FAA Risk Assessment for Neurological Conditions

Two organ systems of the body create a lot of angst among civil and military regulators. Since the advent of medical certification standards more than 60 years ago, cardiovascular and neurological conditions have been identified as posing significant risk for sudden and subtle incapacitation. As a result, these conditions attract the FAA’s attention in evaluating pilots’ eligibility for medical certification.

Cardiovascular disease, from a regulatory viewpoint, is somewhat more cut-and-dried in that certification policy establishes a “cut point” for certification in many cases because of defined limits to acceptable risk. For example, in the presence of obstructive coronary artery disease with “myocardial ischemia,” a term indicating a lack of adequate blood supply to the heart muscle, the long-standing FAA policy considers the condition to pose an unacceptable risk and will deny certification. 

Neurological events pose a dilemma for the FAA because some symptoms and signs are indications of conditions that can carry a higher risk for subtle rather than sudden incapacitation. Current FAA policy requires extensive, and unfortunately, expensive, testing to determine not only the clinical picture but also the cognitive status for individuals who have experienced traumatic brain injury, post-traumatic stress disorder, substance abuse/dependence, HIV, ADHD or other mental health diagnoses, cerebrovascular accidents as in strokes or TIA (transient ischemic attack), and other conditions that can produce neurological impairment.

For many years the FAA has required a battery of neurocognitive tests to assess brain function, or “perceptual cognition” as it is referred to by clinical psychologists. These areas include executive functioning (decision making), problem solving, reaction times, multi-tasking, and immediate and short-term memory. These tests are designed to identify even subtle changes in cognitive function, and the results play a key role in assessing a person’s eligibility for medical certification. 

Critics of neurocognitive testing argue that for many pilots who are required to undergo these evaluations, there is no individual baseline against which the current evaluation can be compared to determine if there have been “aeromedically significant” changes in cognitive functioning. An experienced pilot who has thousands of hours of safe flying who suffers a mild head injury in an accident and is asked to provide a neuro assessment that isn’t a completely normal study may be deemed no longer safe to resume flying.
Another significant hurdle for neurocognitive testing is the cost. The average evaluation with the minimum testing required by the FAA may easily cost $5,000, which, in most cases, is not covered by health insurance and must be paid out of pocket. The clinical psychologists and neuropsychologists who administer the evaluations invest many hours in each case, not just in conducting the tests, but in scoring the results and preparing the final report with detailed findings of each specific test that was performed. The clinical and administrative time investment drives up the costs and makes these tests prohibitively expensive and sometimes out of the reach of new student pilots or non-professional pilots who don’t have financial help from their employers.

The FAA is including neurocognitive testing requirements for an increasing number of neurological conditions that affect pilots across the entire age spectrum. Adverse results can represent significant roadblocks in the pathway to medical certification for current and prospective pilots.
Portrait of Gary Crump, AOPA's director of medical certification with a Cessna 182 Skylane at the National Aviation Community Center.
Frederick, MD USA
Gary Crump
Gary is the Director of AOPA’s Pilot Information Center Medical Certification Section and has spent the last 32 years assisting AOPA members. He is also a former Operating Room Technician, Professional Firefighter/Emergency Medical Technician, and has been a pilot since 1973.

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