Handbook of Aviation Neuropsychology (eBook)

|9|Chapter 1  Practicing Aviation Neuropsychology in a Civilian Regulatory Environment

Randy J. Georgemiller

Benchmark Events in the Development of US Civilian Aviation Neuropsychology

Federal regulation of the United States National Airspace System (NAS) began in the mid-1920s with the Air Commerce Act in 1926 (Kraus, 2008). With advances in aviation technology, increased air traffic, and a series of midair collisions, these factors led to the passage of the Federal Aviation Act (August 23, 1958), marking the beginning of the Federal Aviation Administration (FAA; Kraus, 2008). The simplicity and brevity of the FAA’s mission mask the complexity of the endeavor: “Our continuing mission is to provide the safest, most efficient aerospace system in the world” (FAA, n.d.-b). On a daily basis the FAA oversees more than 45,000 flights and the transport of 2.9 million airline passengers spanning the 29 million miles of the US NAS (FAA, n.d.-a).

The contribution of aviation neuropsychology to the FAA safety mission began many years after the agency’s inception. One of the earliest formal entries into the aviation regulatory environment was the inclusion of psychology in the Human Intervention Motivational Study (HIMS). HIMS (n.d.) began in 1974 and is a joint undertaking by the FAA, airlines, and airline pilot unions to address the issue of substance dependence and abuse among airline transportation pilots. Regarding substance dependence, previously a permanently disqualifying condition for medical certification leading to job termination, the HIMS program was designed to reduce the risk to flight safety posed by alcohol and drug dependence among pilots and return them to the cockpit by offering special issuance authorization/medical waivers based on identification, treatment, and monitoring. HIMS set the standard for other professional programs such as state medical board impaired professional programs. (For more information about HIMS, refer to Chapter 11 by Quay Snyder.) The process of evaluation and monitoring included psychologists who assessed psychological and cognitive factors in collaboration with psychiatrists. Psychology’s unique contribution to HIMS was the ability to identify potential neurocognitive deficits by way of standardized neuropsychological measures associated with substance dependence and other coexisting conditions from the time of pilot identification, into treatment, and the monitoring phase as needed. For psychology’s involvement in the program, the only requirements were to tag-team with a psychiatrist in performing the evaluations, be licensed, and complete an introductory HIMS training designed for select medical professionals, airline personnel, and airline union representatives.

|10|Another turning point for neuropsychologists was when the FAA solicited a proposal from the American Medical Association (AMA) in 1977 “for an authoritative document concerning the current state of knowledge about selected neurological and neurosurgical conditions” (FAA Office of Aerospace Medicine, 1981, p. i). Expert panels that included representatives from the American Academy of Neurology (AAN) and American Association of Neurological Surgeons (AANS) provided a report that was designed to inform FAA “regulatory standards, examination procedures, and decisions about medical certification of airman applicants” (FAA, 1981, p. i). While outlining diagnostic and treatment requirements for various potentially disqualifying conditions to include cardiovascular disease, intracranial tumors, head injuries, demyelinating and degenerative diseases, extrapyramidal disorders, neuromuscular disorders, injuries to the peripheral and cranial nerves and spinal cord, seizure disorders and disturbances of consciousness, migraine and other headaches, and dizziness and disorders of equilibrium, throughout the document the need for “psychometrics, psychological testing, and neuropsychological examination” for specified conditions is highlighted. Linking these diagnostic procedures, there is reference to various cognitive abilities associated with neurological conditions that would jeopardize aviation safety to include intellectual skills, mental processing speed, memory, verbal skills, and executive abilities – cognitive domains that clinical neuropsychology is particularly well suited to assess. In the AMA document there is even an outline of a standardized neuropsychological protocol for the assessment of head injury in pilots (FAA Office of Aerospace Medicine, 1981, p. 56), which 40  years later still includes some procedures that are in use by the FAA to assist with making medical certification determinations.

Shortly afterward, the FAA again contracted with the AMA (AMA, 1984) to review medical standards for civilian aviation per Part 67 of the Federal Aviation Regulations (FAR; Code of Federal Regulations, 2023). The two-volume technical report is summarized and analyzed by Engelberg et al. (1986). As it pertains to neuropsychology, the AMA report offered a series of changes to the Aviation Medical Examination to include “Mini-mental status” (AMA, 1984, p. II-9). A brief four-item test was outlined, which included word repetition and recall, serial sevens, figure drawing from memory, and digit span. (AMA, 1984, p. III-16). If failed, the full Mini-Mental State Examination was to be administered (Folstein et al., 1975). Standards for medical certification for a variety of mental and behavioral disorders included psychiatric evaluation in conjunction with psychological testing. Neuropsychological evaluation protocols were discussed in detail as pertaining to the assessment of dementia.

The report went on to recommend adoption of the five-question Mini-Mental State Examination with further study as to its acceptance by aviation medical examiners (AMEs) as well as research into its utility in detecting cognitive impairment among pilots. This was followed by a recommendation for development of a computerized test of cognitive function to be administered and scored at the AME’s office. The goal of such a measure “would be a screening test that would detect significant cognitive impairments that may otherwise go unrecognized during a routine physical examination” (AMA, 1984, p. V-2).

In response to the AMA study results, Banich et al. (1989) challenged the recommendation of adopting a mini-mental status examination (Folstein et al., 1975) as part of the AME flight physical. The authors indicated that the screening tests were designed to differentiate clinical from normal populations and make determinations regarding capacity for self-care, not the cognitive skills necessary to pilot an aircraft. They went on to review the literature based on job analysis to define the critical cognitive skills required for aviation: “perceptual-motor abilities; spatial abilities; working memory; attentional performance; processing flexi|11|bility; and planning or sequencing abilities (Banich et al., 1989, p. 362). Their recommendation was to incorporate extant neuropsychological tests into a cognitive screening device.

Associated with the issue of screening pilot cognitive status as part of medical certification, the FAA embarked on an 8-year study to develop a comprehensive, computer-administered and scored cognitive screening test designed to detect subtle potentially disqualifying cognitive deficits in aviators. This resulted in the development of CogScreen–Aeromedical Edition (CogScreen-AE; Kay, 1995, 2013). In the final phase of the project, 403 commercial airline pilots provided the basis for the initial normative database. A series of aviation-relevant cognitive skills are tapped by the test: “attention, immediate- and short-term memory, visual-perceptual functions, sequencing functions, logical problem solving, calculation skills, reaction time, simultaneous information processing abilities, and executive functions” (Kay, 1995, p. 1). The test has been applied to a civilian pilot population but also to military aviators (Chee et al., 2021; King et al., 2012) and has assisted with informing policy decisions, such as changing the Age 60 Rule that advanced the retirement age for air carrier captains and pilots to 65...