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Aviation health - The healthy option

Global rules are needed to manage a global system—a concept perfectly illustrated by aviation’s collaboration in improving safety. Health issues require the same treatment 

The challenge for health-related issues is a broad one—touching Passengers with Reduced Mobility (PRMs) as well as crew Flight Time Limitations (FTLs)—but also very current. Efficiently managing any intensification of Influenza A (H1N1) requires a common evaluation framework not apparent in existing US and EU laws.

On the whole, aviation is ready for any increase in H1N1 numbers as the northern hemisphere heads toward winter. The World Health Organization (WHO) has already declared a pandemic so there is little more to anticipate from elevated warning levels. Government reaction in May to June, when the virus first came to attention, was largely in line with WHO recommendations. IATA set up a website to monitor operational requirements and this is still being updated.

“We are working very closely with WHO,” says Claude Thibeault, IATA Medical Advisor. “Besides its Medical Manual dealing with crew health, IATA also has guidance material available on suspected communicable diseases, which has been accepted by both ICAO and WHO.”

However, despite the precautions it could still be far from plain sailing as problems could occur at point of entry. “Countries could implement measures at the last minute or be very reactionary,” explains Thibeault. “Planning is difficult when there are many potential unknowns.”

“An international carrier serving a multitude of countries could find it challenging to keep both them and passengers informed of requirements,” he continues. “Airlines may waste a lot of resources trying to comply with knee-jerk reactions.”
To prevent operational disruption as much as possible, IATA will continue to act as an information exchange, gathering data and making it available to airlines.

A question of degree

One area that could present a challenge is government guidance on when to deny boarding for passengers with communicable diseases such as H1N1. European rules allow airlines to request medical clearance for travel in a broad range of situations—including cases of suspected communicable diseases. In the US, Department of Transport rules only permit denied boarding if there is a “direct threat”.

The difficulty is in establishing where H1N1 fits on the spectrum of potential outcomes when, for most people, the consequences are no more severe than seasonal influenza.

“The trans-Atlantic market is one of the busiest in the world,” says Thibeault. “Most of the flights are operated as codeshares. Which rules do you operate by? We need a clear and consistent set of guidelines to be effective.”

The US is working on a broad contingency plan coordinated through the Department of Homeland Security (DHS). “If the play book that is being developed brings clarity and harmonization based on WHO standards, it’s a good thing,” says Thibeault.
In a recent visit to Washington, Giovanni Bisignani, IATA Director General and CEO, noted DHS does not need to start from scratch. “The groundwork is done,” he says. “Global standards are the most effective means to deal with global problems. The WHO and IATA have developed effective guidance. There is no need to re-invent the wheel.”

Differences in definition

Beyond H1N1, PRM laws are another area that would benefit from harmonization across borders. EC regulation 1107/2006 covers the rights of passengers with disabilities and reduced mobility in the European Union. Airlines are only legally involved with onboard aspects—arranging suitable seating, carrying necessary medical equipment and so forth.
Civil aviation authorities are entrusted with enforcing 1107/2006—the aim being compliance rather than penalizing after the event. Unfortunately, when they do have to impose fines, there is little consistency across the EU and the amount can vary wildly.
The US has the 1986 Air Carrier Access Act and subsequent Department of Transport (DOT) revisions. Like the EU law, the basic reasoning is that no airline can refuse passage on disability grounds alone. The devil is in the detail.

“The US has a much broader definition of disability than Europe, which is more concerned with physical conditions that limit mobility,” says Thibeault. “The US includes very temporary conditions and illnesses, such as cancer and cardiac diseases. This creates problems in terms of medical clearance and can really affect airline operations when journeys start in one jurisdiction and end in another. Passengers could get assistance in one direction but not the other or may even be denied boarding. This is very complex legally, not to mention the implications for customer service. Global standards must come into force.”

The differences go beyond these definitions. In the EU, airlines must notify airports if there are passengers requiring assistance 36 hours prior to departure (the passenger must notify the airline 48 hours before the flight). Only dogs qualify as service animals and the number of disabled passengers must not exceed the number of those able to assist in an emergency. By contrast, the US has no law about notification, a broader interpretation of service animals and sets no limit on the disabled passengers.

The European Civil Aviation Conference meets twice a year with the DOT but these are more information-sharing exercises than real discussions about harmonization. Because these issues are more driven by political bodies than by flight safety and health, it is very difficult for any international bodies such as ICAO and WHO to intervene.

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Waking up to tiredness
Health-sector guidance will be sought on the operational issue of pilot fatigue—yet another area in need of harmonization. Flight Time Limitations (FTLs) vary from country to country, which is not so surprising given that determining those limitations in strict medical terms is far from easy.

The idea of FTLs first aired in 1949 in ICAO Annex 6, although it left specifics to member states. The Annex was updated in 1961 to include, for example, the need for record keeping and recognizing cumulative fatigue. In 1995, cabin crew were specifically mentioned.
In November 2009, further revisions were published including new definitions of key words such as “fatigue”. The real development, however, is still to come. ICAO has formed a Fatigue Risk Management (FRM) Task Force, a move fully supported by IATA and airlines such as Etihad and Air New Zealand.

Anthony Evans, Chief of the ICAO Medical Section, describes FRM as a safety management approach to fatigue. “Prescriptive regulation has rule-based limitations,” he says. “It can be too costly if unnecessarily restrictive or unsafe if too liberal. By contrast, FRM is performance-based and relies on a scientific analysis of risk.”

By depending on measuring, monitoring and analysis of fatigue during specific operations, FRM may enable an airline to schedule crew outside the current prescriptive rules if fatigue is proven not to be an issue, and similarly could ground an aircrew even if they are within their prescribed hours.

“It will enhance an airline’s core safety performance,” says Evans. “Ultimately, airlines could link the information on fatigue directly to operational performance and get a very clear picture of the most efficient and safe scheduling.”
The Task Force will complete its work in December and aims to produce documentation—a circular or manual—in early 2010. Importantly, the work being done is not necessarily about reducing hours but, rather, understanding the issue of fatigue and so increasing safety and productivity.

“A global solution through ICAO will deliver the best results,” confirms IATA Director General and CEO, Giovanni Bisignani.



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