobeconsideredwere,amongotherthings,thosecausedbyage,recurringheartattackandsleepapnoea.Theriskofthepilot losinghis functioningabilitywashigherafterthesecondheart attack. The increased risk did not manifest itself in more limitations. Aeromedicalguidance material only partly supports the overall risk assessment, especially after therecurring acutemyocardial infarction. For example, the Australian licensing authority hasprovided regulations on risk assessment and risk management. The purpose of theirguidelinesistomakeiteasierfortheAMEtomakeanoverallriskassessment.

2.4 Significanceofthedutyofnotification

Doctorsarenotrequiredtonotifyanychangesinthestateofaprivateorcommerciallicenceholder’shealthtothelicensingauthority.Atthehospital,afterthefirsttwoheartattacks,thepilotwasreminded tovisit theAME.Following the third infarct thepilot’smedicalrecordscontained no mention of a reminder to visit an AME before continuing to fly. A duty ofnotificationcouldreducethenumberofillness-relatedincapacitationsand,so,improveflightsafety.

2.5 Thepilot’shealthcare

Thepilot’scomprehensivehealthcarewasdistractedby the fact that thepublichealthcaresystemdidnotseemtohaveaclearpictureoftheaeromedicalexaminer’srole.Inpractice,theAMEmainlyparticipatesinthepilot’smedicalassessment,ratherthantreatment.Thereasonfor this is that people only tend to visit AMEs in conjunction with recurring medicalexaminations associated with certification. It isworth noting that the doctor treating thepilot’sillnessesreceivedtheinformationfromthepilot’sownaccount.

23

2.6 Analysisoftherescueoperation

Thedispatchedunits arrived at the sitewithinapproximately tenminutes from the alarm.Emergency medical care was immediately given to the pilot. Judging by the ERC’s riskassessmentandtheinformationrelayedtotherescueunitstheunitsmayhavemisinterpretedthesituationasbeingamoreseriousairaccidentthanjusttaxiingintoaditch.Thedispatchedunitsweresufficient,evensomewhatlarge,intermsofnumberandqualitywithrespecttothemagnitudeofthesituation.Ontheotherhand,thesufficientnumberofunitsarrivingatthesitewouldhavemade itpossible toproperlymanage an evenmore serious accident.Thisbeingthecase,theERC’sdecisiontodispatcharesponsetoan“airaccident,mediumsize”wascorrect.

24

3 CONCLUSIONS

3.1 Findings

1. The patient suffered his first heart attack in March 2011, at the age of 59. Balloonangioplastywasperformedinthreedifferentplacesonthenarrowedleftcoronaryartery;theywerethenstented.

2. Inafollow-upexaminationinMay2011atthehospitalthepilotwasremindedtovisitanaeromedicalexaminerbeforecontinuingtofly.

3. Thepilotapplied formedicalcertification.Asadditionalaccountsthelicensingauthoritydemanded,amongotherthings,thattheresultsofastressechocardiogram,a24-hourECGmonitoring,andthecardiologist’sevaluationbedeliveredtothembyOctober2011.TheresultsofthestressechocardiogramwerenotdeliveredbyOctober2011.

4. InMarch2012 the licensing authority issued themedical certificatewith the conditionthat, in addition to the aeromedical examination, the pilotwould have to produce theresultsofanexerciseECGandacardiologist’sevaluation.Nostressechocardiogramwasdoneinconjunctionwiththe2012medicalassessment.

5. The patient suffered his second heart attack in September 2013, at the ageof 62.Thenarrowed leftcoronaryarterywas treatedwithballoonangioplastyandstenting inoneplace.

6. Duringthehospitalisationthepilotwasremindedtovisitanaeromedicalexaminerbeforecontinuingtofly

7. Inearly2014thepilotwasdiagnosedwithsevereobstructivesleepapnoea.InresponsetothisContinuousPositiveAirwayPressure(CPAP)treatmentwasinitiated.

8. TheAMEgrantedthemedicalcertificationinOctober2014andfinalisedtheexaminationinJanuary2015.Nostressechocardiogramwasdoneinconjunctionwiththeassessment.

9. The licensing authority did not have the 24-hour Holter monitor test result or thecardiologist’sstatement.

10. ThepatientsufferedhisthirdheartattackinlateJanuary2015,attheageof63.Duringthehospitalisationnomentionofthepilot’sflyinghobbywasmadeinhismedicalrecords.

11. FollowingtheheartattacksthepilotmadenocontactwithhisownAMEorthelicensingauthority.

12. ThepilotsawadoctorinSeptember2015.Atthattimeitcameupintheconversationthathis‘flyerdrivinglicence’wasstillvalid.HewasmistakenabouttheprivilegesincludedinanLAPLmedicalcertificate.

25

13. OnSaturday24September2016,thedayoftheaccident,thepilot flewtheaircraft fromEuraaerodromeinKauttuatoTuulikki-VampulaaerodromeinHuittinen.Thepilothadtohand-starttheenginebyswingingthepropeller.Duringthestartprocessthepilottooka15minutebreakbecausehewasoutofbreath.

14. Thepilottookoffforasecondflight.Duringtheflightthepilotreportedthathewouldlandearlierthanplannedbecausehedidnotfeelwell.

15. Thepilot found itdifficulttocontroltheaircraftduringtheapproachand landing.Whiletaxiing,theaircraftendedupinaditchnexttothetaxiway.

16. Almostimmediatelyafterdeplaningthepilotcollapsedtotheground.Hewaspronounceddeadat13.36.

17. Thereweretwopassengersontheflight,oneofwhomhadasuddenattackandhadtobehospitalised.

18. Restoringmedicalcertificationafteraheartattackrequiresafollow-upperiod,additionaltestinginaccordancewiththeregulations,consultationwiththelicensingauthorityandaspecificlimitation.

19. OnthebasisoftheRegulationandtheguidancematerial,thereisnodifferenceinclasses1, 2 and 3 when being considered 6 months after recovery from a heart attack for amedicalcertificate

20. Documentsdonotrevealtowhichlevelthepilot’soverallriskwasassessedinthe2015aeromedicalexaminationwherehewascertified.

21. The AMC Part-MED only partly supports decision-making associated with overall riskassessmentorforplacinglimitationsasameansofriskmanagement.

22. With the exception ofAMEs, Finnish doctors are not required to notify any diagnosedpermanentchangeinthestateofapilot’shealththatjeopardisesflightsafety.

23. The rescueand theEMSunitsdispatched to the sitewereable toproperlymanage theaccident

26

3.2 Probablecauses

Thecauseoftheaccidentwasthepilot’sheartattackduringtheflight.Thepilotsufferedfrommulti-vesselcoronaryheartdiseaseandwithinthefiveyearshehadhadthreeheartattacks.

The pilotwas unawareof the privilegesof amedical certification and the validitiesof thelicence.

Whilethepublichealthcaresystemwasawareofthepilot’sflyinghobby,nationallegislationdoesnot laydownanydutyofnotificationassociatedwithmedical certification todoctorstreatinglicenceholders.

Thepilot’shigheroverall riskof a recurringheart attack, as regards flight safety,wasnotrecognised. The European guidance material only partly provides for decision-makingassociated with overall risk assessment. For the time being, aeromedical processes forassessing the level of acceptable risk, especially following recurring heart attacks, areinsufficient.

27

4 SAFETYRECOMMENDATIONS

4.1 Providinganinternationalprocessforariskassessmentafterheartattack

TheInternationalCivilAviationOrganization(ICAO)spearheadsthedevelopmentofupdateddecision-makingmechanismsforaviationmedicine.Manysuddenincapacitationsresultfromcardiovasculardiseases,bothingeneralaviationandincommercialaviation.Theprognosisofa heart attack is nowadaysmuchmoreoptimistic.Thebetter prognosis is caused by new,moderncardiologicaltreatmentssuchasstentingintheacutephaseofheartattackaswellasthenew,extremelyeffectivecholesterol-loweringmedications.For thisreason,aeromedicalexaminersreceivepilotscoming formedicalassessmentthathavehadmorethanoneheartattack.Fresh epidemiological findingsprovide informationon theprognosesof treatmentsandnewmedications.Thismakesitpossibletoplacepilotsinriskcategoriesasregardstheriskofapossiblerecurringheartattack.

TheSafetyInvestigationAuthorityrecommendsthat

4.2 Aeromedicalexaminers’competencybasedrecurrenttraining

SomeAMEscarryoutalownumberofaeromedicalassessmentsandthevastmajorityoftheirmedical activity is spent in performing othermedical tasks.Especially their proficiency inperforminganaeromedicalriskassessmentmaynotbeattheintendedlevel.

TheSafetyInvestigationAuthorityrecommendsthat

TheInternationalCivilAviationOrganization(ICAO)reviewtheexistingguidancematerialcontainedintheManualofCivilAviationMedicinetoincludeariskassessmentmodeltofacilitateaero-medicaldecision-makingintheevaluationofpilotsatriskfromrecurrentheartattacks.[2017-S34]

TheEuropeanAviationSafetyAgency(EASA)improveAMEriskassessmentcompetencythroughsafetypromotion,competencybasedrecurrenttrainingandspecifictrainingonthenationalproceduresforreferralandconsultationaswellasfortheuseoflimitations.[2017-S35]

28

4.3 Doctors’nationaldutyofnotification

InFinlanddoctorsarealwaysrequiredtonotifyalicenceholder’simpairedstateofhealthtothepolice if thedriver isdetermined tobeunfit todrive forat leastsixmonths.Regardingpilots,doctorsworkingingeneralhealthcaredonothaveanycomparabledutyofnotificationtotheFinnishlicensingauthority.

InNorway thedutyofnotificationhasbeen ineffectsince1982and itapplies toallhealthcareprofessionals.AccordingtoNorwegianexperiencesithasbeenbeneficialtoflightsafety.Such regulations also clarify the role of the doctor treating the person and improve theexchange of information among the health care authorities and those assessing medicalcertification.

TheSafetyInvestigationAuthorityrecommendsthat

4.4 Safetyofgeneralaviationandsportaviation

Thepilotwaslackingthebasicknowledgeofthesignificanceofreportingmedicalissuesandtheprivilegesassociatedwiththepilot’slicence.Itispossibletoadvancethesafetyofgeneralaviationandsportaviationbyimprovingcommunicationsandtrainingmaterialstotheflightcommunity.

TheSafetyInvestigationAuthorityrecommendsthat

TheFinnishMinistryofTransportandCommunicationsstandardisethedutyofnotificationbetweenaviationandroadtransport,associatedwithaperson’sstateofhealth,aspartofadvancingthesafetyofflight.[2017-S36]

TheFinnishTransportSafetyAgencyseetoitthatthepractitionersofgeneralandsportaviationreceiveclarifyinginformationpertainingtotheprivilegesassociatedwiththepilot’slicenceandthesignificanceoftherequirementtoreportmedicalissues.[2017-S37]

29

Helsinki21June2017

IsmoAaltonen KalleBrusi AnttiVirtanen

AlpoVuorio

30

REFERENCES

Thefollowingdocuments(ortheircopies)usedasmaterialintheinvestigationarearchivedatSafetyInvestigationAuthority,Finland

1. Thedecisiontolaunchtheinvestigation.

2. Photosfromtheaccidentsite.

3. E-mail correspondencewith theEuropean SocietyofAerospaceMedicine (ESAM),CivilAviationAuthority-Norway,andtheFinnishTransportSafetyAgency(Trafi).

4. Recordingsandtranscriptsmadeofinterviews.

5. Epicrisesrelatedtothepilot’smedicaltreatment.

31

SUMMARYOFTHECOMMENTSTOTHEDRAFTFINALREPORT

Thedraft finalreportwassenttocommentstotheInternationalCivilAviationOrganization(ICAO), theEuropeanAviationSafetyAgency (EASA), theFinnishTransportSafetyAgency(Trafi),theMinistryofTransportandCommunicationsandtheEmergencyResponseCentreAdministration.

ICAO submittedno significant comments to the contentof thedraft final report.Moreover,they emphasised that the present version of the ICAO’sManual of CivilAviationMedicineincludestheaeromedicalfollow-upprocessforassessingrecoveryfromheartattack.Updatesforassessingthefollow-upforrecurringheartattacksmaybewarranted.

EASAsubmittednosignificantcommentstothecontentofthedraftfinalreport.Itseemsthatthe recommendation directed at them could be integrated into the ongoing developmentproject for improving aero-medical examiners’ competency. This project could includeadditionalAMEtraininginriskmanagement.

TheFinnishTransportSafetyAgency’scommentscallattentiontothefactthattheAMEhadnotincludedanyinformationofthe24-hourECGmonitoringtestperformedinJanuary2015,or the cardiologist’s consultations.Furthermore,TheFinnishTransportSafetyAgency callsattentiontothefactthatthepilotrepeatedlyfailedtoreportanychangesinhisstateofhealth.TheFinnishTransportSafetyAgencyremindsthatstressechocardiogramtestsarenotwidelyavailableinFinland.

In addition, it was stated that when the AMC Part-MED entered into force, aero-medicalexaminerswillnormallyissuemedicalcertificationsontheirown.Whenneeded,pursuanttothedemandsofregulationsorattheirowndiscretion,theywilleitherconsult,orcompletelyreferthedecisionto,theFinnishTransportSafetyAgency’sTrafficMedicineUnit.WhentheAMEissuedthemedicalcertificationfollowingtheexaminationafterthesecondheartattackhedidnotconsultthelicensingauthority.

TheMinistryofTransportandCommunicationscommentedtherecommendationdirectedatthem so that the already ongoing legislative project would harmonise the practices formedicalnotification in rail and air traffic and innavigation,and that the goalwouldbe toachievecorrespondingsafetyimprovementsasinthedutyofnotificationinroadtraffic.

TheEmergencyResponseCentreAdministrationhadnocommentstothedraftfinalreport.