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This paper reviews aeromedical decision-making in psychiatry. It explains the "one-percent rule", the general medical criteria for fitness for flying and how they are applied to psychiatric disorders.

The present study was designed to investigate the frequency of media stigmatization of mentally ill persons after the crash of the "Germanwings"-aircraft on March 2015.Evaluation of 251 texts, which were published in 12 national German newspapers. Categorical distinction between risky coverage and explicit characteristics of stigmatization.In 64.1 % of the evaluated texts, a psychiatric disease of the co-pilot was discussed as the possible cause of the crash, making this the most widely-used explanation in the media that we view "risky coverage". Characteristics of explicit stigmatization were found in 31.5 % of the texts. Most prominent category of explicit stigmatization was the rubric "Metaphorical language/dramatizations". It was found in 23.5 % of the articles.Predominantly risky coverage of mentally ill persons has occured in the wake of a spectacular crime. By obtaining professional expertise of psychiatrists and consistent interpretation of journalistic guidelines, unintended effects of stigmatization could be avoided in the future.

Flight safety could be increased by approximately one million times within the last 100 years by rigorously analyzing and correcting system deficiencies. Aviation safety strategies can help to increase patient safety. A few examples: the pilot in command takes critical safety decisions without economical restraints. Safety-relevant decisions should be made as if the captain's family would be on board. Organizational deficiencies can be detected using a non-punitive reporting system. The pilot is encouraged to report errors without the fear of being punished. Well-trained specialists, supporting and correcting each other are an important prerequisite for error detection and error correction. An optimal hierarchical gradient helps to reduce risks. Strategies for risk reduction require more personnel, increase costs and slow down the working speed. Safety is expensive and safety can be bought.

Health care safety levels range below other complex industries. Civil aviation has throughout its history developed methods and concepts that have made the airplane into one of the safest means of mass transport. Key elements are accident investigations that focus on cause instead of blame, human-centered design of machinery and processes, continuous training of all personnel and a shared safety culture. These methods and concepts can basically be applied to medicine which has successfully been achieved in certain areas, however, a comprehensive implementation remains to be completed. This applies particularly to including the topic of safety into relevant curricula. Physicians are obliged by the oath"primum nil nocere" to act, but economic as well as political pressure will eventually confine professional freedom if initiative is not taken soon.

Safety is of extraordinary value in commercial aviation. Therefore, sophisticated and complex systems have been developed to ensure safe operation. Within this system, the pilots are of specific concern: they form the human-machine interface and have a special responsibility in controlling and monitoring all aircraft systems. In order to prepare pilots for their challenging task, specific selection of suitable candidates is crucial. In addition, for every commercial pilot regulatory requirements demand a certain number of simulator training sessions and check flights to be completed at prespecified intervals. In contrast, career choice for intensive care medicine most likely depends on personal reasons rather than eligibility or aptitude. In intensive care medicine, auditing, licensing, or mandatory training are largely nonexistent. Although knowledge of risk management and safety culture in aviation can be transferred to the intensive care unit, the diversity of corporate culture and tradition of leadership and training will represent a barrier for the direct transfer of standards or procedures. To accomplish this challenging task, the analysis of appropriate fields of action with regard to structural requirements and the process of change are essential.

In mass disasters, the main task of the medicolegal expert is to support the victims' identification. As such events are rare, the knowledge obtained during previous operations should be evaluated and published to improve the quality and effectiveness of the identification work in future disasters. This report describes the experience gained at the Institute of Forensic Medicine of the Humboldt University in Berlin during the identification of the victims of three aircraft accidents (1972, 1986, 1989). The advantages and disadvantages of the identification methods used are discussed. Medicolegal experts should make themselves familiar with available experiences to be adequately prepared for the responsible task of identifying the victims in an emergency.

The European Union plans to harmonize the aviation requirements, in particular the flight crew licensing requirements. On 23 May 2007, the German Federal Ministry of Transport, Building and Urban Affairs published the Flight Crew Licensing Requirements, which are based on the Joint Aviation Requirements, Flight Crew Licensing 3, Amendment 5. These guidelines also list the examination methods to be used for testing the medical fitness of pilots. In this Amendment some examinations which were part of the routine tests before JAR-FCL3 became effective have been deleted, e.g. the exercise ECG. This article presents two cases from the autopsy material of the Institute of Legal Medicine in Hanover and discusses the problems associated with the new examination guidelines.

In the years 1974 to 1990, 39 pilots died in 34 crashes of fighter planes of the National People's Army; 32 victims were examined forensically. For the present study all autopsy protocols and examination reports available in the German Federal Military Archives in Freiburg could be evaluated. Both officer cadets and experienced pilots of high military ranks were among the victims. The majority of the crashes (24 out of 34) was caused by human failure. Health problems or the use of alcohol and medications did not play a role in the aircraft accidents. All killed pilots were identified. The injury patterns after fatal ejection are different from the patterns seen after impact with a plane. Such patterns of findings are meaningful in the reconstruction of unknown sequences of events leading to the accidents and for the assessment of the pilots' capacity to act at the moment of the incident

The working conditions for medical staff in German hospitals with emergency units are characterised by stress peaks. In such moments mistakes are more likely to be made. Communication problems and misunderstandings caused by these settings are the most frequent causes for blunders, errors and mistakes. The aim is to show an easy way to reduce the incidence of these problems.Within this prospectively randomised trial we compare the ability of 50 physicians to remember standardised information on patient's data passed on to them in a briefing. Half of the subjects used the so called 5-finger method as an easy means of memorising standardised information. The other 25 physicians memorised the patient's data in the usual way. In order to assess the information recalled by the subjects, all of them were asked to answer 15 questions on the data they had been given an hour earlier.The subjects who used the 5-finger method were able to give on average 9.88 (of 15) correct answers and thus remembered significantly (p = 0.031) more information than the members of the control group.Communication errors caused by homophony, ambiguity, anticipation and mental models are can be avoided in well-structured communication situations. The rules for such a type of communication can easily be learned and applied. Standardised communication has already proved to reduce the error rates in aviation. We conclude that it can be helpful to introduce standardised communication rules such as the 5-finger method in medical communication.

The crash of a US Dakota in 1946 in the alps of Bernese Oberland initiated an immense reaction of rescue. Aims, problems and challanges are the same today.

Epidemiological analysis of injury patterns and mechanisms help in identifying the expertise that military surgeons need in a combat setting and also in adjusting training requirements accordingly. This paper attempts to assess the surgical specialties and skills of particular importance in the management of casualties in crisis areas.MEDLINE (1949-2007) and Google search were used. Causes of death among casualties in Afghanistan and the Iraq war were analyzed.The leading causes of injury were explosive devices, gunshot wounds, aircraft crashes, and terrorist attacks. Of the casualties, 55% died in hostile action and 45% in nonhostile incidents. Chest or abdominal injuries (40%) and brain injuries (35%) were the main causes of death for soldiers killed in action. The case fatality rate in Iraq was approximately half as high as in the Vietnam War. In contrast, the amputation rate was twice as high. Approximately 8-15% of the deaths appeared to be preventable.Military surgeons must have excellent skills in the fields of thoracic, visceral, and vascular surgery as well as practical skills in neurosurgery and oral and maxillofacial surgery. It also is of vital importance to ensure the availability of sufficient medical evacuation capabilities. Furthermore, there is a need for a standardized registration system for all injuries similar to the German Trauma Registry.

Travelling by airplane is of increasing importance in modern society. Psychiatric disorders seldom cause incidents in aircrafts. Scandal sheets and serious newspapers as well report on disturbances of a flight by psychiatric patients. Up until now psychiatric research is not engaging in unruly flight passengers suffering from psychotic symptoms. We describe a passenger who became psychotic during an international flight. In addition, we provide an overview over publications dealing with unruly passengers due to psychosis and describe similar cases.

The medical history of 1468 patients of German Air Rescue in 1993 has been investigated with regard to indications and rules which are used for the repatriation of sick or injured persons from abroad by aircraft. Decisions for repatriation should be made according to objective standardized criteria. The combination of the American Advisory Committee for Aeronautics rules with social components are suitable for this. In 2/3 of the patients, the indications are a mixture of medical and social components. The cost of the transportation are very high in many cases. The start of an action to fly home is determined also by the insuring body. As a result of this, the patient's influence is small. It is necessary to be a member of a rescue organisation for unproblematical repatriation.

In 1996 the new European Flight Crew Medical Requirements were finalized. The ophthalmological changes compared to the existing German standards range from the organization of evaluations to the necessary frequency of examinations. They also cover different examination techniques and different criteria for fitness. The changes in the requirements for ophthalmological fitness primarily affect ametropia, anisometropia, color vision and phoria. Knowledge of the European requirements is very important to advise pilots and any patient interested in becoming a pilot.

For both VFR and as IFR flight, visual assessment is the major source of information for the pilot. The new possibilities for change of refraction by means of corneal refractive surgery have led to an increasing demand from pilots for these new methods. Can these methods successfully be applied for aviation purposes? The valid regulations for medical standards of pilots, as well as the future international regulations such as JAR and ICAO, are explained in this respect. A report is given on the work of the Advisory Board of the German Federal Government Air Traffic Authority and on the cases treated so far and their outcome, and recommendations are expressed. Concerning the legal situation and clinical experience, advice for pilots, aviation medical examiners and ophthalmologists is given.

Radiology plays an important role in the identification of unknown corpses. Positive radiographic identification by comparison with ante-mortem films is an established technique in this setting. The value of identification depends on the ante- and post-mortem processing parameters which should be equal. A film-holder which is normally used in clinical dentistry has been modified for forensic investigation. The difficulties in placing and retaining intra-oral films in the mouths of deceased persons are minimised by the use of this holder. New equipment for film marking is described and different exposition times recording to the thickness of covering soft tissues were developed. Mistakes in the developing process are discussed. A forensic case underlines the advantages of systematic investigation.

High technology and automation have not been able to significantly improve flight safety within the last two decades. The main cause of aviation accidents was and is human error. Therefore, the most powerful tools to reduce risks in aviation deal with the human operator on the flight deck. Pilot selection, training and teamwork are of the utmost importance. The simulator is a valuable training aid. Simulation provides realistic scenarios that can be used to train optimal pilot behavior in emergency situations. Many complex abnormal situations can be only managed in teamwork. That is the reason why training programmes for improved team behavior (crew resource management) are becoming more and more important.

The authors report the analysis of mass disasters, which had been dealt with by forensic experts, on the territory of the former GDR. The report comes on the initiative of the Society of Forensic Medicine and with the support of regional institutes. For the period 1960 to 1989, 20 events with 738 casualties were registered. The number of victims was particularly high in aviation and rail disasters as well as in the Zwickau mine disaster. The Forensic Institute of the Humboldt-University in Berlin was engaged in the investigation of the three airplane crashes on Berlin territory and near Berlin (Königs-Wusterhausen 1972, Berlin-Bohnsdorf 1986 and Berlin-Schönefeld 1989) as well as of the railway disaster near Lebus in 1977. As a result of the analysis, the experience gained in three decades regarding the planning, organization and realization of the identification of victims is dealt with in more detail. It emphasizes the significance of close cooperation with dentists and criminalists. Because of ethical, legal and criminalistic reasons the aim should always be a complete examination (including autopsy) of the victims as well as their identification.

Mass-disasters with high numbers of victims are a real challenge to the specialists. The role of forensic experts is generally emphasized. The missions of the Leipzig Taskgroup for identification and the experience gained during them confirm, that special training necessary staff members is. Compared with the general signs of identity, like clothing, jewelry and accessories, scars etc., the marks of ears and observations of forensic odonto-stomatology provide good chances for identification. For forensic odonto-stomatology, we developed computer programs.

Parasailing is a new sport resulting in an increasing number of severe injuries. The analysis of 152 accidents reveals typical trauma mechanisms for the different flight positions. 87 patients (57%) had their crash during the landing approach. 68 pilots (45%) were affected during their primary training course. Spine lesions were found in 30 patients. Lower limb injuries occurred in 44 cases. Detailed trauma evaluation can give a clue for systematic prophylaxis.

In December, 1988, an American military pilot obviously losing his orientation brought down his jet fighter into a residential area of Remscheid, FRG. This paper reports on the medicolegal experiences gained during identification the victims. The officials plants for duty in case of disaster are discussed.

Between January 1987 and December 1988 36 patients with injuries resulting from hanggliding were admitted to the Interlaken hospital. 6 (17%) of them were women. 14 patients were between 20-30 years old. 24 patients presented injuries of the lower limb, in 10 cases the spine was affected. From the total 39 injuries 20 had to been treated by operation. The accidents occur equally while starting or landing, during the flight incidents are very rare. The majority of the patients had only little experience in hanggliding or underwent insufficient training, indicating the most important point to be dealt with in the future.

Paragliding--a relatively new sport to Switzerland--brought 23 patients with 48 injuries (38% lower limb and 29% spinal) within a period of 8 months to the Inselspital University hospital in Berne. The aim of the study in characterizing these injuries is to formulate some guidelines towards prevention. With over 90% of accidents occurring at either take off or landing, emphasis on better training for the beginner is proposed with strict guidelines for the more experienced pilot flying in unfavourable conditions.

It is supposed that some fatal aviation accidents of "cause unknown" especially of light and private airplanes are possibly intended by a suicidal act. However it is difficult to prove this suggestion. A case of a light aircraft accident is reported in which the medicolegal autopsy and the police investigation revealed, unexpected, a simultaneous homicide and suicide caused by a stabbing attack on the pilot. This paper stresses the importance of autopsies of the victims in aircraft accident investigation and discuss the medicolegal and psychopathological aspects of the case.

Until not too long ago, psychogenic trance was considered to be a 'conversion hysteria'. But clinical syndromes and personality disorders are now seen as separate entities; therefore, psychogenic trance is part of the so-called 'dissociative disorders'. Here, the integrative functions of the psyche are reduced and control of memory, identity, sensoric and motoric functions are impaired. As a consequence, certain disorders are observed, which have common characteristics, such as onset (psychogenic trauma), course (initial panic or belle indifference) and psychodynamics (repression of an unbearable reality). The following disorders can be distinguished: --psychogenic amnesia: partial or complete loss of memory --psychogenic trance: temporary loss of habitual identity with more or less full awareness of surroundings --psychogenic fugue: apparently purposeful journey away from home with psychogenic amnesia --psychogenic stupor: profound diminuation or absence of voluntary movement and no responsiveness to external stimuli.

On February 8th 1988, a two-motor passenger aircraft of Metroliner type with 21 people on board entered a front of heavy weather at an altitude of 900 m and crashed after being struck by lightning which led to complete breakdown of the electrical systems on board. The site of the crash was in the marshy Ruhr meadows. The formation of the terrain enabled a subdivision into plan squares for rescue. The identification of the 21 bodies was carried out in the Essen Institute of Forensic Medicine in collaboration with the identification commission of the Federal Criminal Investigation Office. The experience and recommendations for future (possibly larger-scale) disasters derived from this are described. Furthermore, the accident pattern in the casualties typical for this air crash is discussed.