text: Acceptable Means of Compliance and Guidance Material to

text: Commission Regulation (EU) No 1178/2011 of 3 November 2011

text: laying down technical requirements and administrative procedures related to civil aviation aircrew pursuant to

text: Regulation (EC) No 216/2008

text: of the European Parliament and of the Council.

text: Annex to ED Decision 2011/015/R

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identifier: AMC & GM to Part-MED

amnesord: Part-MED - Medical Requirements for Aircrew

beslut: ED Decision 2011/015/R

nummer: part-med

publisher: Europeiska unionens byrå för luftfartssäkerhet

sprak: en

title: AMC & GM to Part-MED

serie: amc-gm

text: European Aviation Safety Agency Acceptable Means of Compliance and Guidance Material to Part-MED

type: rubrik

text: Initial issue

type: stycke

text: 15 December 2011

text: TABLE OF CONTENTS

text: SUBPART A 5 General requirements 5

text: Section 1 5 General 5 AMC1 MED.A.015 Medical confidentiality 5 AMC1 MED.A.020 Decrease in medical fitness 5 AMC1 MED.A.025 Obligations of AeMC, AME, GMP and OHMP 5 Section 2 5

text: Requirements for medical certificates 5

text: AMC1 MED.A.030 Medical certificates 5 AMC1 MED.A.035 Application for a medical certificate 6 AMC1 MED.A.045 Validity, revalidation and renewal of medical certificates 6

text: SUBPART B 7 Specific requirements for class 1, class 2 and LAPL medical certificates 7 AMC for class 1, class 2 and LAPL medical certificates 7

text: Section 1 7 General 7 AMC1 MED.B.001 Limitations to class 1, class 2 and LAPL medical certificates 7 GM1 MED.B.001 Limitation codes 8 Section 2 9

text: Specific requirements for class 1 medical certificates 9

text: AMC1 MED.B.010 Cardiovascular system 9 AMC1 MED.B.015 Respiratory system 16 AMC1 MED.B.020 Digestive system 17 AMC1 MED.B.025 Metabolic and endocrine systems 18 AMC1 MED.B.030 Haematology 18 AMC1 MED.B.035 Genitourinary system 19 AMC1 MED.B.040 Infectious disease 20 AMC1 MED.B.045 Obstetrics and gynaecology 21 AMC1 MED.B.050 Musculoskeletal system 21 AMC1 MED.B.055 Psychiatry 21 AMC1 MED.B.060 Psychology 22 AMC1 MED.B.065 Neurology 23 AMC1 MED.B.070 Visual system 24 AMC1 MED B.075 Colour vision 27 AMC1 MED.B.080 Otorhino-laryngology 27 AMC1 MED.B.085 Dermatology 28 AMC1 MED.B.090 Oncology 28 Section 3 29

text: Specific requirements for class 2 medical certificates 29

text: AMC2 MED.B.010 Cardiovascular system 29 AMC2 MED.B.015 Respiratory system 32 AMC2 MED.B.020 Digestive system 33 AMC2 MED.B.025 Metabolic and endocrine systems 33

text: AMC2 MED.B.030 Haematology 34 AMC2 MED.B.035 Genitourinary system 35 AMC2 MED.B.040 Infectious diseases 35 AMC2 MED.B.045 Obstetrics and gynaecology 36 AMC2 MED.B.050 Musculoskeletal system 36 AMC2 MED.B.055 Psychiatry 36 AMC2 MED.B.060 Psychology 37 AMC2 MED.B.065 Neurology 37 AMC2 MED.B.070 Visual system 37 AMC2 MED B.075 Colour vision 38 AMC2 MED.B.080 Otorhino-laryngology 39 AMC2 MED.B.085 Dermatology 40 AMC MED.B.090 Oncology 40 Section 4 41

text: Specific requirements for LAPL medical certificates 41

text: AMC1 MED.B.095 Medical examination and/or assessment of applicants for LAPL medical certificates 41 AMC2 MED.B.095 Cardiovascular system 41 AMC3 MED.B.095 Respiratory system 42 AMC4 MED.B.095 Digestive system 43 AMC5 MED.B.095 Metabolic and endocrine systems 43 GM1 MED.B.095 Diabetes mellitus Type 2 treated with insulin 45 AMC6 MED.B.095 Haematology 45 AMC7 MED.B.095 Genitourinary system 45 AMC8 MED.B.095 Infectious disease 45 AMC9 MED.B.095 Obstetrics and gynaecology 45 AMC10 MED.B.095 Musculoskeletal system 45 AMC11 MED.B.095 Psychiatry 46 AMC12 MED.B.095 Psychology 46 AMC13 MED.B.095 Neurology 46 AMC14 MED.B.095 Visual system 47 AMC15 MED.B.095 Colour vision 47 AMC16 MED.B.095 Otorhino-laryngology 48

text: SUBPART C 49 Requirements for medical fitness of cabin crew 49

text: Section 1 49 General requirements 49 AMC1 MED.C.005 Aero-medical assessments 49 Section 2 49

text: Requirements for aero-medical assessment of cabin crew 49

text: AMC1 MED.C.025 Content of aero-medical assessments 49 AMC2 MED.C.025 Cardiovascular system 49 AMC3 MED.C.025 Respiratory system 51 AMC4 MED.C.025 Digestive system 51 AMC5 MED.C.025 Metabolic and endocrine systems 52 AMC6 MED.C.025 Haematology 52

text: AMC7 MED.C.025 Genitourinary system 52 AMC8 MED.C.025 Infectious disease 52 AMC9 MED.C.025 Obstetrics and gynaecology 53 AMC10 MED.C.025 Musculoskeletal system 53 AMC11 MED.C.025 Psychiatry 53 AMC12 MED.C.025 Psychology 53 AMC13 MED.C.025 Neurology 53 AMC14 MED.C.025 Visual system 54 AMC15 MED.C.025 Colour vision 54 AMC16 MED.C.025 Otorhino-laryngology 55 AMC17 MED.C.025 Dermatology 55 AMC18 MED.C.025 Oncology 55 GM1 MED.C.025 Content of aero-medical assessments 56 Section 3 58

text: Additional requirements for applicants for, and holders of, a cabin crew attestation

text: 58 AMC1 MED.C.030 Cabin crew medical report 58 AMC1 MED.C.035 Limitations 59

text: SUBPART D 60 Aero-medical examiners (AMEs) 60

text: AMC1 MED.D.010 Requirements for the issue of an AME certificate 60 AMC1 MED.D.015 Requirements for the extension of privileges 60 GM1 MED.D.030 Refresher training in aviation medicine 61

text: AMC/GM to PART-MEDICAL

text: SUBPART A

text: General requirements

text: Section 1

text: General

text: AMC1 MED.A.015 Medical confidentiality

text: To ensure medical confidentiality, all medical reports and records should be securely held with accessibility restricted to personnel authorised by the medical assessor.

text: AMC1 MED.A.020 Decrease in medical fitness

text: If in any doubt about their fitness to fly, use of medication or treatment: (a) holders of class 1 or class 2 medical certificates should seek the advice of an AeMC or AME; (b) holders of LAPL medical certificates should seek the advice of an AeMC, AME, or of the GMP who issued the holder’s medical certificate; (c) suspension of exercise of privileges: holders of a medical certificate should seek the advice of an AeMC or AME when they have been suffering from any illness involving incapacity to function as a member of the flight crew for a period of at least 21 days.

text: AMC1 MED.A.025 Obligations of AeMC, AME, GMP and OHMP

text: (a) The report required in MED.A.025 (b)(4) should detail the results of the examination and the evaluation of the findings with regard to medical fitness. (b) The report may be submitted in electronic format, but adequate identification of the examiner should be ensured. (c) If the medical examination is carried out by two or more AMEs or GMPs, only one of them should be responsible for coordinating the results of the examination, evaluating the findings with regard to medical fitness, and signing the report.

text: Section 2

text: Requirements for medical certificates

text: AMC1 MED.A.030 Medical certificates

text: (a) A class 1 medical certificate includes the privileges and validities of class 2 and LAPL medical certificates. (b) A class 2 medical certificate includes the privileges and validities of a LAPL medical certificate.

text: AMC1 MED.A.035 Application for a medical certificate

text: When applicants do not present a current or previous medical certificate to the AeMC, AME or GMP prior to the relevant examinations, the AeMC, AME or GMP should not issue the medical certificate unless relevant information is received from the licensing authority.

text: AMC1 MED.A.045 Validity, revalidation and renewal of medical certificates

text: The validity period of a medical certificate (including any associated examination or special investigation) is determined by the age of the applicant at the date of the medical examination.

text: Subpart B

text: Specific requirements for class 1, class 2 and LAPL medical certificates

text: AMC for class 1, class 2 and LAPL medical certificates

text: Section 1

text: General

text: AMC1 MED.B.001 Limitations to class 1, class 2 and LAPL medical certificates

text: (a) An AeMC or AME may refer the decision on fitness of the applicant to the licensing authority in borderline cases or where fitness is in doubt. (b) In cases where a fit assessment can only be considered with a limitation, the AeMC, AME or the licensing authority should evaluate the medical condition of the applicant in consultation with flight operations and other experts, if necessary. (c) Limitation codes:

text: Code Limitation

text: 1 TML restriction of the period of validity of the medical certificate 2 VDL correction for defective distant vision 3 VML correction for defective distant, intermediate and near vision 4 VNL correction for defective near vision 5 CCL correction by means of contact lenses only 6 VCL valid by day only 7 HAL valid only when hearing aids are worn 8 APL valid only with approved prosthesis 9 OCL valid only as co-pilot 10 OPL valid only without passengers (PPL and LAPL only) 11 SSL special restriction as specified 12 OAL restricted to demonstrated aircraft type 13 AHL valid only with approved hand controls 14 SIC specific regular medical examination(s) - contact licensing authority 15 RXO specialist ophthalmological examinations (d) Entry of limitations (1) Limitations 1 to 4 may be imposed by an AME or an AeMC. (2) Limitations 5 to 15 should only be imposed: (i) for class 1 medical certificates by the licensing authority;

text: (ii) for class 2 medical certificates by the AME or AeMC in consultation with the licensing authority; (iii) for LAPL medical certificates by an AME or AeMC. (e) Removal of limitations (1) For class 1 medical certificates, all limitations should only be removed by the licensing authority. (2) For class 2 medical certificates, limitations may be removed by the licensing authority or by an AeMC or AME in consultation with the licensing authority. (3) For LAPL medical certificates, limitations may be removed by an AeMC or AME.

text: GM1 MED.B.001 Limitation codes

text: TML Time limitation

text: The period of validity of the medical certificate is limited to the duration as shown on the medical certificate. This period of validity commences on the date of the medical examination. Any period of validity remaining on the previous medical certificate is no longer valid. The pilot should present him/herself for re-examination when advised and should follow any medical recommendations.

text: VDL Wear corrective lenses and carry a spare set of spectacles

text: Correction for defective distant vision: whilst exercising the privileges of the licence, the pilot should wear spectacles or contact lenses that correct for defective distant vision as examined and approved by the AME. Contact lenses may not be worn until cleared to do so by the AME. If contact lenses are worn, a spare set of spectacles, approved by the AME, should be carried.

text: VML Wear multifocal spectacles and carry a spare set of spectacles

text: Correction for defective distant, intermediate and near vision: whilst exercising the privileges of the licence, the pilot should wear spectacles that correct for defective distant, intermediate and near vision as examined and approved by the AME. Contact lenses or full frame spectacles, when either correct for near vision only, may not be worn.

text: VNL Have available corrective spectacles and carry a spare set of spectacles

text: Correction for defective near vision: whilst exercising the privileges of the licence, the pilot should have readily available spectacles that correct for defective near vision as examined and approved by the AME. Contact lenses or full frame spectacles, when either correct for near vision only, may not be worn.

text: VCL Valid by day only

text: The limitation allows private pilots with varying degrees of colour deficiency to exercise the privileges of their licence by daytime only. Applicable to class 2 medical certificates only.

text: OML Valid only as or with qualified co-pilot

text: This applies to crew members who do not meet the medical requirements for single crew operations, but are fit for multi-crew operations. Applicable to class 1 medical certificates only.

text: OCL Valid only as co-pilot

text: This limitation is a further extension of the OML limitation and is applied when, for some well defined medical reason, the pilot is assessed as safe to operate in a co-pilot role but not in command. Applicable to class 1 medical certificates only.

text: OPL Valid only without passengers

text: This limitation may be considered when a pilot with a musculoskeletal problem, or some other medical condition, may involve an increased element of risk to flight safety which might be acceptable to the pilot but which is not acceptable for the carriage of passengers. Applicable to class 2 and LAPL medical certificates only.

text: OSL Valid only with safety pilot and in aircraft with dual controls

text: The safety pilot is qualified as PIC on the class/type of aircraft and rated for the flight conditions. He/she occupies a control seat, is aware of the type(s) of possible incapacity that the pilot whose medical certificate has been issued with this limitation may suffer and is prepared to take over the aircraft controls during flight. Applicable to class 2 and LAPL medical certificates only.

text: OAL Restricted to demonstrated aircraft type

text: This limitation may apply to a pilot who has a limb deficiency or some other anatomical problem which had been shown by a medical flight test or flight simulator testing to be acceptable but to require a restriction to a specific type of aircraft.

text: SIC Specific regular medical examination(s) contact licensing authority

text: This limitation requires the AME to contact the licensing authority before embarking upon renewal or recertification medical assessment. It is likely to concern a medical history of which the AME should be aware prior to undertaking the assessment.

text: RXO Specialist ophthalmological examinations

text: Specialist ophthalmological examinations are required for a significant reason. The limitation may be applied by an AME but should only be removed by the licensing authority.

text: Section 2

text: Specific requirements for class 1 medical certificates

text: AMC1 MED.B.010 Cardiovascular system

text: (a) Examination Exercise electrocardiography An exercise ECG when required as part of a cardiovascular assessment should be symptom limited and completed to a minimum of Bruce Stage IV or equivalent. (b) General

text: (1) Cardiovascular risk factor assessment

text: (i) Serum lipid estimation is case finding and significant abnormalities should require review, investigation and supervision by the AeMC or AME in consultation with the licensing authority. (ii) An accumulation of risk factors (smoking, family history, lipid abnormalities, hypertension, etc.) should require cardiovascular evaluation by the AeMC or AME in consultation with the licensing authority. (2) Cardiovascular assessment (i) Reporting of resting and exercise electrocardiograms should be by the AME or an accredited specialist.

text: (ii) The extended cardiovascular assessment should be undertaken at an AeMC or may be delegated to a cardiologist. (c) Peripheral arterial disease If there is no significant functional impairment, a fit assessment may be considered by the licensing authority, provided: (1) applicants without symptoms of coronary artery disease have reduced any vascular risk factors to an appropriate level; (2) applicants should be on acceptable secondary prevention treatment; (3) exercise electrocardiography is satisfactory. Further tests may be required which should show no evidence of myocardial ischaemia or significant coronary artery stenosis. (d) Aortic aneurysm (1) Applicants with an aneurysm of the infra-renal abdominal aorta may be assessed as fit with a multi-pilot limitation by the licensing authority. Follow-up by ultra-sound scans or other imaging techniques, as necessary, should be determined by the licensing authority. (2) Applicants may be assessed as fit by the licensing authority after surgery for an infra-renal aortic aneurysm with a multi-pilot limitation at revalidation if the blood pressure and cardiovascular assessment are satisfactory. Regular cardiological review should be required. (e) Cardiac valvular abnormalities (1) Applicants with previously unrecognised cardiac murmurs should undergo evaluation by a cardiologist and assessment by the licensing authority. If considered significant, further investigation should include at least 2D Doppler echocardiography or equivalent imaging. (2) Applicants with minor cardiac valvular abnormalities may be assessed as fit by the licensing authority. Applicants with significant abnormality of any of the heart valves should be assessed as unfit. (3) Aortic valve disease (i) Applicants with a bicuspid aortic valve may be assessed as fit if no other cardiac or aortic abnormality is demonstrated. Follow-up with echocardiography, as necessary, should be determined by the licensing authority. (ii) Applicants with aortic stenosis require licensing authority review. Left ventricular function should be intact. A history of systemic embolism or significant dilatation of the thoracic aorta is disqualifying. Those with a mean pressure gradient of up to 20 mmHg may be assessed as fit. Those with mean pressure gradient above 20 mmHg but not greater than 40 mmHg may be assessed as fit with a multi-pilot limitation. A mean pressure gradient up to 50 mmHg may be acceptable. Follow-up with 2D Doppler echocardiography, as necessary, should be determined by the licensing authority. Alternative measurement techniques with equivalent ranges may be used. (iii) Applicants with trivial aortic regurgitation may be assessed as fit. A greater degree of aortic regurgitation should require a multi-pilot limitation. There should be no demonstrable abnormality of the ascending aorta on 2D Doppler echocardiography. Follow-up, as necessary, should be determined by the licensing authority.

text: (4) Mitral valve disease (i) Asymptomatic applicants with an isolated mid-systolic click due to mitral leaflet prolapse may be assessed as fit. (ii) Applicants with rheumatic mitral stenosis should normally be assessed as unfit. (iii) Applicants with uncomplicated minor regurgitation may be assessed as fit. Periodic cardiolological review should be determined by the licensing authority. (iv) Applicants with uncomplicated moderate mitral regurgitation may be considered as fit with a multi-pilot limitation if the 2D Doppler echocardiogram demonstrates satisfactory left ventricular dimensions and satisfactory myocardial function is confirmed by exercise electrocardiography. Periodic cardiological review should be required, as determined by the licensing authority. (v) Applicants with evidence of volume overloading of the left ventricle demonstrated by increased left ventricular end-diastolic diameter or evidence of systolic impairment should be assessed as unfit. (f) Valvular surgery Applicants with cardiac valve replacement/repair should be assessed as unfit. A fit assessment may be considered by the licensing authority. (1) Aortic valvotomy should be disqualifying. (2) Mitral leaflet repair for prolapse is compatible with a fit assessment, provided postoperative investigations reveal satisfactory left ventricular function without systolic or diastolic dilation and no more than minor mitral regurgitation. (3) Asymptomatic applicants with a tissue valve or with a mechanical valve who, at least 6 months following surgery, are taking no cardioactive medication may be considered for a fit assessment with a multi-pilot limitation by the licensing authority. Investigations which demonstrate normal valvular and ventricular configuration and function should have been completed as demonstrated by: (i) a satisfactory symptom limited exercise ECG. Myocardial perfusion imaging/stress echocardiography should be required if the exercise ECG is abnormal or any coronary artery disease has been demonstrated; (ii) a 2D Doppler echocardiogram showing no significant selective chamber enlargement, a tissue valve with minimal structural alteration and a normal Doppler blood flow, and no structural or functional abnormality of the other heart valves. Left ventricular fractional shortening should be normal. Follow-up with exercise ECG and 2D echocardiography, as necessary, should be determined by the licensing authority. (4) Where anticoagulation is needed after valvular surgery, a fit assessment with a multi-pilot limitation may be considered after review by the licensing authority. The review should show that the anticoagulation is stable. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range. (g) Thromboembolic disorders Arterial or venous thrombosis or pulmonary embolism are disqualifying whilst anticoagulation is being used as treatment. After 6 months of stable anticoagulation as prophylaxis, a fit assessment with multi-pilot limitation may be considered after review by the licensing authority. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range. Pulmonary embolus should require full evaluation. Following cessation of

text: anti-coagulant therapy, for any indication, applicants should require review by the licensing authority. (h) Other cardiac disorders (1) Applicants with a primary or secondary abnormality of the pericardium, myocardium or endocardium should be assessed as unfit. A fit assessment may be considered by the licensing authority following complete resolution and satisfactory cardiological evaluation which may include 2D Doppler echocardiography, exercise ECG and/or myocardial perfusion imaging/stress echocardiography and 24-hour ambulatory ECG. Coronary angiography may be indicated. Frequent review and a multi-pilot limitation may be required after fit assessment. (2) Applicants with a congenital abnormality of the heart, including those who have undergone surgical correction, should be assessed as unfit. Applicants with minor abnormalities that are functionally unimportant may be assessed as fit by the licensing authority following cardiological assessment. No cardioactive medication is acceptable. Investigations may include 2D Doppler echocardiography, exercise ECG and 24-hour ambulatory ECG. Regular cardiological review should be required. (i) Syncope (1) Applicants with a history of recurrent vasovagal syncope should be assessed as unfit. A fit assessment may be considered by the licensing authority after a 6-month period without recurrence provided cardiological evaluation is satisfactory. Such evaluation should include: (i) a satisfactory symptom limited 12 lead exercise ECG to Bruce Stage IV or equivalent. If the exercise ECG is abnormal, myocardial perfusion imaging/stress echocardiography should be required; (ii) a 2D Doppler echocardiogram showing neither significant selective chamber enlargement nor structural or functional abnormality of the heart, valves or myocardium; (iii) a 24-hour ambulatory ECG recording showing no conduction disturbance, complex or sustained rhythm disturbance or evidence of myocardial ischaemia. (2) A tilt test carried out to a standard protocol showing no evidence of vasomotor instability may be required. (3) Neurological review should be required. (4) A multi-pilot limitation should be required until a period of 5 years has elapsed without recurrence. The licensing authority may determine a shorter or longer period of multi-pilot limitation according to the individual circumstances of the case. (5) Applicants who experienced loss of consciousness without significant warning should be assessed as unfit.

text: (j) Blood pressure (1) The diagnosis of hypertension should require cardiovascular review to include potential vascular risk factors. (2) Anti-hypertensive treatment should be agreed by the licensing authority. Acceptable medication may include: (i) non-loop diuretic agents; (ii) ACE inhibitors; (iii) angiotensin II/AT1 blocking agents (sartans); (iv) slow channel calcium blocking agents; (v) certain (generally hydrophilic) beta-blocking agents.

text: (3) Following initiation of medication for the control of blood pressure, applicants should be re-assessed to verify that the treatment is compatible with the safe exercise of the privileges of the licence held.

text: (k) Coronary artery disease (1) Chest pain of uncertain cause should require full investigation. (2) In suspected asymptomatic coronary artery disease, exercise electrocardiography should be required. Further tests may be required, which should show no evidence of myocardial ischaemia or significant coronary artery stenosis. (3) Evidence of exercise-induced myocardial ischaemia should be disqualifying. (4) After an ischaemic cardiac event, including revascularisation, applicants without symptoms should have reduced any vascular risk factors to an appropriate level. Medication, when used to control cardiac symptoms, is not acceptable. All applicants should be on acceptable secondary prevention treatment. (i) A coronary angiogram obtained around the time of, or during, the ischaemic myocardial event and a complete, detailed clinical report of the ischaemic event and of any operative procedures should be available to the licensing authority:

text: (A) there should be no stenosis more than 50 % in any major untreated vessel, in any vein or artery graft or at the site of an angioplasty/stent, except in a vessel subtending a myocardial infarction. More than two stenoses between 30 % and 50 % within the vascular tree should not be acceptable;

text: (B) the whole coronary vascular tree should be assessed as satisfactory by a cardiologist, and particular attention should be paid to multiple stenoses and/or multiple revascularisations;

text: (C) an untreated stenosis greater than 30 % in the left main or proximal left anterior descending coronary artery should not be acceptable. (ii) At least 6 months from the ischaemic myocardial event, including revascularisation, the following investigations should be completed (equivalent tests may be substituted):

text: (A) an exercise ECG showing neither evidence of myocardial ischaemia nor rhythm or conduction disturbance;

text: (B) an echocardiogram showing satisfactory left ventricular function with no important abnormality of wall motion (such as dyskinesia or akinesia) and a left ventricular ejection fraction of 50 % or more;

text: (C) in cases of angioplasty/stenting, a myocardial perfusion scan or stress echocardiogram, which should show no evidence of reversible myocardial ischaemia. If there is any doubt about myocardial perfusion in other cases (infarction or bypass grafting) a perfusion scan should also be required;

text: (D) further investigations, such as a 24-hour ECG, may be necessary to assess the risk of any significant rhythm disturbance. (iii) Follow-up should be annually (or more frequently, if necessary) to ensure that there is no deterioration of the cardiovascular status. It should include a review by a cardiologist, exercise ECG and cardiovascular risk assessment. Additional investigations may be required by the licensing authority.

text: (A) After coronary artery vein bypass grafting, a myocardial perfusion scan or equivalent test should be performed if there is any indication, and in all cases within 5 years from the procedure. (B) In all cases, coronary angiography should be considered at any time if symptoms, signs or non-invasive tests indicate myocardial ischaemia. (iv) Successful completion of the 6-month or subsequent review will allow a fit assessment with a multi-pilot limitation.

text: (l) Rhythm and conduction disturbances (1) Any significant rhythm or conduction disturbance should require evaluation by a cardiologist and appropriate follow-up in the case of a fit assessment. Such evaluation should include: (i) exercise ECG to the Bruce protocol or equivalent. Bruce stage 4 should be achieved and no significant abnormality of rhythm or conduction, or evidence of myocardial ischaemia should be demonstrated. Withdrawal of cardioactive medication prior to the test should normally be required; (ii) 24-hour ambulatory ECG which should demonstrate no significant rhythm or conduction disturbance; (iii) 2D Doppler echocardiogram which should show no significant selective chamber enlargement or significant structural or functional abnormality, and a left ventricular ejection fraction of at least 50 %. Further evaluation may include (equivalent tests may be substituted): (iv) 24-hour ECG recording repeated as necessary; (v) electrophysiological study; (vi) myocardial perfusion imaging; (vii) cardiac magnetic resonance imaging (MRI); (viii) coronary angiogram. (2) Applicants with frequent or complex forms of supra ventricular or ventricular ectopic complexes require full cardiological evaluation. (3) Ablation Applicants who have undergone ablation therapy should be assessed as unfit. A fit assessment may be considered by the licensing authority following successful catheter ablation and should require a multi-pilot limitation for at least one year, unless an electrophysiological study, undertaken at a minimum of 2 months after the ablation, demonstrates satisfactory results. For those whose long-term outcome cannot be assured by invasive or non-invasive testing, an additional period with a multi-pilot limitation and/or observation may be necessary. (4) Supraventricular arrhythmias Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, should be assessed as unfit. A fit assessment may be considered by the licensing authority if cardiological evaluation is satisfactory. (i) Atrial fibrillation/flutter

text: (A) For initial applicants, a fit assessment should be limited to those with a single episode of arrhythmia which is considered by the licensing authority to be unlikely to recur.

text: (B) For revalidation, applicants may be assessed as fit if cardiological evaluation is satisfactory. (ii) Applicants with asymptomatic sinus pauses up to 2.5 seconds on resting electrocardiography may be assessed as fit if exercise electrocardiography, echocardiography and 24-hour ambulatory ECG are satisfactory. (iii) Symptomatic sino-atrial disease should be disqualifying. (5) Mobitz type 2 atrio-ventricular block Applicants with Mobitz type 2 AV block should require full cardiological evaluation and may be assessed as fit in the absence of distal conducting tissue disease.

text: (6) Complete right bundle branch block

text: Applicants with complete right bundle branch block should require cardiological evaluation on first presentation and subsequently: (i) for initial applicants under age 40, a fit assessment may be considered by the licensing authority. Initial applicants over age 40 should demonstrate a period of stability of 12 months; (ii) for revalidation, a fit assessment may be considered if the applicant is under age 40. A multi-pilot limitation should be applied for 12 months for those over age 40.

text: (7) Complete left bundle branch block

text: A fit assessment may be considered by the licensing authority: (i) Initial applicants should demonstrate a 3-year period of stability. (ii) For revalidation, after a 3-year period with a multi-pilot limitation applied, a fit assessment without multi-pilot limitation may be considered. (iii) Investigation of the coronary arteries is necessary for applicants over age 40. (8) Ventricular pre-excitation A fit assessment may be considered by the licensing authority: (i) Asymptomatic initial applicants with pre-excitation may be assessed as fit if an electrophysiological study, including adequate drug-induced autonomic stimulation reveals no inducible re-entry tachycardia and the existence of multiple pathways is excluded. (ii) Asymptomatic applicants with pre-excitation may be assessed as fit at revalidation with a multi-pilot limitation. (9) Pacemaker Applicants with a subendocardial pacemaker should be assessed as unfit. A fit assessment may be considered at revalidation by the licensing authority no sooner than 3 months after insertion and should require: (i) no other disqualifying condition; (ii) a bipolar lead system, programmed in bipolar mode without automatic mode change of the device; (iii) that the applicant is not pacemaker dependent; (iv) regular follow-up, including a pacemaker check; and (v) a multi-pilot limitation.

text: (10) QT prolongation Prolongation of the QT interval on the ECG associated with symptoms should be disqualifying. Asymptomatic applicants require cardiological evaluation for a fit assessment and a multi-pilot limitation may be required.

text: AMC1 MED.B.015 Respiratory system

text: (a) Examination (1) Spirometry Spirometric examination is required for initial examination. An FEV1/FVC ratio less than 70 % at initial examination should require evaluation by a specialist in respiratory disease. (2) Chest radiography Posterior/anterior chest radiography may be required at initial, revalidation or renewal examinations when indicated on clinical or epidemiological grounds. (b) Chronic obstructive airways disease Applicants with chronic obstructive airways disease should be assessed as unfit. Applicants with only minor impairment of their pulmonary function may be assessed as fit. (c) Asthma Applicants with asthma requiring medication or experiencing recurrent attacks of asthma may be assessed as fit if the asthma is considered stable with satisfactory pulmonary function tests and medication is compatible with flight safety. Systemic steroids are disqualifying. (d) Inflammatory disease For applicants with active inflammatory disease of the respiratory system a fit assessment may be considered when the condition has resolved without sequelae and no medication is required. (e) Sarcoidosis (1) Applicants with active sarcoidosis should be assessed as unfit. Investigation should be undertaken with respect to the possibility of systemic, particularly cardiac, involvement. A fit assessment may be considered if no medication is required, and the disease is investigated and shown to be limited to hilar lymphadenopathy and inactive. (2) Applicants with cardiac sarcoid should be assessed as unfit. (f) Pneumothorax (1) Applicants with a spontaneous pneumothorax should be assessed as unfit. A fit assessment may be considered if respiratory evaluation is satisfactory: (i) 1 year following full recovery from a single spontaneous pneumothorax; (ii) at revalidation, 6 weeks following full recovery from a single spontaneous pneumothorax, with a multi-pilot limitation; (iii) following surgical intervention in the case of a recurrent pneumothorax provided there is satisfactory recovery. (2) A recurrent spontaneous pneumothorax that has not been surgically treated is disqualifying.

text: (3) A fit assessment following full recovery from a traumatic pneumothorax as a result of an accident or injury may be acceptable once full absorption of the pneumothorax is demonstrated. (g) Thoracic surgery (1) Applicants requiring major thoracic surgery should be assessed as unfit for a minimum of 3 months following operation or until such time as the effects of the operation are no longer likely to interfere with the safe exercise of the privileges of the applicable licence(s). (2) A fit assessment following lesser chest surgery may be considered by the licensing authority after satisfactory recovery and full respiratory evaluation. (h) Sleep apnoea syndrome/sleep disorder Applicants with unsatisfactorily treated sleep apnoea syndrome should be assessed as unfit.

text: AMC1 MED.B.020 Digestive system

text: (a) Oesophageal varices Applicants with oesophageal varices should be assessed as unfit. (b) Pancreatitis Applicants with pancreatitis should be assessed as unfit pending assessment. A fit assessment may be considered if the cause (e.g. gallstone, other obstruction, medication) is removed. (c) Gallstones (1) Applicants with a single asymptomatic large gallstone discovered incidentally may be assessed as fit if not likely to cause incapacitation in flight. (2) An applicant with asymptomatic multiple gallstones may be assessed as fit with a multi-pilot limitation.

text: (d) Inflammatory bowel disease

text: Applicants with an established diagnosis or history of chronic inflammatory bowel disease should be assessed as fit if the inflammatory bowel disease is in established remission and stable and that systemic steroids are not required for its control. (e) Peptic ulceration Applicants with peptic ulceration should be assessed as unfit pending full recovery and demonstrated healing. (f) Abdominal surgery (1) Abdominal surgery is disqualifying for a minimum of 3 months. An earlier fit assessment may be considered if recovery is complete, the applicant is asymptomatic and there is only a minimal risk of secondary complication or recurrence. (2) Applicants who have undergone a surgical operation on the digestive tract or its adnexa, involving a total or partial excision or a diversion of any of these organs, should be assessed as unfit for a minimum period of 3 months or until such time as the effects of the operation are no longer likely to interfere with the safe exercise of the privileges of the applicable licence(s).

text: AMC1 MED.B.025 Metabolic and endocrine systems

text: (a) Metabolic, nutritional or endocrine dysfunction Applicants with metabolic, nutritional or endocrine dysfunction may be assessed as fit if the condition is asymptomatic, clinically compensated and stable with or without replacement therapy, and regularly reviewed by an appropriate specialist. (b) Obesity Applicants with a Body Mass Index  35 may be assessed as fit only if the excess weight is not likely to interfere with the safe exercise of the applicable licence(s) and a satisfactory cardiovascular risk review has been undertaken. (c) Addison’s disease Addison’s disease is disqualifying. A fit assessment may be considered, provided that cortisone is carried and available for use whilst exercising the privileges of the licence(s). Applicants may be assessed as fit with a multi-pilot limitation. (d) Gout Applicants with acute gout should be assessed as unfit. A fit assessment may be considered once asymptomatic, after cessation of treatment or the condition is stabilised on anti-hyperuricaemic therapy. (e) Thyroid dysfunction Applicants with hyperthyroidism or hypothyroidism should be assessed as unfit. A fit assessment may be considered when a stable euthyroid state is attained.

text: (f) Abnormal glucose metabolism

text: Glycosuria and abnormal blood glucose levels require investigation. A fit assessment may be considered if normal glucose tolerance is demonstrated (low renal threshold) or impaired glucose tolerance without diabetic pathology is fully controlled by diet and regularly reviewed. (g) Diabetes mellitus Subject to good control of blood sugar with no hypoglycaemic episodes: (1) applicants with diabetes mellitus not requiring medication may be assessed as fit; (2) the use of antidiabetic medications that are not likely to cause hypoglycaemia may be acceptable for a fit assessment with a multi-pilot limitation.

text: AMC1 MED.B.030 Haematology

text: (a) Abnormal haemoglobin Applicants with abnormal haemoglobin should be investigated. (b) Anaemia (1) Applicants with anaemia demonstrated by a reduced haemoglobin level or haematocrit less than 32 % should be assessed as unfit and require investigation. A fit assessment may be considered in cases where the primary cause has been treated (e.g. iron or B12 deficiency) and the haemoglobin or haematocrit has stabilised at a satisfactory level. (2) Anaemia which is unamenable to treatment is disqualifying.

text: (c) Polycythaemia Applicants with polycythaemia should be assessed as unfit and require investigation. A fit assessment with a multi-pilot limitation may be considered if the condition is stable and no associated pathology is demonstrated. (d) Haemoglobinopathy (1) Applicants with a haemoglobinopathy should be assessed as unfit. A fit assessment may be considered where minor thalassaemia or other haemoglobinopathy is diagnosed without a history of crises and where full functional capability is demonstrated. The haemoglobin level should be satisfactory. (2) Applicants with sickle cell disease should be assessed as unfit. (e) Coagulation disorders Applicants with a coagulation disorder should be assessed as unfit. A fit assessment may be considered if there is no history of significant bleeding episodes. (f) Haemorrhagic disorders Applicants with a haemorrhagic disorder require investigation. A fit assessment with a multi-pilot limitation may be considered if there is no history of significant bleeding. (g) Thrombo-embolic disorders (1) Applicants with a thrombotic disorder require investigation. A fit assessment with a multi-pilot limitation may be considered if there is no history of significant clotting episodes. (2) An arterial embolus is disqualifying. (h) Disorders of the lymphatic system Applicants with significant localised and generalised enlargement of the lymphatic glands and diseases of the blood should be assessed as unfit and require investigation. A fit assessment may be considered in cases of an acute infectious process which is fully recovered or Hodgkin’s lymphoma or other lymphoid malignancy which has been treated and is in full remission. (i) Leukaemia (1) Applicants with acute leukaemia should be assessed as unfit. Once in established remission, applicants may be assessed as fit. (2) Applicants with chronic leukaemia should be assessed as unfit. After a period of demonstrated stability a fit assessment may be considered. (3) Applicants with a history of leukaemia should have no history of central nervous system involvement and no continuing side-effects from treatment of flight safety importance. Haemoglobin and platelet levels should be satisfactory. Regular followup is required. (j) Splenomegaly Applicants with splenomegaly should be assessed as unfit and require investigation. A fit assessment may be considered when the enlargement is minimal, stable and no associated pathology is demonstrated, or if the enlargement is minimal and associated with another acceptable condition.

text: AMC1 MED.B.035 Genitourinary system

text: (a) Abnormal urinalysis Investigation is required if there is any abnormal finding on urinalysis.

text: (b) Renal disease (1) Applicants presenting with any signs of renal disease should be assessed as unfit. A fit assessment may be considered if blood pressure is satisfactory and renal function is acceptable. (2) The requirement for dialysis is disqualifying. (c) Urinary calculi (1) Applicants with an asymptomatic calculus or a history of renal colic require investigation. (2) Applicants presenting with one or more urinary calculi should be assessed as unfit and require investigation. (3) A fit assessment with a multi-pilot limitation may be considered whilst awaiting assessment or treatment. (4) A fit assessment without multi-pilot limitation may be considered after successful treatment for a calculus. (5) With residual calculi, a fit assessment with a multi-pilot limitation may be considered. (d) Renal/urological surgery (1) Applicants who have undergone a major surgical operation on the urinary tract or the urinary apparatus involving a total or partial excision or a diversion of any of its organs should be assessed as unfit for a minimum period of 3 months or until such time as the effects of the operation are no longer likely to cause incapacity in flight. After other urological surgery, a fit assessment may be considered if the applicant is completely asymptomatic and there is minimal risk of secondary complication or recurrence. (2) An applicant with compensated nephrectomy without hypertension or uraemia may be considered for a fit assessment. (3) Applicants who have undergone renal transplantation may be considered for a fit assessment if it is fully compensated and tolerated with only minimal immunosuppressive therapy after at least 12 months. Applicants may be assessed as fit with a multi-pilot limitation. (4) Applicants who have undergone total cystectomy may be considered for a fit assessment if there is satisfactory urinary function, no infection and no recurrence of primary pathology. Applicants may be assessed as fit with a multi-pilot limitation.

text: AMC1 MED.B.040 Infectious disease

text: (a) Infectious disease General In cases of infectious disease, consideration should be given to a history of, or clinical signs indicating, underlying impairment of the immune system. (b) Tuberculosis Applicants with active tuberculosis should be assessed as unfit. A fit assessment may be considered following completion of therapy. (c) Syphilis Acute syphilis is disqualifying. A fit assessment may be considered in the case of those fully treated and recovered from the primary and secondary stages.

text: (d) HIV infection (1) HIV positivity is disqualifying. A fit assessment with a multi-pilot limitation may be considered for individuals with stable, non-progressive disease. Frequent review is required. (2) The occurrence of AIDS or AIDS-related complex is disqualifying. (e) Infectious hepatitis Infectious hepatitis is disqualifying. A fit assessment may be considered after full recovery.

text: AMC1 MED.B.045 Obstetrics and gynaecology

text: (a) Gynaecological surgery An applicant who has undergone a major gynaecological operation should be assessed as unfit for a period of 3 months or until such time as the effects of the operation are not likely to interfere with the safe exercise of the privileges of the licence(s) if the holder is completely asymptomatic and there is only a minimal risk of secondary complication or recurrence. (b) Severe menstrual disturbances An applicant with a history of severe menstrual disturbances unamenable to treatment should be assessed as unfit. (c) Pregnancy (1) A pregnant licence holder may be assessed as fit with a multi-pilot limitation during the first 26 weeks of gestation, following review of the obstetric evaluation by the AeMC or AME who should inform the licensing authority. (2) The AeMC or AME should provide written advice to the applicant and the supervising physician regarding potentially significant complications of pregnancy.

text: AMC1 MED.B.050 Musculoskeletal system

text: (a) An applicant with any significant sequela from disease, injury or congenital abnormality affecting the bones, joints, muscles or tendons with or without surgery requires full evaluation prior to a fit assessment. (b) In cases of limb deficiency, a fit assessment may be considered following a satisfactory medical flight test or simulator testing. (c) An applicant with inflammatory, infiltrative, traumatic or degenerative disease of the musculoskeletal system may be assessed as fit provided the condition is in remission and the applicant is taking no disqualifying medication and has satisfactorily completed a medical flight or simulator flight test. A limitation to specified aircraft type(s) may be required. (d) Abnormal physique, including obesity, or muscular weakness may require medical flight or flight simulator testing. Particular attention should be paid to emergency procedures and evacuation. A limitation to specified aircraft type(s) may be required.

text: AMC1 MED.B.055 Psychiatry

text: (a) Psychotic disorder A history, or the occurrence, of a functional psychotic disorder is disqualifying unless a cause can be unequivocally identified as one which is transient, has ceased and will not recur.

text: (b) Organic mental disorder An organic mental disorder is disqualifying. Once the cause has been treated, an applicant may be assessed as fit following satisfactory psychiatric review. (c) Psychotropic substances Use or abuse of psychotropic substances likely to affect flight safety is disqualifying. (d) Schizophrenia, schizotypal or delusional disorder Applicants with an established schizophrenia, schizotypal or delusional disorder should only be considered for a fit assessment if the licensing authority concludes that the original diagnosis was inappropriate or inaccurate or, in the case of a single episode of delirium, provided that the applicant has suffered no permanent impairment. (e) Mood disorder An established mood disorder is disqualifying. After full recovery and after full consideration of an individual case a fit assessment may be considered, depending on the characteristics and gravity of the mood disorder. If a stable maintenance psychotropic medication is confirmed, a fit assessment should require a multi-pilot limitation. (f) Neurotic, stress-related or somatoform disorder Where there is suspicion or established evidence that an applicant has a neurotic, stressrelated or somatoform disorder, the applicant should be referred for psychiatric opinion and advice. (g) Personality or behavioural disorder Where there is suspicion or established evidence that an applicant has a personality or behavioural disorder, the applicant should be referred for psychiatric opinion and advice. (h) Disorders due to alcohol or other substance use (1) Mental or behavioural disorders due to alcohol or other substance use, with or without dependency, are disqualifying. (2) A fit assessment may be considered after a period of two years documented sobriety or freedom from substance use. At revalidation or renewal a fit assessment may be considered earlier with a multi-pilot limitation. Depending on the individual case, treatment and review may include: (i) in-patient treatment of some weeks followed by: (A) review by a psychiatric specialist; and (B) ongoing review including blood testing and peer reports, which may be required indefinitely. (i) Deliberate self-harm A single self-destructive action or repeated acts of deliberate self-harm are disqualifying. A fit assessment may be considered after full consideration of an individual case and may require psychiatric or psychological review. Neuropsychological assessment may also be required.

text: AMC1 MED.B.060 Psychology

text: (a) Where there is suspicion or established evidence that an applicant has a psychological disorder, the applicant should be referred for psychological opinion and advice. (b) Established evidence should be verifiable information from an identifiable source which evokes doubts concerning the mental fitness or personality of a particular individual. Sources for this information can be accidents or incidents, problems in training or

text: proficiency checks, delinquency or knowledge relevant to the safe exercise of the privileges of the applicable licence. (c) The psychological evaluation may include a collection of biographical data, the administration of aptitude as well as personality tests and psychological interview. (d) The psychologist should submit a written report to the AME, AeMC or licensing authority as appropriate, detailing his/her opinion and recommendation.

text: AMC1 MED.B.065 Neurology

text: (a) Epilepsy (1) A diagnosis of epilepsy is disqualifying, unless there is unequivocal evidence of a syndrome of benign childhood epilepsy associated with a very low risk of recurrence, and unless the applicant has been free of recurrence and off treatment for more than 10 years. One or more convulsive episodes after the age of 5 are disqualifying. In the case of an acute symptomatic seizure, which is considered to have a very low risk of recurrence, a fit assessment may be considered after neurological review. (2) An applicant may be assessed as fit by the licensing authority with a multi-pilot limitation if: (i) there is a history of a single afebrile epileptiform seizure; (ii) there has been no recurrence after at least 10 years off treatment; (iii) there is no evidence of continuing predisposition to epilepsy. (b) Conditions with a high propensity for cerebral dysfunction An applicant with a condition with a high propensity for cerebral dysfunction should be assessed as unfit. A fit assessment may be considered after full evaluation. (c) Clinical EEG abnormalities (1) Electroencephalography is required when indicated by the applicant’s history or on clinical grounds. (2) Epileptiform paroxysmal EEG abnormalities and focal slow waves should be disqualifying. (d) Neurological disease Any stationary or progressive disease of the nervous system which has caused or is likely to cause a significant disability is disqualifying. However, in case of minor functional losses associated with stationary disease, a fit assessment may be considered after full evaluation. (e) Episode of disturbance of consciousness In the case of a single episode of disturbance of consciousness, which can be satisfactorily explained, a fit assessment may be considered, but a recurrence should be disqualifying. (f) Head injury An applicant with a head injury which was severe enough to cause loss of consciousness or is associated with penetrating brain injury should be reviewed by a consultant neurologist. A fit assessment may be considered if there has been a full recovery and the risk of epilepsy is sufficiently low.

text: (g) Spinal or peripheral nerve injury, myopathies An applicant with a history or diagnosis of spinal or peripheral nerve injury or myopathy should be assessed as unfit. A fit assessment may be considered if neurological review and musculoskeletal assessments are satisfactory.

text: AMC1 MED.B.070 Visual system

text: (a) Eye examination (1) At each aero-medical revalidation examination, an assessment of the visual fitness should be undertaken and the eyes should be examined with regard to possible pathology. (2) All abnormal and doubtful cases should be referred to an ophthalmologist. Conditions which indicate ophthalmological examination include, but are not limited to, a substantial decrease in the uncorrected visual acuity, any decrease in best corrected visual acuity and/or the occurrence of eye disease, eye injury, or eye surgery. (3) Where specialist ophthalmological examinations are required for any significant reason, this should be imposed as a limitation on the medical certificate. (b) Comprehensive eye examination A comprehensive eye examination by an eye specialist is required at the initial examination. All abnormal and doubtful cases should be referred to an ophthalmologist. The examination should include: (1) history; (2) visual acuities - near, intermediate and distant vision (uncorrected and with best optical correction if needed); (3) examination of the external eye, anatomy, media (slit lamp) and fundoscopy; (4) ocular motility; (5) binocular vision; (6) colour vision; (7) visual fields; (8) tonometry on clinical indication; and (9) refraction hyperopic initial applicants with a hyperopia of more than +2 dioptres and under the age of 25 should undergo objective refraction in cycloplegia. (c) Routine eye examination A routine eye examination may be performed by an AME and should include: (1) history; (2) visual acuities - near, intermediate and distant vision (uncorrected and with best optical correction if needed); (3) examination of the external eye, anatomy, media and fundoscopy; (4) further examination on clinical indication. (d) Refractive error (1) At initial examination an applicant may be assessed as fit with: (i) hypermetropia not exceeding +5.0 dioptres;

text: (ii) myopia not exceeding –6.0 dioptres; (iii) astigmatism not exceeding 2.0 dioptres; (iv) anisometropia not exceeding 2.0 dioptres provided that optimal correction has been considered and no significant pathology is demonstrated. (2) Initial applicants who do not meet the requirements in (1)(ii), (iii) and (iv) above should be referred to the licensing authority. A fit assessment may be considered following review by an ophthalmologist. (3) At revalidation an applicant may be assessed as fit with: (i) hypermetropia not exceeding +5.0 dioptres; (ii) myopia exceeding –6.0 dioptres; (iii) astigmatism exceeding 2.0 dioptres; (iv) anisometropia exceeding 2.0 dioptres provided that optimal correction has been considered and no significant pathology is demonstrated. (4) If anisometropia exceeds 3.0 dioptres, contact lenses should be worn. (5) If the refractive error is +3.0 to +5.0 or –3.0 to –6.0 dioptres, there is astigmatism or anisometropia of more than 2 dioptres but less than 3 dioptres, a review should be undertaken 5 yearly by an eye specialist. (6) If the refractive error is greater than –6.0 dioptres, there is more than 3.0 dioptres of astigmatism or anisometropia exceeds 3.0 dioptres, a review should be undertaken 2 yearly by an eye specialist. (7) In cases (5) and (6) above, the applicant should supply the eye specialist’s report to the AME. The report should be forwarded to the licensing authority as part of the medical examination report. All abnormal and doubtful cases should be referred to an ophthalmologist. (e) Uncorrected visual acuity No limits apply to uncorrected visual acuity.

text: (f) Substandard vision (1) Applicants with reduced central vision in one eye may be assessed as fit if the binocular visual field is normal and the underlying pathology is acceptable according to ophthalmological assessment. A satisfactory medical flight test and a multi-pilot limitation are required. (2) An applicant with acquired substandard vision in one eye may be assessed as fit with a multi-pilot limitation if: (i) the better eye achieves distant visual acuity of 6/6 (1.0), corrected or uncorrected; (ii) the better eye achieves intermediate visual acuity of N14 and N5 for near; (iii) in the case of acute loss of vision in one eye, a period of adaptation time has passed from the known point of visual loss, during which the applicant should be assessed as unfit; (iv) there is no significant ocular pathology; and

text: (v) a medical flight test is satisfactory. (3) An applicant with a visual field defect may be assessed as fit if the binocular visual field is normal and the underlying pathology is acceptable to the licensing authority.

text: (g) Keratoconus Applicants with keratoconus may be assessed as fit if the visual requirements are met with the use of corrective lenses and periodic review is undertaken by an ophthalmologist.

text: (h) Heterophoria Applicants with heterophoria (imbalance of the ocular muscles) exceeding: (1) at 6 metres: 2.0 prism dioptres in hyperphoria, 10.0 prism dioptres in esophoria, 8.0 prism dioptres in exophoria and (2) at 33 centimetres: 1.0 prism dioptre in hyperphoria, 8.0 prism dioptres in esophoria, 12.0 prism dioptres in exophoria should be assessed as unfit. The applicant should be reviewed by an ophthalmologist and if the fusional reserves are sufficient to prevent asthenopia and diplopia a fit assessment may be considered.

text: (i) Eye surgery The assessment after eye surgery should include an ophthalmological examination. (1) After refractive surgery, a fit assessment may be considered, provided that: (i) pre-operative refraction was not greater than +5 dioptres; (ii) post-operative stability of refraction has been achieved (less than 0.75 dioptres variation diurnally); (iii) examination of the eye shows no post-operative complications; (iv) glare sensitivity is within normal standards; (v) mesopic contrast sensitivity is not impaired; (vi) review is undertaken by an eye specialist. (2) Cataract surgery entails unfitness. A fit assessment may be considered after 3 months. (3) Retinal surgery entails unfitness. A fit assessment may be considered 6 months after successful surgery. A fit assessment may be acceptable earlier after retinal laser therapy. Follow-up may be required. (4) Glaucoma surgery entails unfitness. A fit assessment may be considered 6 months after successful surgery. Follow-up may be required.

text: (5) For (2), (3) and (4) above, a fit assessment may be considered earlier if recovery is complete. (j) Correcting lenses Correcting lenses should permit the licence holder to meet the visual requirements at all distances.

text: AMC1 MED B.075 Colour vision

text: (a) At revalidation, colour vision should be tested on clinical indication.

text: (b) The Ishihara test (24 plate version) is considered passed if the first 15 plates, presented

text: in a random order, are identified without error.

text: (c) Those failing the Ishihara test should be examined either by:

text: (1) anomaloscopy (Nagel or equivalent). This test is considered passed if the colour match is trichromatic and the matching range is 4 scale units or less; or by (2) lantern testing with a Spectrolux, Beynes or Holmes-Wright lantern. This test is considered passed if the applicant passes without error a test with accepted lanterns.

text: AMC1 MED.B.080 Otorhino-laryngology

text: (a) Hearing (1) The applicant should understand correctly conversational speech when tested with each ear at a distance of 2 metres from and with the applicant’s back turned towards the AME. (2) The pure tone audiogram should cover the 500 Hz, 1 000 Hz, 2 000 Hz and 3 000 Hz frequency thresholds. (3) An applicant with hypoacusis should be referred to the licensing authority. A fit assessment may be considered if a speech discrimination test or functional flight deck hearing test demonstrates satisfactory hearing ability. A vestibular function test may be appropriate. (4) If the hearing requirements can only be met with the use of hearing aids, the hearing aids should provide optimal hearing function, be well tolerated and suitable for aviation purposes. (b) Comprehensive otorhinolaryngological examination A comprehensive otorhino-laryngological examination should include: (1) history; (2) clinical examination including otoscopy, rhinoscopy, and examination of the mouth and throat; (3) tympanometry or equivalent; (4) clinical assessment of the vestibular system. (c) Ear conditions (1) An applicant with an active pathological process, acute or chronic, of the internal or middle ear should be assessed as unfit. A fit assessment may be considered once the condition has stabilised or there has been a full recovery.

text: (2) An applicant with an unhealed perforation or dysfunction of the tympanic membranes should be assessed as unfit. An applicant with a single dry perforation of non-infectious origin and which does not interfere with the normal function of the ear may be considered for a fit assessment. (d) Vestibular disturbance An applicant with disturbance of vestibular function should be assessed as unfit. A fit assessment may be considered after full recovery. The presence of spontaneous or positional nystagmus requires complete vestibular evaluation by an ENT specialist. Significant abnormal caloric or rotational vestibular responses are disqualifying. Abnormal vestibular responses should be assessed in their clinical context. (e) Sinus dysfunction An applicant with any dysfunction of the sinuses should be assessed as unfit until there has been full recovery. (f) Oral/upper respiratory tract infections A significant, acute or chronic infection of the oral cavity or upper respiratory tract is disqualifying. A fit assessment may be considered after full recovery. (g) Speech disorder A significant disorder of speech or voice is disqualifying.

text: AMC1 MED.B.085 Dermatology

text: (a) Referral to the licensing authority should be made if doubt exists about the fitness of an applicant with eczema (exogenous and endogenous), severe psoriasis, bacterial infections, drug induced, or bullous eruptions or urticaria.

text: (b) Systemic effects of radiant or pharmacological treatment for a dermatological condition

text: should be considered before a fit assessment can be considered.

text: (c) In cases where a dermatological condition is associated with a systemic illness, full

text: consideration should be given to the underlying illness before a fit assessment may be considered.

text: AMC1 MED.B.090 Oncology

text: (a) Applicants who underwent treatment for malignant disease may be assessed as fit by the

text: licensing authority if: (1) there is no evidence of residual malignant disease after treatment; (2) time appropriate to the type of tumour has elapsed since the end of treatment; (3) the risk of inflight incapacitation from a recurrence or metastasis is sufficiently low; (4) there is no evidence of short or long-term sequelae from treatment. Special attention should be paid to applicants who have received anthracycline chemotherapy; (5) satisfactory oncology follow-up reports are provided to the licensing authority. (b) A multi-pilot limitation should be applied as appropriate. (c) Applicants with pre-malignant conditions of the skin may be assessed as fit if treated or excised as necessary and there is regular follow-up.

text: Section 3

text: Specific requirements for class 2 medical certificates

text: AMC2 MED.B.010 Cardiovascular system

text: (a) Examination Exercise electrocardiography An exercise ECG when required as part of a cardiovascular assessment should be symptom-limited and completed to a minimum of Bruce Stage IV or equivalent. (b) General (1) Cardiovascular risk factor assessment An accumulation of risk factors (smoking, family history, lipid abnormalities, hypertension, etc.) requires cardiovascular evaluation. (2) Cardiovascular assessment Reporting of resting and exercise electrocardiograms should be by the AME or an accredited specialist. (c) Peripheral arterial disease A fit assessment may be considered for an applicant with peripheral arterial disease, or after surgery for peripheral arterial disease, provided there is no significant functional impairment, any vascular risk factors have been reduced to an appropriate level, the applicant is receiving acceptable secondary prevention treatment, and there is no evidence of myocardial ischaemia. (d) Aortic aneurysm (1) Applicants with an aneurysm of the thoracic or abdominal aorta may be assessed as fit, subject to satisfactory cardiological evaluation and regular follow-up. (2) Applicants may be assessed as fit after surgery for a thoracic or abdominal aortic aneurysm subject to satisfactory cardiological evaluation to exclude the presence of coronary artery disease. (e) Cardiac valvular abnormalities (1) Applicants with previously unrecognised cardiac murmurs require further cardiological evaluation. (2) Applicants with minor cardiac valvular abnormalities may be assessed as fit. (f) Valvular surgery (1) Applicants who have undergone cardiac valve replacement or repair may be assessed as fit if post-operative cardiac function and investigations are satisfactory and no anticoagulants are needed. (2) Where anticoagulation is needed after valvular surgery, a fit assessment with an OSL or OPL limitation may be considered after cardiological review. The review should show that the anticoagulation is stable. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range.

text: (g) Thromboembolic disorders Arterial or venous thrombosis or pulmonary embolism are disqualifying whilst anticoagulation is being used as treatment. After 6 months of stable anticoagulation as prophylaxis, a fit assessment with an OSL or OPL limitation may be considered after review in consultation with the licensing authority. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range. Pulmonary embolus should require full evaluation.

text: (h) Other cardiac disorders (1) Applicants with a primary or secondary abnormality of the pericardium, myocardium or endocardium may be assessed as unfit pending satisfactory cardiological evaluation. (2) Applicants with a congenital abnormality of the heart, including those who have undergone surgical correction, may be assessed as fit subject to satisfactory cardiological assessment. Cardiological follow-up may be necessary and should be determined in consultation with the licensing authority.

text: (i) Syncope Applicants with a history of recurrent vasovagal syncope may be assessed as fit after a 6-month period without recurrence, provided that cardiological evaluation is satisfactory. Neurological review may be indicated.

text: (j) Blood pressure (1) When the blood pressure at examination consistently exceeds 160 mmHg systolic and/or 95 mmHg diastolic, with or without treatment, the applicant should be assessed as unfit. (2) The diagnosis of hypertension requires review of other potential vascular risk factors. (3) Applicants with symptomatic hypotension should be assessed as unfit.

text: (4) Anti-hypertensive treatment should be compatible with flight safety.

text: (5) Following initiation of medication for the control of blood pressure, applicants should be re-assessed to verify that the treatment is compatible with the safe exercise of the privileges of the licence held.

text: (k) Coronary artery disease (1) Chest pain of uncertain cause requires full investigation. (2) In suspected asymptomatic coronary artery disease cardiological evaluation should show no evidence of myocardial ischaemia or significant coronary artery stenosis. (3) After an ischaemic cardiac event, or revascularisation, applicants without symptoms should have reduced any vascular risk factors to an appropriate level. Medication, when used to control angina pectoris, is not acceptable. All applicants should be on acceptable secondary prevention treatment. (i) A coronary angiogram obtained around the time of, or during, the ischaemic myocardial event and a complete, detailed clinical report of the ischaemic event and of any operative procedures should be available to the AME. (A) There should be no stenosis more than 50 % in any major untreated vessel, in any vein or artery graft or at the site of an angioplasty/stent, except in a vessel subtending a myocardial infarction. More than two stenoses between 30 % and 50 % within the vascular tree should not be acceptable.

text: (B) The whole coronary vascular tree should be assessed as satisfactory and particular attention should be paid to multiple stenoses and/or multiple revascularisations. (C) An untreated stenosis greater than 30 % in the left main or proximal left anterior descending coronary artery should not be acceptable. (ii) At least 6 months from the ischaemic myocardial event, including revascularisation, the following investigations should be completed (equivalent tests may be substituted): (A) an exercise ECG showing neither evidence of myocardial ischaemia nor rhythm disturbance; (B) an echocardiogram showing satisfactory left ventricular function with no important abnormality of wall motion and a satisfactory left ventricular ejection fraction of 50 % or more; (C) in cases of angioplasty/stenting, a myocardial perfusion scan or stress echocardiogram which should show no evidence of reversible myocardial ischaemia. If there is doubt about revascularisation in myocardial infarction or bypass grafting, a perfusion scan should also be required; (D) further investigations, such as a 24-hour ECG, may be necessary to assess the risk of any significant rhythm disturbance. (iii) Periodic follow-up should include cardiological review. (A) After coronary artery bypass grafting, a myocardial perfusion scan (or satisfactory equivalent test) should be performed if there is any indication, and in all cases within five years from the procedure for a fit assessment without a safety pilot limitation. (B) In all cases, coronary angiography should be considered at any time if symptoms, signs or non-invasive tests indicate myocardial ischaemia. (iv) Successful completion of the six month or subsequent review will allow a fit assessment. Applicants may be assessed as fit with a safety pilot limitation having successfully completed only an exercise ECG. (4) Angina pectoris is disqualifying, whether or not it is abolished by medication.

text: (l) Rhythm and conduction disturbances

text: Any significant rhythm or conduction disturbance should require cardiological evaluation and an appropriate follow-up before a fit assessment may be considered. An OSL or OPL limitation should be considered as appropriate. (1) Ablation A fit assessment may be considered following successful catheter ablation subject to satisfactory cardiological review undertaken at a minimum of 2 months after the ablation. (2) Supraventricular arrhythmias (i) Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, may be assessed as fit if cardiological evaluation is satisfactory. (ii) Applicants with atrial fibrillation/flutter may be assessed as fit if cardiological evaluation is satisfactory. (iii) Applicants with asymptomatic sinus pauses up to 2.5 seconds on resting electrocardiography may be assessed as fit if cardiological evaluation is satisfactory.

text: (3) Heart block (i) Applicants with first degree and Mobitz type 1 AV block may be assessed as fit. (ii) Applicants with Mobitz type 2 AV block may be assessed as fit in the absence of distal conducting tissue disease. (4) Complete right bundle branch block Applicants with complete right bundle branch block may be assessed as fit subject to satisfactory cardiological evaluation. (5) Complete left bundle branch block Applicants with complete left bundle branch block may be assessed as fit subject to satisfactory cardiological assessment. (6) Ventricular pre-excitation Asymptomatic applicants with ventricular pre-excitation may be assessed as fit subject to satisfactory cardiological evaluation. (7) Pacemaker Applicants with a subendocardial pacemaker may be assessed as fit no sooner than 3 months after insertion provided: (i) there is no other disqualifying condition; (ii) a bipolar lead system is used, programmed in bipolar mode without automatic mode change of the device; (iii) the applicant is not pacemaker dependent; and (iv) the applicant has a regular follow-up, including a pacemaker check.

text: AMC2 MED.B.015 Respiratory system

text: (a) Chest radiography Posterior/anterior chest radiography may be required if indicated on clinical grounds. (b) Chronic obstructive airways disease Applicants with only minor impairment of pulmonary function may be assessed as fit. (c) Asthma Applicants with asthma may be assessed as fit if the asthma is considered stable with satisfactory pulmonary function tests and medication is compatible with flight safety. Systemic steroids should be disqualifying. (d) Inflammatory disease Applicants with active inflammatory disease of the respiratory system should be assessed as unfit pending resolution of the condition. (e) Sarcoidosis (1) Applicants with active sarcoidosis should be assessed as unfit. Investigation should be undertaken with respect to the possibility of systemic involvement. A fit assessment may be considered once the disease is inactive. (2) Applicants with cardiac sarcoid should be assessed as unfit. (f) Pneumothorax (1) Applicants with spontaneous pneumothorax should be assessed as unfit. A fit assessment may be considered if respiratory evaluation is satisfactory six weeks following full recovery from a single spontaneous pneumothorax or following

text: recovery from surgical intervention in the case of treatment for a recurrent pneumothorax. (2) A fit assessment following full recovery from a traumatic pneumothorax as a result of an accident or injury may be acceptable once full absorption of the pneumothorax is demonstrated. (g) Thoracic surgery Applicants requiring major thoracic surgery should be assessed as unfit until such time as the effects of the operation are no longer likely to interfere with the safe exercise of the privileges of the applicable licence(s). (h) Sleep apnoea syndrome Applicants with unsatisfactorily treated sleep apnoea syndrome should be assessed as unfit.

text: AMC2 MED.B.020 Digestive system

text: (a) Oesophageal varices Applicants with oesophageal varices should be assessed as unfit. (b) Pancreatitis Applicants with pancreatitis should be assessed as unfit pending satisfactory recovery. (c) Gallstones (1) Applicants with a single asymptomatic large gallstone or asymptomatic multiple gallstones may be assessed as fit. (2) Applicants with symptomatic single or multiple gallstones should be assessed as unfit. A fit assessment may be considered following gallstone removal. (d) Inflammatory bowel disease Applicants with an established diagnosis or history of chronic inflammatory bowel disease may be assessed as fit provided that the disease is stable and not likely to interfere with the safe exercise of the privileges of the applicable licence(s). (e) Peptic ulceration Applicants with peptic ulceration should be assessed as unfit pending full recovery. (f) Abdominal surgery (1) Abdominal surgery is disqualifying. A fit assessment may be considered if recovery is complete, the applicant is asymptomatic and there is only a minimal risk of secondary complication or recurrence. (2) Applicants who have undergone a surgical operation on the digestive tract or its adnexa, involving a total or partial excision or a diversion of any of these organs, should be assessed as unfit until such time as the effects of the operation are no longer likely to interfere with the safe exercise of the privileges of the applicable licence(s).

text: AMC2 MED.B.025 Metabolic and endocrine systems

text: (a) Metabolic, nutritional or endocrine dysfunction Metabolic, nutritional or endocrine dysfunction is disqualifying. A fit assessment may be considered if the condition is asymptomatic, clinically compensated and stable. (b) Obesity Obese applicants may be assessed as fit only if the excess weight is not likely to interfere with the safe exercise of the applicable licence(s).

text: (c) Addison’s disease Applicants with Addison’s disease may be assessed as fit provided that cortisone is carried and available for use whilst exercising the privileges of the licence. (d) Gout Applicants with acute gout should be assessed as unfit until asymptomatic. (e) Thyroid dysfunction Applicants with thyroid disease may be assessed as fit once a stable euthyroid state is attained. (f) Abnormal glucose metabolism Glycosuria and abnormal blood glucose levels require investigation. A fit assessment may be considered if normal glucose tolerance is demonstrated (low renal threshold) or impaired glucose tolerance is fully controlled by diet and regularly reviewed. (g) Diabetes mellitus Applicants with diabetes mellitus may be assessed as fit. The use of antidiabetic medications that are not likely to cause hypoglycaemia may be acceptable.

text: AMC2 MED.B.030 Haematology

text: (a) Abnormal haemoglobin Haemoglobin should be tested when clinically indicated. (b) Anaemia Applicants with anaemia demonstrated by a reduced haemoglobin level or low haematocrit may be assessed as fit once the primary cause has been treated and the haemoglobin or haematocrit has stabilised at a satisfactory level. (c) Polycythaemia Applicants with polycythaemia may be assessed as fit if the condition is stable and no associated pathology is demonstrated. (d) Haemoglobinopathy Applicants with a haemoglobinopathy may be assessed as fit if minor thalassaemia or other haemoglobinopathy is diagnosed without a history of crises and where full functional capability is demonstrated. (e) Coagulation and haemorrhagic disorders Applicants with a coagulation or haemorrhagic disorder may be assessed as fit if there is no likelihood of significant bleeding. (f) Thrombo-embolic disorders Applicants with a thrombotic disorder may be assessed as fit if there is no likelihood of significant clotting episodes. (g) Disorders of the lymphatic system Applicants with significant enlargement of the lymphatic glands or haematological disease may be assessed as fit if the condition is unlikely to interfere with the safe exercise of the privileges of the applicable licence(s). Applicants may be assessed as fit in cases of acute infectious process which is fully recovered or Hodgkin's lymphoma or other lymphoid malignancy which has been treated and is in full remission. (h) Leukaemia (1) Applicants with acute leukaemia may be assessed as fit once in established remission.

text: (2) Applicants with chronic leukaemia may be assessed as fit after a period of demonstrated stability. (3) In cases (1) and (2) above there should be no history of central nervous system involvement and no continuing side effects from treatment of flight safety importance. Haemoglobin and platelet levels should be satisfactory. Regular followup is required. (i) Splenomegaly Applicants with splenomegaly may be assessed as fit if the enlargement is minimal, stable and no associated pathology is demonstrated, or if the enlargement is minimal and associated with another acceptable condition.

text: AMC2 MED.B.035 Genitourinary system

text: (a) Renal disease Applicants presenting with renal disease may be assessed as fit if blood pressure is satisfactory and renal function is acceptable. The requirement for dialysis is disqualifying. (b) Urinary calculi (1) Applicants presenting with one or more urinary calculi should be assessed as unfit. (2) Applicants with an asymptomatic calculus or a history of renal colic require investigation. (3) While awaiting assessment or treatment, a fit assessment with a safety pilot limitation may be considered. (4) After successful treatment the applicant may be assessed as fit. (5) Applicants with parenchymal residual calculi may be assessed as fit. (c) Renal/urological surgery (1) Applicants who have undergone a major surgical operation on the urinary tract or the urinary apparatus involving a total or partial excision or a diversion of any of its organs should be assessed as unfit until such time as the effects of the operation are no longer likely to cause incapacity in flight. After other urological surgery, a fit assessment may be considered if the applicant is completely asymptomatic, there is minimal risk of secondary complication or recurrence presenting with renal disease, if blood pressure is satisfactory and renal function is acceptable. The requirement for dialysis is disqualifying. (2) An applicant with compensated nephrectomy without hypertension or uraemia may be assessed as fit. (3) Applicants who have undergone renal transplantation may be considered for a fit assessment if it is fully compensated and with only minimal immuno-suppressive therapy. (4) Applicants who have undergone total cystectomy may be considered for a fit assessment if there is satisfactory urinary function, no infection and no recurrence of primary pathology.

text: AMC2 MED.B.040 Infectious diseases

text: (a) Tuberculosis Applicants with active tuberculosis should be assessed as unfit until completion of therapy.

text: (b) HIV infection A fit assessment may be considered for HIV positive individuals with stable, nonprogressive disease if full investigation provides no evidence of HIV-associated diseases that might give rise to incapacitating symptoms.

text: AMC2 MED.B.045 Obstetrics and gynaecology

text: (a) Gynaecological surgery An applicant who has undergone a major gynaecological operation should be assessed as unfit until such time as the effects of the operation are not likely to interfere with the safe exercise of the privileges of the licence(s). (b) Pregnancy (1) A pregnant licence holder may be assessed as fit during the first 26 weeks of gestation following satisfactory obstetric evaluation. (2) Licence privileges may be resumed upon satisfactory confirmation of full recovery following confinement or termination of pregnancy.

text: AMC2 MED.B.050 Musculoskeletal system

text: (a) An applicant with any significant sequela from disease, injury or congenital abnormality affecting the bones, joints, muscles or tendons with or without surgery should require full evaluation prior to fit assessment. (b) In cases of limb deficiency, a fit assessment may be considered following a satisfactory medical flight test. (c) An applicant with inflammatory, infiltrative, traumatic or degenerative disease of the musculoskeletal system may be assessed as fit, provided the condition is in remission and the applicant is taking no disqualifying medication and has satisfactorily completed a medical flight test. A limitation to specified aircraft type(s) may be required. (d) Abnormal physique or muscular weakness may require a satisfactory medical flight test. A limitation to specified aircraft type(s) may be required.

text: AMC2 MED.B.055 Psychiatry

text: (a) Psychotic disorder A history, or the occurrence, of a functional psychotic disorder is disqualifying unless in certain rare cases a cause can be unequivocally identified as one which is transient, has ceased and will not recur. (b) Psychotropic substances Use or abuse of psychotropic substances likely to affect flight safety is disqualifying. If a stable maintenance psychotropic medication is confirmed, a fit assessment with an OSL limitation may be considered. (c) Schizophrenia, schizotypal or delusional disorder An applicant with a history of schizophrenia, schizotypal or delusional disorder may only be considered fit if the original diagnosis was inappropriate or inaccurate as confirmed by psychiatric evaluation or, in the case of a single episode of delirium, provided that the applicant has suffered no permanent impairment. (d) Disorders due to alcohol or other substance use (1) Mental or behavioural disorders due to alcohol or other substance use, with or without dependency, are disqualifying.

text: (2) A fit assessment may be considered in consultation with the licensing authority after a period of two years documented sobriety or freedom from substance use. A fit assessment may be considered earlier with an OSL or OPL limitation. Depending on the individual case, treatment and review may include: (i) in-patient treatment of some weeks followed by: (A) review by a psychiatric specialist; and (B) ongoing review, including blood testing and peer reports, which may be required indefinitely.

text: AMC2 MED.B.060 Psychology

text: Applicants with a psychological disorder may need to be referred for psychological or neuropsychiatric opinion and advice.

text: AMC2 MED.B.065 Neurology

text: (a) Epilepsy An applicant may be assessed as fit if: (1) there is a history of a single afebrile epileptiform seizure, considered to have a very low risk of recurrence; (2) there has been no recurrence after at least 10 years off treatment; (3) there is no evidence of continuing predisposition to epilepsy. (b) Conditions with a high propensity for cerebral dysfunction An applicant with a condition with a high propensity for cerebral dysfunction should be assessed as unfit. A fit assessment may be considered after full evaluation. (c) Neurological disease Any stationary or progressive disease of the nervous system which has caused or is likely to cause a significant disability is disqualifying. In case of minor functional loss associated with stationary disease, a fit assessment may be considered after full evaluation. (d) Head injury An applicant with a head injury which was severe enough to cause loss of consciousness or is associated with penetrating brain injury may be assessed as fit if there has been a full recovery and the risk of epilepsy is sufficiently low.

text: AMC2 MED.B.070 Visual system

text: (a) Eye examination (1) At each aero-medical revalidation examination an assessment of the visual fitness of the licence holder should be undertaken and the eyes should be examined with regard to possible pathology. Conditions which indicate further ophthalmological examination include, but are not limited to, a substantial decrease in the uncorrected visual acuity, any decrease in best corrected visual acuity and/or the occurrence of eye disease, eye injury, or eye surgery. (2) At the initial assessment, the examination should include: (i) history; (ii) visual acuities - near, intermediate and distant vision (uncorrected and with best optical correction if needed); (iii) examination of the external eye, anatomy, media and fundoscopy;

text: (iv) ocular motility; (v) binocular vision; (vi) colour vision and visual fields; (vii) further examination on clinical indication. (3) At the initial assessment the applicant should submit a copy of the recent spectacle prescription if visual correction is required to meet the visual requirements. (b) Routine eye examination A routine eye examination should include: (1) history; (2) visual acuities - near, intermediate and distant vision (uncorrected and with best optical correction if needed); (3) examination of the external eye, anatomy, media and fundoscopy; (4) further examination on clinical indication. (c) Visual acuity In an applicant with amblyopia, the visual acuity of the amblyopic eye should be 6/18 (0,3) or better. The applicant may be assessed as fit, provided the visual acuity in the other eye is 6/6 (1,0) or better, with or without correction, and no significant pathology can be demonstrated. (d) Substandard vision (1) Reduced stereopsis, abnormal convergence not interfering with near vision and ocular misalignment where the fusional reserves are sufficient to prevent asthenopia and diplopia may be acceptable. (2) An applicant with substandard vision in one eye may be assessed as fit subject to a satisfactory flight test if the better eye: (i) achieves distant visual acuity of 6/6 (1,0), corrected or uncorrected; (ii) achieves intermediate visual acuity of N14 and N5 for near; (iii) has no significant pathology. (3) An applicant with a visual field defect may be considered as fit if the binocular visual field is normal and the underlying pathology is acceptable. (e) Eye surgery (1) The assessment after eye surgery should include an ophthalmological examination. (2) After refractive surgery a fit assessment may be considered provided that there is stability of refraction, there are no postoperative complications and no increase in glare sensitivity. (3) After cataract, retinal or glaucoma surgery a fit assessment may be considered once recovery is complete. (f) Correcting lenses Correcting lenses should permit the licence holder to meet the visual requirements at all distances.

text: AMC2 MED B.075 Colour vision

text: (a) The Ishihara test (24 plate version) is considered passed if the first 15 plates, presented in a random order, are identified without error.

text: (b) Those failing the Ishihara test should be examined either by: (1) anomaloscopy (Nagel or equivalent). This test is considered passed if the colour match is trichromatic and the matching range is 4 scale units or less; or by (2) lantern testing with a Spectrolux, Beynes or Holmes-Wright lantern. This test is considered passed if the applicant passes without error a test with accepted lanterns. (c) Colour vision should be tested on clinical indication at revalidation or renewal examinations.

text: AMC2 MED.B.080 Otorhino-laryngology

text: (a) Hearing (1) The applicant should understand correctly conversational speech when tested with each ear at a distance of 2 metres from and with the applicant’s back turned towards the AME. (2) An applicant with hypoacusis may be assessed as fit if a speech discrimination test or functional cockpit hearing test demonstrates satisfactory hearing ability. An applicant for an instrument rating with hypoacusis should be assessed in consultation with the licensing authority. (3) If the hearing requirements can be met only with the use of hearing aids, the hearing aids should provide optimal hearing function, be well tolerated and suitable for aviation purposes. (b) Examination An ear, nose and throat (ENT) examination should form part of all initial, revalidation and renewal examinations. (c) Ear conditions (1) An applicant with an active pathological process, acute or chronic, of the internal or middle ear should be assessed as unfit until the condition has stabilised or there has been a full recovery. (2) An applicant with an unhealed perforation or dysfunction of the tympanic membranes should be assessed as unfit. An applicant with a single dry perforation of non-infectious origin which does not interfere with the normal function of the ear may be considered for a fit assessment. (d) Vestibular disturbance An applicant with disturbance of vestibular function should be assessed as unfit pending full recovery. (e) Sinus dysfunction An applicant with any dysfunction of the sinuses should be assessed as unfit pending full recovery. (f) Oral/upper respiratory tract infections A significant acute or chronic infection of the oral cavity or upper respiratory tract is disqualifying until full recovery. (g) Speech disorder A significant disorder of speech or voice should be disqualifying. (h) Air passage restrictions An applicant with significant restriction of the nasal air passage on either side, or

text: significant malformation of the oral cavity or upper respiratory tract may be assessed as fit if ENT evaluation is satisfactory. (i) Eustachian tube function An applicant with significant dysfunction of the Eustachian tubes may be assessed as fit in consultation with the licensing authority.

text: AMC2 MED.B.085 Dermatology

text: In cases where a dermatological condition is associated with a systemic illness, full consideration should be given to the underlying illness before a fit assessment can be considered.

text: AMC MED.B.090 Oncology

text: (a) Applicants may be considered for a fit assessment after treatment for malignant disease if: (1) there is no evidence of residual malignant disease after treatment; (2) time appropriate to the type of tumour has elapsed since the end of treatment; (3) the risk of in-flight incapacitation from a recurrence or metastasis is sufficiently low; (4) there is no evidence of short or long-term sequelae from treatment that may adversely affect flight safety; (5) special attention is paid to applicants who have received anthracyline chemotherapy; (6) arrangements for an oncological follow-up have been made for an appropriate period of time. (b) Applicants with pre-malignant conditions of the skin may be assessed as fit if treated or excised as necessary and there is a regular follow-up.

text: Section 4

text: Specific requirements for LAPL medical certificates

text: AMC1 MED.B.095 Medical examination and/or assessment of applicants for LAPL medical certificates

text: When a specialist evaluation is required under this section, the aero-medical assessment of the applicant should be performed by an AeMC, an AME or, in the case of AMC 5(d), by the licensing authority.

text: AMC2 MED.B.095 Cardiovascular system

text: (a) Examination Pulse and blood pressure should be recorded at each examination. (b) General (1) Cardiovascular risk factor assessment An accumulation of risk factors (smoking, family history, lipid abnormalities, hypertension, etc.) requires cardiovascular evaluation. (2) Aortic aneurysm Applicants with an aortic aneurysm may be assessed as fit subject to satisfactory cardiological evaluation and a regular follow-up. (3) Cardiac valvular abnormalities Applicants with a cardiac murmur may be assessed as fit if the murmur is assessed as being of no pathological significance. (4) Valvular surgery After cardiac valve replacement or repair a fit assessment may be considered if post-operative cardiac function and investigations are satisfactory. Anticoagulation, if needed, should be stable. (5) Other cardiac disorders: (i) Applicants with other cardiac disorders may be assessed as fit subject to satisfactory cardiological assessment. (ii) Applicants with symptomatic hypertrophic cardiomyopathy should be assessed as unfit. (c) Blood pressure (1) When the blood pressure consistently exceeds 160 mmHg systolic and/or 95 mmHg diastolic, with or without treatment, the applicant should be assessed as unfit. (2) The initiation of medication for the control of blood pressure should require a period of temporary suspension of the medical certificate to establish the absence of significant side effects. (d) Coronary artery disease (1) Applicants with suspected myocardial ischaemia should be investigated before a fit assessment can be considered.

text: (2) Applicants with angina pectoris requiring medication for cardiac symptoms should be assessed as unfit. (3) After an ischaemic cardiac event, including myocardial infarction or revascularisation, applicants without symptoms should have reduced any vascular risk factors to an appropriate level. Medication, when used to control cardiac symptoms, is not acceptable. All applicants should be on acceptable secondary prevention treatment. (4) In cases under (1), (2) and (3) above, applicants who have had a satisfactory cardiological evaluation to include an exercise test or equivalent that is negative for ischaemia may be assessed as fit. (e) Rhythm and conduction disturbances (1) Applicants with a significant disturbance of cardiac rhythm or conduction should be assessed as unfit unless a cardiological evaluation concludes that the disturbance is not likely to interfere with the safe exercise of the privileges of the LAPL. (2) Pre-excitation Applicants with ventricular pre-excitation may be assessed as fit subject to satisfactory cardiological evaluation. Applicants with ventricular pre-excitation associated with a significant arrhythmia should be assessed as unfit. (3) Pacemaker A fit assessment may be considered subject to satisfactory cardiological evaluation.

text: AMC3 MED.B.095 Respiratory system

text: (a) Asthma and chronic obstructive airways disease Applicants with asthma or minor impairment of pulmonary function may be assessed as fit if the condition is considered stable with satisfactory pulmonary function and medication is compatible with flight safety. Systemic steroids may be disqualifying depending on dosage needed and corresponding side effects. (b) Sarcoidosis (1) Applicants with active sarcoidosis should be assessed as unfit. Investigation should be undertaken with respect to the possibility of systemic involvement. A fit assessment may be considered once the disease is inactive. (2) Applicants with cardiac sarcoidosis should be assessed as unfit. (c) Pneumothorax (1) Applicants with spontaneous pneumothorax may be assessed as fit subject to satisfactory respiratory evaluation following full recovery from a single spontaneous pneumothorax or following recovery from surgical treatment for a recurrent pneumothorax. (2) Applicants with traumatic pneumothorax may be assessed as fit following full recovery. (d) Thoracic surgery Applicants who have undergone major thoracic surgery may be assessed as fit following full recovery. (e) Sleep apnoea syndrome/sleep disorder Applicants with unsatisfactorily treated sleep apnoea syndrome should be assessed as unfit.

text: AMC4 MED.B.095 Digestive system

text: (a) Gallstones Applicants with symptomatic gallstones should be assessed as unfit. A fit assessment may be considered following gallstone removal. (b) Inflammatory bowel disease Applicants with an established diagnosis or history of chronic inflammatory bowel disease may be assessed as fit provided that the disease is stable and not likely to interfere with the safe exercise of the privileges of the licence. (c) Abdominal surgery Applicants who have undergone a surgical operation on the digestive tract or its adnexae may be assessed as fit provided recovery is complete, they are asymptomatic and there is only a minimal risk of secondary complication or recurrence. (d) Pancreatitis Applicants with pancreatitis may be assessed as fit after satisfactory recovery.

text: AMC5 MED.B.095 Metabolic and endocrine systems

text: (a) Metabolic, nutritional or endocrine dysfunction Applicants with metabolic, nutritional or endocrine dysfunction may be assessed as fit subject to demonstrated stability of the condition and satisfactory aero-medical evaluation. (b) Obesity Obese applicants may be assessed as fit if the excess weight is not likely to interfere with the safe exercise of the licence. (c) Thyroid dysfunction Applicants with thyroid disease may be assessed as fit once a stable euthyroid state is attained. (d) Diabetes mellitus (1) The use of antidiabetic medications that are not likely to cause hypoglycaemia should be acceptable for a fit assessment. (2) Applicants with diabetes mellitus Type 1 should be assessed as unfit. (3) Applicants with diabetes mellitus Type 2 treated with insulin may be assessed as fit with limitations for revalidation if blood sugar control has been achieved and the process under (e) and (f) below is followed. An OSL limitation is required. A TML limitation for 12 months may be needed to ensure compliance with the follow-up requirements below. Licence privileges should be restricted to aeroplanes and sailplanes only. (e) Aero-medical assessment by, or under the guidance of, the licensing authority: (1) A diabetology review at yearly intervals, including: (i) symptom review; (ii) review of data logging of blood sugar; (iii) cardiovascular status. Exercise ECG at age 40, at 5-yearly intervals thereafter and on clinical indication, including an accumulation of risk factors; (iv) nephropathy/ nephropathy status.

text: (2) Ophthalmological review at yearly intervals, including: (i) visual fields Humphrey-perimeter; (ii) retinas full dilatation slit lamp and documentation; (ii) cataract clinical screening. The development of retinopathy requires a full ophthalmological review. (3) Blood testing at 6-monthly intervals: (i) HbA1c; target is 7,5–8,5 %; (ii) renal profile; (iii) liver profile; (iv) lipid profile. (4) Applicants should be assessed as temporarily unfit after: (i) changes of medication/insulin leading to a change to the testing regime until stable blood sugar control can be demonstrated; (ii) a single unexplained episode of severe hypoglycaemia until stable blood sugar control can be demonstrated. (5) Applicants should be assessed as unfit in the following cases: (i) loss of hypoglycaemia awareness; (ii) development of retinopathy with any visual field loss; (iii) significant nephropathy; (iv) any other complication of the disease where flight safety may be jeopardised. (f) Pilot responsibility Blood sugar testing is carried out during non-operational and operational periods. A whole blood glucose measuring device with memory should be carried and used. Equipment for continuous glucose monitoring (CGMS) should not be used. Pilots should prove to the AME or AeMC or licensing authority that testing has been performed as indicated below and with which results. (1) Testing during non-operational periods: normally 3–4 times/day or as recommended by the treating physician, and on any awareness of hypoglycaemia. (2) Testing frequency during operational periods: (i) 120 minutes before departure; (ii) <30 minutes before departure; (iii) 60 minutes during flight; (iv) 30 minutes before landing. (3) Actions following glucose testing: (i) 120 minutes before departure: if the test result is >15 mmol/l, piloting should not be commenced. (ii) 10–15g of carbohydrate should be ingested and a re-test performed within 30 minutes if: (A) any test result is <4,5 mmol/l; (B) the pre-landing test measurement is missed or a subsequent goaround/diversion is performed.

text: GM1 MED.B.095 Diabetes mellitus Type 2 treated with insulin

text: (a) Pilots and their treating physician should be aware that if the HbA1c target level was set to normal (non-diabetic) levels, this will significantly increase the chance of hypoglycaemia. For safety reasons the target level of HbA1c is therefore set to 7,5– 8,5 % even though there is evidence that lower HbA1c levels are correlated with fewer diabetic complications. (b) The safety pilot should be briefed pre-flight on the potential condition of the pilot. The results of blood sugar testing before and during flight should be shared with the safety pilot for the acceptability of the values obtained.

text: AMC6 MED.B.095 Haematology

text: Applicants with a haematological condition, such as: (a) abnormal haemoglobin including, but not limited to, anaemia, polycythaemia or haemoglobinopathy; (b) coagulation, haemorrhagic or thrombotic disorder; (c) significant lymphatic enlargement; (d) acute or chronic leukaemia; (e) enlargement of the spleen may be assessed as fit subject to satisfactory aero-medical evaluation.

text: AMC7 MED.B.095 Genitourinary system

text: (a) Applicants with a genitourinary disorder, such as: (1) renal disease; or (2) one or more urinary calculi, or a history of renal colic may be assessed as fit subject to satisfactory renal/urological evaluation. (b) Applicants who have undergone a major surgical operation in the urinary apparatus may be assessed as fit following full recovery.

text: AMC8 MED.B.095 Infectious disease

text: HIV infection: applicants who are HIV positive may be assessed as fit if investigation provides no evidence of clinical disease.

text: AMC9 MED.B.095 Obstetrics and gynaecology

text: (a) Pregnancy Holders of a LAPL medical certificate should only exercise the privileges of their licences until the 26th week of gestation under routine antenatal care. (b) Applicants who have undergone a major gynaecological operation may be assessed as fit after full recovery.

text: AMC10 MED.B.095 Musculoskeletal system

text: Applicants should have satisfactory functional use of the musculoskeletal system to enable the safe exercise of the privileges of the licence.

text: AMC11 MED.B.095 Psychiatry

text: (a) Applicants with a mental or behavioural disorder due to alcohol or other substance use should be assessed as unfit pending recovery and freedom from substance use and subject to satisfactory psychiatric evaluation after treatment. (b) Applicants with an established history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder should be assessed as unfit. (c) Psychotropic substances Use or abuse of psychotropic substances likely to affect flight safety should be disqualifying. If a stable maintenance psychotropic medication is confirmed, a fit assessment with an appropriate limitation may be considered. (d) Applicants with a psychiatric condition, such as: (1) mood disorder; (2) neurotic disorder; (3) personality disorder; (4) mental or behavioural disorder should undergo satisfactory psychiatric evaluation before a fit assessment may be considered. (e) Applicants with a history of significant or repeated acts of deliberate self-harm should undergo satisfactory psychiatric and/or psychological evaluation before a fit assessment can be considered.

text: AMC12 MED.B.095 Psychology

text: Applicants with a psychological disorder may need to be referred for psychological opinion and advice.

text: AMC13 MED.B.095 Neurology

text: (a) Epilepsy and seizures (1) Applicants with an established diagnosis of and under treatment for epilepsy should be assessed as unfit. A re-assessment after all treatment has been stopped for at least 5 years should include a neurological evaluation. (2) Applicants may be assessed as fit if: (i) there is a history of a single afebrile epileptiform seizure considered to have a very low risk of recurrence; and (ii) there has been no recurrence after at least 5 years off treatment; or (iii) a cause has been identified and treated and there is no evidence of continuing predisposition to epilepsy. (b) Neurological disease (1) Applicants with any stationary or progressive disease of the nervous system which has caused or is likely to cause a significant disability should be assessed as unfit. The AME or AeMC should assess these applicants taking into account the privileges of the licence held and the risk involved. An OPL limitation may be appropriate if a fit assessment is made. (2) In case of minor functional loss associated with stationary disease, a fit assessment may be considered after full evaluation.

text: (c) Head injury Applicants with a head injury which was severe enough to cause loss of consciousness or is associated with penetrating brain injury may be assessed as fit if there has been a full recovery and the risk of epilepsy is sufficiently low. (d) Spinal or peripheral nerve injury Applicants with a history or diagnosis of spinal or peripheral nerve injury may be assessed as fit if neurological review and musculoskeletal assessments are satisfactory.

text: AMC14 MED.B.095 Visual system

text: (a) Applicants should not possess any abnormality of the function of the eyes or their adnexa or any active pathological condition, congenital or acquired, acute or chronic, or any sequelae of eye surgery or trauma, which is likely to interfere with the safe exercise of the privileges of the applicable licence(s). (b) Eye examination The examination should include visual acuities (near, intermediate and distant vision) and visual field. (c) Visual acuity (1) Visual acuity with or without corrective lenses should be 6/9 (0,7) binocularly and 6/12 (0,5) in each eye. (2) Applicants who do not meet the required visual acuity should be assessed by an AME or AeMC, taking into account the privileges of the licence held and the risk involved. (3) Applicants should be able to read an N5 chart (or equivalent) at 30–50cms and an N14 chart (or equivalent) at 100cms, with correction if prescribed. (c) Substandard vision Applicants with substandard vision in one eye may be assessed as fit if the better eye: (1) achieves distant visual acuity of 6/6 (1,0), corrected or uncorrected; (2) achieves distant visual acuity less than 6/6 (1,0) but not less than 6/9 (0,7), after ophthalmological evaluation. (d) Visual field defects Applicants with a visual field defect may be assessed as fit if the binocular visual field or monocular visual field is normal. (e) Eye surgery (1) After refractive surgery, a fit assessment may be considered, provided that there is stability of refraction, there are no post-operative complications and no significant increase in glare sensitivity. (2) After cataract, retinal or glaucoma surgery a fit assessment may be considered once recovery is complete. (f) Correcting lenses Correcting lenses should permit the licence holder to meet the visual requirements at all distances.

text: AMC15 MED.B.095 Colour vision

text: Applicants for a night rating should correctly identify 9 of the first 15 plates of the 24-plate edition of Ishihara pseudoisochromatic plates or should be colour safe.

text: AMC16 MED.B.095 Otorhino-laryngology

text: (a) Hearing (1) Applicants should understand correctly conversational speech when tested at a distance of 2 metres from and with the applicant’s back turned towards the examiner. (2) Applicants with hypoacusis should demonstrate satisfactory functional hearing ability. (b) Ear conditions Applicants for a LAPL medical certificate with: (1) an active pathological process, acute or chronic, of the internal or middle ear; (2) unhealed perforation or dysfunction of the tympanic membrane(s); (3) disturbance of vestibular function; (4) significant restriction of the nasal passages; (5) sinus dysfunction; (6) significant malformation or significant, acute or chronic infection of the oral cavity or upper respiratory tract; or (7) significant disorder of speech or voice should undergo further medical examination and assessment to establish that the condition does not interfere with the safe exercise of the privileges of the licence.

text: Subpart C

text: Requirements for medical fitness of cabin crew

text: Section 1

text: General requirements

text: AMC1 MED.C.005 Aero-medical assessments

text: (a) When conducting aero-medical examination and/or assessments of cabin crew, their medical fitness should be assessed with particular regard to their physical and mental ability 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, providing first aid; (2) manipulate the aircraft systems and emergency equipment 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. narrowbodied or wide-bodied, single/multi-deck, single/multi-crew operation; (3) continuously sustain the aircraft environment whilst performing duties, e.g. altitude, pressure, re-circulated air, noise; and the type of operations such as short/medium/long/ultralong haul; and (4) perform the required duties and responsibilities efficiently during normal and abnormal operations, and in emergency situations and psychologically demanding circumstances e.g. assistance to crew members and passengers 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.

text: Section 2

text: Requirements for aero-medical assessment of cabin crew

text: AMC1 MED.C.025 Content of aero-medical assessments

text: Aero-medical examinations and/or assessments of cabin crew members should be conducted according to the specific medical requirements in AMC2 to AMC18 MED.C.025.

text: AMC2 MED.C.025 Cardiovascular system

text: (a) Examination (1) A standard 12-lead resting electrocardiogram (ECG) and report should be completed on clinical indication, at the first examination after the age of 40 and then at least every five years after the age of 50. If cardiovascular risk factors such as smoking, abnormal cholesterol levels or obesity are present, the intervals of resting ECGs should be reduced to two years. (2) Extended cardiovascular assessment should be required when clinically indicated. (b) Cardiovascular system - general (1) Cabin crew members with any of the following conditions:

text: (i) aneurysm of the thoracic or supra-renal abdominal aorta, before surgery; (ii) significant functional abnormality of any of the heart valves; or (iii) heart or heart/lung transplantation should be assessed as unfit. (2) Cabin crew members with an established diagnosis of one of the following conditions: (i) peripheral arterial disease before or after surgery; (ii) aneurysm of the abdominal aorta, before or after surgery; (iii) minor cardiac valvular abnormalities; (iv) after cardiac valve surgery; (v) abnormality of the pericardium, myocardium or endocardium; (vi) congenital abnormality of the heart, before or after corrective surgery; (vii) a cardiovascular condition requiring systemic anticoagulant therapy; (viii) recurrent vasovagal syncope; (ix) arterial or venous thrombosis; or (x) pulmonary embolism should be evaluated by a cardiologist before a fit assessment can be considered. (c) Blood pressure Blood pressure should be recorded at each examination. (1) The blood pressure should be within normal limits. (2) The initiation of medication for the control of blood pressure should require a period of temporary suspension of fitness to establish the absence of any significant side effects. (d) Coronary artery disease (1) Cabin crew members with: (i) cardiac ischaemia; (ii) symptomatic coronary artery disease; or (iii) symptoms of coronary artery disease controlled by medication should be assessed as unfit. (2) Cabin crew members who are asymptomatic after myocardial infarction or surgery for coronary artery disease should have fully recovered before a fit assessment can be considered. (e) Rhythm/conduction disturbances (1) Cabin crew members with any significant disturbance of cardiac conduction or rhythm should undergo cardiological evaluation before a fit assessment can be considered. (2) Cabin crew members with a history of: (i) ablation therapy; or (ii) pacemaker implantation should undergo satisfactory cardiovascular evaluation before a fit assessment can be made.

text: (3) Cabin crew members with: (i) symptomatic sinoatrial disease; (ii) complete atrioventricular block; (iii) symptomatic QT prolongation; (iv) an automatic implantable defibrillating system; or (v) a ventricular anti-tachycardia pacemaker should be assessed as unfit.

text: AMC3 MED.C.025 Respiratory system

text: (a) Cabin crew members with significant impairment of pulmonary function should be assessed as unfit. A fit assessment may be considered once pulmonary function has recovered and is satisfactory. (b) Cabin crew members should be required to undergo pulmonary function tests on clinical indication. (c) Cabin crew members with a history or established diagnosis of: (1) asthma; (2) active inflammatory disease of the respiratory system; (3) active sarcoidosis; (3) pneumothorax; (4) sleep apnoea syndrome/sleep disorder; or (5) major thoracic surgery should undergo respiratory evaluation with a satisfactory result before a fit assessment can be considered. (d) Cabin crew members who have undergone a pneumonectomy should be assessed as unfit.

text: AMC4 MED.C.025 Digestive system

text: (a) Cabin crew members with any sequelae of disease or surgical intervention in any part of the digestive tract or its adnexa likely to cause incapacitation in flight, in particular any obstruction due to stricture or compression, should be assessed as unfit. (b) Cabin crew members should be free from herniae that might give rise to incapacitating symptoms. (c) Cabin crew members with disorders of the gastro-intestinal system, including: (1) recurrent dyspeptic disorder requiring medication; (2) pancreatitis; (3) symptomatic gallstones; (4) an established diagnosis or history of chronic inflammatory bowel disease; or (5) after surgical operation on the digestive tract or its adnexa, including surgery involving total or partial excision or a diversion of any of these organs may be assessed as fit subject to satisfactory evaluation after successful treatment and full recovery after surgery.

text: AMC5 MED.C.025 Metabolic and endocrine systems

text: (a) Cabin crew members should not possess any functional or structural metabolic, nutritional or endocrine disorder which is likely to interfere with the safe exercise of their duties and responsibilities. (b) Cabin crew members with metabolic, nutritional or endocrine dysfunction may be assessed as fit, subject to demonstrated stability of the condition and satisfactory aeromedical evaluation. (c) Diabetes mellitus (1) Cabin crew members with diabetes mellitus requiring insulin may be assessed as fit if it can be demonstrated that adequate blood sugar control has been achieved and hypoglycaemia awareness is established and maintained. Limitations should be imposed as appropriate. A requirement to undergo specific regular medical examinations (SIC) and a restriction to operate only in multi-cabin crew operations should be placed as a minimum. (2) Cabin crew members with diabetes mellitus not requiring insulin may be assessed as fit if it can be demonstrated that adequate blood sugar control has been achieved

text: and hypoglycaemia awareness, if applicable considering the medication, is achieved.

text: AMC6 MED.C.025 Haematology

text: Cabin crew members with a haematological condition, such as: (a) abnormal haemoglobin including, but not limited to, anaemia, polycythaemia or haemoglobinopathy; (b) coagulation, haemorrhagic or thrombotic disorder; (c) significant lymphatic enlargement; (d) acute or chronic leukaemia; or (e) enlargement of the spleen may be assessed as fit subject to satisfactory aero-medical evaluation.

text: AMC7 MED.C.025 Genitourinary system

text: (a) Urine analysis should form part of every aero-medical examination and/or assessment. The urine should not contain any abnormal element(s) considered to be of pathological significance. (b) Cabin crew members with any sequela of disease or surgical procedures on the kidneys or the urinary tract, in particular any obstruction due to stricture or compression likely to cause incapacitation should be assessed as unfit. (c) Cabin crew members with a genitourinary disorder, such as: (1) renal disease; or (2) a history of renal colic due to one or more urinary calculi may be assessed as fit subject to satisfactory renal/urological evaluation. (d) Cabin crew members who have undergone a major surgical operation in the urinary apparatus involving a total or partial excision or a diversion of its organs should be assessed as unfit and be re-assessed after full recovery before a fit assessment can be made.

text: AMC8 MED.C.025 Infectious disease Cabin crew members who are HIV positive may be assessed as fit if investigation provides no

text: evidence of clinical disease and subject to satisfactory aero-medical evaluation.

text: AMC9 MED.C.025 Obstetrics and gynaecology

text: (a) Cabin crew members who have undergone a major gynaecological operation should be assessed as unfit until full recovery. (b) Pregnancy (1) A pregnant cabin crew member may be assessed as fit only during the first 16 weeks of gestation following review of the obstetric evaluation by the AME or OHMP. (2) A limitation not to perform duties as single cabin crew member should be considered. (3) The AME or OHMP should provide written advice to the cabin crew member and supervising physician regarding potentially significant complications of pregnancy resulting from flying duties.

text: AMC10 MED.C.025 Musculoskeletal system

text: (a) A cabin crew member should have sufficient standing height, arm and leg length and muscular strength for the safe exercise of their duties and responsibilities. (b) A cabin crew member should have satisfactory functional use of the musculoskeletal system.

text: AMC11 MED.C.025 Psychiatry

text: (a) Cabin crew members with a mental or behavioural disorder due to alcohol or other problematic substance use should be assessed as unfit pending recovery and freedom from problematic substance use and subject to satisfactory psychiatric evaluation. (b) Cabin crew members with an established history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder should be assessed as unfit. (c) Cabin crew members with a psychiatric condition such as: (1) mood disorder; (2) neurotic disorder; (3) personality disorder; or (4) mental or behavioural disorder should undergo satisfactory psychiatric evaluation before a fit assessment can be made. (d) Cabin crew members with a history of a single or repeated acts of deliberate self-harm should be assessed as unfit. Cabin crew members should undergo satisfactory psychiatric evaluation before a fit assessment can be considered.

text: AMC12 MED.C.025 Psychology

text: (a) Where there is established evidence that a cabin crew member has a psychological disorder, he/she should be referred for psychological opinion and advice. (b) The psychological evaluation may include a collection of biographical data, the review of aptitudes, and personality tests and psychological interview. (c) The psychologist should submit a report to the AME or OHMP, detailing the results and recommendation. (d) The cabin crew member may be assessed as fit to perform cabin crew duties, with limitation if and as appropriate.

text: AMC13 MED.C.025 Neurology

text: (a) Cabin crew members with an established history or clinical diagnosis of:

text: (1) epilepsy; or (2) recurring episodes of disturbance of consciousness of uncertain cause should be assessed as unfit. (b) Cabin crew members with an established history or clinical diagnosis of: (1) epilepsy without recurrence after five years of age and without treatment for more than ten years; (2) epileptiform EEG abnormalities and focal slow waves; (3) progressive or non-progressive disease of the nervous system; (4) a single episode of disturbance of consciousness of uncertain cause; (5) loss of consciousness after head injury; (6) penetrating brain injury; or (7) spinal or peripheral nerve injury should undergo further evaluation before a fit assessment can be considered.

text: AMC14 MED.C.025 Visual system

text: (a) Examination (1) a routine eye examination should form part of the initial and all further assessments and/or examinations; and (2) an extended eye examination should be undertaken when clinically indicated. (b) Distant visual acuity, with or without correction, should be with both eyes 6/9 or better. (c) A cabin crew member should be able to read an N5 chart (or equivalent) at 30–50 cm, with correction if prescribed. (d) Cabin crew members should be required to have normal fields of vision and normal binocular function. (e) Cabin crew members who have undergone refractive surgery may be assessed as fit subject to satisfactory ophthalmic evaluation. (f) Cabin crew members with diplopia should be assessed as unfit. (g) Spectacles and contact lenses: If satisfactory visual function is achieved only with the use of correction: (1) in the case of myopia, spectacles or contact lenses should be worn whilst on duty; (2) in the case of hyperopia, spectacles or contact lenses should be readily available for immediate use; (3) the correction should provide optimal visual function and be well tolerated; (4) orthokeratologic lenses should not be used.

text: AMC15 MED.C.025 Colour vision

text: Cabin crew members should be able to correctly identify 9 of the first 15 plates of the 24-plate edition of Ishihara pseudoisochromatic plates. Alternatively, cabin crew members should demonstrate that they are colour safe.

text: AMC16 MED.C.025 Otorhino-laryngology

text: (a) Hearing should be satisfactory for the safe exercise of cabin crew duties and responsibilities. Cabin crew with hypoacusis should demonstrate satisfactory functional hearing abilities. (b) Examination (1) An ear, nose and throat (ENT) examination should form part of all examinations and/or assessments. (2) Hearing should be tested at all assessments and/or examinations: (i) the cabin crew member should understand correctly conversational speech when tested with each ear at a distance of 2 meters from and with the cabin crew member’s back turned towards the examiner; (ii) notwithstanding (i) above, hearing should be tested with pure tone audiometry at the initial examination and when clinically indicated; (iii) at initial examination the cabin crew member should not have a hearing loss of more than 35 dB at any of the frequencies 500 Hz, 1 000 Hz or 2 000 Hz, or more than 50 dB at 3 000 Hz, in either ear separately. (c) Cabin crew members with: (1) an active pathological process, acute or chronic, of the internal or middle ear; (2) unhealed perforation or dysfunction of the tympanic membrane(s); (3) disturbance of vestibular function; (4) significant restriction of the nasal passages; (5) sinus dysfunction; (6) significant malformation or significant, acute or chronic infection of the oral cavity or upper respiratory tract; (7) significant disorder of speech or voice should undergo further medical examination and assessment to establish that the condition does not interfere with the safe exercise of their duties and responsibilities.

text: AMC17 MED.C.025 Dermatology

text: In cases where a dermatological condition is associated with a systemic illness, full consideration should be given to the underlying illness before a fit assessment may be made.

text: AMC18 MED.C.025 Oncology

text: (a) After treatment for malignant disease, cabin crew members should undergo satisfactory oncological and aero-medical evaluation before a fit assessment may be considered. (b) Cabin crew members with an established history or clinical diagnosis of intracerebral malignant tumour should be assessed as unfit. Considering the histology of the tumour, a fit assessment may be considered after successful treatment and full recovery.

text: GM1 MED.C.025 Content of aero-medical assessments

text: (a) When conducting aero-medical examinations and/or assessments, typical cabin crew duties as listed in (b) and (c), particularly those to be performed during abnormal operations and emergency situations, and cabin crew responsibilities to the travelling public should be considered in order to identify: (1) any physical and/or mental conditions that could be detrimental to the performance of the duties required from cabin crew; and (2) which examination(s), test(s) or investigation(s) should be undergone to complete an appropriate aero-medical assessment. (b) Main cabin crew duties and responsibilities during day-to-day normal operations (1) During pre/post-flight ground operations with/without passengers on board: (i) monitoring of situation inside the aircraft cabin and awareness of conditions outside the aircraft including observation of visible aircraft surfaces and information to flight crew of any surface contamination such as ice or snow; (ii) assistance to special categories of passengers (SCPs) such as infants and children (accompanied or unaccompanied), persons with disabilities or reduced mobility, medical cases with or without medical escort, and inadmissible, deportees and passengers in custody; (iii) observation of passengers (any suspicious behaviour, passengers under the influence of alcohol and/or drugs, mentally disturbed), observation of potential able-bodied persons, crowd control during boarding and disembarkation; (iv) safe stowage of cabin luggage, safety demonstrations and cabin secured checks, management of passengers and ground services during re-fuelling, observation of use of portable electronic devices; (v) preparedness to carry out safety and emergency duties at any time, and security alertness. (2) During flight: (i) operation and monitoring of aircraft systems, surveillance of the cabin, lavatories, galleys, crew areas and flight crew compartment; (ii) coordination with flight crew on situation in the cabin and turbulence events/effects; (iii) management and observation of passengers (consumption of alcohol, behaviour, potential medical issues), observation of use of portable electronic devices; (iv) safety and security awareness and preparedness to carry out safety and emergency duties at any time, and cabin secured checks prior to landing. (c) Main cabin crew duties and responsibilities during abnormal and emergency operations (1) In case of planned or unplanned emergency evacuation: briefing and/or commands to passengers including SCPs and selection and briefing to able-bodied persons; crowd control monitoring and evacuation conduct including in the absence of command from the flight crew; post-evacuation duties including assistance, first aid and management of survivors and survival in particular environment; activation of applicable communication means towards search and rescue services. (2) In case of decompression: checking of crew members, passengers, cabin, lavatories, galleys, crew rest areas and flight crew compartment, and administering oxygen to crew members and passengers as necessary.

text: (3) In case of pilot incapacitation: secure pilot in his/her seat or remove from flight crew compartment; administer first aid and assist operating pilot as required. (4) In case of fire or smoke: identify source/cause/type of fire/smoke to perform the necessary required actions; coordinate with other cabin crew members and flight crew; select appropriate extinguisher/agent and fight the fire using portable breathing equipment (PBE), gloves, and protective clothing as required; management of necessary passengers movement if possible; instructions to passengers to prevent smoke inhalation/suffocation; give first aid as necessary; monitor the affected area until landing; preparation for possible emergency landing. (5) In case of first aid and medical emergencies: assistance to crew members and/or passengers; correct assessment and correct use of therapeutic oxygen, defibrillator, first-aid kits/emergency medical kit contents as required; management of events, of incapacitated person(s) and of other passengers; coordination and effective communication with other crew members, in particular when medical advice is transmitted by frequency to flight crew or by a telecommunication connection. (6) In case of disruptive passenger behaviour: passenger management as appropriate including use of restraint technique as considered required. (7) In case of security threats (bomb threat on ground or in-flight and/or hijack): control of cabin areas and passengers’ management as required by the type of threat, management of suspicious device, protection of flight crew compartment door. (8) In case of handling of dangerous goods: observing safety procedures when handling the affected device, in particular when handling chemical substances that are leaking; protection and management of self and passengers and effective coordination and communication with other crew members.

text: Section 3

text: AMC1 MED.C.030 Cabin crew medical report

text: The cabin crew medical report to be provided in writing to the applicants for, and holders of, a cabin crew attestation after completion of each aero-medical assessment should be issued: (a) in the national language(s) and/or in English; and (b) according to the format below, or another format if all, and only, the elements specified below are provided.

text: CABIN CREW MEDICAL REPORT FOR CABIN CREW ATTESTATION (CCA) APPLICANT OR HOLDER

text: (1) State where the aero-medical assessment of the CCA applicant/holder was conducted: (2) Name of CCA applicant/holder: (3) Nationality of CCA applicant/holder: (4) Date and place of birth of CCA

text: applicant/holder: (dd/mm/yyyy)

text: (5) Expiry date of the previous aero-medical

text: assessment: (dd/mm/yyyy)

text: (6) Date of the aero-medical assessment:

text: (dd/mm/yyyy)

text: (7) Aero-medical assessment: (fit or unfit) (8) Limitation(s) if applicable: (9) Date of the next required aero-medical

text: assessment: (dd/mm/yyyy)

text: (10) Date of issue and signature of the AME, or OHMP, who issued the cabin crew medical

text: report:

text: (11) Seal or stamp: (12) Signature of CCA applicant/holder:

text: AMC1 MED.C.035 Limitations

text: When assessing whether the holder of a cabin crew attestation may be able to perform cabin crew duties safely if complying with one or more limitations, the following possible limitations should be considered: (a) a restriction to operate only in multi-cabin crew operations (MCL); (b) a restriction to specified aircraft type(s) (OAL) or to a specified type of operation (OOL); (c) a requirement to undergo the next aero-medical examination and/or assessment at an earlier date than required by MED.C.005(b) (TML); (d) a requirement to undergo specific regular medical examination(s) (SIC); (e) a requirement for visual correction (CVL), or by means of corrective lenses only (CCL); (f) a requirement to use hearing aids (HAL); and (g) special restriction as specified (SSL).

text: SUBPART D

text: Aero-medical examiners (AMEs)

text: AMC1 MED.D.010 Requirements for the issue of an AME certificate

text: (a) Basic training course for AMEs The basic training course for AMEs should consist of 60 hours theoretical and practical training, including specific examination techniques. (b) The syllabus for the basic training course should cover at least the following subjects: — Introduction to aviation medicine; — Physics of atmosphere and space; — Basic aeronautical knowledge; — Aviation physiology; — Ophthalmology, including demonstration and practical; — Otorhinolaryngology, including demonstration and practical; — Cardiology and general medicine; — Neurology; — Psychiatry in aviation medicine; — Psychology; — Dentistry; — Accidents, escape and survival; — Legislation, rules and regulations; — Air evacuation, including demonstration and practical; — Medication and flying.

text: AMC1 MED.D.015 Requirements for the extension of privileges

text: (a) Advanced training course for AMEs The advanced training course for AMEs should consist of another 60 hours of theoretical and practical training, including specific examination techniques. (b) The syllabus for the advanced training course should cover at least the following subjects: — Pilot working environment; — Aerospace physiology, including demonstration and practical; — Ophthalmology, including demonstration and practical; — Otorhinolaryngology, including demonstration and practical; — Cardiology and general medicine, including demonstration and practical; — Neurology/psychiatry, including demonstration and practical; — Human factors in aviation, including demonstration and practical;

text: — Tropical medicine; — Hygiene, including demonstration and practical; — Space medicine. (c) Practical training in an AeMC should be under the guidance and supervision of the head of the AeMC. (d) After the successful completion of the practical training, a report of demonstrated competency should be issued.

text: GM1 MED.D.030 Refresher training in aviation medicine

text: (a) During the period of authorisation, an AME should attend 20 hours of refresher training. (b) A proportionate number of refresher training hours should be provided by, or conducted under the direct supervision of the competent authority or the Medical Assessor. (c) Attendance at scientific meetings, congresses and flight deck experience may be approved by the competent authority for a specified number of hours against the training obligations of the AME. (d) Scientific meetings that should be accredited by the competent authority are: (1) International Academy of Aviation and Space Medicine Annual Congresses; (2) Aerospace Medical Association Annual Scientific Meetings; and (3) other scientific meetings, as organised or approved by the Medical Assessor. (e) Other refresher training may consist of: (1) flight deck experience; (2) jump seat experience; (3) simulator experience; and (4) aircraft piloting.