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BACKGROUND:This study examines the relationship between seat restraints and injuries of children and infants who were passengers on an aircraft and gives a detailed analysis of children whose behavior contributed to an accident.METHODS:A total of 58 accident reports from 1980 until 2015 were extracted from the NTSB online database in which children were mentioned. In at least 10 cases the childs behavior contributed to the accident.RESULTS:Violations of regulations by the Federal Aviation Authority (FAA) as well as the age and number of children and infants on board were each reported inconsistently. Violations of regulations were significantly more common when accidents occurred during the takeoff phase. Child behaviors that caused accidents included distraction of crew, not wearing a seatbelt, and running into dangerous areas.CONCLUSIONS:Pilots and crew, especially in General Aviation, need to be made aware of the need to enforce FAA regulations concerning child restraint systems. It is recommended that children both on the ground and inside an aircraft have adult supervision in addition to supervising aircraft crew to prevent distractions that harm the safe operation of an aircraft.Kalagher H, de Voogt A. Children and infants in aviation accidents. Aerosp Med Hum Perform. 2021; 92(5):353357.

Comparison of post-mortem dental findings to ante mortem dental records is a well-established, frequently used scientific means of human identification. Dentistry has adapted a form of CT scanning that uses a cone-shaped beam and is thus termed cone beam computed tomography (CBCT). CBCT is presently being used in many aspects of dentistry including osseointegrated implant planning, orthodontics, endodontics, investigation of pathology, and assessment prior to complex dental extractions. The identification of seven individuals from multiple fatality incident was undertaken using a simple technique for completing comparative radiographic dental identifications using post-mortem medical computed tomographic (CT) image-acquisition techniques and commercially available dental software normally used in clinical care. The authors will show the means by which the harvesting of anatomically important data from medical CTs and conversion of these files was undertaken to provide crisp, clear post-mortem dental images for forensic comparison to assist in the identification of two adults and provide age stratification of three juveniles. The use of this technique has shown to be beneficial for expediting efficient identification of deceased individuals, helping to isolate which cases may need additional scientific methods of identification, saving time and money to the organization and eliminating biological/body substance or radiation exposure to the operator. The application of this software for use in forensic dental identification cases is presented, and the methodology to create post-mortem images suitable for comparison is detailed.

This study examines patterns of skeletal trauma in propeller-driven aircraft crashes and blast-related ground loss incidents from WWII. Specifically, descriptions and criteria used to characterize aircraft deceleration- versus blast-related skeletal injuries are examined from 35 recently identified forensic anthropology cases to determine possible diagnostic traits and characterize skeletal trauma associated with these events. Among these cases, blast trauma is more localized within the skeleton and is associated with one or few primary directions of force. It is recommended that analysts differentiate between secondary and nonspecific blast trauma categories. Conversely, aircraft crash deceleration trauma is more widespread throughout the skeleton, with torsional fractures and injuries occurring from multiple or indeterminate directions. These traits reflect factors such as more complex loading environments than is seen in blast events. Two case studies are presented in detail to further illustrate differences in aircraft crash and blast-related incidents. Both studies emphasize consideration of the body as a whole unit to facilitate interpretations. While the cases presented herein result from historic war-related casualties that characterize the Defense POW/MIA Accounting Agency's (DPAA) casework, these skeletal cases provide guidelines more appropriate than clinically derived criteria developed through assessments of soft tissue injuries. These guidelines can be used by anthropologists and pathologists working with skeletal remain from mass disasters and other complex contexts, as well as provide avenues for future research.

Introduction We aimed to describe the epidemiology and injury patterns of aviation sports crashes in the Austrian mountains and identify risk factors. Methods In this retrospective cohort study, out-of-hospital data on patients who sustained crashes when participating in aviation sports from January 1, 2006 through December 31, 2015 were assessed. The out-of-hospital data were merged with in-hospital data obtained from Innsbruck Medical University Hospital. Results A total of 2037 persons were involved in 1856 aviation sports crashes. Data on 126 in-hospital patients were available. Wind and pilot error were the most common causes. Most injuries occurred in paragliders (n=111, 88%). Most commonly, paragliders sustained injuries to the lumbar spine and hang gliders to the thoracic spine. Rescue operations were undertaken mainly by helicopter emergency medical services (n=87, 69%) or combined rescue forces (ground and helicopter, n=100, 79%.). The Injury Severity Score was 15±15, with a peak in patients with isolated injuries of the lower extremities (n=38, 32%) and a second peak in patients with multiple trauma (n=44, 35%). Conclusions In the Austrian mountains, wind and pilot errors are the most common causes of aviation crashes. Aviation sports crashes frequently resulted in severe injuries and multiple trauma. The lumbar spine is particularly at risk in paragliders, whereas the thoracic spine is commonly affected in hang gliders. Injuries frequently caused long-term paralysis and limitations in quality of life. To minimize long-term consequences and save lives, skilled and well-equipped teams may be beneficial to provide effective on-site care and safe transportation to a trauma center.

Gyroplanes are mainly used for sports aviation. Experience is required when flying these special aircraft because in 40% of gyroplane crashes, the passengers do not survive. Herein, a fatal gyroplane crash of a tandem-seat gyroplane with two occupants is reported. The occupants, both 49-year-old males, fell from a height of approximately 20 m to 30 m. In both cases, the cause of death was polytrauma with typical findings of deceleration trauma. The pilot, who probably lost his helmet in the crash, had a ring fracture at the base of his skull. As there is not much literature on autopsy findings in the case of light aircraft crashes, these autopsy findings are presented and discussed.

Sensing surfaces like a mosquito Although sonar or lidar are used by autonomous vehicles to detect nearby objects, these approaches incur significant equipment and signal-processing costs. Nakata et al. show that mosquitos detect surfaces using the flow fields caused by the movement of their own wings (see the Perspective by Young and Garratt). Near surfaces, there are small changes in the pressure and velocity that mosquitos can detect using their sensitive antennae. The authors translated this process into a simple, low-cost approach for detecting surfaces near a flying quadcopter. Science , this issue p. 634 ; see also p. 586

INTRODUCTION: Fatigue is a critical safety issue to U.S. Air Force (USAF) flight and ground crew. Nearly 15 yr of mishap reports were analyzed to determine how fatigue affects USAF operations with the goal of improving fatigue risk management policies and tools.METHODS: Summary data for 19,920 aviation mishap reports dating back to 2003 were collected from the Air Force Safety Automated System (AFSAS). Fatigue-related mishaps were identified based on designations provided within AFSAS. Other metrics examined were characteristics such as timing, cost, and aircraft metrics, among others. Contingency tables built from these metrics were used to assess fatigue-related trends across the aviation community.RESULTS: While only 3.88% of all mishaps were identified as fatigue-related, they are associated with 2.1 billion of medical expenses and property damage, or 18% of the 11.7 billion total cost of all mishaps included in the study. Nearly a quarter of the fatigue-related mishaps fall into the most severe mishap category and more than half occurred between 0100 and 0700, local time. Fatigue-related mishaps tended to be more common for Remotely Piloted Aircraft (RPA) and ground operations.DISCUSSION: Fatigue is very costly to the USAF despite the relatively low incidence rate of fatigue-related mishaps. This is because larger proportions of severe mishaps were found to be fatigue-related. RPA and ground maintenance operators might be especially susceptible to fatigue and potentially lack adequate fatigue mitigation support and training tailored to their unique operational environment, suggesting a need to improve upon fatigue mitigation tools and strategies.Gaines AR, Morris MB, Gunzelmann G. Fatigue-related aviation mishaps. Aerosp Med Hum Perform. 2020; 91(5):440447.

Objective The aim is to provide a high-level synthesis of human factors research that contributed to the development of detect-and-avoid display requirements for unmanned aircraft systems (UAS). Background The integration of UAS into the U.S. National Airspace System is a priority under the Federal Aviation Administration’s Modernization and Reform Act. For UAS to have routine access to the National Airspace System, UAS must have detect-and-avoid capabilities. One human factors challenge is to determine how to display information effectively to remote pilots for performing detect-and-avoid tasks. Method A high-level review of research informing the display requirements for UAS detect-and-avoid is provided. In addition, description of the contributions of human factors researchers in the writing of the requirements is highlighted. Results Findings from human-in-the-loop simulations are used to illustrate how evidence-based guidelines and requirements were established for the display of information to assist pilots in performing detect-and-avoid. Implications for human factors are discussed. Conclusion Human factors researchers and engineers made many contributions to generate the data used to justify the detect-and-avoid display requirements. Human factors researchers must continue to be involved in the development of standards to ensure that requirements are evidence-based and take into account human operator performance and human factors principles and guidelines. Application The research presented in this paper is relevant to the design of UAS, the writing of standards and requirements, and the work in human–systems integration.

BACKGROUND: General Aviation (GA) pilots who encounter hazardous weather inflight have a high probability of incurring fatal accidents. To mitigate this problem, previous research investigated pilot decision making and the effects of new technology. Limited investigations have examined usability and interpretability of observation and forecast weather products available to pilots. Therefore, this study examined the interpretability of weather observation and forecast reports that GA pilots use for preflight weather planning and the impact of pilot certification level on the interpretability of these displays.METHOD: There were 204 GA pilots (Mean age = 22.50 yr; Median flight hours = 131.0) who completed a 90-item multiple choice Aviation Weather Product Test. The questions portrayed static weather displays available on the NOAA/National Weather Service Aviation Weather Center website. The questions were designed to have high cognitive fidelity in comparison with preflight weather planning tasks.RESULTS: The results revealed overall low mean interpretability scores (Mean percent correct= 59.29%, SD = 16.01%). The scores for observation products and product attributes were lower for student pilots than experienced pilots. Forecast product scores for student and private pilots did not differ, however, student pilot scores were significantly lower than instrument rated private and commercial pilots.DISCUSSION: The low interpretability scores indicate that GA pilots misinterpret weather information provided by most weather observation and forecast products. Possible contributing factors to the low product interpretation scores include poor usability and a lack of training. Future research should measure the usability of weather displays designed for pilots.Blickensderfer BL, Guinn TA, Lanicci JM, Ortiz Y, King JM, Thomas RL, DeFilippis N. Interpretability of aviation weather information displays for general aviation. Aerosp Med Hum Perform. 2020; 91(4):318–325.

INTRODUCTION: Exposure to high G force is a known safety hazard in military aviation as well as civilian aerobatic flight. Tolerance to high G forces has been well studied in military pilots, but there is little research directed at civilian pilots who may have medications or medical conditions not permitted in military pilots.METHODS: In this case-control study, we identified 89 fatal high-G aerobatic accidents and 4000 fatal control accidents from 1995 through 2018 from the NTSB accident database and the FAA autopsy database. We retrieved medications and medical conditions from the FAA's pilot medical databases. Logistic regression models were used to explore the associations of drugs, medical conditions, height, and medical waivers with high-G accidents.RESULTS: Seven drugs (alprazolam, clonidine, ethanol, meclizine, phentermine, triamterene, and zolpidem) reached statistical significance in our models, but had such small case counts that we consider these findings to be uncertain, except for ethanol, which was found in seven cases. Of these, only triamterene was known to the FAA. Statistically significant medical predictors included only alcohol abuse (seven cases) and liver disease (only two cases).DISCUSSION: Our analysis found that the drug ethanol and the condition alcohol abuse are significantly associated with high-G accidents. Seven other factors were statistically significant, but should only be considered as hypothesis generating due to very low case counts. Our study does not suggest that restricting pilots with otherwise permissible medications or medical conditions from aerobatics is warranted.Mills WD, Greenhaw RM, Wang JMP. A medical review of fatal high-G U.S. aerobatic accidents. Aerosp Med Hum Perform. 2019; 90(11):959–965.

INTRODUCTION:Helicopter Emergency Medical Service (HEMS) is a mode of transportation designed to expedite the transport of a patient. Compared to other modes of emergency transport and other areas of aviation, historically HEMS has had the highest accident-related fatality rates. Analysis of these accident data has revealed factors associated with an increased likelihood of accident-based fatalities. Here we report the results of an analysis on the likelihood of a fatality based on various factors as a result of a HEMS accident, employing a Bayesian framework.METHODS:A retrospective study was conducted using data extracted from the NTSB aviation accident database from April 31, 2005, to April 26, 2018. Evidence from Baker et al. (2006) was also used as prior information spanning from January 1, 1983, to April 30, 2005.RESULTS:A Bayesian logistic regression was implemented using the prior information and current data to calculate a posterior distribution confidence interval of possible values in predicting accident fatality. The results of the model indicate that flying at night (OR 3.06; 95 C.I 2.14, 4.48; PoD 100), flying under Instrument Flight Rules (OR 7.54; 95 C.I 3.94, 14.44; PoD 100), and post-crash fires (OR 18.73; 95 C.I 10.07, 34.12; PoD 100) significantly contributed to the higher likelihood of a fatality.CONCLUSION:Our results provide a comprehensive analysis of the most influential factors associated with an increased likelihood of a fatal accident occurring. We found that over the past 35 yr these factors were consistently associated with a higher likelihood of a fatality occurring.Simonson RJ, Keebler JR, Chaparro A.A Bayesian approach on investigating helicopter emergency medical fatal accidents.Aerosp Med Hum Perform. 2021; 92(7):563569.

INTRODUCTION: Aerobatic flight operations involve a higher level of risk than standard flight operations. Aerobatics imposes considerable stresses on both the aircraft and the pilot. The purpose of this study was to analyze civilian aerobatic aircraft accidents in Australia, with particular emphasis on the underlying accident causes and survival outcomes.METHODS: The accident and incident database of the Australian Transport Safety Bureau was searched for all events involving aerobatic flight for the period 19802010.RESULTS: A total of 51 accidents involving aircraft undertaking aerobatic operations were identified, with 71 aircraft occupants. Of the accidents, 27 (52.9) were fatal, resulting in a total of 36 fatalities. There were 24 nonfatal accidents. In terms of injury outcomes, there were 4 serious and 9 minor injuries, and 22 accidents in which no injuries were recorded. Fatal accidents were mainly due to loss of control by the pilot (44.4), in-flight structural failure of the airframe (25.9), and terrain impact (25.9). G-LOC was considered a possible cause in 11.1 of fatal accidents. Nonfatal accidents were mainly due to powerplant failure (41.7) and noncatastrophic airframe damage (25). Accidents involving aerobatic maneuvering have a significantly increased risk of a fatal outcome (odds ratio 26).DISCUSSION: The results of this study highlight the risks involved in aerobatic flight. Exceeding the operational limits of the maneuver and the design limits of the aircraft are major factors contributing to a fatal aerobatic aircraft accident. Improved awareness of G physiology and better operational decision-making while undertaking aerobatic flight may help prevent further accidents.Newman DG. Factors contributing to accidents during aerobatic flight operations. Aerosp Med Hum Perform. 2021; 92(8):612618.

Objective To determine viability of drowsiness detection, researchers study the feasibility of photoplethysmogram (PPG) data collection from the geography of the aviation headset, correlating to electrocardiogram (ECG) reference. Background Fatigue has been a probable cause, contributing factor, or a finding in 20% of transportation incidents and accidents studied between January 2001 and December 2012. This operational hazard is particularly troublesome within aviation and airline operations. Method PPG and ECG data were collected synchronously from Federal Aviation Administration (FAA) commercially rated pilots during flight simulation in the window of circadian low (WOCL). Valid PPG and ECG data from 14 participants were analyzed, which yielded approximately 2 hr of data per participant for fatigue-related analysis. Results The results of the study demonstrate clear trends toward decreased heart rate for both ECG and PPG and suggest progression of drowsiness between four separate periods (T1, T2, T3, and T4) selected during the study; however, the mean heart rate change from T1 to T4 was statistically significant. Conclusion The results suggest that ECG and PPG data can be an important tool to observe conditions where drowsiness or fatigue may add risk to the operation. In addition, the data show high correlation between ECG and PPG data, further suggesting that a simpler PPG sensor, mounted within the geography of the aviation headset, may streamline the operationalization of important physiological data. Application Incorporation of PPG sensors and associated signal processing methods into facilitating equipment, such as the aviation headset, may add a layer to operational safety.

INTRODUCTION: Modafinil is a wakefulness-promoting stimulant that has been approved by the Republic of Singapore Air Force (RSAF) as a fatigue countermeasure medication since 2011. Each RSAF aircrew member must undergo a ground test to exclude operationally relevant adverse drug effects prior to consuming the medication for operational reasons. This study describes the RSAF's modafinil ground testing outcomes over a 7-yr period.METHODS: This is a retrospective case series of 243 RSAF aircrew members who underwent modafinil 100-mg test dosing over the 7-yr period from September 2011 to September 2018.RESULTS: The median age was 31 yr (range, 21-53 yr) and mean age was 31.7 yr ± 6.19 yr. Of the aircrew members, 234 (96.3%) were men and all were of Asian ethnicity. Of the subjects, 237 (97.5%) were medically cleared for the operational use of modafinil. Among the six (2.47%) who failed modafinil ground testing, headache (cumulative incidence, 1.65%), anxiety (cumulative incidence, 0.41%), diarrhea (cumulative incidence, 0.41%), and insomnia (cumulative incidence, 0.41%) were reported as the side effects experienced. None of the aircrew members experienced major adverse drug events.DISCUSSION: Our findings suggest a low occurrence of adverse drug effects among military aircrew members who undergo modafinil test dosing prior to using the drug operationally. To our knowledge, this is the single largest published case series of modafinil ground testing outcomes among Asian military aviators.Ooi T, Wong SH, See B. Modafinil as a stimulant for military aviators. Aerosp Med Hum Perform. 2019; 90(5):480-483.

INTRODUCTION: This study explores the safety risk due to delayed detection of hazardous health conditions that would result from increasing the duration of U.S. first-class aeromedical certificates from 6 mo to 12 mo for pilots ages 40 yr old through 60 yr old.METHODS: All pilots who submitted a U.S. first-class application in 2014 with no electrocardiogram and with the previous exams 4.5 to 7.5 mo prior were selected from the FAA pilot medical database. Proportions of Federal Aviation Administration (FAA) denial pathology codes and Aviation Medical Examiner (AME) deferrals were compared for these exams within and between age groups from 40 yr old through 75 yr old. The absolute incidence rates for delayed detection were calculated and relative incidence of these proportions was compared graphically.RESULTS: The relative risk between age groups for delayed identification of disqualifying medical conditions showed that the 56-60-yr-old group would be at about twice the risk as the 40-45-yr-old group. The absolute incidence for the 56-60-yr-old group was 0.46% for denial conditions and 0.60% for AME deferrals over 6 mo.DISCUSSION: Increasing FAA first-class medical certificate duration from 6 mo to 12 mo would put 56-60-yr-old pilots at double the currently accepted risk for delayed detection of significant medical conditions. The absolute risk for this 6-mo delayed identification for the 56-60-yr-old group would average 0.53%.Mills WD, DeJohn CA. Safety implications of 6-month vs. 1-year first-class aeromedical certificates. Aerosp Med Hum Perform. 2019; 90(5):484-487.

Introduction Fire and emergency service workers, including Aircraft Rescue and Fire Fighting members, may be called on to perform confined space entry and rescue operations. The purpose of the present study was to develop a comprehensive and valid understanding of the present state of confined space entry and rescue training effectiveness and resultant compliance or use of best practices among trained Aircraft Rescue and Fire Fighting personnel. Method The study used a convergent, parallel mixed-methods approach. Qualitative data (n = 20) were collected via semi-structured interviews at four locations. Data were coded, analyzed and super-ordinate and sub-ordinate themes were derived. Quantitative data (n = 158) from Aircraft Rescue and Fire Fighting members were analyzed. Results Interviewees believed there is a lack of standardization in training, but believed training should not be completed in the same format every time. Several participants (50%) desired more realistic training. Other concerns were associated with staffing, personal readiness, and resource adequacy. With regard to survey outcomes, most respondents reported that their organizations completed confined space training (69.8%), but only 55.3% indicated this training was conducted as a full-scale exercise and nearly 40% indicated that rescue practice was not performed despite standards mandating annual rescue practice. Following training, 55.4% indicated training evaluation information was not presented. Conclusions Participants mostly agreed their training effectively addressed OSHA requirements, such as how to test the atmosphere, the need for and use of personal protective equipment, how to identify pertinent permit information and methods to retrieve victims in limited space. Some gaps exist between current training practices and established training requirements and standards. Practical applications Aircraft Rescue and Fire Fighting organizations need to bolster aspects of their training, particularly with regard to standardizing training efforts, practicing rescues, providing evaluation feedback and written materials and providing adequate resources.

Flight risk assessment tools (FRATs) aid pilots in evaluating risk arising from the flight environment. Current FRATs are subjective, based on linear analyses and subject-matter expert interpretation of flight factor/risk relationships. However, a 'flight system' is complex with non-linear relationships between variables and emergent outcomes. A neural network was trained to categorize high and low-risk flight environments from factors such as the weather and pilot experience using data extracted from accident and incident reports. Negative outcomes were used as markers of risk level, with low severity outcomes representing low-risk environments and high severity outcomes representing high-risk environments. Eighteen models with varied architectures were created and evaluated for convergence, generalization and stability. Classification results of the highest performing model indicated that neural networks have the ability to learn and generalize to unseen accident and incident data, suggesting that they have the potential to offer an alternative to current risk analysis methods.

BACKGROUND: Maxillofacial shields (MFSs) are an available piece of aviation protective equipment designed to integrate into aircrew helmets and protect the face from wind and flying debris. Aviators have anecdotally reported that MFSs have provided blunt impact protection during impact events (i.e., a crash); however, no such cases have been formally documented in the literature.CASE REPORTS: Two cases were identified where aircrew wearing MFSs were involved in mishaps resulting in maxillofacial blunt impacts. In the first case, an OH-58 pilot struck the cyclic with his head/face during a crash. In the second case, a CH-47 crew chief was struck in the face by a maintenance panel dislodged from the aircraft. In both cases the MFS was damaged, but neither service member experienced injuries as a result of impact to the face.DISCUSSION: The cases illustrate the effectiveness of the MFS against blunt impact during aviation mishaps. While MFS use is currently optional for aircrew, it is believed that increased MFS use would result in fewer or less severe facial injuries as well as decrease the associated time and monetary losses due to injury.Weisenbach CA, McGhee JS. Aviation maxillofacial shields and blunt impact protection in U.S. Army helicopter mishaps. Aerosp Med Hum Perform. 2021; 92(1):5053.

While airlines generate massive amounts of operational data every year, the ability to use the collected material to improve safety has begun to plateau. With the increasing demand for air travel, the aviation industry is continually growing while simultaneously being required to ensure the level of safety within the system remains constant. The purpose of this paper is to explore whether the traditional analysis methods that have historically made aviation ultra-safe have reached their theoretical limits or merely practical ones. This analysis argues that the underlying logic governing the traditional (and current) approaches to assess safety and risk within aviation (and other safety critical systems) is abductive and therefore focused on creating explanations rather than predictions. While the current “fly-fix-fly” approach has, and will continue to be, instrumental in improving what (clearly) fails, alternative methods are needed to determine if a specific operation is more or less risky than others. As the system grows, so too does the number of ways it can fail, creating the possibility that more novel accidents may occur. The paper concludes by proposing an alternative approach that explicitly adds temporality to the concepts of safety and risk. With this addition, a deductive analysis approach can be adopted which, while low in explanatory power, can be used to create predictions that are not bound to analyzing only outcomes that have occurred in the past but instead focuses on determining the deviation magnitude between the operation under analysis and historically commensurate operations. QC 20210527

Birdstrikes are an important threat to aviation safety. A standardized, scientific process for assessing birdstrike risk could prevent accidents, thereby improving the flight safety and reducing economic losses. However, China currently lacks a unified birdstrike risk assessment system. Here, we propose and validate a new model for assessing birdstrike risk in order to fill that need. The model consists of two elements. First, empirical data are collected on the occurrence of birds at the airport and in a surrounding 8 km buffer. Second, each species is evaluated with a risk assessment matrix that takes into account the number of birds, weight, flight altitude, a tendency to cluster, and range of activity. These five factors allow each species to be divided into one of three risk levels: high danger (level 3), moderate danger (level 2) and low danger (level 1). We propose corresponding birdstrike prevention measures for each level. We apply this method to the civil aviation airport in Ordos, China. We found that 20 of the 118 species of birds in and around the airport were high danger birds (level 3). To validate this process, we compared these species with records of birdstrike accidents in a database maintained by the Civil Aviation Administration of China (CAAC) for 2007–2016. We found that 42% of the species we identified as high risk had been involved in at least one birdstrike accident, and that the remaining 58% belonged to families that appeared in the database. The high degree of overlap gives us high confidence in the practicality of our risk assessment model, which is based on the risk management concept of ISO 31000. Critically, this new model and method for predicting bird strike risk can be replicated at other airports around the world, even where no extensive records have been kept of past birdstrikes.

BACKGROUND: From 2007, the Federal Aviation Administration (FAA) permitted pilots who have had a heart transplant to be considered for recertification under special issuance at the third-class level. The objective of this study was to evaluate certification safety and determine if any adverse outcome occurred in this airman group as a consequence of this policy.METHODS: Methods involved collecting data from the FAA Document Imaging Workflow System to identify airmen undergoing cardiac transplantation since 2007, and examining medical and safety-related outcomes through the National Transportation Safety Board-related accident database and the Centers for Disease Control and Prevention National Death Index.RESULTS: Included in the study were 36 airmen, with 16 recertified at the class 3 level and 20 denied certification. No aviation accidents or recorded deaths occurred in the group of 16 airmen undergoing recertification. Of these airmen, 13 underwent a second successful recertification and 6 underwent a third attempt, with 5 being successful. Two airmen have declared their intention to fly under BasicMed. Of the 20 airmen denied recertification, 16 were denied for failure to provide information. There were three deaths in this denied group.DISCUSSION: The policy allowing third-class heart transplant recipient recertification appears to be safe. Aviation safety is not being compromised by allowing these airmen to resume flying, with the exception that recertification should continue under the special issuance system and not through BasicMed.Norris A, Skaggs V, Kaye D, De Voll J, McGiffin D. Selective recertification of pilots who have undergone a cardiac transplant. Aerosp Med Hum Perform. 2020; 91(9):732736.

Human factors are important causes of hazardous chemical storage accidents, and clarifying the relationship between human factors can help to identify the logical chain between unsafe behaviors and influential factors in accidents. Therefore, the human factor relationship of hazardous chemical storage accidents was studied in this paper. First, the human factors analysis and classification system (HFACS), which originated from accident analysis in the aviation field, was introduced. Since some items were designed for aviation accident analysis, such as the item &ldquo, Crew Resource Management&rdquo, it is not fully applicable to the analysis of hazardous chemical storage accidents. Therefore, this article introduced some modifications and changes to make the HFACS model suitable for the analysis of hazardous chemical storage accidents. Based on the improved HFACS model, 42 hazardous chemicals storage accidents were analyzed, and the causes were classified. After analysis, we found that under the HFACS framework, the most frequent cause of accidents is resource management, followed by violations and inadequate supervision, and finally the organizational process and technological environment. Finally, according to the statistical results for the various causes of accidents obtained from the improved HFACS analysis, the chi-square test and odds ratio analysis were used to further explore the relevance of human factors in hazardous chemical storage accidents. The 16 groups of significant causal relationships among the four levels of factors include resource management and inadequate supervision, planned inappropriate operations and technological environment, inadequate supervision and physical/mental limitations, and technological environment and skill-based errors, among others.

With the advent of commercial human spaceflight, it is important to analyze the historical safety of humans traveling to, in, and from space. We break down the fatality rates of human spaceflight and compare them to those of several terrestrial transportation modes. We created a database of human space travel, containing the vehicles, launches, and the total time and distance traveled. For the 4 fatal space missions and 18 fatalities, we determined the fatality rates, calculated by several methods, including rates per trip, person, and distance traveled, stratified by the mission segment affected. Two of the 326 launches did not reach space, and 8 others were suborbital. There have been 1285 person-launches to space; the total time in space is estimated to be 55,939 person-days; and the total distance traveled is approximately 23.5 billion person-miles. One fatal trip occurred on the way to orbit and the other 3 during the return. There has yet to be a fatality in orbit, and there have been none on any space flight since 2003. The per-trip and per-person fatality rates are 1.2% and 1.4%, respectively, but the per mile rate is much lower, depending on the flight segment.

Introduction All modern military jet aircraft are equipped with rocket-assisted ejection systems. Jet aircraft operate in the majority of the conflict regions throughout the world, and in nearly all modern countries during peacetime. Civilian and military emergency services may be called upon to treat aircrews that have ejected and should be familiar with the common injury patterns associated with aircraft ejection. Methods A systematic review and meta-analysis of the literature were undertaken using the preferred reporting for systematic reviews and meta-analyses (PRISMA) methodology. Peer-reviewed journal and conference papers published between 1 January 1971 and 15 June 2019 were included. Our primary outcomes of interest were mortality and major injury rates. The I2 test was used to assess heterogeneity among the included studies, and data were pooled under random effects models. In addition, all ejection cases in the Israeli Air Force (IAF) between 1990 and 2019 were studied. The data were manually extracted from the accident records and the electronic medical records system. Results We identified 14 studies that included 1710 aircrew ejections. Heterogeneity was high (I2>75%). Pooled mean mortality and major injury rates were 10.5% (95% CI 6.8-14.8%) and 29.8% (95% CI 20.1-40.6%), respectively. The major injuries included spinal fractures (61.6%), extremity trauma (27.3%), and head trauma (8.9%). During the IAF study period, a total of 37 aircrew ejected from 26 IAF aircraft. The fatality rate was 5.4% and 18.9% suffered major injuries. Conclusions Although ejection is lifesaving, it is associated with unique injury patterns that should be addressed during clinical evaluation. Because of their high prevalence, spinal precautions are paramount until spinal injury can be ruled out, generally by advanced imaging. Looking forward, injury patterns will continue to evolve in parallel with improving ejection seat systems.

Human error is an important risk factor for flight safety. Although the human error assessment and reduction technique (HEART) is an available tool for human reliability derivation, it has not been applied in flight safety assessment. The traditional HEART suffers from imprecise calculation of the assessed proportion of affect (APOA) because it heavily depends on a single expert's judgment. It also fails to provide remedial measures for flight safety problems. To overcome these defects of the HEART, this study proposes an integrated human error quantification approach that uses the improved analytic hierarchy process method to determine the APOA values. Then, these values are fused to the HEART method to derive the human error probability. A certain flight task is completed to assess human reliability. The results demonstrate that the proposed method is a reasonable and feasible tool for quantifying human error probability and assessing flight safety in the aircraft manipulation process. In addition, the critical error-producing conditions influencing flight safety are identified, and improvement measures for high-error-rate operations are provided. The proposed method is useful for reducing the possibility of human error and enhancing flight safety levels in aircraft operation processes.

The precise evaluation of the potential damage caused by large commercial aircraft crash into civil structures, especially nuclear power plants (NPPs), has become essential design consideration. In this study, impact of Boeing 767 against rigid wall and outer containment building (reinforced concrete) of an NPP are simulated in ANSYS/LS-DYNA by using both force time history and missile target interaction methods with impact velocities ranging from 100 m/s to 150 m/s. The results show that impact loads, displacements, stresses for concrete and steel reinforcement, and damaged elements are higher in case of force time history method than missile target interaction method, making the former relatively conservative. It is observed that no perforation or scabbing takes place in case of 100 m/s impact speed, thus preventing any potential leakage. With full mass of Boeing 767 and impact velocity slightly above 100 m/s, the outer containment building can prevent local failure modes. At impact velocity higher than 120 m/s, scabbing and perforations are dominant. This concludes that in design and assessment of NPP structures against aircraft loadings, sufficient thickness or consideration of steel plates are essential to account for local failure modes and overall structural integrity. Furthermore, validation and application of detail 3D finite element and material models to full-scale impact analysis have been carried out to expand the existing database. In rigid wall impact analysis, the impact forces and impulses from FE analysis and Riera's method correspond well, which satisfies the recommendations of relevant standards and further ensure the accuracy of results in full-scale impact analysis. The methodology presented in this paper is extremely effective in simulating structural evaluation of full-scale aircraft impact on important facilities such as NPPs.

The objective of this work is to advance the understanding of helicopter accidents by examining and quantifying the association between helicopter-specific configurations (number of main rotor blades, number of engines, rotor diameter, and takeoff weight) and the likelihood of accidents. We leverage a dataset of 8,338 turboshaft helicopters in the U.S. civil fleet and 825 accidents from 2005 to 2015. We use the dataset to develop a logistic regression model using the method of purposeful selection, which we exploit for inferential purposes and highlight the novel insights it reveals. For example, one important question for the design and acquisition of helicopters is whether twin-engine turboshaft helicopters exhibit a smaller likelihood of accidents than their single-engine counterparts, all else being equal. The evidence-based result we derive indicates that the answer is contingent on other covariates, and that a tipping point exists in terms of the rotor diameter beyond which the likelihood of accidents of twin-engines is higher (worse) than that of their single-engine counterparts. Another important result derived here is the association between the number of main rotor blades and likelihood of accidents. We found that for single-engine turboshaft helicopters, the four-bladed ones are associated with the lowest likelihood of accidents. We also identified a clear coupling between the number of engines and the rotor diameter in terms of likelihood of accidents. In summary, we establish important relationships between the different helicopter configurations here considered and the likelihood of accident, but these are associations, not causal in nature. The causal pathway, if it exists, may be confounded or mediated by other variables not accounted for here. The results provided here lend themselves to a rich set of interpretive possibilities, and because of their significant safety implications they deserve careful attention from the rotorcraft community.

Introduction The special issuance (SI) waiver is the primary mechanism for U.S. pilots who do not meet FAA standards to obtain a medical certificate. About 34,000 pilots possess an SI waiver, but there is a large gap in knowledge of the relationship of SI waivers to aviation safety. Methods All FAA pilot medical exams from 2002 through 2011 were matched to the National Transportation Safety Board accident database. The association of an SI waiver with accidents was explored using logistic regression models. Accident rates were also calculated using a novel technique based on pilots' reported flight times on their applications for medical certification. Results For third-class flight exams overall, the presence of an SI waiver is associated with 8.7% lower odds of an accident than regular issuance exams. The calculated overall accident rate was 6.6 per 100,000 h. For the first and second-class exams, there was no significant association of SI waivers with safety for the overall group. The oldest and youngest pilots in the third-class group and the younger pilots in the first and second-class groups had somewhat elevated accident odds. The significance of these higher odds is uncertain, especially for the younger pilots who have a probable flight time bias. Discussion The overall FAA program of special issuance waivers shows no detrimental effect on aviation accidents and enables a large number of pilots to safely continue their aviation pursuits in spite of failure to meet specific regulatory medical standards.Mills WD, Davis JT. The U.S. experience with special issuance waivers. Aerosp Med Hum Perform. 2018; 89(10):905-911.

BACKGROUND Analysis of mishap data is an obvious measure of performance for those who wish to improve flight safety and affect aviation capability development within military forces. METHODS This study examined rotary-wing accident information held by UK Ministry of Defence authorities for the 16-yr (inclusive) period from January 2000 through December 2015 in order to ascertain incidence patterns. Serious accidents of military registered aircraft operated by Joint Helicopter Command, the Royal Navy, the Search and Rescue Force, and the Defence Helicopter Flying School were included in the analysis. A secondary intent of the review was to examine the influence of broad-based organizational changes on the overall incidence of rotary-wing accidents across the U.K. Ministry of Defence that grew out of the report published by Charles Haddon-Cave, QC, following his wide-ranging investigation into the catastrophic crash of Royal Air Force Nimrod XV230 that occurred during a routine mission in Southern Afghanistan. RESULTS During the 16-yr period between January 2000 and December 2015, 53 rotary-wing accidents occurred. The overall accident rate was 2.32 accident events per 100,000 flight hours. Spatial disorientation accidents remain a prevalent risk in this study, being acknowledged in 43% of accidents. Prior to the Haddon-Cave report, the accident rate was 2.81 events per 100,000 flight hours. Following the report, the accident rate decreased to 1.24 events per 100,000 flight hours. DISCUSSION The decrease in the accident rate between 2000 and 2015 shares a temporal association with the adoption and operationalization of the recommendations found in Haddon-Cave's report.Bushby AJR, Powell-Dunford N, Porter WD. UK military rotary-wing accidents: 2000-2015. Aerosp Med Hum Perform. 2018; 89(9):842-847.

Background Flight crew fatigue is an important factor in aviation, leading organizations to implement fatigue risk management programs to reduce risk. The U.S. Air Force Air Mobility Command (AMC) has implemented the Aviation Operational Risk Management (AvORM) program to aid mission schedulers and flight crews in mitigating flight risks and identifying appropriate levels of risk. The AvORM program uses a scheduling tool and underpinning biomathematical fatigue model. This study examined self-reported fatigue-related incidents within AMC, which provides some indirect and anecdotal evidence as to the effectiveness of the scheduling tool. Methods Archival data from the AMC Aviation Safety Action Program (ASAP) Safety Reporting System was examined. Report content themes were created through an inductive approach in terms of fatigue prevalence, antecedents, and consequences. Results Fatigue was estimated as a factor in 4% of the reports. The two most commonly referenced fatigue antecedents were associated with mission/duty length and mission scheduling/planning factors. Factors associated with aircraft operation violations were the most cited consequences of fatigue. Fatigue was almost twice as likely to be reported as a secondary rather than primary contributing factor. Aircrew reported both positive and negative aspects of AvORM resources in mission planning and fatigue mitigation. Discussion Examination of ASAP reports suggests that fatigue is a contributing factor to safety incidents. Although the AvORM program highlights potential flight risks by utilizing a scheduling tool built upon an underlying biomathematical fatigue model, human fatigue continues to impact safety, suggesting an ongoing need for improved fatigue risk management and mitigation.Morris MB, Wiedbusch MD, Gunzelmann G. Fatigue incident antecedents, consequences, and aviation operational risk management resources. Aerosp Med Hum Perform. 2018; 89(8):708-716.

INTRODUCTION: The Statement of Demonstrated Ability (SODA) is a type of U.S. aeromedical waiver used for disqualifying conditions that are not expected to change. About 21,000 (2%) U.S. pilots possess a SODA waiver.METHODS: We matched all pilot medical exams from the FAA’s medical certification database from 2002 through 2011 to their respective accidents in the National Transportation Safety Board accident database. The association of SODA waivers and SODA conditions with the odds of an accident were explored using logistic regression techniques.RESULTS: For 3rd class flight exams, the presence of a SODA waiver was not associated with the odds of an accident. For the 1st and 2nd class exams, the accident odds ratio (OR = 1.45) was statistically significant. Crop dusting operations accounted for 17 of the 40 accidents where SODAs were present and returned a significant accident OR = 1.68. SODAs were not associated with the odds of accidents during other commercial operations. Six SODA conditions (amputation, internal eye, external eye, visual fields, bone and joint, and miscellaneous) were also found to have elevated ORs but were based on very small accident counts. NTSB investigators and the authors reviewed all accidents and none thought the SODA condition to be contributory.DISCUSSION: SODA waivers were not associated with increased accident odds except for crop dusting operations. Six specific SODA conditions also had elevated odds of an accident, but there was no evidence they contributed to the accidents. Overall, U.S. pilots with SODA waivers appear to have a satisfactory safety record.Mills WD, Davis JT. U.S. Statement of Demonstrated Ability aeromedical waivers. Aerosp Med Hum Perform. 2019; 90(12):1034–1040.

In the United Kingdom, oil and gas workers have been transported by helicopter to their workplace at offshore installations for more than fifty years. During that time, there have been numerous fatal helicopter accidents. Despite calls from trade unions, families, and politicians, a public inquiry has never been held into offshore helicopter transport. The authors consider whether enough has been done to ensure the safety of these workers to meet legal and ethical standards. They analyze the legal position, the implementation of recommendations made in the wake of these accidents, and the way in which the power imbalance between oil and gas companies and helicopter operators influences safety in this area. They conclude that a public inquiry is required into helicopter safety in the U.K. Continental Shelf area.

INTRODUCTION: The value of aeromedical certification in reducing adverse medical outcomes is an especially important question for this era of increasing flight operations that do not require an FAA medical certificate. The study of this question has previously been thwarted by a lack of information about pilots when their medical certificates are not renewed.METHODS: We matched airmen in the FAA medical certification database to the U.S. Social Security Death Index to identify date of death for deceased pilots. Logistic regression models were used to explore associations of certification data with odds of death while holding a medical certificate and within 4 yr of expiration of a medical certificate.RESULTS: FAA aeromedical waivers were associated with 33% lower odds of death while holding a medical certificate and 35% increased odds of death within 4 yr after expiration of a medical certificate. Denial was associated with 21% increased odds of death in the next 4 yr. Only 13 of 47 medical conditions having significant associations were associated with increased odds of death during certification.DISCUSSION: We found that FAA aeromedical certification reduces the odds of death while holding a medical certificate compared to the 4 yr after certificate expiration. We believe this helps provide a positive answer to the question of whether medical certification reduces medically related events.Mills WD, Greenhaw RM. Association of medical certification factors with all-cause mortality in U.S. aviators. Aerosp Med Hum Perform. 2019; 90(11):938–944.

Diabetes mellitus (DM) could cause pilot incapacitation and result in aviation fatalities. The mechanisms could be directly as a consequence of acute hypoglycemia/subacute diabetic ketoacidosis (DKA) or indirectly as an acute cardiovascular event by contributing to the development of atherosclerosis in coronary or carotid and cerebral arteries. In this study, DM-related fatal flight accidents in the US National Transport Bureau's database between years 2011-2016 were analyzed with special emphasis on postmortem (PM) glucose levels and correlation of toxicological reports with anamnestic information on DM. Additionally, autopsy results on coronary arteries were reviewed. In 43 out of 1491 (similar to 3%) fatal accidents pilots had DM. Postmortem glucose or glycated hemoglobin percentage (Hb1Ac) was measured in 12 of the 43 cases; while antidiabetic medication was found in 14 of the cases (only two of the cases had both glucose measurements and medication). With the increasing prevalence of DM, a possibility of pilot incapacitation due to DM or complications of DM should be actively studied, even if no anamnestic information of DM was available. While PM hypoglycemia is difficult to assess, we propose a systematic investigation based on measurement of glucose, Hb1Ac%, and ketone bodies, and documentation of atherosclerotic lesions in major arteries to identify or rule out DM as a cause of pilot incapacitation.

Background The U.S. Navy's casualty-receiving ships provide remote damage control resuscitation platforms to treat injured combatants deployed afloat and ashore. We report a significant mass casualty incident aboard the USS Bataan, and the most warm fresh whole blood (WFWB) transfused at sea for traumatic hemorrhagic shock since the Vietnam War. Methods Casualty-receiving ships have robust medical capabilities, including a frozen blood bank with packed red blood cells (pRBC) and fresh frozen plasma (FFP). The blood supply can be augmented with WFWB collected from a "walking blood bank." Results Following a helicopter crash, six patients were transported by MV-22 Osprey to the USS Bataan. Patient 1 had a pelvic fracture, was managed with a pelvic binder, and received 4 units of pRBC, 2 units of FFP, and 6 units of WFWB. Patient 2, with a comminuted tibia and fibula fracture, underwent lower extremity four-compartment fasciotomy, and received 4 units of WFWB. Patient 3 underwent several procedures, including left anterior thoracotomy, aortic cross-clamping, exploratory laparotomy, small bowel resection, and tracheostomy. He received 8 units of pRBC, 8 units of FFP, and 28 units of WFWB. Patients 4 and 5 had suspected spine injuries and were managed nonoperatively. Patient 6, with open tibia and fibula fractures, underwent lower extremity four-compartment fasciotomy with tibia external fixation and received 1 unit of WFWB. All patients survived aeromedical evacuation to a role 4 medical facility and subsequent transfer to local hospitals. Conclusion Maritime military mass casualty incidents are challenging, but the U.S. Navy's casualty-receiving ships are ready to perform remote damage control resuscitation at sea. Activation of the ship's walking blood bank to transfuse WFWB is essential for hemostatic resuscitations afloat. Level of evidence Study type: case series, level V.

Aviation and healthcare are complex industries and share many similarities: the cockpit and the operating theater, the captain and the surgeon. While North American commercial aviation currently enjoys a tremendous safety record, it was not always this way. A spike of accidents in 1973 caused 3214 aviation-related fatalities. Over the past 20years, the rate of fatal accidents per million flights fell by a factor of five, while air traffic increased by more than 86%. There have been no fatalities on a U.S. carrier for over 12years. Last year, there were 251,454 deaths in the United States owing to medical error. Pilots pioneered ways to address risks through crew resource management (CRM), and threat and error management (TEM). Both strategies, which are aimed at minimizing risk and optimizing safety, are applicable to surgery and the healthcare industry. These strategies as well as the Swiss Cheese Model, Checklists and the Normalization of Deviance will be reviewed in this article.

The purpose of this study was to describe radiological fracture patterns of the acetabulum sustained after fatal small aircraft aviation accidents, aiming at facilitating a better understanding of trauma mechanisms in a forensic setting. Postmortem conventional radiographs or CT scans of 29 victims of 20 small aircraft aviation accidents were analyzed for skeletal acetabular trauma. Among the 29 fatalities (27 males and 2 females, median age 55 years (range: 21-76 years)), 20 victims had pelvic fractures (69%), of which 19 victims (66%) had one or more acetabular fractures. Bilateral acetabular fractures occurred in 11 victims. When considering left and right acetabula in each victim as separate entities, 38 of the 58 acetabula included in this case series exhibited one or more fractures. Both the anterior and posterior acetabular columns were fractured in 28 acetabula. Acetabular fractures were frequently encountered in this series of 29 victims of small fatal aircraft accidents. Fractures of the acetabulum occur from ventrally directed impact (i.e. to the knee) or laterally directed impact (i.e. to the greater trochanter of the femur). Radiological descriptions of the fracture patterns can therefore aid in the forensic analysis of the mechanism of trauma in aviation accidents. Postmortem multi-slice CT scan images are preferrable in the assessment of acetabular fractures.

Though aviation is practiced in airplanes and anesthesiology in operating rooms, the two professions have substantial parallels. Both require readiness to manage a crisis situation, where lives are at stake, at a moment's notice and with incomplete information. The determinants of quality performance in both professions extend far beyond knowledge base and formal training. The science of human factors, a prominent cornerstone of the aviation industry, has not yet found the same place in medicine, but it could change the understanding and execution of medical decision-making in profound ways. This article reviews specific components of crisis management and root cause analysis in aviation that can serve as models for improving those same aspects within anesthesiology.

Participation rates in extreme sports have grown exponentially in the last 40 yr, often surpassing traditional sporting activities. The purpose of this study was to examine injury rates in foot-launched flying sports, i.e., sports in which a pilot foot-launches into flight with a wing already deployed.This paper is based on a retrospective analysis of the reports of incidents that occurred between 2000 and 2014 among the British Hang Gliding and Paragliding Association members.The majority of the 1411 reported injuries were in the lower limb, followed by the upper limb. The most common lower limb injury was to the ankle and included fractures, sprains, and dislocations. The distribution of injures was different in each discipline. The calculated yearly fatality rate (fatalities/100,000 participants) was 40.4 in hang gliding, 47.1 in paragliding, 61.9 in powered hang gliding and 83.4 in powered paragliding; the overall value for foot-launched flight sports was 43.9.Significant differences in injury rates and injury patterns were found among different sport disciplines that can be useful to steer research on safety, and adopt specific safety rules about flying, protective clothing and safety systems in each of these sports.Feletti F, Aliverti A, Henjum M, Tarabini M, Brymer E. Incidents and injuries in foot-launched flying extreme sports. Aerosp Med Hum Perform. 2017; 88(11):1016-1023.

Introduction: This study compared beta-blockers reported by pilots with the medications found by postmortem toxicology analysis of specimens received from fatal aviation accidents between 1999 and 2015. Several studies have compared drugs using the standard approach: Compare the drug found by toxicology analysis with the drug reported by the pilot. This study uniquely examined first the pilot-reported medication and then compared it to that detected by toxicology analysis. This study will serve two purposes: (1) determine the capability of a toxicology laboratory to detect reported medications, and (2) identify pilots with medications below detectable limits. Method: All information required for this study was extracted from the Toxicology Data Base system and was searched using ToxFlo or SQL Server Management Studio. The following information was collected and analyzed: pilot-reported trade and/or generic drug, date specimens received, time of accident, type of aviation operations (CFR), state, pilot level, age, class of medical, specimen type, specimen concentration, dose reported, frequency reported associated with the accident, quantity reported, National Transportation Safety Board (NTSB) accident event number, and all NTSB reports. Results: There were 319 pilots that either reported taking a beta-blocker or were found to be taking a beta-blocker by postmortem toxicology analysis. Metoprolol and Atenolol were the most commonly found beta-blockers (81%) in this study. Discussion: Time of death, therapeutic concentration, and specimen type were found to be factors in the ability of the laboratory to detect beta-blockers. Dose did not correlate with the ability of the toxicology laboratory to detect the beta-blocker. Conclusions: Beta-blockers taken by pilots will, in most cases, be found by a competent postmortem forensic toxicology laboratory at therapeutic concentrations. The dose taken by the pilot was not found to be a factor in the ability of the laboratory to identify beta-blockers. Time of dose, route of administration, specimen tested, and therapeutic concentration of the drug were found to be factors in the ability of the laboratory to identify beta-blockers in postmortem specimens taken from pilots that died in aviation accidents.

INTRODUCTION General aviation includes all civilian aviation apart from operations involving paid passenger transport. Unfortunately, this category of aviation holds a lackluster safety record, accounting for 94% of civil aviation fatalities. In 2014, of 1143 general aviation accidents, 20% were fatal compared with 0 of 29 airline mishaps in the United States. Herein, research findings over the past 30 yr will be reviewed. Accident risk factors (e.g., adverse weather, geographical region, post-impact fire, gender differences) will be discussed. The review will also summarize the development and implementation of stringent crashworthiness designs with multi-axis dynamic testing and head-injury protection and its impact on mitigating occupant injury severity. The benefits and drawbacks of new technology and human factor considerations associated with increased general aviation automation will be debated. Data on the safety of the aging general aviation population and increased drug usage will also be described. Finally, areas in which general aviation occupant survival could be improved and injury severity mitigated will be discussed with the view of equipping aircraft with 1) crash-resistant fuel tanks to reduce post-impact conflagration; 2) after-market ballistic parachutes for older aircraft; and 3) current generation electronic locator beacons to hasten site access by first responders.Boyd DD. A review of general aviation safety (1984-2017). Aerosp Med Hum Perform. 2017; 88(7):657-664.

We examine whether reporting on violent and terrorist acts committed in July 2016 by persons who, among other characteristics, were suspected to have mental health issues did impact on mental illness stigma, and whether any changes added to changes observed after the Germanwings plane crash in 2015. Three identical online surveys (in 2014, 2015 and 2016) were conducted among persons >15 years old from an established market research panel in Germany (N=2195). Participants answered questions about a woman ("Anne") with either depression or schizophrenia as described in an unlabeled vignette. In the 2016 survey (

Background Currently it is not unusual for general aviation pilots in the United States to continue to fly beyond the age of 70, even into their 80s and 90s. Pilots have regular examinations according to protocols which do not specify special or additional requirements for pilots over 70 yr of age. Additionally, the third class medical reforms passed by the U.S. Senate on 15 July 2016 could potentially result in even less stringent medical certification requirements for general aviation pilots. Methods Accident rates, medical parameters, autopsy findings, and toxicological findings from the U.S. National Transportation Safety Board (NTSB) general aviation (GA) accident database were analyzed to assess potential risk factors with accident outcomes. Results During 2003-2012, there were 114 (113 men, 1 woman) general aviation fatal accidents involving pilots ages 70 to 92 yr. A combination of 3 or more drugs were found in 13 (13%) of deceased pilots. The most frequent drugs were first generation antihistamines and antidepressants represented the next highest proportion of possible performance-affecting medications. Conclusion This study indicates that there are critical medical factors that may contribute to fatal accidents among elderly pilots. Polypharmacy use should be taken into consideration, especially during periodic health examinations and fatal aviation investigations involving elderly pilots.Vuorio A, Asmayawati S, Budowle B, Griffiths R, Strandberg T, Kuoppala J, Sajantila A. General aviation pilots over 70 years old. Aerosp Med Hum Perform. 2017; 88(2):142-145.

In the military or emergency services, operational requirements and/or community expectations often preclude formal prescriptive working time arrangements as a practical means of reducing fatigue-related risk. In these environments, workers sometimes employ adaptive or protective behaviours informally to reduce the risk (i.e. likelihood or consequence) associated with a fatigue-related error. These informal behaviours enable employees to reduce risk while continuing to work while fatigued. In this study, we documented the use of informal protective behaviours in a group of defence aviation personnel including flight crews. Semi-structured interviews were conducted to determine whether and which protective behaviours were used to mitigate fatigue-related error. The 18 participants were from aviation-specific trades and included aircrew (pilots and air-crewman) and aviation maintenance personnel (aeronautical engineers and maintenance personnel). Participants identified 147 ways in which they and/or others act to reduce the likelihood or consequence of a fatigue-related error. These formed seven categories of fatigue-reduction strategies. The two most novel categories are discussed in this paper: task-related and behaviour-based strategies. Broadly speaking, these results indicate that fatigued military flight and maintenance crews use protective 'fatigue-proofing' behaviours to reduce the likelihood and/or consequence of fatigue-related error and were aware of the potential benefits. It is also important to note that these behaviours are not typically part of the formal safety management system. Rather, they have evolved spontaneously as part of the culture around protecting team performance under adverse operating conditions. When compared with previous similar studies, aviation personnel were more readily able to understand the idea of fatigue proofing than those from a fire-fighting background. These differences were thought to reflect different cultural attitudes toward error and formal training using principles of Crew Resource Management and Threat and Error Management.

Background One of the most difficult challenges in aviation medicine is to diagnose, as early as possible, pilots with psychiatric disorders that may impair pilot performance and increase the risk of incidents and accidents. This diagnosis applies particularly to bipolar disorder (BD), where return to flying duty is not an option in the majority of cases. BD is a long-term mental disorder presenting remittent depressive, hypomanic, manic, or mixed episodes between low symptomatic or asymptomatic intermediate periods. Onset in most cases is in late teen or early adult years. Suicidal intentions and suicide risk are significantly elevated in individuals with BD compared to the general population. Methods A systematic literature search was performed of BD and aviation accidents and the National Transportation Safety Board database of fatal general aviation accidents was searched. One case report and two database reports of interest from 1994 to 2014 were identified. Results The findings set a minimum frequency of BD in general aviation fatalities to be approximately 2 out of 8648 (0.023%) in the United States. Discussion The reported incidence may underestimate the real number of BD cases for several reasons, including the fact that the medical history of pilots is not always available or is sometimes not the primary interest of a safety investigation. This study suggests that the demarcation of psychiatric disorder related to fitness to fly is an important step in safety.Vuorio A, Laukkala T, Navathe P, Budowle B, Bor R, Sajantila A. Bipolar disorder in aviation medicine. Aerosp Med Hum Perform. 2017; 88(1):42-47.

Background Otitis externa secondary to irritant or chemical exposure is well documented; however, specifically secondary to jet fuel exposure and its associated toxicology is not. Over 2 million military and civilian personnel per year are occupationally exposed to aviation fuels. Case report An aircraft maintainer presented with noninfectious acute otitis externa secondary to external ear canal exposure to JP-5 jet fuel. Proper exposure guidelines were followed, but it was not realized that the external ear canal was involved. The first symptoms to emerge were vertigo, dizziness, and disequilibrium; however, on physical exam it appeared that there was no middle ear involvement. Discussion Otitis externa normally does not present with vestibular symptoms as the pathology affects the external ear canal dermal tissue. Upon review of JP-5's toxicology profile, dermal absorption is a route of entry and can cause general neurological symptoms, including loss of coordination. This case highlights potential deficiencies in the standardized safety data sheets that are used after exposure. Without mention of possible auricular exposure one may focus on the logical protection of the eyes, mouth, and visible skin. This is concerning due to potential delayed exposure symptoms, dermal absorption, high level of dermal destruction, and the close proximity to the sensory system. The goal of this case report is to improve the knowledge of providers caring for personnel who may be exposed and to suggest possible revisions to the Safety Data Sheets for jet fuel.Long RJ, Charles RA. Aviation fuel exposure resulting in otitis externa with vertigo. Aerosp Med Hum Perform. 2018; 89(7):661-663.

INTRODUCTION: In this article an analysis is made of existing legal provisions and policies regarding medical confidentiality and the use of medical information on pilots, for the reporting of unfit pilots and for accident and incident investigation. An overview is given of the applicable international, European and several national legal frameworks in relation to this question. The applicable national legislation and relating policies of the Netherlands, the U.S., and Canada are compared on this subject. These three States (countries) are selected because of the differences between them in legal provisions when it comes to medical confidentiality of pilots' health information. The article will conclude with tools derived from this analysis, which can be used to find a balance between medical confidentiality vs. aviation safety.Schuite JM. Aviation safety vs. medical confidentiality: disclosure of health information for accident prevention and investigation. Aerosp Med Hum Perform. 2019; 90(10):872-881.