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How Risk Based Decision Making Helps Us Help You

Source:, By James Fraser, M.D. Federal Air Surgeon

If you’ve been following these pages, you’re probably aware of my long standing goal to get as many airmen as possible safely into the air. When I first became the Federal Air Surgeon, I set an ambitious goal of having 95 percent of airmen leave the Aviation Medical Examiner’s (AME) office with a medical certificate in hand. Historically, that number had been around 90 percent. I’m excited to report that as we closed out fiscal year 2016, we achieved a result of 97.7 percent of airmen walking out with a medical certificate in hand. This is tantalizingly close to my dream goal of 98 percent.

How Did We Get Here?

One of the things that helped push us so close to our goal was the use of Risk Based Decision Making (RBDM). RBDM, when applied to medical certification, allows us to look at where there is risk in our system and determine how we might be able to mitigate it. We started by looking at deferred airmen with specific conditions and cross-referencing that information with accident and incident data. In many cases, we found no relationship between the two.

Based on this information we made a decision, using RBDM, to focus more on conditions that could cause sudden or subtle incapacitation instead of general health threats. While your AME could still note these general health conditions, they wouldn’t be grounds for deferral. We also began to rewrite the AME Guide to leverage the experience of our AMEs and allow them greater freedom to issue certificates without FAA intervention. Some of the changes to our AME Guide and procedures included the Conditions AMEs Can Issue (CACI) and AME Assisted Special Issuance (AASI) programs, which both give AMEs more tools to prevent deferrals.

We also learned to apply mitigating strategies that allow us to issue certificates that previously would not have been possible. Sometimes those mitigations are part of our Special Issuance (SI) process and other times they are through our normal certification process (i.e., CACI). In the case of SI, one of those mitigations is shorter duration certificates (one year as opposed to two). Other mitigations might be a requirement for additional information or tests, or some other strategy that we can use to reduce that risk. This could apply to either process.

How Are We Moving Forward?

When we started the process of updating the AME Guide, we knew it would be an uphill task. Our goal was to make as much of the AME Guide as accessible as possible not only to our AMEs, but also to airmen. This process is continuous. It will never end, nor should it. As technology, medicine, and treatments advance, we will have more opportunities to certificate even more airmen.

One area we’ve opened up more recently is depression. It wasn’t long ago that depression was a condition we didn’t certify. After much consideration and research, we have developed procedures that allow some pilots receiving certain treatments to be certificated under specific conditions. That’s a huge step, one that wouldn’t be possible without RBDM.

We realize that sometimes these risk mitigation strategies can seem onerous or difficult to comply with. One of the most frequent complaints is that insurance won’t cover the test you want at the time you want it. We do understand that these tests can be expensive. Overall, we have reduced the number of tests we require, and we will continue to look for such opportunities.

The reality is that there will still be times when some tests are required. In that case, please work with us and your AME to see how we can resolve the issue. Maybe we can use a different test or move the timing to better align with insurance requirements. If we can find a way to mitigate that risk, we can probably work it out.


As these pages go to press (Jan/Feb 2017), I will be retiring from the FAA. I want to take this opportunity to say what an honor it has been to serve as your Federal Air Surgeon. I also want to thank those who took the time to write or attend one of my presentations. Your feedback has been an important part of getting us so far in our goal of certificating as many airmen as safely possible.

James Fraser received a B.A., M.D., and M.P.H. from the University of Oklahoma. He completed a thirty year Navy career and retired as a Captain (O6) in January 2004. He is certified in the specialties of Preventive Medicine (Aerospace Medicine) and Family Practice. He is a Fellow of the Aerospace Medical Association and the American Academy of Family Practice.

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