Health Promotion Amendment (Amendment 173 to Annex 1)

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1 Health Promotion Amendment (Amendment 173 to Annex 1) Dr Ansa Jordaan Chief, Aviation Medicine Section, ICAO Lima/ September 2016

2 Overview Old recommendations Rationale for change New amendment Amendment Process State Comments International Organizations Comments ICAO Secretariat comments ANC (Air Navigation Commission) discussion ICAO timeline for implementation Implementation Task list for States

3 Old Recommendations Recommendation. In alternate years, for Class 1 applicants under 40 years of age, the Licensing Authority should, at its discretion, allow medical examiners to omit certain routine examination items related to the assessment of physical fitness, whilst increasing the emphasis on health education and prevention of ill health. Note. Guidance for Licensing Authorities wishing to reduce the emphasis on detection of physical disease, whilst increasing the emphasis on health education and prevention of ill health in applicants under 40 years of age, is contained in the Manual of Civil Aviation Medicine (Doc 8984). Problem: Not implemented, overly prescriptive

4 Old recommendations Recommendation. From 18 November 2010 States should apply, as part of their State safety programme, basic safety management principles to the medical assessment process of licence holders, that as a minimum include: a) routine analysis of in-flight incapacitation events and medical findings during medical assessments to identify areas of increased medical risk; and b) continuous re-evaluation of the medical assessment process to concentrate on identified areas of increased medical risk. Problem: Not implemented, no guidance?

5 Reasons for change Recommendations not implemented Medical assessment reactive and not pro-active No synergy between medical assessment process and aviation safety risk management process Studies have shown that certain medical conditions in the general population can be prevented or delayed by lifestyle changes Health promotion activities have been proven to be effective in improving health By applying basic safety management principles to the medical assessment process, the prevalence of medical conditions in license holders can be reduced This will in turn improve flight safety

6 Amendment scope Upgrade of existing Recommendation to a Standard Applying basic safety management principles to the medical assessment process

7 Upgrading Standard to a Recommendation Recommendation. From 18 November 2010 States should shall apply, as part of their State safety programme, basic safety management principles to the medical assessment process of licence holders, that as a minimum include: a) routine analysis of in-flight incapacitation events and medical findings during medical assessments to identify areas of increased medical risk; and b) continuous re-evaluation of the medical assessment process to concentrate on identified areas of increased medical risk. Rationale: Raise from Recommendation to Standard safety management principle mature, acceptable to States and will align medical assessment process to safety management process

8 Amendment scope Deletion of a Recommendation In alternate years for class 1 applicants under the age of 40 years increase emphasis on health education Replaced with a Standard Implement aviation-related health promotion for all licence holders subject to a Medical Assessment

9 Deletion of recommendation Recommendation. In alternate years, for Class 1 applicants under 40 years of age, the Licensing Authority should, at its discretion, allow medical examiners to omit certain routine examination items related to the assessment of physical fitness, whilst increasing the emphasis on health education and prevention of ill health. Note. Guidance for Licensing Authorities wishing to reduce the emphasis on detection of physical disease, whilst increasing the emphasis on health education and prevention of ill health in applicants under 40 years of age, is contained in the Manual of Civil Aviation Medicine (Doc 8984).

10 Replacement with a Standard The Licensing Authority shall implement appropriate aviation-related health promotion for licence holders subject to a Medical Assessment to reduce future medical risks to flight safety. Note 1. Standard indicates how appropriate topics for health promotion activities may be determined. Note 2. Guidance on the subject is contained in the Manual of Civil Aviation Medicine (Doc 8984). Note 3. Guidance on the relationship between the Licensing Authority and the implementation of Medical Assessment for licence holders is contained in the Manual of Procedures for Establishment and Management of a State s Personnel Licensing System (Doc 9379). Rationale: Health promotion principles and safety promotion principles aligned. Topics of health promotion material informed by analysis of incapacitation events and medical findings

11 Amendment process: Proposal origin

12 Amendment process: Proposal development

13 Amendment process: Preliminary review

14 Amendment process: Proposal origin

15 Amendment process Date Action 8 10 Oct 2014 Meeting MPSG 9 June 2015 Initial review ANC (Air Navigation Commission) 17 July 2015 State Letter sent to States 1 Oct 2015 Deadline for comments 12 Nov 2015 Final review ANC (including 65 replies) 12 Jan 2016 Approved by ANC 22 Feb 2016 Adopted by ICAO Council 17 March 2016 State Letter sent to States 11 July 2016 Effective date 8 Nov 2018 Applicable date

16 States comments National joint monitoring arrangement may be introduced with enhanced cooperation between the Licensing Authorities (LA) and accredited medical bodies Focus on overall human factors with pilot training on risk factors in addition to raising awareness during their medical check-ups Should be applicable as from 10 November 2016 Shortages of staffing in LA and thus concerned about additional efforts required

17 State comments Recommend an implementation period of 5 years to allow for Licensing Authorities to adapt to the new Standard Guidance material to be better explained in Manual of Civil Aviation Medicine Difficult to measure the effects of health promotion May prove not to be effective Lack of significant cost-benefit analysis

18 State comments Health promotion in aviation safety should not be a government task; these measures are in the interest of insurance companies and employers Support applicable date of Nov 2018 for (applying SMS principles and gathering data) Introductory phase of at least 5 years to be provided for implementation of (health promotion) Should focus exclusively on commercial pilots

19 State comments May have additional resource and training implications Suggest passing responsibility to operators or the State s public Health Agency Flexibility is crucial in implementing the standards A proactive approach with increased emphasis on prevention promotes better collaboration and engagement of all parties

20 International Organizations comments Health promotion will likely enhance flight safety Guidance materials to be developed to avoid potential misinterpretation and misuse of the amendment Results to be monitored in a scientific way

21 International Organizations comments ICAO to consider establishing a group tasked with developing guidance, knowledge and methodology Wording of guidance material to be explicit about the intent being promotional in nature and not a preamble to further testing of aircrews

22 ICAO Secretariat Comments Current system does not accurately identify a notable proportion with significant medical condition at the time of examination It would be preferable to prevent such conditions arising in the first place Several conditions of aeromedical significance have been demonstrated to be amenable to prevention

23 ICAO Secretariat Comments Some examiners and States are already applying health promotion, but it is not applied as a systematic approach Health promotion is in keeping with safety promotion principles Health promotion with potential improvement in health will benefit flight safety in all areas

24 ICAO Secretariat Comments Intention is to provide promotional material and not increase test requirements Intention is not to recommend additional treatment, unless the DAME is also the applicant s regular treating physician Licensing Authority is responsibility for continuous improvement in flight safety and to reduce aeromedical component of risk LA responsible for flight safety in general, thus applicable to all license holders requiring a medical assessment

25 ICAO Secretariat Comments Flexible performance-based approach advised to make it possible for states to use: Phased-in stepwise approach taking into account resources and costs Proportionate approach allowing more emphasis to be placed on particular groups of licence holders e.g. commercial pilots Collaborative approach encouraging LA to collaborate with operators, licence holder representative bodies, public health authorities etc. Need not involve the medical examiner if State prefers to adopt an alternative approach

26 ICAO Secretariat Comments Monitoring and effectiveness of standard Tracking changes to risk indices e.g. monitoring BMI of a group of licence holders over a period of time ICAO survey 5 years after implementation

27 ANC discussion Amendments Clearly define that is triggered and defined by A monitoring process to be established with consideration for the best strategy for oversight of the Standard Application All license holders requiring to hold a medical assessment Applicability date November 2018 Due to flexible approach being implemented Feasible only if guidance material are available before 2018

28 ANC discussion Guidance material Updated and completed by December 2016 (English) Updated and completed by July 2017 (all 6 official languages) in keeping with Annex 19 amendments Liaise with States and organizations in development of guidance material

29 ANC discussion Guidance material Future USOAP CMA audits and protocol questions to be based on guidance material Training, education, communication and reporting to be taken into account when developing guidance material Include strategy for monitoring and oversight of the Standards

30 Implementation Task List for States Conduct gap analysis of implementation of current Recommended Practices (Annex 1, paragraphs and ) Review current health promotion activities (if any) by LA Consider current health promotion activities (if any) by other relevant entities e.g. operators, licence holder representative bodies Review ICAO guidance material (available 2017) on health promotion

31 Implementation Task List for States Consult with other relevant entities to develop a strategy and priority areas Develop a plan to incorporate the amendment as part of safety promotion activities of the State Safety Programme that includes an analysis on the effectiveness of implemented activities Be prepared to report to ICAO in response to a questionnaire, to be distributed no earlier than five years after the applicability date, concerning the methods of implementation of the provisions, the challenges faced and their effectiveness or anticipated effectiveness

32 ICAO Timeline of implementation Date Action Venue April 2016 Introduction of Standard Formation of Advisory Workgroup to assist with development of guidance material & tools AsMA, Atlantic City Sept 2016 Discussion of interim guidance material & tools ECAM, Norway Nov 2016 Discussion of interim guidance material & tools ICASM, Delhi Dec 2016 May 2017 July 2017 Guidance material available in English Progress report on implementation of guidance material & tools Guidance material translation in all languages AsMA, Denver Oct 2017 Progress report on implementation and challenges ICASM, Rome

33 ICAO Timeline of implementation Date Action Venue Nov 2017 Consultation with States to assist with incorporation of amendment in State Safety Programme May 2018 Workshop to develop draft protocol questions AsMA June 2018 Consultation with States on protocol questions Oct 2018 Introduction of protocol questions ICASM Nov 2018 Nov 2023 Applicability date Ongoing monitoring - International Aerospace Medicine Conferences Ongoing availability of ICAO and workgroup to assist with implementation challenges Survey distribution to States to determine impact AsMA, ICASM, ECAM

34 State letter Published 3 August 2016 Completion of Health Promotion Questionnaire by 14 October 2016 Nomination of a medical focal point for states Will assist with finalization of guidance material and implementation in a harmonized and gradual manner

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