Ever since two pilots fell asleep in the cockpit of a Bombardier CRJ operating as Go! Flight 1002 during a February 2008 flight from Honolulu to Hilo, Hawaii, the NTSB has urged the FAA to tackle the issue of obstructive sleep apnea (OSA) among pilots. The captain of that aircraft was diagnosed with severe OSA after the flight. The FAA responded to the NTSB recommendations, first with education and now by warning pilots that if their body mass index (BMI) exceeds a certain number, they will be singled out for apnea testing by a board-certified sleep specialist.

The BMI warning came as notification of a new policy that FAA Federal Air Surgeon Fred Tilton plans to implement, under which pilots with a BMI of 40 or above will be required to be evaluated for OSA. “Once we have appropriately dealt with every airman examinee who has a BMI of 40 or greater, we will gradually expand the testing pool by going to lower BMI measurements until we have identified and assured treatment for every airman with OSA,” Tilton wrote. Although the new policy has not yet been implemented, the FAA is aware that some FAA aviation medical examiners (AMEs) have deferred medical certificate issuance based on BMI, according to an FAA spokeswoman. “The policy is not yet implemented,” she told AIN. “We added a message to AMEs on the system they use to remind them that the policy is not yet implemented and that a BMI over 40 alone is not a reason to defer a certificate.” At press time, implementation was expected in January.

Whether or not medical insurance will cover this testing depends on the pilot’s success in convincing his insurance provider that the testing is necessary. A referral from an FAA AME would not necessarily suffice for coverage, according to David Hale, executive director of Pilot Medical Solutions of Bethany, Okla. “Generally, [apnea testing] requires a sleep study, which is an overnight test typically conducted at a medical center. Then [assuming a diagnosis of OSA] there is the purchase of devices such as CPAP [a continuous positive airway pressure machine] and/or surgery.” The total cost, including the CPAP, can run into thousands of dollars, according to a pilot interviewed by AIN.

While aviation industry reaction to Tilton’s announcement has been largely one of outrage, the fact is that OSA is a serious problem for many people, not just pilots, and not just overweight people (see article on page XX). Tilton wants the new policy to apply to air traffic controllers, too, but for some reason he doesn’t mention other critical personnel such as flight attendants and mechanics. The U.S. Department of Transportation’s Federal Motor Carrier Safety Administration has tried to implement OSA evaluation for truck drivers, but this effort has been held up by a new law that will require formal rulemaking for OSA screening. A similar bill for aviation–H.R. 3578–was introduced by House aviation subcommittee chairman Frank LoBiondo (R-N.J.) and at press time was pending consideration by the full House of Representatives.

In an FAA webinar held on December 12, Tilton, NTSB board member and fatigue expert Mark Rosekind and board-certified sleep specialist Mark Ivey emphasized their support for the new policy. The FAA estimates that 5,000 pilots have a BMI of 40 or above and 120,000 have a BMI of 30 or above. According to Teofilo Lee-Chiong, professor of medicine at the University of Colorado, Denver, above a BMI of 40 the prevalence of OSA is 50 to 90 percent. “But even 30 percent of people below a BMI of 30 have sleep apnea,” he said.

In the Q&A session at the end of the webinar, Tilton admitted, “I am a little chagrined [this policy] has created furor. There is a high probability it will prevent an accident. There is strong compelling evidence that treating someone with sleep apnea is the right thing to do. If at any time this process is impeding [a pilot’s] ability to get into the air, we stand ready to help.” Tilton also said that “If Congress passes a law [forcing industry consultation], we’ll be compliant with it. Until it does so, we will move forward with this [without consultation].”

“This is unacceptable,” said Doug Carr, NBAA vice president for safety, security and regulation. “The FAA is preparing to roll out a major new requirement on pilots without providing a data-driven justification for the policy, explaining its costs and benefits or giving any means for the pilots who would be affected to give the agency feedback on it. For many of the pilots at NBAA member companies, flying an airplane is how they make a living, so we take very seriously the FAA’s seeming lack of concern, and lack of transparency, on this matter.”

Even AMEs don’t all agree with Tilton’s policy. The Civil Aviation Medical Association sent a letter to FAA Administrator Michael Huerta, urging the FAA to adopt educational efforts and drop the mandate for AMEs to determine BMI and refer pilots to sleep specialists. “The FAA is not tasked to provide long-term prognoses, but rather to determine the likelihood of pilot incapacitation for the duration of the medical certificate,” the association noted.

The Case for Sleep Apnea Testing

A corporate pilot who asked not to be identified told AIN about his experience with OSA. He is the safety officer for his company’s flight department and feels that his diagnosis and successful treatment for OSA saved his life. His BMI, incidentally, is exactly 30.

About six years ago he was experiencing a lack of sleep, and friends and family members told him he looked terrible. During a visit with an internist about another problem, the doctor asked if there was anything else he would like to discuss. He told the doctor that a friend said he looked terrible, and the doctor (who is also a sleep disorder specialist) asked about his sleep history and whether or not he dreamed. The pilot said he did not, and for the doctor this was a key clue that the pilot had a problem. The doctor offered to conduct a sleep evaluation. “I was not thinking about my FAA medical,” the pilot said. “Based on my principles of taking care of myself and wanting to see my grandkids, I got wired up.”

A week later the doctor told the pilot he had OSA. The diagnosis automatically disqualified him from flying because his medical certificate was no longer valid. During a subsequent test, he slept with a CPAP machine and felt so rejuvenated afterwards that he drove for nine hours without using any of the crutches–coffee and gum–that he normally relied on. “I told my wife I felt great!” he said.

After two weeks sleeping with the CPAP, he did a mean wakefulness test, which involves various periods of having to stay awake while lying in a dark room. “The hardest one is after lunch,” he recalled. “You have to make sure the brain isn’t doing any kind of microsleep.”

His AME helped put together the results of the second test with the CPAP and the mean wakefulness test and then sent the paperwork to the Aeromedical Division, and six weeks later the pilot received his medical certificate. “The whole point is that the CPAP works,” he said.

According to Hale of Pilot Medical Solutions, “It is an onerous bureaucratic process, but pilots should know that almost all cases [of treated sleep apnea] are eligible for FAA medical recertification. In addition, those who [are] using devices such as CPAP are statistically more likely to get better sleep and have less fatigue than the general population.”

Concerns about FAA Overreach

While the medical science of OSA is indisputable, the questionable way the FAA is planning to target overweight pilots has sparked a furor, given that OSA is not limited to those with high body mass. Many pilots who responded to AIN’s request for comments on this subject expressed concern that the FAA is abusing its power and will be emboldened to target pilots for other deficiencies.

“The FAA should remain out of the bedroom on this one,” one pilot wrote, “but I also agree that Dr. Tilton makes an excellent point. That said, there is definitely no need for regulation. The FAA should leave it to the individual to self-certify for flight.”

Another reader wrote: “Sleep apnea is difficult to diagnose even when a person is having problems and [because] some have it when in good condition and within normal weight. The FAA needs to butt out and concentrate on real safety issues.”

“The FAA’s proposed change to withhold approval of a pilot’s fitness to fly is overly intrusive,” a pilot commented. “As a kid, I worked on a farm and developed a muscular build, oversized legs, large upper chest and wide neck. It is patently unfair and a devious act of profiling to force me to spend thousands of dollars to prove I do not have sleep apnea.”