Self-Reporting Mental Illness by Airline Pilots Introduction Mental illness is a widespread, highly stigmatised disorder that affects over half of the population of Australians during their lifetime...

Self-Reporting Mental Illness by Airline Pilots
Abstract: Mental Illness in a pilot can dramatically affect their capabilities of flying a plane. However, due to many factors, mental illness is common in most pilots in Australia. Due to many factors such as homelife, work pressure, etc., the mental health of many pilots is unstable. The study aims to look at some of the responses that Pilots and DAMEs have provided, in order to answer three main research questions. The first question is “What is the current CASA screening process into pilot mental health?”, the second question, “How effective is this process and what can be done to improve it?” and the final question, “What would encourage pilots to seek help for their potential mental health issues”. The methodology was to survey the DAMEs and pilots, and make recommendations based on the survey. The research aims to improve the mental health of the pilots, in order to ensure that pilots with mental illnesses that are serious, get the help they need.
Introduction
Mental illness is a widespread, highly stigmatised disorder that affects over half of the population of Australians during their lifetime (Health Direct, 2016). With up to one in ten people affected by mental illness dying by suicide (Health Direct, 2016), this has massive implications to the aviation industry; an industry based on safety and trust, that a large number of the general population use on a regular basis. In particular regular public transport, more commonly known as airline operations, the general public have little understanding of the process of flight, and put their lives in the hands of professional, clear thinking, and mentally stable pilots to see them safely to their destination. A potential problem exists where the pilot hides an underlying mental health issue from their doctor, family and employer. This problem has been highlighted by events such as Germanwings Flight 9525 of March 2015, in which a pilot utilised a passenger aircraft as a means to commit suicide. In addition to killing many innocent people. A critical factor that led to the accident was the lack of medical information provided to the Germanwings about their pilot’s mental situation, as it was dependent upon self-declaration (BEA, 2016).

The mental health of pilots in Australia is currently assessed by the pilot’s Designated Aviation Medical Examiner (DAME) in an annual medical assessment to gain a Class One medical certificate; a check required to be fit for flight. However, if this medical is not passed then the pilot’s livelihood, lifestyle, income and family could be in jeopardy. The question arises; do pilots fear reporting changes to their mental health or suspicion of mental illness because they fear punitive measures imposed by the government aviation regulator or their employer? Combined with the dominance of pilots being male (McCarthy, Budd & Ison, 2015), and males being only 27% likely to seek help for mental illness (White, 2013), this creates a potential for a massive problem.

With mental health being a very important factor in how a person acts and the decisions they make, this can have a drastic effect on the safety of air travel. Due to society’s negative perception of mental illness, many people already struggle to talk about their feelings for fear that something is wrong with them. Pilots have the added stress of potentially being stood down if they are found to be medically unfit. As a result, there could be added pressure on pilots to appear as if they are coping in their lives to avoid a loss of livelihood, and it may be incredibly difficult for a pilot to come forward and talk to a professional without any punitive actions taking place. It raises the questions: what is the current Australian Civil Aviation Safety Authority (CASA) screening process into pilot mental health? how effective is this process and what can be done to improve it? And what would encourage pilots to seek help for their potential mental health issues? The research aim for this study is to develop an understanding of the process and effectiveness of mental health screening in the aviation industry, and if improvements can be made for pilots to more willingly access professional help if need be.

Literature Review
Mental Illness and Stigma
Healthy, strong minded pilots are critical to the safety within the aviation industry, as they are responsible for countless lives that are flown around Australia, and the world, everyday (CASA, 2017). However, pilots are not immune to mental illness. A study by Wu et. al. (2016) estimated from a survey that as much as 12.6% of airline pilots are vulnerable to developing depression, nearly identical to estimates of US military personnel. Of those pilots, 13.5% had worked in the last week. In comparison, CASA (2018) approximate that one in six (16.7%) will suffer from depression at least once in their life.

There are many types of illnesses that can affect mental health. Some of the major types include; depression, anxiety, schizophrenia, bipolar mood disorder and personality disorder (Department of Health, 2007). Mental illness is commonplace worldwide, with more than an estimated 300 million people affected (World Health Organisation (WHO), 2018). Depression, unlike other mental illnesses, is a serious health condition that can cause work ethic to suffer as well as social exclusion. The World Health Organisation (WHO) (2018) assert that, if left untreated or undiagnosed, depression can lead to suicide, with suicide being the second leading cause of death in 15 - 29 year olds, with an approximated death toll of 800,000 people per year.

However, with mental illnesses being highly stigmatised due to misinformation, prejudice, and discrimination (Beyondblue, 2015), those with mental illness are unlikely to seek treatment due to feelings of shame, guilt, disgrace and embarrassment because of their condition. These conditions may instil feelings of worthlessness and low self-esteem. Stigma exists because many do not fully understand mental illness, and the media can reinforce and sensationalise negative stereotypes, such as people with mental illness being crazy, violent, unpredictable and untreatable (HealthDirect, 2017). Stigma can be both personal and perceived. According to Calear, Griffiths and Christensen (2011), personal stigma refers to an individual's personal thoughts and beliefs about depression. Perceived stigma is the individual's perception of other people’s thoughts and feelings about depression.

Mental Illness in Pilots Studies
Commercial airline pilots are usually seen as being healthier than the general public (Ykes et al., 2012). This is mainly attributed to pilots having the need to undergo annual or biannual medical examinations to obtain a Class 1 medical certificate. However, these medical examinations do not always detect mental illness whether developing or mature within pilots. This can lead to serious issues where pilots begin to feel overwhelmed from stressors at home or from the workload of commercial operations. According to CASA (2018), many stressors of the job have the ability to worsen depressive symptoms, such as time zone changes, fatigue, and remote locations. Having a heavy workload and less than adequate physical exercise can increase the prevalence of common mental disorders by up to 31% (Aerospace Medical Association, 2012). This can result in commercial pilots breaking down and potentially dying from suicide.

From a study on depression and suicide in commercial airline pilots, twenty aircraft assisted suicide cases were analysed. From this analysis, it was found that pilots younger than the age of 40 were five times more likely to use aircraft as a means to commit suicide than those above the age of 40 (Pasha & Stokes, 2018). In a similar study in the US, it was found that though the total number of fatal general aviation accidents has declined, the number of aviation-assisted suicides increased between 1993-2002.  It is also stressed that the suicides were likely triggered by events occurring long after the medical certification process had been completed (Lewis et. al., 2007). This alludes to the possibility of the Class One medical being ineffective due to being completed only once a year.

In another study that analysed the use of SSRI antidepressants in pilot-fatality incidents, it was found that only 7 of 59 (12%) pilots in the study had reported their psychiatric condition. In later medical examination, 6 of the 7 pilots indicated they were free from conditions and reissued medical certificates. (Sen et al., 2007)

In most cases, aircraft assisted suicide only has one fatality being the pilot themselves such as the one that follows; A 54-year-old male pilot was being treated by a psychotherapist for severe depression. At a later date. the pilot had departed an airport in a Cessna 172K and approximately thirty minutes after takeoff, flew straight into a mountain side. The pilot’s therapist told the investigating officers that the pilot had stated, ‘‘If he killed himself, he would do it in a plane” (Lewis et al., 2007). However, as seen in the Germanwings 9525 accident that follows, these suicides do not always end up in one casualty. Instead, these attempts at death can end up with hundreds dead.

Germanwings Flight 9525 and Other Related Incidents
In March of 2015, the co-pilot of Germanwings Flight 9525 may have intentionally locked the captain out of the cockpit and flew the Airbus A320-200 into terrain of the French Alps, killing all 150 people on board. After investigation, it was revealed that the co-pilot had a history of depression and was experiencing a psychotic depressive episode that began the previous year (Pasha & Stokes, 2018).

During August 2008, the co-pilot had started to suffer from severe depressive episodes. He had suicidal thoughts, but during multiple psychiatrist sessions had made numerous “no suicide pacts” (BEA, 2015). The co-pilot had undertaken antidepressant medication between January and July of 2009 and psychotherapeutic treatment from January 2009 until October 2009 (BEA, 2015). His treating psychiatrist stated that the co-pilot had fully recovered in July 2009. There were several sick leave certificates issued by physicians, however, none of them were forwarded to Germanwings (BEA, 2015).
The Germanwings incident, though being the most recent, was not isolated; In 1999, Egyptair Flight 990 crashed into the Atlantic Ocean sixty miles south of Nantucket, USA. The crash was investigated by the American National Transportation Safety Board (NTSB) and believed the cause was likely to have been deliberate actions by the first officer. There were 203 people on board (NTSB, 2002). Similarly, in 1997 Silkair Flight 185 was also suspected to have crashed into terrain due to pilot suicide with 104 people on board. During investigation, it was found that the captain was found to have suffered difficulties at work over the previous six months and had amassed a significant debt (NTSC, 2000). In March 2016, a Qantas pilot was suspected to have hired a Cessna 172 and crashed into the sea off the coast of New South Wales. Despite being the only person on board, the suspected suicide came only a month after passing a Class 1 medical. The pilot was struggling to deal with the breakdown of his marriage (Houghton, 2016).
Though rare, suicides made by commercial airline pilots utilising aircraft are devastating, involving high casualties and resulting in high direct and indirect costs to airlines. The Germanwings incident highlights a lack of action by aviation operators and regulators in assisting the control of mental health among airline pilots.

Changes Made by EASA
Following Germanwings Flight 9525, the European Aviation Safety Agency (EASA) responded by convening a Task Force to analyse the current European Union (EU) method of medical screening. The Task Force issued recommendations in July 2015, including; the implementation of a “two persons in the cockpit” principle, pilot psychological examination prior to employment with airlines, airlines implementing random drug and alcohol screening, pilot support systems, creation of a European aeromedical data repository and a program for oversight of aeromedical examiners (European Commission, 2015). The Task Force also noted that the emphasis on assisting pilots with mental health lies in the medical and psychological assessment of pilots and stated that their report “strives to reach a balance between medical secrecy and safety” (European Commission, 2015).

The two-person occupancy in the cockpit principle was the first of the recommendations that was widely accepted by the aviation community. Though only a recommendation by EASA, many aviation operators were quick to establish this as a standard procedure, as it was seen as the easiest and quickest way to prevent a similar incident to Germanwings Flight 9525 (Neuman, 2015).

In July of 2018 three more of the Task Force’s recommendations were accepted and published as law; European airlines now have to conduct psychological screening pre-employment and pilots for European airlines also have access to a support program. In addition, pilots and cabin crew of European and foreign airlines that fly into EU territories will be subject to alcohol testing. This practice is already done by many European airlines but will be extended to all during the next two years (EASA, 2018).

The massive drawback is that this change has taken three years to implement, and that only four of the six recommendations were accepted and implemented. In addition, the originally recommended drug and alcohol screening program was cut into an alcohol-only screening program.
On top of this, two years on from the Germanwings incident, airlines began to doubt the effectiveness of the two-person cockpit occupancy procedure. They believe it creates as much risk as it mitigates, and some scrapped the practice altogether (Bryan, 2017).

Current Australian Mental Illness Screening (Sheridyn Armstrong)
In Australia, CASA had recommended a two-person cockpit occupancy rule immediately following Germanwings Flight 9525. It was specifically implemented in commercial aircraft seating more than fifty passengers. However, after a review in 2018, CASA had recommended air operators make their own safety evaluation on the practice (CASA, 2018). Essentially, CASA is leaving it up to the airlines to make their own decision on whether or not it is a safer practice.
The current Australian method of mental illness screening for pilots lies within the annual renewal of the Class One medical; without passing this medical, a pilot cannot legally fly in a commercial operation. This system has been updated within the last few years to make the process quicker for DAMEs by converting the process to an online portal. The pilot fills in their medical history in CASA’s online Medical Record System (MRS) (CASA, 2018) before seeing the DAME. This shortens the Class One medical application and renewal process by asking basic medical history questions prior to the appointment.

The extent to which mental illness is covered within the MRS is limited. It has a section for “mood” and within this it questions for common symptoms of mental illness such as anxiety, panic attacks, hallucinations, psychotic episodes and asks for any history of bipolar disorder and...