Dames Guide

Department / Division: Aviation Safety Operations
Document Owner: E:ASO
Name of Document: GUIDE FOR MEDICAL EXAMINERS
Table of Contents
1. AUTHORISATION ...................................................................................................... 6
2. RECORD OF AMENDMENTS ....................................................................................... 7
3. LIST OF EFFECTIVE PAGES ....................................................................................... 8
4. LIST OF DEFINITIONS AND ABBREVIATIONS USED IN THIS DOCUMENT .......................... 9
4.1. Definitions ................................................................................................................ 9
4.2. Abbreviations .......................................................................................................... 17
5. REFERENCE DOCUMENTS (check name the manuals ) ................................................. 18
5.1. FOREWORD .......................................................................................................... 19
5.2. LEGAL RESPONSIBILITIES OF DESIGNATED AVIATION MEDICAL EXAMINERS ................ 21
5.3. IMPLEMENTATION OF THE EMPIC MEDICAL MODULE ................................................. 24
6. SECTION 1 ............................................................................................................ 27
6.1. International Civil Aviation Organisation ......................................................................... 27
6.1.1. Definition of ICAO Standards and Recommended Practices Standards ................................. 27
6.1.2. History of aviation medicine ........................................................................................ 27
6.1.3. Safety management .................................................................................................. 28
6.2. Basis for Regulatory Aeromedical Decision Making .......................................................... 29
6.3. Acceptable Aeromedical Risk ...................................................................................... 30
6.4. Contribution to Aviation Safety of Medical Examinations .................................................... 30
6.5. Stringent Medical Requirements .................................................................................. 31
6.6. Safety Management as a Way Forward ......................................................................... 31
6.6.1. Information from routine medical examinations ................................................................ 33
6.6.2. Reporting of medical conditions ................................................................................... 33
6.7. Conclusions ............................................................................................................ 37
6.8. Mental Health and Behavioural Questions for Use by Medical Examiners .............................. 38
6.9. Flexibility in the Application of Medical Requirements ....................................................... 43
6.9.1. The Exercise of Flexibility ........................................................................................... 43
6.9.2. The terms “waiver” and “flexibility” ................................................................................ 44
6.9.3. Medical Practical Flight Test and Medical Deficiency Compensation and Flight Safety .............. 44
6.10. Flight Crew Incapacitation .......................................................................................... 45
6.10.1. Controlling the risk of pilot incapacitation ....................................................................... 45
6.10.2. Causes of Incapacitation ............................................................................................ 46
6.10.3. Pilot Incapacitation Training ........................................................................................ 47
6.10.4. “Two communications” rule ......................................................................................... 48
6.10.5. Cognitive incapacitation ............................................................................................. 48
6.10.6. “Fail-Safe Crew”....................................................................................................... 49
6.11. Crew Resource Management ...................................................................................... 50
6.12. Evidence-Based Decision Making ................................................................................ 50
6.13. Conclusions ............................................................................................................ 51
6.14. The 1% Rule ........................................................................................................... 51
6.15. Licence Limitations ................................................................................................... 52
7. SECTION 2 ............................................................................................................ 53
7.1. History of Aviation Medicine in South Africa .................................................................... 53
7.2. Establishment and Management of the SACAA ............................................................... 54
7.3. Targeted Medical Standards ....................................................................................... 55
7.4. Aeromedical Committee of the Civil Aviation Authority (ICAO Flexibility) ................................ 55
7.4.1. Composition and appointment of the Aeromedical Committee ............................................. 56
DAMES GUIDE Revision March 2023 Page 2 of 303
7.4.2. Responsibilities of the Aeromedical Committee and dates of the meetings ............................. 56
7.5. Designated Aviation Medical Examiners ........................................................................ 56
8. SECTION 3 ............................................................................................................ 56
8.1. Designation of Aviation Medical Examiners .................................................................... 56
8.1.1. Designated junior aviation medical examiner................................................................... 57
8.1.2. Designated aviation medical examiner .......................................................................... 57
8.1.3. Designated Senior Aviation Medical Examiner ................................................................ 57
9.3.1.1 Designation ............................................................................................................ 59
9.3.1.2 Termination of designation ......................................................................................... 59
9.3.1.3 Responsibilities of designated medical examiners ............................................................ 59
9.3.1.4 Selection and retention of DAMEs ................................................................................ 59
9.3.1.5 Criteria for designation .............................................................................................. 60
9.3.1.6 Procedures for renewing designations ........................................................................... 63
9.3.1.7 Procedures for terminating or not renewing designations. .................................................. 63
9.3.1.8 Fees related to designation. ........................................................................................ 64
9.4 Legal Issues ........................................................................................................... 64
9.4.1 Confidentiality of information ....................................................................................... 64
9.4.2 Training of Medical Examiners .................................................................................... 65
9.4.3 Examination of South African Pilot in Foreign Countries .................................................... 65
9.4.4 Certification Process of Medical Examinations ................................................................ 66
9.4.5 Summary of Requirements for Designated Aviation Medical Examiners ................................ 66
9.5 Civil Aviation Regulations 67 ....................................................................................... 67
9.5.1 Part 67: Medical certification ....................................................................................... 67
9. Applicability 67.00.1 .................................................................................................. 67
9.1. Functions of Director regarding medical examinations 67.00.3 ............................................ 69
9.2. 67.00.4: Designation of aviation medical examiners .......................................................... 71
9.3. 67.00.5 Class 4 medical certificates .............................................................................. 71
9.4. Period of validity of medical certificates 67.00.6 ............................................................... 72
9.5. Application for Medical Certificate 67.00.7 ..................................................................... 74
9.6. Duties of holder of medical certificate 67.00.9 ................................................................. 75
9.7. Validations 67.00.10 ................................................................................................. 76
9.8. Foreign Medical Examinations (check) .......................................................................... 78
9.9. Period of validity of medical records 67.00.12 ................................................................. 78
9.10. Substance Abuse 67.00.13 ......................................................................................... 78
9.11. Suspension or cancellation of medical certificate 67.00.14 ................................................. 80
9.12. Medical Confidentiality 67.00.15 .................................................................................. 80
9.13. Class I medical certificates: Physical and mental standards ................................................ 85
9.14. Class II medical certificates ........................................................................................ 87
9.15. Class III medical certificates........................................................................................ 88
9.16. Visual standards ...................................................................................................... 91
9.16.1. Class I medical certificates ......................................................................................... 91
9.16.2. Class II Medical Certificates ........................................................................................ 95
9.16.3. Class III medical certificates........................................................................................ 98
9.16.4. Class I medical certificate ......................................................................................... 101
10. SECTION 4: TECHNICAL STANDARDS (MEDICAL PROTOCOLS) .................................. 108
10.1. Neurological or Neuropsychological Protocols ............................................................... 108
10.2. Cardiovascular Protocols ......................................................................................... 108

10.3. Respiratory Protocols .............................................................................................. 109

10.4. Endocrinology ....................................................................................................... 109
10.5. Oncology ............................................................................................................. 109
10.6. Psychiatry ............................................................................................................ 110
10.7. Others ................................................................................................................. 110
11. SECTION 5 .......................................................................................................... 110
11.1. Epilepsy ............................................................................................................... 110
11.1.1. Epilepsy for Cabin Crew .......................................................................................... 111
11.1.2. Benign Rolandic Epilepsy of childhood ........................................................................ 112
11.1.3. Single Seizure ....................................................................................................... 114
11.1.4. General information in relation to classification of seizures ............................................... 114
11.1.5. Risk factors for developing a Second Seizure or Epilepsy ................................................ 114
11.1.6. Follow-Up Requirements .......................................................................................... 115
11.2. Migraines ............................................................................................................. 116
11.2.1. Classification of migraines ........................................................................................ 116
11.2.2. Cluster Headache .................................................................................................. 117
11.2.3. Mild Head Injury or Traumatic Brain Injury (TBI)............................................................. 118
11.2.4. Moderate head injury or traumatic brain injury (TBI) ........................................................ 119
11.2.5. Severe head injury or traumatic brain injury (TBI) ........................................................... 120
11.2.6. Post-Traumatic Syndrome (Concussion) ...................................................................... 121
11.2.7. Syncope .............................................................................................................. 121
11.2.8. Transient Memory Loss or Global Amnesia .................................................................. 122
11.2.9. Brain Tumours ....................................................................................................... 122
11.2.10. Brain abscess ....................................................................................................... 125
11.2.11. Neurosyphilis ........................................................................................................ 126
11.2.12. Dementia ............................................................................................................. 126
11.2.13. Stroke ................................................................................................................. 126
11.2.14. Parkinson’s Disease ............................................................................................... 128
11.2.15. Protocols on hypertension ........................................................................................ 144
Moderate/severe Hypertension ................................................................................................. 145
11.2.15. Cardiovascular Risk Assessment ............................................................................... 146
11.2.16. Coronary Artery Disease Protocol .............................................................................. 149
PROTOCOLS FOR THE RESPIRATORY SYSTEM ...................................................................... 153
Protocol on Asthma ............................................................................................................... 153
Protocol on Pneumothorax ...................................................................................................... 154
Tuberculosis ........................................................................................................................ 161
Endocrinology System............................................................................................................ 161
Type 2 Diabetes Mellitus......................................................................................................... 161
11.2.17. Protocol on diagnosed Addison’s disease. ................................................................... 177
Oncology Protocols ............................................................................................................... 179
11.2.18. Aeromedical consideration ....................................................................................... 179
11.2.19. Protocol for specific cancers ..................................................................................... 181
Kidney Diseases ................................................................................................................... 195
HIV/AIDS PROTOCOL-Class 1,2 & 3 ........................................................................................ 196
Protocol for Obstetrics and Gynaecology .................................................................................... 203
Protocol on Warfarin Anticoagulant Drug .................................................................................... 207
11.3. Bone Marrow Protocol ............................................................................................. 210

11.4. Protocol on Plavix Prescription Drug ........................................................................... 211

11.5. Protocol on Mood Disorder (Depressions) .................................................................... 212
11.6. Protocol on Rheumatoid Arthritis ................................................................................ 215
11.7. Protocol on Coagulation and Thrombotic Disorders ........................................................ 215
11.8. Monocular/Amblyopic Protocol .................................................................................. 216
11.9. Colour Vision Protocol ............................................................................................. 216
11.10. Substance Abuse ................................................................................................... 222
12. Class VI Medical Standards-Protocols -Cabin Crew and Recreational Pilots ......................... 246
13. HIV/AIDS Protocol for Cabin Crew and Recreational pilot ................................................ 268
14. Pharmacology-Acceptable Medication ......................................................................... 270
15 Guidelines……………………...…………….……………………………………………….. 270
16 List of medication…………………………………………………………………………….. 271
17 History section on the examination …………………………………………………………296
18 Practical flight Test……………………………………………………………………………301
19 END…………………………………………………………………………………………….303

1. AUTHORISATION
This DAMEs Guide is a living document. In the event of development in, or an amendment to, the scope and
functions of this DAMEs, or developments in the aviation industry that necessitate changes, changes must be
made, and this guide must be amended. Everyone affected by this manual is encouraged to propose ideas
and changes to this document for general improvement, both in terms of the content and the professional
execution of their duties.
Compile By Senior Manager: AVMED

Name in Block Letters L. BOGATSU
Signature Date 24th March 2023
Approved by Executive: Acting Air Safety Operations

Name in Block Letters MR ERIC MATABA
Signature Date 24th March 2023

2. RECORD OF AMENDMENTS
(All amendments to this Manual must be made in accordance with GP002 which contains the Manual
Amendment Procedure see GP002c)
Amendment Approved By:

Pages Affected Date Amended Signature
Number Name
March 2023 Dr.Bogatsu

3. LIST OF EFFECTIVE PAGES
Revision No.: Original
Column 1 Column 2
* PAGE REVISION DATED * PAGE REVISION DATED
*Indicates page revised, added, or deleted by this revision. Column 2 should be completed only when column 1 is full.

4. LIST OF DEFINITIONS AND ABBREVIATIONS USED IN THIS DOCUMENT

4.1. Definitions
TERMINOLOGY DESCRIPTION
Ab initio When referring to flight training, means the practical training required towards
the first issue of a national pilot’s licence or PPL, issued in terms of Part 61 or
Part 62 of the Civil Aviation Regulations, or for the endorsement of such a
licence with an additional category of aircraft, and for the purpose of regulation
91.02.3, which excludes cross-country flight training
Accredited medical Means the conclusion reached by one or more medical experts that is
conclusion acceptable to the Director for the purposes of the case concerned, in
consultation with flight operations or other experts as necessary
Advisor Means a person designated by the Director in terms of Regulation 12.01.7
Aerial work Means an aircraft operation in which an aircraft is used for specialized services
as determined by the Director, such as:
a) agricultural spraying, seeding, and dusting.
b) cloud spraying, seeding, and dusting.
c) culling.
d) construction.
e) aerial harvesting.
f) aerial patrol, observation, and survey.
g) aerial advertisement, including banner towing and other towing of
objects.
h) search and rescue.
i) parachuting.
j) aerial recording by photographic or electronic means.
k) fire spotting, control and fighting; and
l) spraying, seeding, or dusting other than for agricultural purposes and
clouds
Aerobatic flight Means manoeuvres intentionally performed by the pilot-in-command (PIC) of
an aircraft and involving an abrupt change in the attitude of the aircraft, an

abnormal attitude, or an abnormal variation in speed, which is not necessary

for normal flight
Aerodrome control service Means an air traffic control service provided for the control of aerodrome traffic
Aerodrome control tower Means an air traffic control unit established to provide an air traffic control
service to aerodrome traffic
Aeronautical Information Means a circular containing information which does not qualify for the
Circular origination of a Notice to Airmen (NOTAM) or for inclusion in the Aeronautical
Information Publication (AIP) issued by the Director in terms of Regulation
11.01.2
Air ambulance Means an aircraft used for the purposes of transporting a patient, or a person
for whom there can be reasonable expectations that they will require medical
attention during the transportation, and equipped in accordance with the
provisions of Part 138 of the Civil Aviation Regulations
Air traffic service assistant Means the holder of an air traffic service licence and rating who provides:
a) assistant services to an air traffic controller; or
b) co-ordination services, clearance delivery services, flight information
services or aerodrome flight information services
Aviation recreation Means flying of a microlight, glider, balloon, gyroplane, hang glider, paraglider,
model aircraft, light sport aeroplane, touring motor glider, or parachute, or
involvement in aviation events
Adulteration Means any process by which an individual knowingly interferes with (or
attempts to interfere with) the processes of specimen collection, transport or
analysis with the intention of avoiding a legitimate test result. The actions
undertaken can include (but are not limited to) the addition of water or foreign
substances to the specimen, specimen substitution, damaging bottle seals or
packaging and the deliberate consumption of interfering substances or copious
volumes of water prior to specimen collection
Aliquot Means a fractional part of a specimen (taken as a sample representing the
whole specimen) used for testing;
Authorising scientist Means a person who reviews all pertinent data and quality control results in
order to attest to the validity of the laboratory's test reports. This person may

also function as the Toxicologist (see under Toxicologist)

Calibrator Means a solution of known concentration used to calibrate a measurement
procedure or to compare the response obtained with the response of a test
sample/unknown sample. The concentration of the analyte of interest in the
calibrator is known within limits ascertained during its preparation. Calibrators
may be used as single point measurements or to establish a calibration curve
over a range of interest
Chain of custody Refers to procedures to account for each specimen by tracking its handling
and storage from the point of collection to final disposal. These procedures
require that the donor identity be confirmed and that a chain of custody form is
used from the time of collection to receipt by the laboratory. Within the
laboratory appropriate chain of custody records must account for the samples
until disposal
Chain of custody form Means a form used to document the procedures from the time of collection
until receipt by the laboratory
Cabin crew member Means a crew member licensed in terms of Part 64 of the Civil Aviation
Regulations who performs, in the interest of the safety of passengers, duties
assigned by the operator or the PIC of the aircraft, but who shall not act as a
flight crew member
Cargo aircraft Means any aircraft, other than a passenger aircraft, which is carrying goods or
property
Collection cup Refers to a single-use container, made of plastic, large enough to easily catch
and hold at least 55 mL of urine voided from the body. Must be individually
wrapped in a sealed plastic bag or shrink wrapping, or must have a peelable,
sealed lid or other easily visible tamper-evident system
Collecting officer Means a person trained to collect specimens from donors
Collection site Means a place where individuals present themselves for the purpose of
providing a specimen for subsequent analysis
Confirmation test Means an analytical procedure to identify and quantify the presence of a
specific drug or analyte which is independent of the initial test, and which uses
a different technique and chemical principle from that of the screen test in

order to ensure reliability and accuracy

Cut-off Means a concentration level set to determine whether the sample is positive or
negative for the presence of a drug
Customer Means the organisation requesting the drug testing service
Donor Means the individual from whom a specimen is collected
Critical phases of flight Includes all ground operations involving taxi, take-off, climb to cruise up to 10
000 feet and approach from cruise below 10 000 feet
Commercial air transport Means the provider of a commercial air transport operation
operator
Co-pilot Means a licensed, type-rated pilot required by the Regulations to serve in any
piloting capacity other than as PIC, but excluding a pilot who is on board the
aircraft for the purpose of receiving flight instruction
Designated Aviation Medical Means an aviation medical examiner designated by the Director in terms of
Examiner (DAME) Regulation 67.00.4
Enforcement Officer Means an authorised officer, inspector, or authorised person
Fatigue A physiological state of reduced mental or physical performance capability
resulting from sleep loss or extended wakefulness, circadian phase, or
workload (mental and/or physical activity) that can impair a crew member’s
alertness and ability to safely operate an aircraft or perform safety-related
duties
Flight crew member A licensed crew member charged with duties essential to the operation of an
aircraft during flight time
Flight time – aeroplanes The total time from the moment an aeroplane first moves for the purpose of
taking off until the moment it finally comes to rest at the end of the flight.
Note: Flight time as defined here is synonymous with the term “block to block”
time or “chock to chock” time in general usage, which is measured from the
time an aeroplane first moves for the purpose of taking off until it finally stops
at the end of the flight
Flight time – helicopters The total time from the moment a helicopter’s rotor blades start turning until the
moment the helicopter finally comes to rest at the end of the flight, and the
rotor blades are stopped

General aviation operation Means an aircraft operation other than a commercial air transport, corporate
aviation, air ambulance or aerial work operation
Glider Means a heavier-than-air aircraft, other than a hang-glider, that is supported in
flight by the dynamic reaction of the air against its fixed, lifting surfaces, and
whereof free flight does not depend on an engine
Gyroglider Means a non-power-driven heavier-than-air aircraft, supported in flight by the
reactions of the air on one or more rotors rotating freely on substantially
vertical axes
Gyroplane Means a power-driven heavier-than-air aircraft, supported in flight by the
reactions of the air on one or more rotors rotating freely on substantially
vertical axes
Hang glider Means a non-power-driven heavier-than-air aircraft capable of being carried,
foot launched, and landed solely by the energy and use of the pilot’s legs,
having:
• a rigid primary structure with pilot weight shift as the primary method of
control; or
• a rigid primary structure with movable aerodynamic surfaces as the
primary method of control in at least two axes,
and which, for the purposes of Parts 24, 94 and 96 of the Civil Aviation
Regulations, includes a powered hang glider
Helicopter Means a heavier-than-air aircraft supported in flight mainly by the reactions of
the air on one or more power-driven rotors on substantially vertical axes
Human factors principles Means the principles which apply to aeronautical design, certification, training,
operations, and maintenance of aircraft, and which seek safe interface
between the human and other system components by proper consideration of
human performance
Human performance Means the capabilities and limitations of a human being that have an impact on
the safety and efficiency of aeronautical operations and services
Medical assessor Means a physician, qualified and experienced in the practice of aviation
medicine, who evaluates medical reports submitted to the Authority by medical
examiners.

Note 1: Medical assessors evaluate medical reports submitted to the Licensing

Authority by medical examiners.
Note 2: Medical assessors are expected to maintain the currency of their
professional knowledge
Medical service provider Means the person, associated with an air ambulance operator for the purposes
of taking responsibility for the medical aspects of the operation and who is
subject to the legislation administered by the Department of Health
Micro-light aeroplane Means an aeroplane of which the minimum flying speed and the maximum
take-off mass have been restricted for classification purposes. The values of
these restrictions are defined in Document SA-CATS 24
Laboratory Means the facility that is approved by the South African National Accreditation
Standard (SANAS) providing the analytical services for detecting abuse of
drugs
Medical Review Officer Means a medical physician responsible for receiving laboratory results from
(MRO) the drug-testing laboratory who has knowledge of substance abuse and has
appropriate training or experience to interpret and evaluate an individual's
positive test result, in light of declared information
Negative result (screen) Means a preliminary result established by a screening test which indicates that
a drug possibly present in the sample is not detected above a specified cut-off
Negative result Means a result reported by the laboratory that indicates that a suspected drug
(confirmation) present in the sample is below a specified cut-off
Non-negative result Means a preliminary result established by screening test that indicates a drug
possibly present in the sample is detected above a specified cut-off. A
specimen that is reported as adulterated, substituted or invalid
Positive result (confirmation) Means a result reported by the laboratory as positive, in which case there is
conclusive evidence that a drug is present in the sample tested at a level
greater than or equal to the confirmation cut-off concentration
Pilots Means to manipulate the flight controls of an aircraft during flight time and may
also be referred to as ‘pilot flying’ (PF);
Pilot-in-command (PIC) Means the pilot designated by the operator as being in command and charged
with the safe conduct of a flight, irrespective of whether or not he or she is

manipulating the controls

Pilot-in-command (PIC) Means a co-pilot performing the duties and functions of a PIC under the
under supervision supervision of the PIC in accordance with a method of supervision acceptable
to the Authority
Power-assisted glider Means a glider with a maximum all-up mass of not more than 850 kg, fitted
with a retractable engine that is used mainly for the purpose of launch and
climb and short periods of free flight
Powered glider Means an aircraft equipped with one or more engines which, with the engine or
engines not operating, has the performance characteristics of a glider
Powered hang glider Means a hang glider fitted with an engine attached either to the structure or to
the pilot, and which may also be fitted with a detachable undercarriage, to
support its launch and climb
Powered paraglider Means a paraglider fitted with an engine attached to the pilot to assist in its
launch and in short local powered flights, and which may have a fixed or
detachable undercarriage
Problematic use of The use of one or more psychoactive substances by aviation personnel in a
substances way that:
a) constitutes a direct hazard to the user or endangers the lives, health,
or welfare of others; and/or
b) causes or worsens an occupational, social, mental, or physical
problem or disorder
Psychoactive substances Means any substance with psychotropic effects, excluding caffeine and
tobacco, but which includes the following:
a) narcotic analgesics such as opiates.
b) illicit substances such as cannabis and cocaine.
c) sedative hypnotics.
d) hallucinogens.
e) central nervous system depressants; and
f) central nervous system stimulants, including volatile solvents and
alcohol
Quality control sample Means a sample used to evaluate whether an analytical procedure is operating

within pre-defined tolerance limits

Reference method Means a method in analytical chemistry considered to be acceptable for
confirmation of results (e.g., mass spectrometry, refractometry, pH electrode)
Sample Means a representative portion of a specimen submitted to a laboratory for
testing
Screen test Means a test to eliminate negative samples from further consideration and to
identify the non-negative specimens that require confirmation testing
Specimen Means the portion of (generally) urine, blood or breath that is collected from a
donor
Standard (1) Means reference material of known purity or a solution containing reference
material at a known concentration
Standard (2) Means an agreed protocol or procedure (e.g., ISO:17025)
Standard Operating Means a written document giving the detailed steps to be followed when
Procedure (SOP) undertaking a particular task (e.g., the analysis of a given drug in a urine
sample)
Toxicologist Means a person (holding a degree in the chemical sciences specializing in
Analytical Chemistry and Toxicology) responsible for interpreting a positive
analytical result for the customer or the customer’s designated Medical Review
Officer (MRO). This person must have suitable training and experience in the
theory and practice of all methods and procedures employed in the laboratory,
including a thorough understanding of chain of custody procedures, quality-
control practices, and analytical procedures relevant to the interpretation of a
result.
Rated air traffic controller An air traffic controller holding a licence and valid ratings appropriate to the
responsibilities exercised by him or her
Rating An authorization entered on or associated with a licence and forming part
thereof, stating special conditions, privileges or limitations pertaining to such
licence
Safety management system A systematic approach to managing safety, including the necessary
organizational structures, accountabilities, policies, and procedures
Safety pilot In terms of Part 61 and Part 91 of the Civil Aviation Regulations, means a pilot

whose sole purpose during flight time is to maintain a visual lookout for threats
to an aircraft during simulated instrument flight and to monitor the aircraft’s
engine and navigation instruments to ensure exceedances do not occur
Safety-sensitive personnel Persons who might endanger aviation safety if they perform their duties and
functions improperly. This definition includes, but is not limited to, flight crew,
cabin crew, aircraft maintenance personnel and air traffic controllers
Second-in-command Means a licensed pilot serving in a piloting capacity other than as PIC, who is
designated as second-in-command, but excluding a pilot who is on board the
aircraft for the sole purpose of receiving flight instruction
Significant In the context of the medical provisions in Annex 1 ICAO significant means to a
degree or of a nature that is likely to jeopardize flight safety
State safety programme An integrated set of regulations and activities aimed at improving safety
Valid When used in connection with a licence, rating, certificate, validation, authority,
approval or similar document, means:
a) that the expiry date on the document, if any, has not been exceeded.
b) that the document has been issued legally and properly to its holder,
and has not been suspended or cancelled by the issuing authority; and
c) that all requirements, prescribed by the Regulations in respect of the
document, have been complied with
4.2. Abbreviations
ABBREVIATION MEANING
AIP Aeronautical Information Publication

AMA Aviation Medical Assessors
AMC Aeromedical Centre
AME Aeromedical Examiner
ASD Alcohol Screening Device
ATF Alcohol Testing Form
ATPL Airline Transport Licence
BAT Breath Alcohol Technician
CPD Continuing Professional Development
CRM Crew Resource Management

DAME Designated Aviation Medical Examiner

DCA Director of Civil Aviation
EEG Electroencephalogram
EBTD Evidential Breath Testing Device (confirmatory breath test)
IAM Institute for Aviation Medicine
ICAO International Civil Aviation Organisation
ICASM International Congress of Aviation and Space Medicine
JAA European Joint Aviation Authorities
LOFT Line-oriented Flight Training
MRO Medical Review Officer
NOTAM Notice to Airmen
PF Pilot Flying
PIC Pilot-in-Command
PPL Private Pilot Licence
QAP Quality Assurance Plan
RPAS Remotely Piloted Aircraft System
SACAA South African Civil Aviation Authority
SANAS South African National Accreditation Standard
SARPS Standards and Recommended Practices
SMS Safety Management System
SOPs Standard Operating Procedures
STT Screening Test Technician
USC Urine Specimen Collection
5. REFERENCE DOCUMENTS
a) ICAO ANNEX 1 CHAPTER 6

b) ICAO DOC 8984
c) ICAO D9654
a) ICAO ANNEX 19
b) ICAO DOC 9379
c) ICAO DOC 9841
d) ICAO DOC 9624
e) ICAO DOC 9734
f) ICAO DOC 9654
g) ICAO DOC 9779
h) ICAO COVid-19
i) PROMOTING, MAINTAINING AND SUPPORTING MENTAL WELL-BEING
IN AVIATION DURING THE COVID-19 PANDEMIC
i) SAFETY MANAGEMENT SYSTEMS: GUIDANCE FOR AEROMEDICAL CENTRES (AEMC)
ii) OTHERS

5.1. FOREWORD
Flying is a highly skilled job that involves a complex interaction between the aviator and the machine in an
environment that is full of stressors. Although the flying machine may fail occasionally, it is the human
component that is the cause of aviation accidents more than 70% of the time. The aircraft environment differs
from other occupational environments with respect to altitude stressors such as hypoxia, noise and vibration,
low humidity leading to dehydration, fatigue, decompression syndrome, acceleration, and spatial
disorientation. Because of these stressors, the aircrew is required to maintain a high level of physical and
mental fitness and is legally required to assess their medical fitness in order to carry out their professional
duties.
Aeromedical decisions must be based on factual and objective data, which is evidence-based and supported
by documentation to ensure aviation safety. Aviation medicine combines aspects of preventative, occupational,
environmental, and clinical medicine with the physiology and psychology of man-in-flight.
The medical standards and policies of the South African Civil Aviation Authority (SACAA) must be compliant
with the Standards and Recommended Practices as stipulated by the International Civil Aviation Organization
(ICAO) Regulations, Chapter 6, Annex 1. ICAO performs safety oversight audits on Contracting States on a
regular basis to monitor compliance with the minimum standards and recommended practices, and States are
required to notify ICAO when there is an inability to meet standards and recommended practices. A difference
will then be filed for each specific requirement which is not being met.
Aviation medical examinations have evolved over the years for three reasons: to predict the success of
training, especially in the military, to ensure a long productive career and to reduce the rate of accidents.
Research in the West indicates that the risk of sudden incapacitation of aircrew is low; this is credited to the
high standards of fitness required for initial screening medicals and follow-up surveillance. Despite the high
medical standards imposed on aviation personnel, however extensive, there is no medical examination that
can entirely exclude the possibility of incapacity; therefore, the problem must be solved with risk management.
The incidence of incapacitation of aircrew due to the effect of medical conditions or physiological impairment is
low: however, it represents a serious potential threat to flight safety.
Most potential pilots with a significant risk of incapacitation (e.g., Epilepsy, Type I Diabetes Mellitus) are
screened out at the time of the initial examination. The civil aviation authorities internationally permit airmen
with certain medical conditions to be medically certified, provided that such permission does not compromise
aviation safety. Unfortunately, a comprehensive review of the proportion of medical conditions leading to
medical unfitness and incapacitation has not been conducted on the African continent. This has led to limited
knowledge of the causes of in-flight incapacitation, medical causes of aircraft accidents and other issues
specific to the African continent. The limited research creates a challenge to the local aviation regulatory
authority, as development and revision of local medical policies are based on information from the West, which
differs significantly regarding the demography of those populations and diseases endemic on the African
continent.
Over the years, a number of studies were documented about the medical conditions affecting the various
aviation populations in the Western world. Knowledge of these medical conditions has assisted in relation to
the regulatory aspect of flight crew licensing and the development of appropriate, evidence-based medical
standards, and this research has also provided information relating to medical conditions responsible for in-
flight medical incapacitation.

In June 2010, the Director of Civil Aviation initially established a committee known as the Aeromedical
Committee, and a number of committees has since been appointed. The Aeromedical Committee is an
advisory body of medical, psychological, and industry partners (IAM, SAASMA, ATNS, RAASA, ALPA and
other ancillary health experts serving to advise the Director on the medical risks of existing or prospective
aviation personnel who are required in terms of the Civil Aviation Regulations (1997), as amended, to hold
medical certificates. The role of the Aeromedical Committee is to apply the ICAO Flexibility Clause and
Accredited Medical Conclusion. Currently the panel meets once per month on the 3rd Tuesday of the month
and a yearly calendar is published on the SACAA websites. All panel cases for consideration have to be
submitted to the SACAA seven (7) working days before the panel.
The establishment of the Aeromedical Committee has minimised unnecessary medical appeals, and with the
involvement of the non-medical aviation industry, has led to a better understanding and definition of the
operational, psychological, training, legal and human resource issues. Through the input of these partners, the
SACAA has been able to review a number of medical protocols, by making use of the B Sc Honours in
Aviation Medicine at the University of Pretoria.
The composition of the Aeromedical Committee was determined by the SACAA, based on a research paper
from the University of Pretoria, which assessed an analysis of common morbidity patterns that lead to medical
unfitness among civil aviation aircrew in South Africa dating from 2000 to 2008.The study revealed that the
most common system accounting for the majority of disqualifications was the central nervous system, with
head injuries and convulsions being the most commonly encountered. The cardiovascular system accounted
for the second most common cause of medical unfitness, with coronary artery disease and hypertension
diseases accounting for the majority of the medical conditions, and psychiatric conditions accounting for the
third most common system affected, with depression and substance abuse being responsible for the majority
of the cases. A small proportion of these candidates had more than one medical condition.
The recent analysis of the cases presented at the Aeromedical Committee, dated 2010 to 2017, has informed
the SACAA on which specialists to appoint and the areas of risk. Knowledge of common conditions will assist
in the development of targeted protocols and the proactive training of aviation personnel. ICAO indicates that
there is evidence that several fatal aviation accidents have been caused by psychiatric disorders or
inappropriate use of psychoactive substances. As part of the periodic aviation medical examination there
should thus be questions that pertain to these issues. Further, the number of non-physical conditions that
could affect the health of pilots and could lead to long-term unfitness in those of middle age appear to be
increasing. The SACAA has included mental health questions in the routine examination of applicants and
encourages DAMEs to spend time on health education and prevention.
The SACAA recognizes the role and the wealth of knowledge at the Institute of Aviation Medicine and
Designated Aviation Medical Examiners, which has led to South Africa being the only country in Africa to host
the International Congress of Aviation and Space Medicine (ICASM) three times. There is a need for senior
DAMEs to mentor regular examiners, share their experience and participate more in decision-making. The
SACAA is encouraged by the increase of the number of DAMEs who have committed to attending the
workshops. The participation of the DAMEs will grant them Continuing Professional Development (CPD)
points.
Our office encourages a good and efficient relationship between the SACAA and the Institute for Aviation
Medical Examiners, as this impacts on our clients’ customer service as we all work on behalf of the Director.

Numerous workshops have been held with the industry, and more of these will take place to promote aviation
medicine, identify challenges, and identify increased areas of risks and possible solutions.
DAMEs play a major role in safety management through information collected in routine medical examinations,
which may assist in medical causes of in-flight medical events. The results of one such research have
suggested that the conditions most likely to result in in-flight medical events were usually first observed during
the period between routine examinations. They were not discovered during the periodic examination by a
medical examiner.
ICAO requires the SACAA to conduct ad-hoc audits on designated aviation medical examiners, and to act
against non-compliant examiners. The purpose of these audits is not punitive, but to improve on the medical
certification systems. The SACAA has submitted legislation which is currently with the Minister for
promulgation; this law will ensure that the Medical Assessors at the SACAA conduct audits on DAMEs’
medical practices. The initial focus will be on new applicants and on those DAMEs who have been making
errors.
DAMEs are to participate in the regulatory review processes (medical protocols) and to familiarize themselves
with the latest amendments to minimize unnecessary delays in the medical certification processes. This will
also prevent the consequence, namely negligent or wrongful certification, which would permit a medically
unqualified person to take control of an aircraft, as this would be a serious situation for the medical examiner,
the SACAA and the public. The designated aviation medical examiners are encouraged to visit the ICAO
website or the CAA website to familiarize themselves with new SACAA developments and to read the ICAO
(8980-AN 895) manual, which is extremely informative.
5.2. LEGAL RESPONSIBILITIES OF DESIGNATED AVIATION MEDICAL EXAMINERS
Part 67 of the Civil Aviation Regulations makes provision for the Director to designate aviation medical
examiners to conduct medical examinations and issued medical certificates on his/her behalf. DAMEs are
delegated the authority to examine applicants for aviation personnel (pilots, air traffic controllers and cabin
crew) medical certificates and to issue or deny issuance of certificates. The first point of contact for aviation
medical examinations are conducted by DAMEs in their private practice on behalf of the Director of the
SACAA. An examiner is a designated representative of the SACAA Administrator with important duties and
responsibilities and it is essential that examiners recognize the responsibility associated with their
appointment.
DAMEs must consider their responsibilities in their capacity as examiners as well as the potential conflicts that
may arise when performing in this dual capacity. The consequences of a negligent or wrongful certification,
which would permit an unqualified person to take the controls of an aircraft or an air traffic controller position,
can be serious for the public, for the Government, and for the examiner. If the examination is cursory and the
examiner fails to find a disqualifying defect that should have been discovered during a thorough and careful
examination, a safety hazard may be created, and the examiner may bear the responsibility for the results of
such action. A number of aviation personnel and DAMEs have been referred to the Legal Department due to
non-compliance with the regulations and technical standards, resulting in penalties imposed.
Of equal concern is the situation in which an examiner deliberately fails to report a disqualifying condition,
either observed during the examination or otherwise known to exist. In this situation, both the applicant and the

examiner, in completing the application and medical report form, may be found to have committed a violation
of Part 185 of the Civil Aviation Regulations, which stipulates that:
Part 185.00.1
(1) A person commits an offence if that person –
a) hinders or obstructs an authorized officer, inspector, or authorized person in the exercising of his or
her powers or the performance of his or her duties.
b) when called upon by an authorized officer, inspector, or authorized person to do so, refuses or fails to
give his or her name and address, or gives a false name or address.
c) obstructs or impedes any other person acting in the exercising or performance of any privileges,
powers or duties conferred on such other person by or under the regulations.
d) makes or causes to be made, either orally or in writing –
e) any fraudulent, misleading, or false statement for the purpose of obtaining any licence, rating,
certificate, permit, approval, authorization, exemption, or other document in terms of the regulations.
f) any fraudulent, misleading, or false entry in any logbook, record or report which is required to be kept,
maintained, made, or used to show compliance with any provision of the regulations.
g) falsifies, counterfeits, alters, defaces, or mutilates, or adds anything to, any licence, rating, certificate,
permit, approval, authorization, exemption or other document issued in terms of the regulations.
h) does or causes, or permits to be done or caused, any act contrary to, or who fails to comply with, any
provision of the regulations, or a direction given, or a prohibition made, or a condition imposed in
terms thereof.
i) exercises a privilege granted by, or uses, any licence, rating, certificate, permit, approval,
authorisation, exemption, or other document issued under the regulations, of which he, she or it is not
the holder.
j) unless otherwise authorised in the regulations, permits a licence, rating, certificate, permit, approval,
authorization, exemption, or other document issued under the regulations, of which he, she or it is the
holder, to be used, or a privilege granted thereby, to be exercised, by any other person.
k) operates or attempts to operate any aircraft in respect of which no valid certificate of registration or
valid certificate of airworthiness have been issued.
l) commits any act, whether by interference with any flight crew member, ATS personnel member or
AME, by tampering with any aircraft, or any part thereof, or by disorderly conduct or otherwise, which
is likely to endanger the safety of any aircraft or its occupants.
m) without the permission of an aerodrome or heliport operator, enters any place within the boundaries of
a licensed aerodrome or heliport which has been closed to the public.
n) gives false information pertaining to the investigation of any aviation accident or incident; and
o) contravenes in any manner the provisions of the Act, and regulations promulgated in terms of the Act
which are administered by the Authority.
(2) Any person who –
a) contravenes any provision of part 5 of the Act, except section 111.
b) contravenes or fails to comply with any provision of a safety plan approved by the Minister and
whereof the contents have been brought to his or her notice; and
c) is guilty of an offence and shall be liable on conviction to a fine not exceeding R50 000 or
imprisonment not exceeding 10 years or to both such fine and imprisonment.
(2) Any aviation participant who – fails to comply with section 111 of the Act or fails to comply with the
national Aviation security program instituted in terms of that section is guilty of an offence and on
conviction liable to a fine or to imprisonment for a period not exceeding ten year or to both such fine or
imprisonment.
(3) Any person who – is convicted of an offence in terms of sub regulation (1), shall be liable to the
penalties prescribed in section 144 of the Act, read with section 332 of the Criminal Procedure Act,
1977 (Act No. 51 of 1977).
The Designated Aviation Medical Examiner (DAME) is delegated authority to:
a) Examine applicants for, and holders of, medical certificates to determine whether they meet the
standards prescribed in Part 67 Regulations and Technical Standards for the issuance of a medical
certificate.
b) Issue or deny medical certificates to applicants or holders of such certificates based upon whether
they meet the applicable medical standards.
Oversight of medical practices by the Medical Assessors
The medical assessors of the SACAA conduct audits in the medical practices of the designated aviation
medical examiners in line with ICAO requirements and part 67.00.4 of the Civil Aviation Regulations and
Technical Standards. The focus of the audits is based on, but not limited to, the following:
a) Medical facility.
b) Communications and IT evaluation (EMPIC Medical Module).
c) HPCSA compliance (medical confidentiality, records storage – hard copies and electronic – in line with
relevant legislation, including the National Department of Health and others).
d) DAMEs are required to familiarize themselves with this legislation.

e) Compliance with legislation conducted by DAMEs;Knowledge of the SACAA Regulations and

Technical Standards.
f) DAMEs’ knowledge of where to find the amended regulations.
g) Practice equipment (calibration, others – documentation is assessed based on the manufacturer’s
specifications).
h) How tests are conducted (e.g., Conversation and Whisper Test); and
i) EMPIC implementation and others.
DAMEs are required to have adequate facilities for performing the required examinations and possess the
following equipment prior to conducting any SACAA examinations. History or current findings may indicate a
need for special evaluations. Examiners shall certify at the time of designation, re-designation, or upon request
that they possess (and maintain as necessary) the equipment specified.
5.3. IMPLEMENTATION OF THE EMPIC MEDICAL MODULE
On behalf of the South African Civil Aviation Authority, we wish to thank all the DAMEs who actively
participated, provided constructive feedback, and attended the EMPIC Medical Training Module hosted by the
SACAA, DAMES, SYNOVA and an expert from Switzerland. These DAMEs are considered to be change
agents, who have been actively providing input on how the SACAA could improve the system and have shared
the challenges that they experienced at the uncomfortable initial phase. The HPCSA was also invited at the
Gauteng Workshop to make presentations on the following:
• Security and duration of storage of medical documentation (manual and electronic records):
• Medical confidentiality; and
• Informed consent.
The role of EMPIC today extends to orchestrating the inputs from the user community to ensure the software
continues to meet all regulatory requirements and at the same time keeps pace with the deployment of new
technologies. EMPIC’s responsibilities also include identification and induction of new collaborators to join the
project. The software, EMPIC-EAP, is unique in that there is no other solution available, worldwide, that
provides an off-the-shelf, fully integrated, scalable, and configurable tool with a long-term development plan
that comprehensibly meets all the requirements for oversight of Safety and Security Regulations by a National
Aviation Authority. The implementation of the EMPIC Medical Module will improve the medical certification
processes with the improved verification processes by minimizing delays in submission of medical records for
verification, which process is sometimes affected by postal strikes and incomplete medical examination forms.
The latter results in the SACAA and the Institute of Aviation Medicine having to address errors, which has time
and costs implications. The implementation of the system will minimize medical tourism, delays in the medical
verification processes, reduces lost documents.
The following features characterize the application:
• Calculating all necessary examinations and computing the validity of the medicals (even for different
examinations of one person at a certain examination date).

• Modelling a pilot’s (and/or EMPIC® ANS) whole medical examination history.

• Multi-user application: several persons can work on a pool of applicants using “worklist”.
• Multi-Licence approach: one applicant can be examined for several different kinds of medical
certificates in parallel.
• Rights system to model different end-user roles with dedicated permissions within the system.
• Access to complete history for AME/AMC (if “own” pilots). AME/AMC can grant read rights to other
AMEs/AMCs to give access to historical data.
The following features characterize the application:
• Numerous checks for completeness and dependency of the medical forms.

• Re-usage of old data from prior examination by “Easy Entry” function.
• Integration of data from external equipment (files such as PDF etc.).
• Automatic data transfer from extended forms to medical examination report.
• Printout of all forms and certificates completely filled in.
• Printout of several different medical certificates (FCL, ANS etc.) per person.
• Modelling specific workflows: expert consultation, temporary unfitness, unfitness, interim enquiry of
AMS, allocating read rights on certain examinations to other physicians, further transfer, transfer back
(reject).
• “Red alert flag” for suspicious applicants (message of the AMS to the user opening a suspicious
candidate).
• Ability to import or scan documents as part of the examinee file.
• Decentralized user management for pilot physicians with larger surgeries (AMCs with shared
workload).
• Ability to distribute work within one surgery between several workstations (multi-user application).
• Possibility to define a responsible AME and the working AME.
• Interface to EMPIC® CM and EMPIC® FCL (also to ANS module) via batch file transfer (due to
installation in DMZ); and
• Export of statistical data.
• The general procedures in EMPIC MED are:
• Examination of a new applicant.
• Examination of a known applicant.
• Declaring an applicant “unfit” OR “fit” (medical certificate is only issued for “fit” applicants);
• Changing the medical status of an applicant, i.e., declaring him/her “temporarily unfit”;
• Expert examination of an applicant; and

• Examination of a rejected applicant.

• N.B. The decision browser supports the national aeromedical section to review the examinations of an
applicant and to declare him/her fit or unfit or to reject him/her for further examination. Please note that
the types of examinations chosen for aviation personnel is deliberated by the AVMED department,
therefore “fit” or “unfit” is based on these examination results.
INTERGRATED EMPIC SYSTEM
EMPIC-EAP – other non-MEDICAL MODULES

EMPIC® CM: Customer Management (Contacts, Addresses, Groups)
EMPIC® SEC: Security, Permission Management to all Modules
EMPIC® SL: Surveillance Layer for Compliance Management
EMPIC® QS: Query Synthesiser, Query Tool for Cross-module
Reports
EMPIC® ERP: Interface to Enterprise Resource Planning Software
EMPIC® WEB: Facilitating Stakeholder Engagement
EMPIC® WF: Workflow
EMPIC® DMS: Interface to Document Management System
EMPIC® FCL-M: Flight Crew Licensing – Medical
EMPIC® FCL: Flight Crew Licensing
EMPIC® ANS: Air Navigation Services Air Traffic
EMPIC® MPL: Maintenance Personnel Licensing
EMPIC® EXS: Examination System

6. SECTION 1
6.1. International Civil Aviation Organisation
The International Civil Aviation Organization (ICAO) is a specialized agency of the United Nations, and it was
created with the signing in Chicago, on 7 December 1944, of the Convention on International Civil Aviation.
The ICAO is the permanent body charged with the administration of the principles laid out in the convention.
The Convention establishes the privileges and restrictions of all Contracting States and provide for the
adoption of International Standards and Recommended Practices (SARPs) regulating international air
transport. The Convention on International Civil Aviation includes several articles which call for the adoption of
international regulations in all fields where uniformity facilitates and improves air navigation.
These regulations, known as Standards and Recommended Practices (SARPs), have been promulgated in
ICAO Annexes to the Convention which are amended from time to time when necessary. Each Annex deals
with a specific aspect of international civil aviation, and those relating to medical regulations for licence
applicants are included mainly in Annex 1 – Personnel Licensing and to some degree in Annex 2 – Rules of
the Air and Annex 6 – Operation of Aircraft. Issues involving preparedness planning for a communicable
disease of public health concern are considered in Annex 6, Annex 9 – Facilitation, Annex 11 – Air Traffic
Services and Annex 14 – Aerodromes.
6.1.1. Definition of ICAO Standards and Recommended Practices Standards
Any specification for physical characteristics, configuration, material, performance, personnel or procedure, the
uniform application of which is recognised as necessary for the safety or regularity of international air
navigation, and to which Contracting States will conform in accordance with the Convention. In the event that a
State finds it impracticable to comply in all respects with any such international standard but allows a less
stringent practice, immediate notification to ICAO is compulsory under Article 38 of the Convention.
Recommended practices.
Any specification for physical characteristics, configuration, material, performance, personnel or procedure, the
uniform application of which is recognised as desirable in the interest of safety, regularity or efficiency of
international air navigation, and to which Contracting States will endeavour to conform in accordance with the
Convention.
6.1.2. History of aviation medicine
In 1970, the Personnel/Training/Medical (PEL/TRG/MED) Divisional Meeting considered that availability of

suitable medical guidance material was of importance to the uniform application of the Standards and
Recommended Practices (SARPs) in Annex 1, as well as in such fast-moving fields as accident investigation
and human factors in aviation. The meeting also recommended that action be taken to provide expert advice to
the ICAO Secretariat in support of the preparation of such medical guidance material. Since that time,
advances have been made, both in medical science generally and in aviation medicine. Assistance and advice
have been provided by aviation medical specialists from many Contracting States, and their valuable
contributions have enabled a second edition of the Medical Manual in 1985 and now this third edition to reflect
those advances as they apply to civil aviation medicine in particular (ICAO Manual 2012).

The third edition of the ICAO Manual was developed with the intent to complement existing texts by
emphasizing the clinical problems encountered in medical certification in civil aviation. This ICAO (8980-AN
895) document is designed for the experienced designated medical examiner as well as for the aviation
medical expert and medical assessor, to aid in the approach and management of intricate borderline cases.
When making a medical assessment, the medical examiner should consider the relevant operating
environment in which the applicant is engaged; for example, single pilot commercial operations carrying
passengers clearly require the most careful medical evaluation in order to reduce the risk of in-flight
incapacitation. Those engaged in multi-crew operations, where there has been effective incapacitation training,
may be considered less stringently. In many such cases, flight safety may be adequately protected by an
operational condition or limitation applied to the licence.
ICAO states that over-regulation, apart from having an adverse financial impact on the State or the aviation
industry, may not improve flight safety; instead, stringent national medical requirements can result in
unnecessary restrictions or premature retirement of licence holders. This may also have the consequence of
licence holders being reluctant to report illness to the medical examiner or the Licensing Authority, and this is
important from the flight safety viewpoint since the value of the medical examination relies to a large extent
upon an accurate medical history. Should States make demands in excess of those included in ICAO SARPs,
the goal of harmonisation across Contracting States will not be achieved and the transfer of skilled personnel
from one State to another will be inhibited. This also encourages “medical tourism” where a licence holder, if
refused a licence on medical grounds in one State because of stringent medical requirements, seeks to obtain
one in another, less demanding State.
In case a more stringent regulation is adopted by States, notification to ICAO is compulsory only when such
regulation is applied also on foreign licence holders and aircraft. However, in a Resolution of 5 February 1999,
the ICAO Council made it clear that, in principle, national requirements “more exacting” than the SARPs would
be detrimental to the framework of the Chicago system within which international civil aviation has developed
and continues to develop. In this Resolution the Council also called upon each Contracting State to utilise the
multilateral mechanism of ICAO where it believes that changes to the content or level of implementation of the
Standards and Recommended Practices in the Annexes to the Chicago Convention are necessary or
desirable.
6.1.3. Safety management
The different interpretations by States (countries) of the aeromedical standards established by the International
Civil Aviation Organisation (ICAO) has resulted in a variety of approaches to the development of national
aeromedical policy, and consequently a relative lack of harmonisation. However, in many areas of aviation,
safety management systems have been recently introduced and may represent a way forward. A safety
management system can be defined as: “A systematic approach to managing safety, including the necessary
organisational structures, accountabilities, policies, and procedures”. There are four main areas where, by
applying safety management principles, it may be possible to better use aeromedical data to enhance flight
safety.
These are: adjustment of the periodicity and content of routine medical examinations to more accurately reflect
aeromedical risk; improvement in reporting and analysis of routine medical examination data; improvement in
reporting and analysis of in-flight medical events; and support for improved reporting of relevant aeromedical
events through the promotion of an appropriate culture by companies and regulatory authorities. This paper

explores how the principles of safety management may be applied to aeromedical systems to improve their
contribution to safety.
Medical requirements for pilots were introduced during the early decades of the last century and although the
content of the aeromedical examination has changed over time, few attempts have been made to monitor or
quantify the safety benefits of the requisite aeromedical standards, it being self-evident that the licence holder
needs to be ‘fit’. ICAO sets medical Standards and Recommended Practices that have been agreed upon
internationally. Despite this global agreement on a suitable international system, regulatory authorities interpret
the medical Standards and Recommended Practices in different ways. In practice, this leads to different fitness
levels being required of licence holders in different States (countries).
Technical
era
Human factors
era
Organizational era
Total system
era
Future
195 197 199 200 201
0 0 0 0 0
s s s s s
6.2. Basis for Regulatory Aeromedical Decision Making
Expert opinion
Aeromedical policy and individual decisions are often based on expert opinion. Although expert opinion may
be evidence-based, such an approach (which may also be termed “eminence-based”) is not as reliable as one
that uses higher levels of evidence. However, expert opinion is often the easiest (quickest and least costly) to
implement and may, therefore, be an attractive option for regulatory authorities. If a medical expert has

experience in aviation medicine and their own specialty, such an opinion may be of great value (it may be the
only possible approach for uncommon conditions), but often opinions vary greatly among experts presented
with similar cases.
The potential for variation in expert opinion was noted in 2004 when a European Joint Aviation Authorities
(JAA) survey was undertaken to assess the value of the electroencephalograph (EEG) in determining medical
fitness. A selection of representative EEG recordings was distributed to neurologists who were advising the
chief medical officers of the various JAA member states. Some EEG were assessed as being acceptable for
unrestricted Class 1 certification by certain consultant neurologists, while the same recordings were assessed
by others as justifying an ‘unfit’ assessment.
Routine screening EEG was subsequently abandoned by the JAA for regulatory purposes. Given this disparity
of views, it is not unexpected that an individual may be assessed as fit in one State and unfit in another,
depending on the view of the expert who is advising the Licensing Authority.
6.3. Acceptable Aeromedical Risk
Another area where a diversity of views can be found among regulatory authorities is the level of aeromedical
risk that is acceptable. Further, authorities differ in their opinions as to whether it is possible to use objective
numeric aeromedical “risk criteria” as a basis for decision making in individual cases or for developing policy.
Of the authorities that do use such risk criteria, there are differences regarding the maximum acceptable level
of risk for certification, although for professional pilots a commonly held norm of maximum risk is 1% per
annum. However, 2% per annum has also been proposed (10) and is in use in at least one State (country). A
pilot incapacitation risk of “1% per annum” infers that if there were 100 pilots with an identical condition, one of
them would be predicted to become incapacitated at some time during the next 12 months (and 99 would not).
While the data for predicting incapacitation in the next 12 months for a condition is not always robust, there are
some common medical conditions (e.g., ischemic heart disease) where high quality epidemiological data exist
and can be used in assessing the aeromedical risk. Without any objective risk criteria, it can be unclear on
what basis an aeromedical decision is being made, and expert opinion that seems ‘reasonable’, often based
on similar precedents, is likely to hold sway.
6.4. Contribution to Aviation Safety of Medical Examinations
Routine periodic examination
There are few published studies on the safety value of the routine medical examination, yet millions of dollars
are spent annually on the process. Regulatory authorities require licence holders to undergo an aeromedical
examination for licence issue and each licence or medical certificate renewal. This examination varies little
throughout a pilot’s career, even though the incidence of most medical conditions varies with age, physical
disease being less common in professional pilots under 40 years of age than in those over 40 years.
Accordingly, physical disease is very rarely a significant factor in two-crew airliner accidents involving younger
pilots. In the general population, behavioural factors such as anxiety and depression are more common in the
under-40s age group, and illicit drug use and alcohol consumption also cause a considerable, increasing
disease burden.
Despite this, relatively little formal attention is given to these aspects in the routine periodic encounter with an
aviation medical examiner, with the emphasis usually placed on the detection of physical disease. Indeed,

although medical examiners may take it upon themselves to include some informal discussion of behavioral or
mental health issues, the examination is often colloquially described as a pilot’s “physical”. Particularly in the
younger licence holder there is an apparent mismatch between the likelihood of the existence of particular
pathologies of flight safety importance (mainly mental and behavioral problems) and the tools being used to
detect them (the traditional medical examination). ICAO is currently in consultation with its member States
(countries) concerning whether the current emphasis on the detection of physical disease is appropriate in the
periodic medical examination for professional pilots under 40 years of age.
6.5. Stringent Medical Requirements
One approach to aeromedical certification embraces a concept that “more stringent” medical standards result
in “more effective” medical standards. At the 2002 Aerospace Medical Association annual scientific meeting,
Hudson reported that 1200 of the professional pilots who sought advice from the U.S. Air Line Pilots
Association medical consulting service had been diagnosed with depression and advised to take
antidepressant medication.
On being advised of the Federal Aviation Administration’s policy of not permitting antidepressant use in
operating pilots, 710 of the 1200 indicated they would not take the recommended treatment and would
continue to fly; 180 indicated they would take the recommended medication and continue to fly while
withholding information concerning the medication from their aviation medical examiner; and 300 indicated
they would stop flying while taking the medication. If this pilot group acted on their intentions, approximately
75% of pilots diagnosed with depression would have continued to fly, unknown to the regulator.
This data is open to a number of possible interpretations. One conclusion may be that regulating against pilots
flying while taking antidepressants is, paradoxically, detrimental to flight safety since this could result in
information concerning an important medical condition being withheld from the regulatory authorities while
pilots continue to operate after having had a diagnosis of depression, treated or not. Conversely it may be
concluded that as the current standards are not being adhered to, additional regulatory action such as more
focused interview or survey techniques (to detect depression) and blood testing (to detect antidepressant use)
is warranted. In a recent AsMA position paper, Jones et al. indicated that the use of modern antidepressants
by pilots, under adequate supervision, need not be detrimental to flight safety.
This suggests that there are safe subpopulations among those with depressive disorders. Also, if pilots wished
to hide their depressive illness and its treatment it is unlikely that interview and survey methods would identify
any except the most clinically depressed. Blood testing for antidepressant medications would be very
expensive if applied to the entire pilot population. We argue, therefore, that this additional data sways the
interpretation of the Hudson data in favour of the first argument: that more stringent standards are not
necessarily beneficial to overall flight safety. This, in turn, suggests that it would be a more effective safety
strategy, both to accept the use of certain selected antidepressants and to structure the routine aeromedical
examination to better identify those who may benefit from psychiatric intervention than it would be to try and
continue to exclude all pilots with depressive disorders and to institute additional measures to try and increase
their detection.
6.6. Safety Management as a Way Forward
Safety management principles

For some years, the concepts of safety management have been applied in the aviation industry, but largely
outside the field of aviation medicine. ICAO has mandated the incorporation of a safety management system
into the management processes of air traffic and aerodrome operators since 2001 and 2005, respectively, and
safety management systems became mandatory in January 2009 for aircraft operator. When introducing a
safety management system, an important first step is for a company to appoint a senior executive who takes
direct responsibility for safety and who has some high-level influence on the distribution of funds. To fulfil this
responsibility, the “accountable executive” needs to set safety targets, monitor and measure safety-related
events, and then revisit and, if necessary, revise the safety targets. In other words, safety should be managed
in a manner similar to other aspects of the business. In the past, this has not always occurred, with
responsibility for safety often being delegated by senior
A recent comparison between in-flight medical events in the United States and the United Kingdom
demonstrated that, in the United Kingdom, relatively minor pilot-related in-flight medical events were reported
to the Licensing Authority at a rate approximately 40 times greater (55:1.3 per 10 million flight hours) than in
the United States. While it is possible that this observation reflects an actual difference between US and UK
pilots in the incidence of minor aeromedical events, it seems more likely that the explanation lies with
differences in the reporting cultures in the United States and the United Kingdom, with relative under-reporting
occurring in the former.

The same studies observed similar reporting rates for US and UK pilots for more serious medical events. A
regular analysis of in-flight events by individual States and a comparison of reporting systems in different
States would be of value in helping to better understand why such differences exist. Efforts to gather and
analyse in-flight medical events may also be hampered by the lack of a single, widely accepted, classification
system. For example, incapacitation from smoke or fumes may be reasonably regarded as medically related,
but there is usually little connection between such events and the fitness of the pilot, as determined by the
medical examiner. In addition, classification of events may need to be undertaken with less than full (medical)
information, which introduces an element of error and subjectivity. Ideally, in order to maximise benefit from
the analysis of in-flight aeromedical events, categorization should be undertaken by an individual who
understands both the aviation environment and aviation medicine.
Medical events that occur between flights: On average, professional pilots spend between 5% and 10% of their
time in the air, so noting events that occur between flights would greatly increase the size and utility of any
database of medical events that affect pilots. An analysis of the medical conditions that come to light between
routine examinations would be particularly useful. Some States require significant medical events to be
reported to the regulatory authority after a certain time period, which provides the basis of a useful database
for medical conditions that may appear, or deteriorate, between routine examinations. Further, as a medical
history is required at each routine medical examination, it should be possible to obtain data on such events,
which could be analysed.
6.6.1. Information from routine medical examinations
There are two types of information available from routine examinations: information from the medical history,
and findings from the examination (mental and physical, including any investigations, e.g.,
electrocardiograms). The aero medical literature contains few studies that have attempted to investigate the
relationship between those medical conditions that are identified during the routine periodic medical
examination and those that cause in-flight medical events. The results of one such study suggested that the
conditions most likely to result in in-flight medical events were usually first observed during the period between
routine examinations – they were not discovered during the periodic examination by a medical examiner. If this
is the case, it would seem important that the Licensing Authority ensures that the licence holder knows what
action to take when such an event occurs so that flight safety is not eroded, and that the medical examiner and
Licensing Authority are informed of the necessary information.
6.6.2. Reporting of medical conditions
Reporting of in-flight incidents involving operational errors may create a fear of adverse repercussions. An
analogy can be made with medical events, both in-flight and on the ground, as a licence holder may withhold
information if he/she believes his/her career may be adversely affected should he/she report a medical
condition. However, systems which encourage reporting of events of safety relevance generate information
that can be used to enhance safety. It is reasonable to assume that if medical conditions of licence holders are
made known to the medical department of a Licencing Authority, a potential exists to improve safety.
Therefore, efforts should be made to encourage such reporting by licence holders. To this end, a regulatory
authority should have, as part of its regulatory regime, a fair, transparent, and consistent system, developed in
consultation with the licence holder’s representative bodies. Such a system should be based as much as
possible on evidence of aeromedical risk, and action in individual cases should be proportionate to the

individual risk. Such an approach might, as a formally stated goal, be included in the mission statement of a
regulatory authority’s medical department, with the aim of returning licence holders to operational status
whenever possible. Experience shows that this is often mentioned as a desirable goal in aviation medicine
circles, but rarely stated formally.
DAMES DUTIES IN CONTINIOUS IDENTIFICATION OF HAZARDS TO PREVENT INCIDENTS & ACCIDENTS
SAFETY MANAGEMENT SYTEM ESIGNATED AVIATION MEDICAL EXAMINERS PROGRAMME

RESPONSIBILITTIES & ROLES IN THE AVIATION MEDICINE PRACTICE
The role of an Accountable Manager in the Aviation Medical Practice
a) Endorses the safety policy.

b) Provides the human and material resources necessary for operating the SMS and achieving the safety
objectives.
c) Nominates the Safety Manager, the Compliance Monitoring Manager.
d) He has corporate authority for ensuring that all activities can be financed and carried out in accordance
with the applicable requirements ant to the standards required by the competent authority.
e) Has overall responsibility for compliance monitoring system.
f) Responsible for establishing an effective management system.
The functions and role of the Safety Manager in the in the Aviation Medical Practice
a) To facilitate hazard identification, risk analysis and management;

b) To monitor the implementation of actions taken to mitigate risks as listed in the safety action plan;
c) To provide periodic reports on safety performance;
d) To ensure maintenance of safety management documentation;
e) To perform safety management initial and recurrent training for personnel and to ensure that it meets
applicable standards;
f) To provide advice on safety matters;

g) To ensure initiation and follow-up of internal occurrence/accident investigations
The functions and role of the Compliance Monitoring Manger in the in the Aviation Medical
Practice
a) Ensures that the company‘s activities are monitored for compliance with the applicable regulatory
requirements.
b) Ensures that the compliance monitoring programme is properly implemented, maintained and
continually reviewed and improved.
c) Requires corrective actions and verifies that corrective action is taken by the manager responsible in
response to any finding of noncompliance.
d) Provides management with an independent assessment of corrective action, implementation and
completion.
e) Monitors corrective action programme
The functions and role of the Internal Auditor in the in the Aviation Medical Practice
a) Carries out audits/inspections;

b) Identifies and records any concerns or findings and the evidence necessary to substantiate such
concerns or findings;
c) Initiates or recommends solutions to concerns or findings;
d) Verifies the implementation of solutions within specific time scales;
e) Reports directly to Compliance Monitoring Manager.
The functions and role of the Head of Aviation Centre
a) Responsibility for coordinating the assessment of examination results and signing reports and initial
class 1 certificates.
b) Assurance that all subordinates meet the qualification requirements for their respective activities.
c) Allocation of responsibilities and duties and issuing introductions to individuals.
d) Evaluation of relevant records in order to avoid the occurrence of undesirable trends.
e) Assurance of a comprehensive document and record management, storage, achieve and liaising with
CAA regarding administration and coordination.
f) Performing medical assessments according to relevant standards and regulations;
g) Responsibility for the establishment and maintenance of medical assessment files;
h) Promoting corporate culture for safety standards of aviation medicine and medical knowledge and
practice

EXAMPLE MEDICAL PRACTICE HAZARD LOG AND RISK ASSESSMENT
6.7. Conclusions
Despite the growth and acceptance of evidence-based practice throughout most fields of medicine, we still find
ourselves routinely using the lowest level of evidence (expert opinion, unsupported by a systematic review) for
regulatory aeromedical decisions. Such decisions are often not based on the explicit acceptance of any
particular level of aeromedical risk. Without guidelines concerning acceptable risk levels, and with reliance on
expert opinion for individual aeromedical decisions, consistent decision making is impeded, and comparisons
between States (countries) are more difficult. A cornerstone of a successful future for regulatory aviation
medicine is consistent decision making by Licensing Authorities using high-level evidence. Such an approach,
if applied by different regulatory authorities, would assist global harmonization of medical fitness requirements.
The principles of safety management can be used to help achieve both these goals. To promote these aims,
several aspects of the aeromedical process should be reviewed and improved, such as:
a) The periodicity and content of periodic medical examinations should be adjusted to better reflect the
medical demographics of applicants and the safety relevance of their medical conditions. For example,
an increased emphasis on alcohol, drugs, and mental health may be warranted for younger pilots
while it would be appropriate to give greater consideration to cardiovascular disease as pilots age.
b) Improvement in reporting and analysis of medical examination data. Few licensing authorities collect
medical examination data in a format that is easily amenable to analysis and there is a lack of data
concerning conditions of aeromedical significance that are discovered during routine medical
examinations.
c) Improved reporting and analysis of in-flight medical event data. Few licensing authorities encourage
the reporting of in-flight aeromedical data. Of those that do, it is rare that the reports are assessed in a
systematic manner. Support for better reporting through the development of an appropriate culture by
companies and a more supportive approach by regulatory authorities to license holders who develop
medical problems should improve the reliability of data on which aeromedical policies are based by
encouraging reporting of medical conditions.
6.8. Mental Health and Behavioural Questions for Use by Medical Examiners
As there is evidence that several fatal aviation accidents have been caused by psychiatric disorders or
inappropriate use of psychoactive substances, it is reasonable that as part of the periodic aviation medical
examination there should be questions that pertain to these issues. Little guidance has been provided
concerning how such aspects could be addressed in the periodic medical examination, although experienced
medical examiners have often informally and spontaneously included them in their evaluation of the applicant.
Further, the number of non-physical conditions that can affect the health of pilots and which can lead to long-
term unfitness in those of middle age appears to be increasing. The conditions addressed by the proposed
questions have been shown to be amenable to preventive action before they develop into significant health
problems and before there is an impact on the pilot’s medical status for flying. There are various
questionnaires with various degrees of complexity available for assessing mental health and behavioural
aspects of an individual’s health. The questions below may serve to promote a relevant discussion between
the medical examiner and the pilot, air traffic controllers and cabin crew.
To encourage dialogue, it is recommended that no written record of the conversation is retained (other than a
record that mental health and behavioral topics were discussed) unless some item of immediate flight safety
risk is uncovered – this understanding should be made clear to the pilot at the outset, thus increasing the
likelihood of a frank discussion. It is to be expected that only rarely will any formal action need to be
considered by the medical examiner to protect flight safety in the light of response to such questions, since the
main aim is to discover behavioral patterns or mental aspects that are amenable to change before they
become sufficiently severe to affect the medical fitness.
The questions suggested address those conditions that are most common in the age range of professional
pilots and those which are most likely to affect performance on the flight deck. Statistics show that the main
psychiatric conditions in this context are mood disorders and certain anxiety disorders, especially panic
episodes. Additionally, in many Contracting States, excessive alcohol intake and use of illicit drugs in the
general population are occurring with increasing frequency, and aviators are not immune from these social
pressures. Questions have been developed to address these issues as well. In developing the questions, a
review of the literature was undertaken by specialists in the field, with the aim of choosing simple questions
that can be answered quite quickly. The vast majority of pilots will respond to all questions in the negative, and
it is unnecessary to request pilots without any relevant problems to undertake a prolonged screening
questionnaire.
Those who answer positively, or with uncertainty, can be engaged in further dialogue by the medical examiner.
The aim is to encourage pilots to consider their lifestyle and thereby improve the likelihood that they will remain
in good mental health during their careers; this, of course, includes the avoidance of problematic use of
psychoactive substances. Occasionally, the medical examiner may find conditions that are amenable to
medical support or even treatment; it is important to detect these at an early stage before they become
significant problems and before they have a long-term impact on the pilot’s medical fitness and on flight safety.
The questions below may not represent the most suitable questions for the pilot populations of all States, but
they offer guidance – a starting point – for States that intend to implement 6.3.1.2.1 and wish to develop an
approach that includes these important aspects of medical fitness. The questions do not necessarily have to

be posed verbally by the medical examiner but could, for example, be given to the applicant to read prior to the
examination.
DUTIES OF AVIATION MEDICAL EXAMINERS HEALTH PROMOTION
Responsibilities of Mental Health Promotion by Aviation Medical Examiners and Other Stakeholders
a) Collaborate in multi-sector, multi-stakeholder activities to promote, maintain and support mental health
and well-being in aviation personnel to ensure operational safety by:
b) Recognizing that there are different cultural approaches and promoting a common understanding of
supportive behaviors and activities;
c) Acknowledging the wide range of emotions in response to COVID-19; these are accepted as normal
reactions to an abnormal situation; and
d) Providing a psycho-socially safe and supportive environment.
Role of the Civil Aviation Authority
a) Ensure collaboration between the aviation authority, aviation medical examiners, aviation medical
assessors, other healthcare professionals, peer support groups and aviation personnel to support the
mental health and well-being for all aviation personnel;
b) Provide appropriate guidance and support to aviation medical examiners to manage the impact of
mental health conditions and other underlying causes such as COVID-19 on mental health and well-
being in a consistent manner;

c) Encourage stakeholders to make available appropriate resources and tools to minimize the mental
health impact including peer support programmes, by referring to ICAO guidance and other relevant
supportive material;
d) Communicate on a regular basis to all stakeholders the means to maintain licensing and proficiency
to enable safe performance of duties.
Professional and Industry Associations Responsibilities
a) Provide access to appropriate services to support health and well-being; and

b) Make peer support programmes available to all aviation personnel.
Industry Service Providers (e.g. aircraft operators, airports, air traffic control organizations, training
organizations, etc.)
a) Raise awareness among leadership and management to support well-being among aviation
personnel;
b) Continue to offer existing resources to support aviation personnel including peer support, employee
assistance programmes (EAP) or other programmes;
c) As far as possible extend access to supportive resources to aviation personnel that have been
furloughed, laid off or made redundant;
d) In the absence of employer-based resources, inform aviation personnel of other available resources;
e) Facilitate access to support programmes for all categories of aviation personnel (e.g. pilots, cabin
crew, air traffic controllers, ground crew, maintenance personnel, aerodrome personnel etc.);
f) Educate on fitness for duty, self-care and the availability of peer support and encourage training
programmes in this regard;
g) Ensure that the safety management system (SMS) addresses mental health related concerns
including the biological and psycho-social risks and its interactions with flight safety; and
h) Identify the best channels to reach out to passengers and provide the relevant information to assist
passengers in their preparations to travel.
Aviation Personnel
a) Practice self-care in all dimensions including healthy nutrition, regular exercise, obtaining sufficient
sleep, practicing mindfulness, reducing stressors, engaging in healthy behaviors and regular
interactions with a personal support network; and
b) Seek support pro-actively to maintain well-being and encourage fellow employees to seek support as
needed.
Aviation Medical Assessors, Aviation Medical Examiners (AMEs) and related Healthcare Professionals
a) Provide a supportive environment for aviation personnel to address their well-being;
b) Proactively discuss work-related challenges during medical certification examinations;
c) Refer for further appropriate support (e.g., to Peer Support Programmes or specialist mental health
support in a collaborative framework);
d) Actively collaborate with fellow AMEs to encourage support, scientific information exchange and
inform decision making, which is consistent with national requirements;
e) Maintain awareness of peer support groups (if available) and keep contact details updated to facilitate
referral of aviation personnel for appropriate support; and
f) Refer to health professionals, as appropriate, where peer support groups are not available or where
more professional support is needed.
Mental Health Screening and Health Promotion
Aviation Medical Examiners are required to interview as part of a screening process of all applicants and
holders of the medical certificates on the questions below to assess if they require further investigation and
referral for treatment if necessary.
Suggested questions for Depression to be asked by Aviation Medical Examiners
i. During the past three months, have you often been bothered by feeling down, depressed, or
hopeless?
ii. During the past three months, have you often been bothered by having little interest or pleasure in
doing things?
iii. During the past three months, have you been bothered by having problems falling asleep, staying
asleep, or sleeping too much, that is unrelated to sleep disruption from night flying or trans-meridian
operations?
iv. In the past three months, has there been a marked elevation in your mood lasting for more than one
week?

Suggested questions for Anxiety/Panic Attack to be asked by Aviation Medical Examiners
i. In the past three months, have you had an episode of feeling sudden anxiety, fearfulness, or
uneasiness?
ii. In the past three months, have you experienced sensations of shortness of breath, palpitations (racing
heartbeat) or shaking while at rest without reasonable cause?
iii. In the past year, have you needed to seek urgent medical advice because of anxiety?
Suggested questions concerning Alcohol Use o be asked by Aviation Medical Examiners
i. Have you ever felt that you should cut down on your drinking?
ii. Have people annoyed you by criticizing your drinking?
iii. Have you ever felt guilty about your drinking?
iv. Have you ever needed a drink first thing in the morning?
v. How many alcoholic drinks would you have in a typical week?
vi. How many alcoholic drinks would you have on a typical day when you are drinking?
Suggested questions concerning Drug Use to be asked by Aviation Medical Examiners
i. Have you used drugs other than those required for medical reasons?
ii. Which non-prescription (over the counter) drugs have you used? When did you last use this
drug/these drugs?
Health Promotion
Aviation Medical Examiners are required to interview as part of a screening process of all applicants and
holders of the medical certificates on the questions below to assess if they require further investigation and
referral for treatment if necessary.Other areas of health promotion includes includes but are not limited to:
a) Health Education on the impact of smocking

b) Health Education on the impact of over and underweight
c) Health Education on screening for cancers and other conditions
d) Others related topics

6.9. Flexibility in the Application of Medical Requirements
The range of variation between individuals is such that if medical Standards are laid down in rigid terms, they
will inevitably exclude a number of applicants who, though not meeting the Standards in all respects, might
nevertheless be considered capable of performing duties safely in the aviation environment. Since the Chicago
Convention lays on Contracting States the duty to promote efficient and safe aviation as well as to regulate it,
provision has been made in Annex 1 for the exercise of a degree of flexibility in the application of medical
Standards, thus avoiding the hardship and injustice which might otherwise occur. It is essential for the
maintenance of flight safety that the manner in which flexibility is exercised should be reasonably uniform
throughout the Contracting States if international acceptance of licences is to be maintained. In the past,
flexibility has been used in widely differing ways by States. The application of the principles set out in this
chapter will assist in achieving uniformity.
6.9.1. The Exercise of Flexibility
If the medical Standards prescribed for a particular licence are not met, the appropriate Medical Assessment
shall not be issued or renewed unless the following conditions are fulfilled:
a) An accredited medical conclusion indicates that in special circumstances the applicant’s failure to
meet any requirement, whether numerical or otherwise, is such that exercise of the privileges of the
licence applied for is not likely to jeopardize flight safety.
b) The relevant ability, skills and experience of the applicant and operational conditions have been given
due consideration.
c) The licence is endorsed with any special limitation or limitations when the safe performance of the
licence holder’s duties is dependent on compliance with such limitation or limitations.
The provision of a degree of flexibility must not lead to a situation where its use becomes the rule rather than
the exception. This has been worded clear in the ICAO manual, so that flexibility may be exercised only in the
exceptional case. Failure to observe this requirement could result in routine approval of individuals not meeting
specific medical requirements, such as visual standards, thus creating an abuse of the primary object of
flexibility. When evidence accumulates that flexibility is being utilised repeatedly in a particular respect, then
the appropriateness of regulations defining the medical requirements comes into question and the suspicion is
raised that the regulations define a requirement which is not in keeping with the demands of flight safety.
However, when decisions to exercise flexibility are backed by an accredited medical conclusion, this indicates
that these decisions have not been regarded as a routine measure but that they have been taken following
close examination and assessment of all the medical facts and their relationship to occupational demands and
personal performance. The degree and intensity of investigation lying behind each decision accurately
measures compliance with the principles behind the flexibility Standard.

The just and safe exercise of flexibility should be confined to the exceptional case, and it ought to be
considered in relation to the expertise of those concerned in applying accredited medical conclusion. As a
consequence, “accredited medical conclusion” is a basic concept and has been specifically defined in Annex 1
as “the conclusion reached by one or more medical experts acceptable to the Licensing Authority for the
purposes of the case concerned, in consultation with flight operations or other experts as necessary. The
estimation of risk imposed by the individual upon flight safety is a most difficult task and one often requiring
experts in a number of aspects of both medicine and aviation. Decisions should recognize that public interest
and safety is the statutory basis for personnel licensing.
6.9.2. The terms “waiver” and “flexibility”
The standard term “waiver” is frequently referred to as the “waiver clause”, and the term “medical waiver” in
connection with medical certification and licensing is generally accepted. However, the use of the term
“waiver”, which in legal usage means “an act of dispensing with a requirement”, and the verb “to waive” which
is defined as “not to insist upon”, “to ignore, neglect or disregard”, “to refrain from applying or enforcing (a rule
etc.) or “to make an exception”, is unfortunate. In fact, the correct exercise of “flexibility” as described is quite
the opposite of “waiver” because the decision to apply the clause is only reached after subjecting the individual
involved to a critical analysis, possibly involving detailed personal examination together with deliberations by
those who formulate the “accredited medical conclusion” and the decision of the Licensing Authority.Waivers
are approved by the Aeromedical Committee through the Medical Assessors commonly on medication that is
new and has not been officially approved on the list of medication that is acceptable or applicants who have
been initiated on a new medical protocol .
6.9.3. Medical Practical Flight Test and Medical Deficiency Compensation and Flight Safety
Where a medical deficiency exists, the extent to which flight safety is affected is the vital factor, rather than the
extent to which failure to attain the medical requirements is capable of being compensated. In some cases, the
question of compensation for a deficiency will be irrelevant, for example where the risk is one of sudden
incapacitation rather than an inability to physically carry out a required task. In other cases, the ability to
compensate, for example, for an orthopaedic dysfunction may be an important factor in the overall assessment
of the effect on flight safety. Previously acquired skills and experience may similarly be irrelevant or important
to the overall assessment of the safety risk. The medical case requiring practical flight test may be identified
through Aeromedical Committee or Verification Processes by the MA or PN. The specialist appointment are
depended on the applicant’s disability.
The medical practical flight test team comprise of MA, FOD flight inspector, Medical Specialist, senior DAME
and other. The minimum time required to arrange a practical flight test is 6 (six) weeks as an aircraft or
simulator have to be arranged. The Medical Department is responsible for coordinating a medical practical
flight.
Medical Appeals
The Act makes provision for applicants to appeal against the medical decisions of the designated aviation
medical examiners, authorized officers or designated bodies to the Director. The SACAA appoints medical
specialists, clinical psychologists and senior designated aviation medical examiners to assist in the
adjudication of medical appeals.

The Director is empowered to establish a medical appeal known as the Medical Appeal Panel (MAP) to
adjudicate of medical appeal cases on ad hoc basis in line with medical practitioners appointed in terms of
section with section 119(2) of the Civil Aviation Act, 2009 (Act No.13 of 2009). The MAP has no executive
powers other than those specifically delegated to it in these Terms of Reference. The MAP is an appeal
advisory body of medical, psychological and ancillary health experts to advise and make recommendations to
the Director on the medical appeals lodged against the decision of the Aeromedical Committee by aviation
personnel who are required in terms of the Civil Aviation Regulations (2011), to hold medical certificates and
privileges.
6.10. Flight Crew Incapacitation
Introduction
The impressive growth of international civil aviation during the past decades has been accompanied by a
continued concern for safety in air travel. The number of air carrier accidents per year will increase if industry
growth continues and accident rates remain unchanged. It is, therefore, essential to continue to examine all
areas which have an impact on flight safety. One such area is that of in-flight pilot incapacitation, which can be
defined as any reduction in medical fitness to a degree or of a nature that is likely to jeopardise flight safety.
This might be regarded as a “medical definition” focusing as it does on medical fitness. Note, however, that
incapacitation can also occur in a medically fit individual, e.g., smoke inhalation or effects of a laser beam on
vision. A doctor practicing aviation medicine should be familiar with the relevant operational environment and
the wide variety of possible causes of incapacitation. Minor degrees of reduced medical fitness may go
undetected by other crew members during normal flight operations and lowered levels of proficiency may be
rationalised, e.g., poor handling may be attributed to lack of recent handling experience. However, when
abnormal conditions or an emergency occur, flight crew may have to perform complex physical and mental
tasks under time constraints, and in such circumstances even a minor deficiency in performance could be
operationally significant. Some effects of mild incapacitation include a reduced state of alertness, a mental
preoccupation which may result in a lack of appreciation of significant factors, increased reaction time, and
impaired judgment.
6.10.1. Controlling the risk of pilot incapacitation
Pilot incapacitation has been of concern for as long as powered flight has existed. It represents an operational
risk, and it can therefore be defined operationally as “any physiological or psychological state or situation that
adversely affects performance”. There are sound reasons for considering an operational definition. From the
operational standpoint, it is irrelevant whether degraded performance is caused by a petit mal episode,
preoccupation with a serious personal problem, fatigue, problematic use of psychoactive substances or a
disordered cardiac function. The effects may be similar, and often other crew members will not know the
difference. A great deal about pilot incapacitation has been learned over the past decades. One of the most
important things is that the risk to aviation safety in situations where a pilot is physically incapacitated can be
virtually eliminated in air transport (multi-crew) operations by training the pilots to cope with such events. In
1984 the medical director of a major British airline reported the results of a study of pilot incapacitation that
remains the most comprehensive to date (see Chapman, 1984). It included over 1 300 “subtle” incapacitations
which were simulated to occur at critical phases of flight during routine competency checks in a simulator.

Five hundred of these incapacitations were deliberately planned to occur with other major failures in a “worst
case” scenario. Major failures were not included in the remaining 800 incapacitations so that “the simulation
was of a subtle incapacitation, still taking place at a critical phase of flight, but as an event in itself and not
complicated by other major failures”. This latter scenario is the more realistic, since the risk of an
incapacitation occurring simultaneously with a major technical failure is extremely remote. In the simulator it
was found that only one in 400 “uncomplicated” incapacitations resulted in a simulator “crash”, because the
second pilot successfully took control on the 399 other occasions. If certain assumptions about a typical multi-
crew flight are made, this knowledge can be used to calculate an acceptable risk of incapacitation for an
individual pilot.
These assumptions are:
a. Each flight lasts one hour.

b. Only 10 per cent of the flight time is critical, viz. take-off and initial climb, approach, and landing (in a one-hour
flight this comprises the first and last three minutes).
c. Pilot incapacitations occur randomly during a flight.
d. One in 100 real-life incapacitations occurring in the critical periods would result in a fatal accident, a more
pessimistic view than that suggested by the simulator studies mentioned above (one in 400), where simulated
incapacitations could be anticipated by the flight crew. Based on these four assumptions, the so-called “1%
rule” has been developed.
6.10.2. Causes of Incapacitation
A dramatic form of pilot incapacitation, although not necessarily its most hazardous, is death in the cockpit. A
survey (1993-1998) of flight crew incapacitation on United States scheduled airlines recorded five deaths in the
cockpit, all owing to cardiovascular diseases. The youngest pilot was 48 years of age when he died. No case
resulted in aircraft damage or operational incident. It should be noted that ICAO introduced the requirement for
incapacitation training in two-pilot operations in the 1970s and this has undoubtedly reduced the risk to flight
safety from pilot incapacitation.
Incapacitations from self-limiting illness may be less dramatic but are considerably more frequent. In two
studies of airline pilots, in 1968 and again in 1988, more than 3 000 airline pilots completed an anonymous
questionnaire survey including questions about whether they had ever experienced an incapacitation during a
flight. In both studies, which revealed remarkably consistent results, about 30% answered “yes”. However, only
about 4% considered their incapacitation a direct threat to flight safety. In both studies the most frequently
cited cause of incapacitation was acute gastroenteritis (see the table below).
Causes of incapacitation in airline pilots, in order of frequency (adapted from Buley, 1969; Green and James,
1991)
1. Uncontrollable bowel action (21%) and “other” gastrointestinal symptoms (54%) 75%
2. Earache/blocked ear 8%
3. Faintness/general weakness 7%
4. Headache, including migraine 6%
5. Vertigo/disorientation 4%

As can be seen, most of these incapacitations are caused by gastrointestinal upsets which are usually
impossible to predict. Whilst they may represent little more than varying degrees of discomfort and
inconvenience, they can also be completely incapacitating. Here is an example taken from a pilot’s report:
“Trip was normal up to time of incident. Approximately half-way between LAS and LAX, shortly after reaching
cruise, I experienced severe abdominal pains which soon rendered me incapable of operating a safe flight. I
turned command over to the First Officer and put the Second Officer in the First Officer’s seat while I lay in
great pain on the cockpit floor.Trip landed safety at LAX with First Officer . . . at the controls. An ambulance
was requested by the crew...
I was taken to the Daniel Freeman Hospital in LAX where . . . (I was given) . . . a diagnosis of gastroenteritis.
I think that spells food poisoning in our language. After some medication I felt wonderfully relieved and was
released from the hospital. “Fortunately, gastroenteritis rarely occurs so suddenly as to prevent a planned
handover of control, thereby minimising the flight safety risk. Pilot incapacitation is clearly both a traditional
aeromedical problem and a straightforward training problem. As long ago as 1970, a past Chief of ICAO’s
Aviation Medicine Section wrote: “It is suggested that acknowledgement of pilot on-duty incapacitation as a
permanent part of the air transport industry scene in the foreseeable future constitutes a constructive rather
than a defeatist medical position. Further, it appears essential that the design, management, operational,
training, and licensing disciplines should recognise that pilot incapacitation must be given due weight in the
overall judgment of what level of safety is practically available.”
Medical screening, by itself, cannot be relied upon to reduce the hazard of incapacitation to an acceptable
minimum level, even if significantly more rigorous medical standards were to be applied. Other important
aspects include pilot education in the causes of incapacitation, pilot training for safe handover of controls in
such an event and, especially, good food hygiene and low-risk, separate meals for the fight crew. From the
operational/training viewpoint, the maxim that “any pilot can become incapacitated at any time” is apposite.
6.10.3. Pilot Incapacitation Training
Pilot training in the early recognition of incapacitation and in safe handover of controls, pioneered in the United
States, has been highly effective in preventing accidents from physical incapacitation. It seems less effective in
the case of mental incapacitation. Because the majority of accidents result from human failure of some sort,
degradation of performance from commonly occurring sub-clinical conditions such as mild anxiety and
depression, sleep loss and circadian rhythm disturbance is an important factor in this area of relative
incapacitation. Although mostly a small problem amongst flight crew, the problematic use of psychoactive
substances is likely to become more important as their general use in society increases.
Incapacitations can be divided into two operational classifications: “obvious” and “subtle”. Obvious
incapacitations are those immediately apparent to the other crew members. The time course of onset can be
“sudden” or “insidious” and complete loss of function can occur. Subtle incapacitations are frequently partial in
nature and can be insidious because the affected pilot may look well and continue to operate but at a less than
optimum level of performance. The pilot may not be aware of the problem or capable of rationally evaluating it.
Subtle incapacitations can create significant operational problems.
A series of 81 simulated obvious and subtle incapacitations showed that pilots needed help in two areas: their
first need was for a method of detecting subtle incapacitations before they became operationally critical; their
second need was for an organised method of handling the incapacitations once they were recognised. It was
learned that all pilot incapacitations create three basic problems for the remaining crew. This is true whether

the incapacitation is obvious or subtle and whether there is a crew of two (or more) members. Although this
study was carried out many years ago, its recommendations are still valid. If an in-flight incapacitation occurs,
the remaining flight crew must:
a. Maintain control of the aircraft.

b. Take care of the incapacitated crew member. (An incapacitated pilot can become a flight deck hazard
and, in any case, is a major distraction to the remaining crew. For this reason, responsibility for the
incapacitated pilot, who should preferably be removed from the flight deck, should be given to the
cabin crew.)
c. Reorganise the cockpit and bring the aircraft to a safe landing.
These three steps became the organised plan for handling in-flight incapacitation. They should be taken
separately and in order.
6.10.4. “Two communications” rule
The “two communications” rule was developed to meet the need for a method of detecting subtle
incapacitations before they become operationally critical. The rule states: “Flight crew members should have a
high index of suspicion of a ‘subtle’ incapacitation any time a crew member does not respond appropriately to
two verbal communications, or any time a crew member does not respond appropriately to any verbal
communication associated with a significant deviation from a standard operating procedure or a standard flight
profile.” This rule is easy, straightforward, and effective.
6.10.5. Cognitive incapacitation
A particular category of incapacitations has been identified as “cognitive.” The problem created by these
incapacitations is how to deal with a pilot who is “mentally disoriented, mentally incapacitated or obstinate,
while physically able and vocally responsive”. In this category, the captain presents the most difficult case.
While cognitive incapacitations may seem to be psychologically based, in some cases the underlying causes
are pathological, as with a brain tumour, causing an erratic performance. Retrospectively, there often seems to
have been ample warning of an impending problem. In most cases of cognitive incapacitation, the pilot
demonstrates manifestly inappropriate behaviour involving action or inaction, and the inappropriate behaviour
is associated with failures of comprehension, perception, or judgment.
These kinds of incidents seldom occur in isolation because, in most cases, they represent a pattern of
behaviour. Two excerpts from reports to NASA’s ASRS (National Aeronautics and Space Administration’s
Aviation Safety Reporting System) illustrate the repetitive nature – or pattern – of what may be examples of
this grey, but important, problem area.“On two occasions we descended through our assigned altitude. I was
the non-flying pilot and made all the callouts. On both occasions, in addition to the required callouts, I informed
the flying pilot that we were descending through our assigned altitude. His corrections were slow and on one
occasion we went 400 feet below, and on the other, 500 feet below the assigned altitude. In addition, his
airspeed and heading control were not precise . . .”

The reporter elaborated further in a telephone call:“Captain reacted almost catatonically to his altitude callouts
and the additional callouts that they were descending through the cleared altitudes. Definitely very delayed
reactions. Other aspects of the trip were reasonably normal except that Captain missed several radio
transmissions. It was as if he simply didn’t hear them.”From a telephone call to a pilot reporting a different
incident:
“Reporter believes Captain has serious and persistent ‘subtle’ incapacitation problem. Reported incident
(which included successive altitude deviations) . . . happened on first trip of the month . . . Remainder of month
with Captain has had same pattern with many cases of very poor performance . . . Seems to be increasingly
slow thinker in the aeroplane. Must be reminded of things several times, even including getting his signature
on required papers . . .”
The deliberate failure to follow established rules and procedures is a very old problem and the “maverick” pilot
is by no means a new phenomenon. One Chief Medical Officer commented on the difficulties with dealing with
aberrant behaviour in the medical context. The following paragraph is taken from his paper given at an
aeromedical examiner symposium in the 1980s:“Psychiatric disturbances giving rise to unusual behavior are . .
. like alcoholism . . . often covered up. There is, however, genuine difficulty here, for aviation attracts
eccentrics — indeed, aviation has only reached its present state because of eccentrics. It is often very difficult
to define the boundaries between normality, eccentricity, and psychiatric disorder, and individuals, not
uncommonly, cross over these boundaries from day to day. The ICAO definition — ‘manifested by repeated
overt acts’ — is a useful indicator of the need for, at least, investigation.”
The nature of air transport operations is such that the individuals in the best position to observe repeated overt
acts and, from a practical standpoint, the only ones situated to do so, are other crew members. This creates a
different sort of resource management problem. It is an obvious challenge for management. It is also a
challenge for pilot-representative organization’s. Control of the incapacitation risk is dependent upon effective
operational monitoring. A basic requirement for that monitoring is that all flight crew members must know what
should be always happening with and to the aeroplane. This is one of the most important reasons for following
standard operating procedures (SOPs) and flying standard flight profiles. The real importance of SOPs lies as
much in the area of information transfer as it does with respect to the issue of the proper way to fly the aircraft.
Routine adherence to SOPs helps to maximise information transfer in much the same way that the use of
standard phraseology does in air traffic control communications.
Detection of subtle incapacitation may be indirect, i.e., as a result of a pilot not taking some anticipated action.
If, for example, the pilot conducting the approach to land silently loses consciousness and his body position is
maintained, the other pilot may not be aware of his colleague’s predicament until the expected order of events
becomes interrupted. Regular verbal communication built into standard operating procedures, and use of the
“two communication rules” are helpful to detect subtle incapacitation, especially when physical control inputs
are unnecessary, e.g. automatic approach.
6.10.6. “Fail-Safe Crew”
The object of “fail-safe crewing” is to provide an adequate number of crew members to cope with flight crew
workloads, and to make it possible to fully integrate the flight crew members into a flight crew team so as to
establish a crew in which there is always at least one fully competent pilot at the controls. Ideally the actions of
each crew member should continuously be monitored by his fellow crew member(s). The concept aims at

achieving maximum safety in the operation of the aircraft and equitable distribution of cockpit workload so as
to ensure the crew can cope with all requirements, including peak demands in adverse weather or under
emergency conditions, such as in-flight pilot incapacitation.
The “fail-safe crew” concept is the key ingredient for successfully dealing with any form of pilot incapacitation.
Support at all levels of management and pilot representation is needed for the “fail-safe crew” to, in practice,
do justice to the concept. Meaningful simulator training, reinforced with a suitable education programme, is a
requirement. The story of controlling the incapacitation risk in air transport is the story of a progress made in a
series of small but important steps. Learning to manage the cognitive incapacitation risk remains an important
goal.
6.11. Crew Resource Management
In modern flight operations, line-oriented flight training (LOFT) emphasises that resource management is
making a substantial contribution to flight safety. A captain representing a pilots association explained the
concept as follows:“. . . One of the basic fundamentals of this philosophy is that it is the inherent responsibility
of every crew member, if he be unsure, unhappy or whatever, to question the pilot-in-command as to the
nature of his concern. Indeed, it would not be going too far to say that if a pilot-in-command were to create an
atmosphere whereby one of his crew members would be hesitant to comment on any action, then he would be
failing in his duty as pilot-in-command…”
Training in crew cooperation, called crew resource management (CRM), is now provided by most major
airlines but frequently not to the same extent by smaller operators. In smaller companies, procedures are less
standardised and a greater degree of individuality is tolerated, so behavioral problems can be expected to be
more common, and experience has shown that this is the case. Over several years CRM has been expanded
to include the interaction between flight and cabin crew in recognition of the fact that cabin crew members can
sometimes have operationally relevant knowledge that flight crew do not have. This was dramatically
demonstrated in the United Kingdom in 1989 when a flight crew shut down the wrong engine of a Boeing 737.
Although the pilots believed their action was correct, the cabin crew had seen flames issuing from the other
engine, but unfortunately this information was not communicated to the flight crew. In the ensuing crash
several passengers and crew members were killed or severely injured. While most would agree that CRM
training is helpful in promoting flight safety, its assessment is more controversial. Interpersonal relationships
are not particularly amenable to measurement, and there is much suspicion among pilots about any process
which attempts, or seems to attempt, to measure personality.
6.12. Evidence-Based Decision Making
A continued assessment of in-flight crew incapacitation as a flight safety hazard requires collection of related
data. Reporting of incapacitation incidents to ICAO is an integral part of an accident/incident reporting system
on a worldwide basis, but suffers from two major difficulties: firstly, the data is incomplete as not all Contracting
States send information on accidents and incidents, and secondly, the data rarely assessed and classified by
personnel who understand the medical implications. Moreover, Contracting States which have their own
reporting system are often hampered by the confidential nature of the information supplied. For example, a
report following an incapacitation is often filed by another crew member who does not reveal the name of the
incapacitated person, making follow-up difficult.

Further, incapacitation data classified by means of a layman’s diagnosis may be incorrect or misleading: a pilot
who collapses with abdominal pain may be suffering from one of a number of medical problems but is likely to
be diagnosed by other crew members as having a gastrointestinal upset. The diagnosis might not be relevant
at the time of incapacitation but is important for monitoring medical standards and in determining where the
maximum benefit for a given effort is achieved with respect to reducing the incidence of in-flight incapacitation.
Attention needs to be given to devising a more accurate, preferably international, method of recording and
classifying data on in-flight incapacitations.
In recent years ICAO has taken the initiative to require a Safety Management System (SMS) to be
incorporated into the routine management of aerodromes, air traffic and airlines. An integral part of SMS is that
of measuring and recording safety events, and of setting targets. In 2010, medical provisions became
applicable in Annex 1 that recommend the application of safety management principles to the medical
assessment process of licence holders, including the routine analysis of in-flight incapacitation events. It is to
be hoped that this development will provide the stimulus towards a more evidence-based application of
aeromedical standards. Safety management principles as applied to the medical certification process are
addressed in more detail in Part I, Chapter 1, of this Manual.
6.13. Conclusions
In-flight pilot incapacitation is a safety hazard and is known to have caused accidents. Such incapacitation
occurs more frequently than many other emergencies that are routinely trained for, such as sudden
decompression. Incapacitation can occur in many forms, ranging from sudden death to a not easily detectable
partial loss of function, and has occurred in all pilot age groups and during all phases of flight. It is important to
recognise the operational ramifications of pilot incapacitation. Medical officers working for regulatory bodies
should be fully aware of the operational aspects. Instruction and training of flight crew concerning action in the
event of in-flight pilot incapacitation should include early recognition of incapacitation as well as the
appropriate action to be taken by other flight crew members.
6.14. The 1% Rule
During the last decades of the 20th century, a number of Contracting States were approaching a fatal accident
rate of one in 107 flying hours. Some Contracting States therefore set as their target a maximum fatal accident
rate of one in 107 flying hours, with human “failure” constituting one tenth of the risk and human failure caused
by medical incapacitation comprising one tenth of the human failure risk, or one hundredth of the total risk, i.e.,
medical incapacitation should not result in a fatal accident more often than one in 109 hours. Based on the
assumptions stated above, a pilot flying a two-pilot aircraft can have an incapacitation risk of no more than one
in 106 hours, and the operation will achieve the target medical cause fatal accident rate of no more than one in
109 hours, since the presence of a second pilot reduces the risk by a factor of 1 000. This is because in a
multi-pilot aircraft only 10% of flight time is critical (risk reduced by a factor of 10) as incapacitations are
assumed to occur randomly.
Therefore, only one in 10 in-flight incapacitations will occur during a critical stage of flight and thus pose a flight
safety risk. Only one in 100 incapacitations occurring at a critical stage of flight is likely to result in a fatal
accident (risk further reduced by a factor of 100). Therefore, the total risk reduction with the addition of a

second pilot is 1/10 × 1/100 = 1/1 000, i.e. the risk is one 1 000th of the risk of single pilot operations. For a
pilot with an incapacitation risk of one in 106 hours, a second pilot therefore reduces the risk of a fatal accident
from pilot incapacitation from one in 106 hours to one in 109 hours. In other words, only one fatal accident in
one thousand in-flight pilot incapacitations would be expected to result in a fatal accident, because the other
pilot would take over safely in the other 999 times. For an individual pilot flying a multi-crew aircraft the
acceptable risk of incapacitation may therefore be increased by a factor of 1 000 from one in 109 to one in 106
hours.
An incapacitation rate of one in 106 hours approximates to a rate of 1% (or one in 102) per annum (since there
are 8 760 – close to 10 000 or 104 – hours in one year). More explicitly:
One in 106 hours = 0.01 in 104 hours (dividing both figures by 100)
One in 104 hours = 1% in 104 hours
1% in 104 hours approximates to 1% in one year (because there are 8 760 hours per year)
The acceptable maximum incapacitation rate of 1% per annum outlined above has become known as the “1%
rule”. This rule specifies a predicted annual medical incapacitation rate which, if exceeded, would exclude a
pilot from flying in a multi-crew aircraft. This is widely regarded as an acceptable risk level and was adopted by
the European Joint Aviation Authorities as the basis of aeromedical risk assessment. The “1% rule” cannot
apply to a solo pilot flying in public transport operations, because it is derived from two-pilot operations and the
availability of a second pilot to take over in the event of one pilot becoming incapacitated. However, the “1%
rule” has also been applied to the private pilot population by some States, on a pragmatic basis, such that a
private pilot who develops a medical problem may be permitted to continue to fly as a solo pilot if his risk of an
incapacitation is 1% per annum or less.
This acceptance of an increased risk of incapacitation in a private pilot seems reasonable since the overall
level of safety demanded of private operations is less than that of commercial operations, and it would
therefore be out of place to demand a professional pilot medical standard for private pilot operations. The “1%
rule” provides a rational, objective method of assessing the fitness of applicants. However, other limits of
acceptable incapacitation risk, such as 2% per annum, or even greater, have been suggested. The important
point is that States should endeavor to define objective fitness criteria to encourage consistency in decision
making and to assist in improving global harmonisation of medical standards.
6.15. Licence Limitations
It should be noted that Annex 1 does allow for medical standards to relate to the specific duties that may be
undertaken by an individual licence holder. This is indicated by relevant statements that appear in the Annex
text referring to safe operation of an aircraft or to safe performance of duties while exercising the privileges of
the licence. It follows that an applicant who has been assessed as unfit for one duty may be found fit for
another, and it is possible to envisage a Licensing Authority deciding that an individual would be precluded
from flying as a pilot while being judged capable of safely exercising the privileges of a flight engineer’s
licence.
It is evident that many such possible operational restrictions exist, but they should only be established after
consultation with flight operations experts. An applicant may be found fit to operate an aircraft as a pilot under
supervision or as a co-pilot but not as a pilot-in-command. In cases where prognosis cannot be given with the

necessary degree of certainty, any potential risk to flight safety may, in general aviation where two pilots are
not normally required, be mitigated by a restriction to fly without passengers, outside controlled airspace or
with the carriage of a “safety pilot”. Such a pilot should receive adequate information about the medical
condition which has led to the restriction “valid with safety pilot only”. In addition, he/she must be capable of
acting as pilot-in-command in case of an emergency.
In commercial aviation, a restriction to multi-crew operations may serve a similar purpose. In such a manner it
is often possible to fit individuals into aviation by restricting their licence or limiting their duties and thus
mitigating the risk to flight safety while retaining the experience of individuals who would otherwise be denied a
licence.
7. SECTION 2
7.1. History of Aviation Medicine in South Africa
The Aeronautical Society of South Africa was formed in 1911, and the pilot’s medical requirements at the time
included a good working knowledge of motorcycle/motorcars, a perfect short and distant eyesight, without the
aid of glasses, a restriction on age (35), and marital status. Dr Danie Craven of rugby fame and Prof Jokkel,
later of “Physical Fitness” at the Stellenbosch University, played a key role at Diskobolos near Kimberley in
aircrew selection and fitness training. The formalisation of Aviation Medicine in South Africa took place when
the Aviation Wing of the South African Medical Corps was established in 1922. At this time, a Royal Air Force
medical officer was seconded to conduct the medical examination on the SAAF pilots and train local
physicians about the processes involved in the selection of pilots. Between the period of 1960 and 1990, the
Air Force upgraded to supersonic aircraft and the need for aviation medicine grew apace. A new Institution for
Aviation Medicine was built to house the new technologies, including centrifuge, decompression chambers, re-
compression chambers and other specialised equipment. Since the expensive equipment and technology were
still housed at the Institute for Aviation Medicine (IAM), all disputes, reviews and appeals, were and still are
referred to this institute for discussion.
After World War II, the civilian aviation environment expanded rapidly and the emphasis on aviation medicine
shifted from the military to the civilian sector. In 1934, Union Airways was bought by the South African
government, and renamed South African Airways on 1 February. The first cities served were Cape Town,
Durban and Johannesburg. Dr Harry Z Gelman, a Consultant Ophthalmologist to the South African Airways
wrote a letter on 10 June 1975 to Dr Marius Van der Spuy, the then Director of SAA’s medical division,
suggesting that SA should host an International Congress of Aviation and Space Medicine. Dr Gelman also
suggested that SAA should become a corporate member of the American Aerospace Medical Association,
which to this very day is still maintained. Dr Harry Z and Mrs Joan Gelman managed against high odds to
attend the 23rd ICASM conference in Mexico at the end of September 1975, and their plan was to win the
1976 ICASM for South Africa. This was during the years of SA’s worldwide isolation. Mrs Joan Gelman was
chosen as chairperson of the International Reception Committee of the (big) American Aerospace Medical
Association for two years in succession at that time, a unique honour which had never been given to a non-
American citizen at the time, and in 1975 the 24th ICASM was awarded to SA to host. At this stage, Dr Harry
Gelman realised that SA should have its own aviation medicine association, and he formed the SA Aviation
Medical Association, which is currently known as the SA Society of Aerospace and Environmental Medicine.
Prior to the establishment of the SACAA, all aviation medicine activities were overseen by the Institute for
Aviation Medicine (IAM), a military institution that reports to the Department of Defence. At the time, all the

aviation medicine activities were centralised, until 1991, when a decision was made to decentralise the
system, and delegate the authority to designated medical examiners to examine and certify applicants.
The Aviation Medical Department of the SACAA was established subsequent to an audit finding by ICAO in
1999, which indicated the need for an in-house medical establishment within the SACAA. With the adoption of
Part 67 of the Regulations and the creation of the Aviation Medical Department, the medical certification
oversight function was now under the SACAA. The SACAA is responsible for ensuring that licensed aviation
personnel meet the medical fitness standards prescribed by the International Civil Aviation Organisation
(ICAO) Annex 1 and the Civil Aviation Regulations Part 67.
7.2. Establishment and Management of the SACAA
The SACAA is a regulatory parastatal body, which was established in October 1998. The SACAA’s mandate is
to control, regulate and promote aviation safety, security and the environment. The SACAA was formed in
keeping with the new government's priorities of policy development, economic restructuring and reducing the
burden on the general taxpayer, which was consistent with international trends. Aviation medicine in South
Africa continuous to be decentralised, with the SACAA being responsible for the designation of aviation
medical examiners, development of medical standards, participation in training of medical examiners,
processing of medical appeals, application of accredited medical conclusions and flexibility. The medical
department is also responsible for the oversight of air ambulances, first aid training for cabin crew, and
oversight of communicable diseases at airports, airlines, and air traffic services.
The Institute of Aviation Medicine conducts medical verification processes on behalf of the Director and also
gives initial and recurrent aviation medicine training to designated examiners. The legal responsibility of the
function of the Institute for Aviation Medicine (IAM) is contained in Part 67.00.3 of the Civil Aviation
Regulations. The SACAA is funded by a combination of user fees, levies and money paid by the Department
of Transport for services performed on their behalf e.g., accident investigations. User fees are based on cost
recovery. The SACAA is governed by a Board of Directors appointed by the Minister of Transport.
Following the establishment of the new SACAA in South Africa, the role of the SACAA in the practice of Civil
Aviation Medicine had to be reviewed, as the Authority’s objective is to promote aviation safety by utilising
resources cost-effectively and by establishing partnerships with the industry. The different options available to
the SACAA were evaluated, based on international practice. The oversight functions of the SACAA pertaining
to aviation medicine were specifically explored, as well as the need for continued review of standards to
ensure compliance with ICAO requirements and to maintain comparable standards with best international
practice. A doctor was appointed on a contract basis in April 1999 to conduct research relating to international
medical requirements and South Africa’s compliance therewith. ICAO performed an audit in November 1999
and recommended the establishment of an in-house medical department. The SACAA’s Aviation Medicine
Department was formally established in April 2000. It was initially established to focus on policy and other
medical matters that had not previously received attention, but soon expanded to include various other
functions and services.
Structure and relationships in civil aviation medicine in South Africa
Medical Assessor

The SACAA utilises the services of medical assessors who are based who are based at the SACAA office.
ICAO defines medical assessors as physicians, qualified and experienced in the practice of aviation medicine,
who evaluate medical reports submitted to the Authority by medical examiners. The medical assessors
evaluate medical reports submitted by medical examiners and are therefore required to maintain the currency
of their professional knowledge.
Following medical examination, the medical examiner must forward the medical examination form and
supporting documentation to the designated SACAA within 60 days of medical examination if the manual
system is used, otherwise where the electronic system, where it will be reviewed by medical assessors at the
SACAA, and once the documents are audited a medical certificate may be issued. This certificate may be
different from the one issued by the medical examiner. The medical assessors at the SACAA conduct
verification of medical examinations performed by the designated medical examiners.
7.3. Targeted Medical Standards
The SACAA, in consultation with IAM, SAASMA, RAASA, ATNS and other medical stakeholders, has identified
a need to review the medical standards for Class IV, Air Traffic Controllers and Cabin Crew. The medical
standards currently in force are not targeted towards the operational environment of licence holders, for
example altitude vs non-altitude issues (ATC), terminology used (grounding vs medical withdrawal), multi-crew
vs single crew environment, etc. Based on the information mentioned above, medical standards for Class Four
(4) medical applicants were approved by CARCOM and are awaiting the revision of the class four (4) category
to be finalised, which will be introduced at a later stage.
7.4. Aeromedical Committee of the Civil Aviation Authority (ICAO Flexibility)
The Director of the SACAA established the first civilian committee, known as the Aeromedical Committee, in
June 2010, and the CAA has since appointed a number of committee members, as their contract is valid for
three years. The Aeromedical Committee is an advisory body of medical, psychological, surgical, and ancillary
health experts charged with advising the SACAA on any medical risks posed by existing or prospective
aviation personnel who are required, in terms of the Civil Aviation Regulations (2011), to hold a medical
certificate. Intricate borderline, protocol and complicated cases are referred to the Aeromedical Committee of
the Civil Aviation Authority for review. The primary role of the Aeromedical Committee is to review and make
recommendations on the medical fitness of licensed aviation personnel referred by the Designated Aviation
Medical Examiners (DAMEs) and Aviation Medical Assessors (AMA) so that expert opinions can be tabled for
the fair and consistent application of assessment.
The purpose of the Aeromedical Committee is to assess complex medical cases and to ensure that medical
certificates are not issued or renewed unless the following conditions are fulfilled (ICAO’s Flexibility Clause):
accredited medical conclusion, which indicates that in special circumstances the applicant’s failure to meet any
requirement, whether numerical or otherwise, is such that exercise of the privileges of the licence applied for,
is not likely to jeopardize flight safety, and that the relevant ability, skills and experience of the applicant and
operational conditions have been given due consideration and the licence is endorsed with any special
limitation or limitations when the safe performance of the licence holder’s duties is dependent on compliance
with such limitation or limitations.

7.4.1. Composition and appointment of the Aeromedical Committee
The appointment of members of the Aeromedical Committee was based on the research conducted through
the University of Pretoria (entitled Common Morbidity Pattern, which leads to medical unfitness in civil aircrew
in South Africa). The objective of this study is to: (1) determine the proportion of medical unfitness among the
different medical classes of civilian aircrew in South Africa, (2) identify the medical conditions that lead to
medical unfitness, (3) compare the morbidity patterns among the classes of medical certificate holders that
lead to medical unfitness, (4) assess the average age of crew found to be medically unfit, and (5) compare the
outcomes of the decision of the IAM panel from 2000 to 2008.The SACAA continuous to assess morbidity
patterns based on the cases presented, to continuously ensure that the relevant specialists are represented.
The specialists appointed to the Aeromedical Committee are required to be linked to the Military Hospital and
are nominated by the Deans of Medical Schools from the following institutions: the University of Pretoria,
Walter Sisulu, University of the Witwatersrand and other Intuitions . The committee also has representatives
from the Institute of Aviation Medical Examiners, the Southern African Aerospace Medicine Association, and
the Airline Pilot Association. Air Traffic Control and Cabin Crew Representatives and Senior Designated
Examiners with experience of occupational, regulatory, and clinical aviation medicine are appointed. On
occasion, the Director of Civil Aviation may appoint specialists who are experts in their field but who are not
linked to u
niversities.
7.4.2. Responsibilities of the Aeromedical Committee and dates of the meetings
The members are required to participate in committee meetings in an objective manner and in a way that
enhances civil aviation safety and the civil aviation industry in general. They provide evidence-based medical
opinions concerning specific medical cases and recommend action required to be taken. The members are
required to conduct research and to investigate and interacting with relevant medical societies or research
institutions to ensure that appropriate medical advice is given to the Director. Members are also required to be
familiar with the requirements of the International Civil Aviation Organisation, other Civil Aviation Authorities
and the South African Civil Aviation Medical Requirements prescribed in Part 67 of the Civil Aviation
Regulations, 2011. The Aeromedical Committee meets once a month, on the third Tuesday of the month, and
all documentation required to be presented at the Aeromedical Committee must be submitted seven (7)
working days before the meeting.
7.5. Designated Aviation Medical Examiners
Applicants for Class 1, Class 2 Class 3 and 4 licences must be examined by a designated aviation medical
examiner (DAME) who has been approved by the Director. The results are documented on the prescribed form
and forwarded to the SACAA or designated institution for verification.
8. SECTION 3
8.1. Designation of Aviation Medical Examiners

8.1.1. Designated junior aviation medical examiner.
An aeromedically qualified doctor designated by the Director, and who is granted the authority to perform
medical examinations or tests required for the issuing of Class 4 medical certificates. The content of training of
the Junior Aviation Medical Examiners is under review.
8.1.2. Designated aviation medical examiner
An aeromedically qualified doctor designated by the Director, after consultation with the designated institution,
and granted the authority to perform medical examinations or tests required for the issuing of Class 2 and
Class 4 medical certificates.
Aviation Medicine (AvMed)
Designation of Aviation Medical Examiners Initial (As-Is)
practitioners
Medical
Submit proof of
Apply for adherence to
Complete Pay Designation
Start designation via training and
Designation form fee
e-mail other
requirements
No
Issue letter with

Update SACAA
Provide File records Designation
Administrator
Requirements website
Designation number
met? Forward
Application form
certificate to
DAMES
Issue
Update internal
Designation
database
Certificate
End
Yes
Yes
No
Manager
Forward
Senior
Designation
Approve? Certificate to the
DCA
DCA
Sign certificate
System
SACAA
MS Access
website
8.1.3. Designated Senior Aviation Medical Examiner
A designated aviation medical examiner given the additional authority to perform medical examinations or tests
required for the issuing of Class 1 and Class 3 medical certificates.
DESIGNATION OF FOREIGN AVIATION MEDICAL EXAMINERS

(1) The designation of foreign aviation medical examiner shall be in line with Part 67 and is valid for a
period of one (1) year and the designation application renewal certificate if the aviation medical
examiner meets the requirements.
(2) A foreign aviation medical examiner shall receive training in aviation medicine and shall have practical
knowledge and experience of the conditions under which the holder of licence and ratings carry out
their duties.
(3) A foreign aviation medical examiner shall have practical knowledge and experience but not limited to
flight experience, simulator experience, on-site observation and any other practical experience
considered necessary by the Director.
(4) A foreign aviation medical examiner shall submit proof of competency in aviation medicine which was
issued by a recognized institution before being designated by the Director.
(5) At the time of initial application for designation, an applicant shall submit the following documents or
copies thereof –
(a) medical degree;

(b) certificate, diploma or degrees of any postgraduate professional training in aerospace
medicine;
(c) registration and letter of good standing with the appropriate Health Professions Council
statement affirming that –
(i) there are no current restrictions of medical practice, and there are no adverse actions
proposed or pending by the appropriate Health Professions Council of the State of
practice; and
(ii) there are no known investigations, charged indictments, or pending actions in any court of
law.
(6) A foreign aviation medical examiner shall perform no less than 15 examinations per year after first 24
months.
(7) A foreign aviation medical examiner shall have the ability to read, write, speak, and understand the
English language.
(8) A medical assessor shall conduct periodic oversight of the competence of all designated foreign
aviation medical examiners to assess suitability of their facilities, equipment, and training of their
personnel. A medical assessor shall conduct audits virtual, when necessary, as determined by the
Director.Physical audit may be required at the costs of a designated foreign aviation medical
examiner.
(9) A designated foreign aviation medical examiner shall attend least 80% of the continuous Medical
Education sessions virtually coordinated by the Medical Assessor on behalf of the Director.
(10) A foreign aviation medical examiner shall pay an annual designation fee as prescribed in Part
187.

11) A foreign aviation medical examiner will be required to undergo training in the policies, procedures and tools used
for the issuance of a medical certificate.
12) A foreign aviation medical examiner shall attend at least one aviation medical conference and/or CME course within
each 4-year interval and travel costs and other expenses for the DAME and staff to attend the conferences are the
responsibility of the attendees.
13) The designation and renewal of a foreign aviation medical examiner is subject to compliance of the stipulated
regulations and technical standards prescribed under Part 67 of the Civil Aviation Regulations”.”
9.3.1.1 Designation
The authority to exercise the powers and perform the duties of a designated aviation medical examiner, which
commences on the date on which the document of designation is issued by the Director to the designated
aviation medical examiner and remains in force for a period of 12 months following this date.
9.3.1.2 Termination of designation
The revoking of a designation before the expiry of the 12-month period.
9.3.1.3 Responsibilities of designated medical examiners
Aviation medical examiners have the responsibility to ensure that only those applicants who are physically and
mentally capable of performing safely, may exercise the privileges of their certificates. To properly perform the
duties associated with these responsibilities, DAMEs must:
a. Keep abreast of the general medical knowledge applicable to aviation.

b. Have detailed knowledge and understanding of all rules, regulations, policies, and procedures relating
to the medical certification of applicants; and
c. Possess acceptable equipment and have adequate facilities necessary to carry out the prescribed
examinations.
9.3.1.4 Selection and retention of DAMEs
In the selection and retention of DAMEs, the designated body or institution will recommend only professionally
qualified, practising physicians who have an expressed interest in promoting aviation safety. Only those
physicians who enjoy the fullest respect of their associates and members of the public, whom they serve, shall
be designated, and retained as DAMEs.

9.3.1.5 Criteria for designation
Authority to perform Class 2 and Class 4 examinations.
Credentials
a. DAMEs shall receive training in aviation medicine and shall have practical knowledge and experience
of the conditions under which the holders of licence and ratings carry out their duties.
b. The practical knowledge and experience shall include, but is not limited to, flight experience, simulator
experience, on-site observation and any other practical experience considered necessary by the
licensing authority.
c. DAMEs must demonstrate to the Director of their competency in aviation medicine before designation.
d. At the time of initial application for designation, the physician must submit the following documents or
copies thereof:
Qualifications
a. Medical Degree.
b. Certificate, diploma, or degrees of any postgraduate professional training.
c. Registration with the Health Professions Council and Proof of good standing.
d. Special consideration will be given to those applicants who are pilots, who have special training or
expertise in aviation medicine, or who were previously designated but have relocated to a new
geographical area.
e. There should be no restrictions of medical practice; and
f. There should be no known investigations, charged indictments or pending actions in any court of law.
g. proof of the ability to read, write, speak, and understand the English language.
Distribution
a. There must be a determined need for a DAME in the area.

b. It should be based on adequacy of coverage related to pilot population; and
c. The applicant must agree to comply with the requirements.
Change of status
DAMEs must promptly notify the SACAA, should there be a change in DAME status of authority to practice
medicine.
Professionalism
a. Be informed regarding the progress in aviation medicine.

b. Be thoroughly familiar with the relevant techniques of examination, medical assessment, as well as
certification of applicants; and
c. To abide by the policies, rules and regulations of the designated institution as approved by the
Director.
Examinations
a. A DAME is required to personally conduct all medical examinations. Other physicians or

paraprofessional personnel may perform specialised parts of the examinations under the general
supervision of the DAME, who must sign the documents, and list his/her designation identification
number, both on the application form and on the medical certificate. In all cases, the DAME must
review, certify, and assume responsibility for accuracy and completeness of the total report of
examination.
b. In the event that the medical examination is to be conducted by two or more medical examiners, the
Director shall appoint one of those medical examiners to be responsible for coordinating the results of
the examination, evaluating the findings with regard to medical fitness and the signing of the reports.
c. The designated aviation medical examiner shall ensure, when submitting medical documentation
manually or electronically for verification to the Medical Assessor, that they list their identification
number as prescribed in technical standard 67.00.4(7).
Facilities and equipment
DAMEs must have adequate facilities for performing the required examinations and possess, or agree to
obtain such equipment, or access to the necessary facilities, prior to conducting any aviation medical
examination.
Conduct
DAMEs must comply with the policies, orders and regulations of the designated body or institution as approved
by the Director.
Authority to perform Class 1 and Class 3 Examinations
In addition to the criteria for designation as a DAME, the physician must demonstrate, by compliance with the
requirements for continued service as a DAME, acceptable prior performance as a DAME, authorised to
perform Class 2 and Class 4 examinations for a period of at least three years.
Prohibited examinations.
A DAME may not perform self-examination for the issuing of a medical certificate nor issue a medical
certificate to himself or herself.
Duration of designation

a. Designation of physicians as DAMEs is effective for one year following the date of issue, unless
terminated earlier by the Director of Civil Aviation or the designee. For continued service as a DAME,
the designee must reregister annually.
b. In the event of office relocation or change in practice, a designation will terminate and may be
reissued, on request, by the Director of Civil Aviation. In respect of the relocation, a determination of
adequacy or coverage will be made.
Authority of a DAME
a. The DAME must personally conduct physical examinations in accordance with the guidance and
practices as laid down by the designated institution.
b. The DAME must issue, defer, or deny medical certificates in accordance with the provisions of the
Civil Aviation Regulations Part 67, subject to reconsideration by the designated institution.
Procedures for Designation
a. Physicians must submit a written application to the Director for designation.

b. The Director will inform the applicant in writing of his or her designation and will issue a Certificate of
Designation
c. The designated institution continuously evaluates the performance of each DAME.
d. Only physicians who have demonstrated satisfactory performance in the past and who continue to
show a definite interest in the DAME programme will be re-designated.
e. In addition, the designated institution must identify those DAMEs committing examination and
certification errors and notify the Director, in writing, for appropriate action to be taken.
Information collected by the designated institution and the CAA includes:
a. Data on the adequacy of information on reports of medical examination.

b. Errors made on reports of aviation medical examinations.
c. DAME interest and participation in aeromedical programmes and conferences; and
d. Reports from the aviation and/or medical community concerning professional performance and
personal conduct as it may reflect on the designated institution as well as the Director.
Basis for termination or non-renewal of designation
a. Failure to re-register punctually each year.

b. No examinations performed during the 12 months of initial designation.
c. Performing less than 15 examinations per year after 24 months, while for senior examiners this figure
shall be 30 examinations per year.
d. Disregard of or failure to demonstrate knowledge of the rules, regulations, policies and procedures of
the designated body or institution.

e. Repeated errors after receiving warnings from the designated body or institution.
f. Failure to attend required conferences and/or continued aviation medical education.
g. Movement of the location of practice from where it is presently designated.
h. Failure to participate in any aviation medical programme when requested to do so by the designated
institution or the Director.
i. Unprofessional conduct in performing examinations.
j. Failure to comply with the provisions of the Civil Aviation Regulations Part 67.
k. Personal conduct or public notoriety that may reflect adversely on the designated body or institution or
the Director.
l. Loss, restriction, or limitation of a licence to practice medicine.
m. Any action that compromises public trust or interferes with the DAME’s ability to fulfil the
responsibilities of his or her designation.
n. Any illness or medical condition that may affect the physician's sound professional judgment or ability
to perform examinations.
o. Arrest, indictment, or conviction for violation of the law.
p. Request by the physician for termination of designation; or
q. Any other reason determined by the Director to be in the best interest of aviation safety.
9.3.1.6 Procedures for renewing designations
Before expiration of designation, the DAME concerned must apply for re-designation, in writing, to the
Director. DAMEs whose re-applications are not received will not be re-designated.
9.3.1.7 Procedures for terminating or not renewing designations.
The designated institution will advise the Director when to terminate or not renew a designation. When it is
determined that a designation should be terminated or not renewed, the following procedures are applicable:
a. The DAME will be notified in writing, by certified mail, of the reason(s) for the proposed action.
b. The written notification will give the DAME the option to respond in writing or in person within 30 days
of the date of letter.
c. In cases where a DAME is suspected of fraud or any other activity for which emergency action is
necessary to assure aviation safety, the SACAA will immediately direct the DAME in writing to cease
all further examinations pending further investigation.
d. The investigation must be conducted expeditiously; however, if the Medical Assessor believes that the
DAME’s cessation of further examinations should continue pending final disposition of the matter by
the Director, he or she may so direct the DAME in writing, by certified mail. The termination
procedures must be accomplished expeditiously.

Whether by determination to not re-designate or termination of designation during the designation year, the
DAME must return all SACAA materials (including forms and certificate of designation) to the Director.
9.3.1.8 Fees related to designation.
From 1 April 2021 the following fees will apply to designation of medical examiners:
Regular examiners: Refer to the annual fee increase.
Senior examiners: Refer to the annual fee increase.
9.4 Legal Issues
9.4.1 Confidentiality of information
Examiners must always ensure that medical information remains confidential. Should an examiner, on the
basis of clinical findings, require more tests, informed consent should be obtained from the applicant.
Information must be released to the SACAA and the designated institution on request for purposes of issuing a
medical certificate or a licence or if the examiner believes that it may have an impact on flight safety. Medical
information may not be released to other parties, nor should it be printed on the medical certificate without the
consent of the applicant.
Medical Examination Forms and Medical Certificates
The medical examiner must send the original medical examination form to the SACAA and issue the applicant
with the original medical certificate, which may be manual or generated by the system.
For both the medical examination form and the medical certificate the following is required:
a. The medical certificate must be an original certificate obtained from the CAA or generated by the
EMPIC System.
b. The medical examination form can be obtained from the CAA or can be downloaded from the CAA
website.
c. No photocopies of medical certificates will be accepted.
d. No examination forms or medical certificates other than the ISO approved CAA documents will be
accepted.
e. All documents must be signed by both parties in all the relevant places.
f. Forms with Tippex will not be accepted.
g. Incomplete/illegible forms or certificates will not be accepted.
h. The medical examiner's code must be on all documentation.
i. If any changes or corrections are made on the medical examination form, corrections must be signed
by both parties.
j. No corrections will be accepted on the medical certificate.

k. Pilot licences and medical certificates are regularly inspected abroad, and they may be detained or
even charged with fraud if all the documentation is not in order. It is therefore essential that the
applicant carries the original medical certificate on his/her person, ensuring that no alteration made on
the medical certificate and that the medical certificate is complete.
l. All documentation must be sent to IAM within 60 days of the date of examination. All late submissions
will render the medical certificate invalid.
9.4.2 Training of Medical Examiners
Medical examiners are required to attend a refresher course or attend an acceptable conference every four
years. In addition, examiners should remain current with changes in legislation and the latest developments in
aviation medicine. This can be achieved by reading publications on the CAA website and the Safety Link.
9.4.3 Examination of South African Pilot in Foreign Countries
An applicant in a foreign country should contact an aviation medical examiner that has been approved by the
Director to perform medical examinations on South African pilots. A list of the approved aviation medical
examiners can be found on the CAA web site.
The examination must be conducted in accordance with the requirements of the Civil Aviation Regulations Part
67 and the corresponding technical standards (SA-CATS-MR). The findings of the medical examination must
be documented on the prescribed form and must be sent to the designated institution for certification.
Alternatively, an applicant can contact an examiner registered with other foreign Civil Aviation Authorities to
perform the relevant Authority’s examination. The examination forms and the medical certificate must be
submitted to the SACAA or the designated institution. The designated institution may request additional
examinations on behalf of the Director of Civil Aviation. The foreign medical examiner must hold a qualification
recognised by aviation authorities internationally and submit proof thereof to the Director. A medical certificate
will be issued by the designated institution or the SACAA and may be different from the certificate initially
issued by the medical examiner. Once the applicant has returned to South Africa, he/she will be required to
undergo a new medical examination by a South African aviation medical examiner.

9.4.4 Certification Process of Medical Examinations

Aviation Medicine(AvMed)
Issuing of Medical Certificate (As-Is)
Consult the
Pilot
Accept
Start DAME for
outcome?
appointment
Conduct medical Requirements Issue medical

met?
Yes
examination certificate
DAMES
No
Submit all
Refer to the medical
Yes
Specialist documents for No
verification
End
Aeromedical Verification
Committee process
Issue Certificate Update Internal

SACAA
(Unfit) database
No
Appeals Issue Certificate

Successful? Yes
Process (Fit)
MS
System
Access
Applicants may appeal to the Director of Civil Aviation during any stage of this process.
9.4.5 Summary of Requirements for Designated Aviation Medical Examiners
Examiner Requirements
Junior medical examiner Pass Short Course in Aerospace Medicine
Attend refresher course or conference every four years.
Acceptable performance
Annual re-registration
Examine Class 4 and 5 Medical Certificate applicants only
Regular medical examiner Pass a 2-week Certificate Aerospace Medicine Course
Perform no examinations during the 12 months of initial designation.
Perform less than 15 examinations per year after 24 months.
Senior medical examiner Acceptable performance as regular examiner for three years
Perform a minimum of 30 examinations annually.

9.5 Civil Aviation Regulations 67
9.5.1 Part 67: Medical certification
List of regulations
67.00.1 Applicability
67.00.2 Classes of medical certificates
67.00.3 Functions of Director regarding medical examinations
67.00.4 Designation of aviation medical examiners
67.00.5 Class 4 medical certificates
67.00.6 Period of validity of medical certificates
67.00.7 Application for medical certificate
67.00.8 Issuing of medical certificate
67.00.9 Duties of holder of medical certificate
67.00.10 Validations
67.00.11 Foreign medical examinations
67.00.12 Period of validity of medical records
67.00.13 Substance abuse
67.00.14 Suspension or cancellation of medical certificate
67.00.15 Medical confidentiality
9. Applicability 67.00.1
• This part applies to the issuing of medical certificates for flight crew, cabin crew and air traffic service
personnel.
• The Director may designate medical officers to perform any functions or duties on his or her behalf, in
terms of this part.
• Where appropriate, the reference to the Director in this part shall be deemed to include medical
assessors referred to in sub-regulation (2).
Classes of medical certificates
The classes of medical certificates are as follows: Class 1 Medical Certificate
• ATPL.
• CPL for aeroplane, airship, and helicopter.
• Class I test pilot rating.
• instrument rating.
Class 1 Medical Certificate
• SPL
• PPL for aeroplane, airship, and helicopter.

• flight engineer licence.

• free balloon CPL.
• Class II test pilot rating.
• commercial glider pilot.
• Part 96 authorisation issued under a Part 62 licence.
Class 3 Class 1 Medical Certificate
• ATC.
• Air Traffic Service Assistant.
• RPL.
a) cabin crew member licence.

b) microlight (conventional microlight weight shift) aeroplane pilot licence.
c) gyroplane pilot licence.
d) free balloon pilot licence (non-commercial).
e) light sport aeroplane pilot licence.
f) touring motor glider pilot licence.
g) glider pilot licence (non-commercial).
h) tandem paraglider pilot licence.
i) powered tandem paraglider and para trike pilot licence.
j) tandem hang-glider pilot licence.
k) powered tandem hang glider pilot licence.
l) powered parachute pilot licence.
m) tandem parachutist or skydiver licence.
n) flight instructor licence for microlight, light sport aeroplane, glider, touring motor glider, gyroplane,
gyro-glider, tandem paraglider, powered paraglider, tandem hang-glider, powered hang-glider, and
tandem powered parachute.
o) national test pilot rating.
p) SPL for the licence categories referred to in subparagraphs (i) to (xvi)
a. paraglider licence.
b. powered paraglider licence.

c. powered paratrike licence.

d. weight shift or surface control hang-glider licence.
e. powered hang-glider licence.
f. parachute licence.
g. powered parachute; solo instructor for para-gliding or hang-glider and all powered versions thereof;
h. paragliding, hang gliding and parachuting student licence.
a. A flight crew member who holds a valid Class 1 medical certificate shall be deemed to hold valid Class
2 and Class 4 medical certificates.
b. An ATS personnel member who holds a valid Class 3 medical certificate shall be deemed to hold a
valid Class 4 medical certificate.
c. Upon expiry of a Class 1 medical certificate referred to in sub-regulation (2), a flight crew member may
request, if he or she does not renew a Class 1 medical certificate, that such expired Class 1 medical
certificate be substituted by a Class 2 or Class 4 medical certificate, which shall be valid for the
remainder of the period for which it would have been valid as a Class 2 or a Class 4 medical certificate
as the case may be in accordance with regulation 67.00.6.
d. Upon expiry of a Class 3 medical certificate referred to in sub-regulation (3), an ATS may, if he or she
does not renew a Class 1 medical certificate, request that such expired Class 1 medical certificate be
substituted by a Class 3 medical certificate, which shall be valid for the remainder of the period for
which it would have been valid as a Class 3 medical certificate in accordance with regulation 67.00.6.
e. The medical requirements, standards or guidelines to be complied with by an applicant for, or a holder
of, a medical certificate is as prescribed in Document SA-CATS 67.
f. A holder of a Class 4 medical certificate who flies above 12 000 ft. shall meet the respiratory and lung
function test requirements of a Class 2 medical certificate as prescribed in Document SA-CATS 67.
g. A person under 60 years of age who submits to the Director a duly completed Class 5 medical self-
declaration in the appropriate prescribed form, signed by a medical practitioner registered under the
Health Professions Act. 1974 (Act No. 56 of 1974), shall be deemed to be a holder of a Class 5
medical certificate.
9.1. Functions of Director regarding medical examinations 67.00.3
(1) The Director must –

a. exercise control over medical examinations or tests and over aviation medical examiners performing
such examinations or tests.
b. determine standards for such examinations or tests and for the training of such aviation medical
examiners.

c. issue or amend medical certificates and keep all books or documents regarding such examinations or
tests.
d. apply basic safety management principles to the medical assessment process of licence holders by
inter alia:
i. routinely collecting and analysing medical findings during medical assessments to identify areas of
increased medical risk.
ii. continuously re-evaluating the medical assessment process to concentrate on identified areas of
increased medical risk;
iii. routinely collecting and analysing incapacitation in-flight and on active duty; and
iv. ensuring that accredited medical conclusions are reached.
The Director may designate a body or institution to –
a. exercise control over medical examinations or tests and over aviation medical examiners performing
such examinations or tests;
b. determine standards for such examinations or tests and for the training of such aviation medical
examiners;
c. issue or amend medical certificates and keep all books or documents regarding such examinations or
tests; and
d. subject to the provisions of regulation 67.00.9, advise the Director on any matter connected with such
examinations, tests or aviation medical examiners and on the training of flight crew and cabin crew in
first aid.
e. The designation referred to in sub-regulation (2) shall be made in writing and shall be published in the
Gazette within 30 days from the date of such designation.
f. The powers and duties referred to in sub-regulation (2) shall be exercised and performed according to
the conditions, rules, requirements, procedures, and standards prescribed in Document SA-CATS 67.
g. The designated body or institution shall permit an authorised officer, inspector or authorised person to
carry out such safety inspections and audits which may be necessary to verify the effective
performance of the designated functions in terms of regulation 67.00.3(2).
h.

9.2. 67.00.4: Designation of aviation medical examiners
1. The Director may, after consultation with the designated body or institution, designate aviation medical
examiners to perform medical examinations or tests required for the issuing of medical certificates.
2. The conditions and requirements for and the rules, procedures and standards connected with a designation
referred to in sub-regulation (1) shall be as prescribed in Document SA-CATS 67.
3. The Director shall sign and issue to each DAME a document which shall state the full name of such aviation
medical examiner and contain a statement that –
a. such aviation medical examiner has been designated in terms of sub-regulation (1); and
b. such aviation medical examiner is empowered to –
i. perform the medical examination or test required for the issuing of the appropriate medical
certificate;
ii. subject to the provisions of regulation 67.00.8, issue such medical certificate; or
iii. defer the issuing of such medical certificate pending an appropriate instruction from the
designated body or institution.
9.3. 67.00.5 Class 4 medical certificates
1. Notwithstanding the provisions of regulation 67.00.4, any medical practitioner who is registered in terms of the
Health Professions Council of South Africa, may perform a medical examination for the purpose of the issuing
of a Class 4 medical certificate.
2. The provisions of regulations 67.00.7(1) and (2) apply with the necessary changes to an application for the
issuing of a Class 4 medical certificate.
3. The medical practitioner concerned shall, within 60 days from the date on which the medical examination has
been performed, submit the application to the designated body or institution for the verification of the application
and the issuing of the medical certificate, together with any appropriate –
a. supporting medical reports; and
b. results of medical examinations or tests performed.
4. An applicant who complies with the appropriate medical requirements and standard referred to in regulation
67.00.2(6), shall be entitled to a medical certificate.
5. On receipt of the documents referred to in sub-regulation (3), the designated body or institution shall –
a. verify the application concerned; and
b. if the applicant complies with the appropriate medical requirements and standards referred to in sub-
regulation 67.00.2(6), issue the medical certificate.
6. The designated body or institution may if a medical conclusion requires that –
a. medical examinations or tests be performed at shorter intervals; or

b. additional examinations or tests be performed;

c. endorse the medial certificate with such requirement or limitation.
9.4. Period of validity of medical certificates 67.00.6
1. A Class 1 medical certificate shall, subject to sub-regulation (5), be issued for a period of –
a. twelve (12) calendar months, calculated from the last day of the calendar month in which the medical certificate
is issued, where the applicant is less than 40 years of age on the date on which the medical certificate is
issued;
b. six (6) calendar months in the case of an airline transport pilot (aeroplane or helicopter), engaged in single-crew
commercial air transport operations, calculated from the last day of the calendar month in which the medical
certificate is issued, where the applicant is 40 years of age or more on the date on which the medical certificate
is issued
c. twelve (12) calendar months in the case of an airline transport pilot (aeroplane or helicopter), engaged in multi-
crew commercial air transport operations, calculated from the last day of the calendar month in which the
medical certificate is issued, where the applicant is 40 years of age or more, but less than 60 years of age, on
the date on which the medical certificate is issued
d. twelve (12) calendar months in the case of a commercial pilot (aeroplane or helicopter), calculated from the last
day of the calendar month in which the medical certificate is issued, where the applicant is 40 years of age or
more, but less than 60 years of age, on the date on which the medical certificate is issued;
e. six (6) calendar months in the case of a pilot as specified in subparagraphs (c) and (d), where the applicant is
60 years of age or more; and
2. A Class 1 medical certificate referred to in sub-regulations (1) (c) and (d) shall be valid, subject to the condition that
the holder –
submits a six (6) monthly medical report, if he or she has a medical disease or risk factor for which he or she
receives regular treatment by his or her treating physician or DAME, and the report shall include:
a. the nature of disease or risk factor;
b. information regarding control of risk factors or disease;
c. complications that have developed as a result of the disease or risk factor; and
d. the type of treatment and side-effects of the treatment.
The licence holder should submit an annual follow-up blood test where applicable and adhere to the requirements of
any Schedule or Protocol as detailed in Document SA-CATS 67, where applicable.
Class 2 and 3 Medical Certificates Period of Validity

3. A Class 2 and 3 medical certificates shall, subject to sub-regulation (5), be issued for a period of –
a. in the case of Class 2 certificate, 60 months calculated from the last day of the calendar month in which the
medical certificate is issued where the holder is less than 40 years of age;
b. in the case of Class 3 certificate, 48 months calculated from the last day of the calendar month in which the
medical certificate is issued where the holder is less than 40 years of age;
c. 24 months, in the case where the holder of a Class 2 or Class 3 medical certificate has passed his or her 40th
birthday;
d. months, when the holder of a Class 2 or Class 3 medical certificate has passed his or her 50th birthday.
Class 4 Medical Certificates Period of Validity
4. A Class 4 medical certificate shall, subject to sub-regulation (5), be issued for a period not exceeding –
a. sixty (60) calendar months, calculated from the last day of the calendar month in which the medical certificate is
issued, where the applicant is less than 40 years of age on the date on which the medical certificate is issued;
and
b. thirty-six (36) calendar months, calculated from the last day of the calendar month in which the medical
certificate is issued, where the applicant is 40 years of age or more on the date on which the medical certificate
is issued.
5. Notwithstanding the provisions of sub-regulations (1), (2) (3) and (4), a DAME may, if indications require that –
a. medical examinations or tests be performed at shorter intervals;
b. additional examinations or tests be performed; or
c. when the safe performance of the duties essential to the operation of an aircraft executed by the holder of such
medical certificate, depends on a reduction in the period of validity of such medical certificate or compliance
with any special limitation;
d. reduce the period of validity of such medical certificate and endorse the medical certificate with the reason for
such reduction or with any such requirement or limitation.
Medical Extension Requirement
a. The holder of a medical certificate shall, at least 15 days immediately preceding the date on which such medical
certificate expires, apply for the extension of such medical certificate.
b. Notwithstanding the provisions of sub-regulations (1), (2), (3), (4) and (5), the Director may, on such conditions
as he or she considers necessary, extend the medical certificate for a period not exceeding 30 days.
9.5. Application for Medical Certificate 67.00.7
1. An application for the issuing of a medical certificate shall be made on the appropriate prescribed form.
2. An applicant who attends a medical examination or test for the issuing of a medical certificate shall –
a. produce proof of his or her identity;
b. produce for inspection any licence held for which the certificate is required, and the most recent
medical certificate held, if any; and
c. provide the DAME with a personal statement of medical facts concerning personal, familial and
hereditary history and sign a declaration confirming the accuracy, completeness and truthfulness of
the information contained in the medical examination form.
3. Subject to the provisions of regulations 67.00.3(2)(c) and 67.00.4(3)(b)(iii), an applicant who complies with the
appropriate medical requirements and standards referred to in regulation 67.00.2(6), shall be entitled to a
4. The DAME, after completing the medical examination, shall complete and sign the appropriate part of the
medical examination form.
5. The DAME shall report to the medical assessor any individual case where, in the DAME’s judgement, an
applicant’s failure to meet any requirement, whether numerical or otherwise, is such that exercise of the
privileges of the licence being applied for or held is likely to jeopardize flight safety.
67.00.8 Verification
1. A medical certificate shall be issued by the DAME concerned on the appropriate prescribed form.
2. The DAME concerned shall, within 60 days from the date on which the medical certificate has been issued,
submit the original application together with any appropriate –
a. supporting medical reports; and
b. results of medical examinations or tests performed, to the designated body or institution for verification
purposes.
3. On receipt of the documents referred to in sub-regulation (2), the designated body or institution shall verify that
the holder of the medical certificate complies with the appropriate medical requirements and standards referred
to in regulation 67.00.2(6).
4. A medical certificate issued by a DAME, shall remain in force, subject to any requirement or limitation endorsed
thereon and for the period for which it was issued, provided that the designated body or institution may –
a. if the medical certificate has been issued to an applicant who does not comply with the appropriate
medical requirements and standards referred to in regulation 67.00.2(6), cancel the medical certificate;
or
b. if medical conclusion requires that –
i. medical examinations or tests be performed at shorter intervals;

ii. additional examinations or tests be performed; or
c. when the safe performance of the duties essential to the operation of an aircraft, of the holder of the
medical certificate, depends on compliance with any special limitation, endorse the medical certificate
with such requirement or limitation.
5. Notwithstanding the provisions of this part, a medical assessor may, in exceptional circumstances, issue or
renew a medical certificate to an applicant who does not meet some of the medical standards prescribed in this
Part if –
a. the accredited medical conclusion indicates that in special circumstances the applicant’s failure to
meet any requirement, whether numerical or otherwise, is such that exercise of the privileges of the
licence applied for is not likely to jeopardize flight safety;
b. the relevant ability, skills and experience of the applicant and operational conditions have been given
due consideration; and
c. the licence is endorsed with any special limitation when the safe performance of the licence holder’s
duties is dependent on compliance with such limitation.
6. For the purposes of sub-regulation (2), the words “original application” includes any incomplete application.
9.6. Duties of holder of medical certificate 67.00.9
1. The holder of a medical certificate shall –
a. carry such medical certificate on his or her person when carrying out the duties as a flight crew
member, an air traffic service personnel member or a cabin crew member, as the case may be;
b. not under any circumstances act as a PIC, or in any other capacity as a flight crew member, an air
traffic service personnel member or a cabin crew member, as the case may be –
i. while he or she is aware of any medical condition or medication which could affect the validity
of such medical certificate;
ii. in the case of female licence holders, while pregnant during periods and under circumstances
as prescribed in Document SA-CATS 67;
iii. if the female holder has given birth in the preceding six weeks; or
iv. after such medical certificate has expired;
c. without undue delay, notify the designated body or institution of any –
i. injury;
ii. hospitalisation;
iii. surgical operation or invasive procedure;
iv. regular use of medication;

v. pregnancy (in the case of female medical certificate holders);
vi. absence due to illness for a period of more than 21 days; or
vii. psychiatric treatment, which renders such holder unable to comply with the appropriate
medical requirements and standards referred to in regulation 67.00.2(6).
2. For the purposes of sub-regulation (1)(c), the holder of a medical certificate shall, before such holder
resumes the exercising of the privileges of the licence held by him or her, furnish the designated body or
institution with proof that he or she has fully recovered from the decrease in medical fitness.
3. The holder of a Class 4 medical certificate shall, after the medical certificate has been issued to him or
her, on an annual basis complete and submit to the designated body or institution the medical declaration
as prescribed in Document SA-CATS 67.
4. No flight crew member shall –
a. consume any alcohol less than 8 hours prior to the specified reporting time for operational duty or
the commencement of a shift;
b. commence an operational duty while the concentration of alcohol in any specimen of blood taken
from any part of his or her body is more than 0,02 gram per 100 millilitres;
c. consume alcohol during the operational duty period or whilst on standby for operational duty; and
d. commence an operational duty period while under the influence of liquor or any drug having a
narcotic effect.
5. Flight crew members shall not –
a. exercise the privileges of their licences and related ratings while under the influence of any
psychoactive substance which might render them unable to exercise these privileges safely and
properly; and
b. engage in any problematic use of substances.
9.7. Validations 67.00.10
1. The Director may, after consultation with the body or institution designated in terms of regulation
67.00.3, recognise a foreign medical report, medical assessment or medical certificate issued by an
appropriate authority for the purpose of validating a foreign flight crew member’s licence, air traffic
service personnel’s licence or cabin crew member’s licence.

2. If, because of duty in a State or territory outside the Republic, deferral of the issuing of a South African
medical certificate for a flight crew member or a cabin crew member, as the case may be, has to be
made, such deferral shall not exceed –
a. a single period of six months in the case of a flight crew member of an aircraft used in non-
commercial operations; or
b. two consecutive periods, each of three months, in the case of a flight crew member or a cabin
crew member, as the case may be, of an aircraft used in commercial operations, provided that
in each case a favourable medical report is obtained after examination by a designated
examiner of the area concerned, or, in cases where such a designated medical examiner is
not available, by a physician legally qualified to practice medicine in that area. A report of the
medical examination shall be sent to the Authority where the licence is issued;
c. in the case of a private pilot, a single period not exceeding 24 months where the medical
examination is carried out by an examiner designated by the Contracting State in which the
applicant is temporarily located. A report of the medical examination shall be sent to the
Authority where the licence is issued.
3. After the expiry of the periods referred to in sub-regulation (2), the applicant will be required to
undergo the appropriate medical examination as soon as he or she returns to the Republic.
67.00.10 Foreign Medical Applications
1. The Director may, after consultation with the body or institution designated in terms of regulation
67.00.3, recognise a foreign medical report, medical assessment or medical certificate issued by an
appropriate authority for the purpose of validating a foreign flight crew member’s licence, air traffic
service personnel’s licence or cabin crew member’s licence.
2. If, because of duty in a State or territory outside the Republic, deferral of the issuing of a South African
medical certificate for a flight crew member or a cabin crew member, as the case may be, has to be
made, such deferral shall not exceed—
a. a single period of six months in the case of a flight crew member of an aircraft used in non-
commercial operations; or
b. two consecutive periods, each of three months, in the case of a flight crew member or a cabin
crew member, as the case may be, of an aircraft used in commercial operations: Provided
that in each case a favourable medical report is obtained after examination by a designated

examiner of the area concerned, or, in cases where such a designated medical examiner is
not available, by a physician legally qualified to practice medicine in that area. A report of the
medical examination shall be sent to the Authority where the licence is issued;
c. in the case of a private pilot, a single period not exceeding 24 months where the medical
examination is carried out by an examiner designated by the Contracting State in which the
applicant is temporarily located. A report of the medical examination shall be sent to the
Authority where the licence is issued.
3. After the expiry of the periods referred to in sub-regulation (2), the applicant will be required to
undergo the appropriate medical examination as soon as he or she returns to the Republic.
9.8. Foreign Medical Examinations
1. The Director may recognise any foreign medical report, history and examination form and
investigations issued by an appropriate authority for the purposes of renewing a flight crew member’s
licence.
2. The holder of the licence referred to in sub-regulation (1) shall submit all the medical records, which
may include, but is not limited to, a history and examination form signed by both the licence holder and
the examining doctor registered with the appropriate authority, and all relevant investigations.
3. All medical records submitted in terms of this regulation should be in English, or, if originally in a
foreign language, translated into English by an official translator.
9.9. Period of validity of medical records 67.00.12
The records of a medical examination shall, for the purpose of issuing a medical certificate, be valid for a
period not exceeding 90 days, and a medical certificate may not be issued after this period on the records of
such examination.
9.10. Substance Abuse 67.00.13
1. If there is reasonable suspicion that the holder of a medical certificate is abusing substances, and
thereby poses a risk to aviation safety, the medical officer designated in terms of regulation 67.00.1(2)
may require such holder to undergo substance abuse testing, which shall be done as prescribed in
Document SA-CATS 67.
2. Reasonable suspicion may be as a result of, but not limited to:

a. Observation of physical symptoms;

b. Physical, behavioural, performance indicators;
c. Direct observation of substance use;
d. A pattern of abnormal conduct/erratic behaviour;
e. Arrest or conviction for a drug related offence; or
f. Being the target of a criminal investigation for such an offence;
g. Evidence of tampering with previous substance test specimen;
h. Post rehabilitation.
3. The holder of a medical certificate must submit themselves within 48 hours of being required to do so,
for preliminary substance abuse testing to a Collection Officer appointed by the Director, or to a DAME
at the holder’s expense, as prescribed in Document SA-CATS 67.
4. A holder of a medical certificate who has undergone preliminary testing must be informed of the
results within three days of receipt thereof.
5. The medical officer referred to in sub-regulation (1) may suspend the medical certificate of a person
who has received a non-negative result and such person must be subjected to further confirmatory
testing.
6. The holder of a medical certificate who has received a negative result must be refunded of medical
expenses incurred for collection and analysis of specimen in respect of the substance abuse testing.
7. The holder of a medical certificate who submits himself or herself after 48 hours of being required to
do so is required to undergo confirmatory testing, as prescribed in the SA-CATS 67.
8. The medical officer designated in terms of regulation 67.00.1(2) shall suspend the medical certificate
of a person who refuses to submit himself or herself to a substance abuse testing after being required
to do so.
9. The holder of a medical certificate whose medical certificate is suspended in terms of sub-regulation
(5) or (8) may appeal to the Director against the suspension within 14 days from the date of the
suspension.
10. The provisions of regulation 185.00.6 apply, with the necessary changes, to an appeal lodged in
terms of sub-regulation (9).
11. The site and specimen collection, packaging, transport and lab analysis must be done as prescribed
in Document SA-CATS 67.

9.11. Suspension or cancellation of medical certificate 67.00.14
1. A medical officer designated in terms of regulation 67.00.1(2) may suspend a medical certificate if
there is a reasonable suspicion that the holder of the medical certificate does not comply with the
requirements prescribed in regulation 67.00.9.
2. The medical officer may require the holder of a medical certificate whose certificate has been
suspended in terms of this regulation, to undergo medical examination at the holder’s expense, at a
medical specialist chosen by the medical officer.
3. A notice of the suspension of medical certificate contemplated in sub-regulation (1) must be given in
writing, stating the reasons for the suspension.
4. Notwithstanding sub-regulation (3), the medical officer may notify the holder of the medical certificate
of the suspension otherwise than in writing, provided that a written notification of such suspension is
submitted to the holder immediately thereafter.
5. A person whose medical certificate is suspended in terms of sub-regulation (1) may appeal to the
Director against the suspension within 14 days from the date of the suspension.
6. The provisions of regulation 185.00.6 apply, with the necessary changes, regarding the appeal
contemplated in sub-regulation (5).
7. The holder of a medical certificate who succeeds in an appeal against the suspension shall be
refunded the expenses referred to in sub-regulation (2).
9.12. Medical Confidentiality 67.00.15
1. Subject to the provisions of sub-regulation (2), all information provided by or on behalf of an applicant
for a medical certificate, which is personal medical information, shall be confidential, and shall be used
only in respect of the medical certificate and the entire medical certification process, unless otherwise
authorised by the applicant.
2. Any medical practitioner employed by the designated body or institution shall ensure the protection of
information referred to in sub-regulation (1) which is kept by such designated body or institution,
provided that when medical information appears to be fraudulent, false or misleading, or when such
medical information will jeopardise aviation safety, or when it is necessary for the purpose of an
appeal in terms of regulation 67.00.13, the medical practitioner shall release to the Director such
information for appropriate investigation and action.

Storage of Medical Records: Privacy, Confidentiality and Security of Patient Health Records
In terms of section 17 (1) of the National Health Act No. 61 of 2003, the person in charge of a health
establishment in possession of a user’s health records, must set up control measures to prevent unauthorised
access to those records and to the storage facility in which, or system by which, records are kept. The above
applies to the storage of all patient health records irrespective of the format of the record, whether electronic or
hard copy. Ensuring secure and timely access to a patient’s health record is essential in delivering safe and
effective healthcare services. 6.4 All patient health records must be protected against improper access and
disclosure. (i.e., storage facilities must have secure restricted and authorised access control, electronic data
must be managed, stored and backed up using internationally accepted standards, e.g., ISO 27799:201, for
information security management in health).
Ensure protection of patient confidentiality during electronic data transmission and when documents are being
transferred between facilities and/or healthcare professionals. Patient health records should ideally be stored
indefinitely particularly if this can be done using an electronic format. If this is not practical, a patient health
record should be stored for at least a minimum of six (6) years as from the date that a patient health record
has become dormant (dormancy commences at the time when a patient was last treated by a healthcare
practitioner).
Ownership of Patient Health Records

A patient health record is owned by the health practitioner or the entity generating such a patient health record.
A patient is entitled to have access and obtain the information contained in such a record (see section 9). In
the case of state institutions, where records e.g., radiographs are the property of the institution, original
records and images should be retained by the institution. Copies must, however, be made available to the
patient (or referring health practitioner) on request for which a reasonable fee may be charged in terms of the
Promotion of Access to Information Act (Act No. 2 of 2000). In cases where patients are required to pay for
records and images (e.g., private patients or patients in private hospitals) such patients must be allowed to
retain such records - unless the health practitioners deem it necessary to retain such records for purpose of
monitoring treatment for a given period. Should the patient however require the records and / or images to
further or protect an interest (e.g., such as consulting with another practitioner) he or she must be allowed to
obtain the originals for these purposes.

As the ownership of patient health records in a multi-disciplinary practice depends on the legal structure of the
practice, the governing body of such multi-disciplinary practice should ensure that these guidelines and the
provisions of the Promotion of the Access to Information Act (Act No. 2 of 2000) relating to health records are
adhered to. The Act requires public institutions to appoint information officers to administer access to
information, and similar provisions apply to private bodies. Should a health practitioner in private practice (both
in a single practice and in a partnership) pass away, his or her estate, which includes the patient health
records, will be administered by the executor of the estate:
i. Should a practice be taken over by another health practitioner, the executor shall carry over the
patient health records to the new health care professional.
ii. The new health practitioner is obliged to take reasonable steps to inform all patients regarding the
change in ownership and that the patient could remain with the new health care practitioner or could
request that their patient health records be transferred to another health care practitioner of their
choice.
iii. Should the practice not be taken over by another health practitioner the executor should inform all
patients in writing accordingly and transfer those patient health records to other health care
practitioners as requested by individual patients;
iv. The remaining patient health records should be kept in safe keeping by the executor for a period of at
least twelve (12) months with full authority to further deal with the files as he or she may deem
appropriate, provided the provisions of the rules on professional confidentiality are observed;
v. It should be noted that certain partnership agreements may make specific provision for the
management of a deceased partner’s share in the partnership after the death of a partner and such
management would include dealing with patient health records.
Access to Health Information and to Patient Health Records
Section 10 of the National Health Act (Act 61 of 2003) states that a health practitioner must provide a patient
with a discharge report at the time of discharge from a health establishment. This report must always be in
writing when discharging an inpatient. A verbal report can be provided in case of an outpatient, although it is
not routinely recommended as a record have to be maintained on patient file. In terms of the law the following
principles apply in regard to access to information in patient health records:
a) A health practitioner shall provide any person of age 12 years and older with a copy or abstract or
direct access to his or her own records regarding medical treatment on request (Children’s Act (Act
No. 38 of 2005).

b) Where the patient is under the age of 16 years, the parent or legal guardian may make the application
for access to the records, but such access should only be given on receipt of written authorization by
the patient (Promotion of Access to Information Act (Act No. 2 of 2000).
c) Information about termination of a pregnancy may not be divulged to any party, except the patient
herself, regardless of the age of the patient (Choice on Termination of Pregnancy Act (Act No. 92 of
1996).
d) A health practitioner shall provide any person of age 12 years and older with a copy or abstract or
direct access to his or her own records regarding medical treatment on request (Children’s Act (Act
No. 38 of 2005).
e) Where the patient is under the age of 16 years, the parent or legal guardian may make the application
for access to the records, but such access should only be given on receipt of written authorization by
the patient (Promotion of Access to Information Act (Act No. 2 of 2000).
f) Information about termination of a pregnancy may not be divulged to any party, except the patient
herself, regardless of the age of the patient (Choice on Termination of Pregnancy Act (Act No. 92 of
1996).
g) No health practitioner shall make information available to any third party without the written
authorisation of the patient or a court order or where non-disclosure of the information would represent
a serious threat to public health (National Health Act (Act No. 61 of 2003.
A health care practitioner may make available the patient health records to a third party without the written
authorisation of the patient or his or her legal representative under the following circumstances:
i. Where a court orders the patient health records to be handed to the third party;
ii. Where the third party is a health care practitioner who is being sued by a patient and needs access to
the records to mount a defence.
iii. Where the third party is a health practitioner who has had disciplinary proceedings instituted against
him or her by the HPCSA and requires access to the patient health records to defend himself or
herself.
iv. Where the health practitioner is under a statutory obligation to disclose certain medical facts, (e.g.,
reporting a case of suspected child abuse in terms of the Children’s Act, (Act No. 38 of 2005)).
v. Where the non-disclosure of the medical information about the patient would represent a serious
threat to public health (National Health Act (Act No. 61 of 2003).
In healthcare institutions, patient health records must be kept under the care and control of the responsible
manager. Access to such patient health records shall be subject to compliance with the requirements of the
Access to Information Act and such conditions as may be approved by the relevant authority. Protection of
Personal Information Act (Act No. 4 of 2013) (POPIA) provides that special personal information, such as
religious beliefs, race, health or sex life, and biometric information may be processed by a health/medical
professional, healthcare institutions or facilities or social services, if such information is necessary for the
proper treatment and care for the data subject or patient for the administration of the institution or professional
practice concerned.
Personal information should be kept confidential; and the rest of the conditions in POPIA should be complied
with. 9.5.2 The POPI Act should be read in conjunction with Ethical Booklet 4- Seeking patients’ informed
consent: The ethical considerations, Ethical Booklet 5- Confidentiality: Protecting and providing information,
and other rules and regulations of the HPCSA.
Checklist for Patient Health Record Keeping in Line with HPCSA
Good notes imply good practice, and the following checklist may serve to guide health care practitioners in the
appropriate keeping of patient records:
a) Records should be complete, but concise.
b) Records should be consistent.
c) Self-serving or disapproving comments should be avoided in patient records. Unsolicited comments

should be avoided (i.e., the facts should be described, and conclusions only essential for patient care
made).
d) A standardised format should be used (e.g., notes should contain in order the history, physical
findings, investigations, diagnosis, treatment, and outcome.
e) If the record needs alteration in the interests of patient care, a line in ink should be put through the
original entry so that it remains legible; the alterations should be signed in full and dated; and, when
possible, a new note should refer to the correction without altering the initial entry.
f) Copies of records should only be released after receiving proper authorisation.
g) Billing records should be kept separate from patient care records.
h) Attached documents such as diagrams, laboratory results, photographs, charts, etc. should always be
labelled. Sheets of paper should not be identified simply by being bound or stapled together – each
individual sheet should be labelled.
Signing of Official Documents in line HPCSA Guidelines
Rule 15 of the HPCSA’s ethical rules states that:-
“Any student, intern or practitioner who, in the execution of his or her professional duties, signs official
documents relating to patient care, such as prescriptions, certificates (excluding death certificates) patient
records, hospital or other reports, shall do so by signing such document next to his or her initials and surname
in block letters.
PART 67 TECHNICAL STANDARDS 67.00.4
General (all classes)
a. Impairment or sudden or subtle incapacitation.
Applicants must be free from any risk factor, disease, or disability, which renders them either unable,
or likely to become suddenly unable, to perform assigned duties safely. These may include effects
and/or adverse effects from the treatment of any condition and drugs or substances of abuse.
b. Medical deficiency: Applicants must be free from any of the following, if it results in a degree of
functional incapacity likely to interfere with the safe operation of an aircraft of with the safe
performance of their duties:
i. Congenital or acquired abnormality.
ii. Active, latent, acute, or chronic disability, disease or illness; and
iii. Wound, injury, or outcome of operation.
While physical medical and mental health forms the most important aspect of aviation medical examination it is
important for the designated aviation medical examiners and medical assessors to emphasize health
education and prevention of ill health for all applicants, with special emphasis on applicants who are under 40
years of age.
9.13. Class I medical certificates: Physical and mental standards
Applicants must have no established medical history or clinical diagnosis of –
Psychiatric
1. Any of the following conditions that are of a severity which renders the applicant incapable of safely
exercising the privileges of the licence, or makes it likely that within two years of the assessment the
applicant will be unable to safely exercise the privileges of the licence, will be disqualifying unless
acceptable and effective treatment has controlled any additional risk of functional disorder or sudden
or subtle incapacitation:
a. a psychotic disorder unless the psychosis was of toxic origin and there has been complete
recovery.
b. alcohol or other psychoactive substance abuse or dependence.
c. character or behaviour disorder, severe enough to have resulted in an overt act.
d. any other psychiatric disorder.

e. an organic mental disorder.
f. a mental or behavioural disorder due to use of psychoactive substance, including dependence

syndrome induced by alcohol or other psychoactive substances.
g. schizophrenia or schizotypal or delusional disorder.
h. a mood (affective) disorder.
i. a neurotic, stress-related or somatoform disorder.
j. a behavioural syndrome associated with physiological disturbance or physical factors.
k. a disorder of adult personality or behaviour, particularly if manifested by repeated overt acts.
l. mental retardation.
m. a disorder of psychological development.
n. a behavioural or emotional disorder with onset in childhood or adolescence; or
o. a mental disorder not otherwise specified.
2. An applicant who has a history of psychoactive substance abuse or dependence may apply for an
exemption to the designated body or institution if the following circumstances exist –
a. the applicant has been under medical treatment for psychoactive substance abuse and the
medical practitioner concerned, approved by the designated body or institution, certifies that the
applicant is free from the effects of psychoactive substance abuse.
b. the applicant provides the name of a sponsor who is prepared to certify that the applicant no
longer takes a psychoactive substance in any form. Such a sponsor must be a person acceptable
to the designated body or institution for this purpose.
c. the applicant signs an undertaking not to take any psychoactive substance while holding a valid
licence.
a. A psychotic disorder unless the psychosis was of toxic origin and there has been complete
recovery.
b. Alcohol or other psychoactive substance abuse or dependence.
c. Character or behaviour disorder, severe enough to have resulted in an overt act.

d. Any other psychiatric disorder.
9.14. Class II medical certificates
Physical and mental standards

Psychiatric
a. a psychotic disorder, unless the psychosis was of toxic origin and there has been complete
recovery;
b. alcohol or other psychoactive substance abuse or dependence;
c. character or behaviour disorder, severe enough to have resulted in an overt act;
d. any other psychiatric disorder;
e. an organic mental disorder;
f. a mental or behavioural disorder due to use of psychoactive substance, including dependence

syndrome induced by alcohol or other psychoactive substances;
g. schizophrenia or schizotypal or delusional disorder;
h. a mood (affective) disorder;
i. a neurotic, stress-related or somatoform disorder;
j. a behavioural syndrome associated with physiological disturbance or physical factors;
k. a disorder of adult personality or behaviour, particularly if manifested by repeated overt acts;
l. mental retardation;
m. a disorder of psychological development;
n. a behavioural or emotional disorder with onset in childhood or adolescence; or

medical practitioner concerned, approved by the designated body or institution, certifies that
the applicant is free from the effects of psychoactive substance abuse;
longer takes a psychoactive substance in any form. Such a sponsor must be a person
acceptable to the designated body or institution for this purpose;
c. the applicant signs an undertaking not to take any psychoactive substance while holding a
valid licence.
acceptable and effective treatment has controlled any additional risk of functional disorder or
sudden or subtle incapacitation:
a. A psychotic disorder, unless the psychosis was of toxic origin and there has been complete
recovery;
b. Alcohol or other psychoactive substance abuse or dependence;
c. Character or behaviour disorder, severe enough to have resulted in an overt act;
9.15. Class III medical certificates
Psychiatric
a. psychotic disorder, unless the psychosis was of toxic origin and there has been complete
recovery;
b. alcohol or other psychoactive substance abuse or dependence;

c. character or behaviour disorder, severe enough to have resulted in an overt act;
d. any other psychiatric disorder;
e. an organic mental disorder;
f. a mental or behavioural disorder due to use of psychoactive substance; this includes

dependence syndrome induced by alcohol or other psychoactive substances;
g. schizophrenia or schizotypal or delusional disorder;
h. a mood (affective) disorder;
i. a neurotic, stress related or somatoform disorder;
j. a behavioural syndrome associated with physiological disturbance or physical factors;
k. a disorder of adult personality or behaviour, particularly if manifested by repeated overt acts;
l. mental retardation;
m. a disorder of psychological development;
n. a behavioural or emotional disorder with onset in childhood or adolescence, or
medical practitioner concerned, approved by the designated body or institution, certifies that the
applicant is free from the effects of psychoactive substance abuse;
longer takes a psychoactive substance in any form. Such a sponsor must be a person acceptable
to the designated body or institution for this purpose;
c. the applicant signs an undertaking not to take any psychoactive substance while holding a valid
licence.
acceptable and effective treatment has controlled any additional risk of functional disorder or
sudden or subtle incapacitation:

a. A psychotic disorder, unless the psychosis was of toxic origin and there has been complete
recovery;
b. Alcohol or other psychoactive substance abuse or dependence;
c. Character or behaviour disorder, severe enough to have resulted in an overt act;
Effect of the flight environment
Proper visual performance is essential for flight crew and air traffic controllers if they are to carry out their
duties safely and efficiently. In the flight environment the following factors should be kept in mind because they
may reduce visual performance significantly:
a. high speed;
b. altitude;
c. inadequate cockpit illumination;
d. glare;
e. acceleration;
f. vibration;
g. poor ergonomics; and
h. adverse cabin environment.
The high speeds of modern aircraft while cruising and during take-off or landing make good static and dynamic
vision and rapid reaction time particularly important. Visual perception is usually the first step in the reflex
chain which initiates the motor activity to avoid collision.Altitude affects the quality and quantity of
electromagnetic radiation to which the flight crew are exposed. During flight above clouds, sunlight is reflected
upwards. This inverse light distribution leaves the instrument panel in shadow while the outside is very bright.
The human visual system is designed to function best with illumination coming from above; in some aircraft
with “bubble” canopies, flight over brightly lit clouds may be very uncomfortable. With increasing altitude, the
sky becomes darker, and the contrast between objects seen against the sky increases.
In most commercial aircraft, cabin pressure is controlled but the slight degree of hypoxia experienced even in
pressurised aircraft may impair dark adaptation, reduce visual fields and visual acuity, and cause a small
increase in intraocular pressure. In prolonged flight, the low humidity of the cabin air may cause dryness and
irritation of the mucous membranes, especially of the eyes and the nasopharynx. Space myopia, empty field
myopia or night myopia may occur at high altitude or at any altitude when it is dark, owing to lack of visual
targets outside the cockpit. Under low-contrast conditions a functional myopia of up to several dioptres may
occur with blurred vision and loss of contrast sensitivity. Studies have shown that this kind of myopia is
relatively common.Inadequate cockpit illumination may produce visual problems. Low light levels cause
reduced visual acuity and aggravate the symptoms of presbyopia making reading of small print difficult.
Coloured maps may be difficult to see.
These problems may be accentuated when red lighting is used because of the chromatic aberration of the
human eye. As much of the in-flight information in commercial aviation is gained from instruments, the minor
gain in dark adaptation level using red light or low levels of white light is generally considered to be outweighed
by the loss in overall visual performance.Furthermore, runway illumination on international airports throughout
the world has now reached levels well above the absolute threshold of light perception. On the other hand,
there are numerous situations in general aviation where some degree of dark adaptation is necessary. High
acceleration forces are important in military aviation, agricultural flying and in aerobatics but less so in ordinary
commercial flying. High G-forces may produce grey-out, blackout or red-out depending on the direction of the
acceleration force.Vibration of cockpit instruments and printed material, especially in the 22–64 Hz range, may
impair vision significantly. This is particularly troublesome in helicopters. Low frequency vibrations of 2–10 Hz
encountered in turbulence or on rough runways can also degrade vision. Application of ergonomic principles
and consideration of human factors have done a good deal to improve cockpit design and facilitate information
flow to flight crew. Better instrument displays and thoughtful location of controls are found in many new aircraft
but there is still room for improvement. Good visual function and adequate colour perception are necessary for
proper use of the wide variety of maps, dials and gauges found in modern cockpits.
The Electronic Flight Instrument System (EFIS) in particular employs many different colours. Although these
systems are designed to provide critical information in monochrome in the event of colour failure, it has been
shown that the addition of colours facilitates the perceptual process and improves the understanding of
geometrical figures. Colours are likely to be increasingly important in the virtual cockpit environment of the
future. With ever-increasing sophistication of aircraft, the tendency for information overload remains, and
colour discrimination in all parts of the spectrum is desirable. The older colour perception testing methods
which were mainly concerned with congenital red-green defects in men will not suffice because they fail to
detect yellow-blue defects which are frequently seen in gender-neutral acquired colour vision deficiencies.
9.16. Visual standards
9.16.1. Class I medical certificates
General
1. An applicant may not have –
a. any condition or congenital abnormality of either eye or its attachments likely to impede the safe
exercise of the privileges of the licence;
b. any abnormality of visual fields or significant defect of binocular function;
c. any manifest squint, or large errors of eye muscle balance (phoria);
d. any anatomical or functional monocularity or substandard vision in one eye at initial issue of a
Class 1 medical certificate. However, medical conclusion may permit experienced licence holders
who develop monocularity or substandard vision to be granted a medical certificate with
appropriate restrictions after an adaptation period of at least six months following the loss of
vision.
2. Monocularity means that either an eye is absent, or its vision cannot be corrected to better than 6/24.
Such applicants require evaluation by an ophthalmologist to determine the cause of the visual loss.
Fitness to fly will be determined on a case-by-case basis. The assessment will include practical flight
testing by the SACAA.
3. For monocularity, the appropriate minimum restrictions initially are as follows:
a. “If flying open cockpit aircraft, protective goggles not restricting visual field must be worn”. (This
must remain as a permanent restriction);
b. “Any accompanying pilot must be made aware of the holder’s monocular vision”. (This must
remain as a permanent restriction);
c. “Not valid for flight as pilot-in-command by day or night until a satisfactory flight test has been
completed with a flight examiner in each case”. (This restriction may be removed at subsequent
assessment, according to the results of the flight test, or amended to the endorsement in (d)
below);
d. “Not valid for flight as pilot-in-command by night until a satisfactory flight test has been completed
with a flight examiner”. (This restriction may be removed at subsequent assessment, according to
the result of the flight test).
4. Substandard vision in one eye means one eye meets the required standards for a particular class of
licence but the visual acuity of the other eye cannot be corrected to the required standards, i.e. central
vision better than 6/24 but worse than 6/9, with normal visual fields. Such applicants require evaluation
by an ophthalmologist to determine the cause of the visual loss. Fitness to fly will be determined on a
case-by-case basis. A practical flight test by SACAA to evaluate visual performance may be required.
5. For substandard vision in one eye (vision between 6/12 and 6/24), the appropriate minimum restrictions
are as follows –
a. “Any accompanying pilot must be made aware of the holder’s substandard vision in one eye”.
(This must remain as a permanent restriction);
b. “Not valid for flight as pilot-in-command by night until a satisfactory flight test has been completed
the results of the flight test.)
6. The relevant protocols are contained in Schedules 21 and 22.
Near vision and intermediate vision
1. Near vision: Applicants must be able to read N5 at a distance of 30-50 cm or have equivalent visual
acuity of 6/9, 20/30.

2. Intermediate vision: An applicant must be able to read N14 at a distance of 100 cm or have equivalent
visual acuity of 6/18, 20/100 at 100 cm.
3. An applicant who meets this standard only by use of spectacles may be granted a medical certificate
provided this is endorsed with the following limitation: “Suitable corrective lenses must be readily
available”.
4. This means that these must be available for immediate use when exercising the privileges of licence.
This limitation may be satisfied by the availability of appropriate bifocal, trifocal or multifocal spectacles
which permit the reading of instruments and a chart or manual held in one hand, without impeding the
use of distance vision through the windscreen when wearing the spectacles. Single vision near
correction (full lenses of one power only, appropriate to reading) is not acceptable, since wearing
these significantly reduces distance visual acuity.
5. Near vision and intermediate vision should be recorded by ticking in the appropriate box if the pilot is
able to see N5 at 30-50 cm and N14 at a distance of 100 cm respectively.
6. Near vision and intermediate vision should be tested using a Pocket Vision Screener.
Distant vision
1. Distant vision is to be examined with a 6 m Snellen Chart. A different chart is to be used for each eye.
Visual acuity with and without correction must be recorded at each examination.
2. Distant visual acuity with or without correction shall be 6/9 or better in each eye separately, and
binocular visual acuity shall be 6/6 or better. No limits apply to uncorrected visual acuity. Where this
standard of visual acuity can be obtained only with correcting lenses, the applicant may be assessed
as fit, provided that –
a. the medical certificate is endorsed with the following limitation: “Suitable corrective lenses must
be worn for distance vision”;
b. such correcting lenses are worn during the exercise of the privileges of the licence or rating
applied for or held; and
c. in addition, a pair of suitable correcting spectacles is kept readily available during the exercise
of the privileges of the applicant’s licence.
3. An applicant accepted as meeting these provisions is deemed to continue to do so unless there is

reason to suspect otherwise, in which case an ophthalmic report is required at the discretion of the
SACAA. Both uncorrected and corrected visual acuity are normally measured and recorded at each
re-examination. Conditions which indicate a need to obtain an ophthalmic report include: a substantial
decrease in the uncorrected visual acuity, any decrease in best corrected visual acuity, and the
occurrence of eye disease, eye injury or eye surgery.
4. Applicants may use contact lenses to meet this requirement, provided that –
a. the lenses are monofocal and non-tinted.

b. the lenses are well tolerated; and
c. a pair of suitable correcting spectacles is kept readily available during the exercise of the
licence privileges.
5. Applicants who use contact lenses may not need to have their uncorrected visual acuity measured at
each re-examination provided the history of their contact lens prescription is known.
6. Applicants with a large refractive error shall use contact lenses or high-index spectacle lenses.
7. Applicants whose uncorrected distant visual acuity in either eye is worse than 6/60 shall be required to
provide a full ophthalmic report prior to initial medical assessment and every five years thereafter. The
purpose of the required ophthalmic examination is to ascertain normal visual performance, and to
identify any significant pathology.
8. Applicants who have undergone surgery affecting the refractive status of the eye shall be assessed as
unfit unless they are free from those sequelae which are likely to interfere with the safe exercise of
their licence and rating privileges.
9. An applicant shall have the ability to read, while wearing the correcting lenses, if any, required by
subsection (2), the N5 chart or its equivalent at a distance of 30-50 cm and the ability to read the N14
chart or its equivalent at a distance of 100 cm. If this requirement is met only by the use of near
correction, the applicant may be assessed as fit provided that this near correction is added to the
spectacle correction already prescribed in accordance with subsection (2). If no such correction is
prescribed, a pair of spectacles for near use shall be kept readily available during the exercise of the
privileges of the licence. When near correction is required, the applicant shall demonstrate that one
pair of spectacles is sufficient to meet both distant and near visual requirements.
10. An applicant who needs near correction to meet this requirement will require “look-over”, bifocal or
perhaps multifocal lenses in order to read the instruments and a chart or manual held in the hand, and
also to make use of distant vision, through the windscreen, without removing the lenses. Single vision
near correction (full lenses of one power only, appropriate for reading) significantly reduces distant
visual acuity and is therefore not acceptable. Whenever there is a requirement to obtain or renew
correcting lenses, an applicant is expected to advise the refractionist of reading distances for the
visual flight deck tasks relevant to the types of aircraft in which the applicant is likely to function.
11. When near correction is required in accordance with the above paragraph, a second pair of near-
correction spectacles shall be kept available for immediate use.
12. The applicant shall be required to have normal fields of vision.
13. The applicant shall be required to have normal binocular function.
14. Reduced stereopsis, abnormal convergence not interfering with near vision, and ocular misalignment
where the fusional reserves are sufficient to prevent asthenopia and diplopia need not be
disqualifying.

Dioptre limits
A need for corrective lenses for either eye within the range of plus or minus 5 dioptres (spherical equivalent)
may be accepted, provided that the distance visual acuity without correction is not worse than 6/60 in each eye
separately. Spectacle lenses outside this range are not routinely acceptable, but medical conclusion may
permit an applicant to be assessed as fit on production of satisfactory specialist reports. The medical certificate
will, where appropriate, be endorsed with the following –
a. “Contact lenses must be worn”; and
b. “Spare spectacles must be readily available”.
9.16.2. Class II Medical Certificates
Visual standards
1. An applicant may not have –
b. any abnormality of visual fields or binocular function;
c. any manifest squint, or large errors of eye muscle balance (phoria).
d. any anatomical or functional monocularity or substandard vision in one eye at initial issue of a
Class 2 medical certificate. However, medical conclusion may permit experienced licence holders
who develop monocularity or substandard vision to be granted a medical certificate with
appropriate restrictions after an adaptation period of at least 6 months following the loss of vision.
Fitness to fly will be determined on a case-by-case basis. The assessment will include practical flight
testing by SACAA.
3. For monocularity, the appropriate minimum restrictions initially are as follows –
a. “If flying open cockpit aircraft, protective goggles not restricting visual field must be worn”. (This
must remain as a permanent restriction);
b. “Any accompanying pilot must be made aware of the holder’s monocular vision”. (This must
remain as a permanent restriction);
c. “Not valid for flight as pilot-in-command by day or night until a satisfactory flight test has been
completed with a flight examiner in each case”. (This restriction may be removed at subsequent
assessment, according to the results of the flight test, or amended to the endorsement in (d)
below);
d. “Not valid for flight as pilot-in-command by night until a satisfactory flight test has been completed
the result of the flight test).
vision better than 6/24 but worse than 6/18, with normal visual fields. Such applicants require
evaluation by an opthalmologist to determine the cause of the visual loss. Fitness to fly will be
determined on a case-by-case basis. In doubtful cases, a practical flight test by SACAA, to evaluate
visual performance may be required.
5. For substandard vision in one eye (vision between 6/18 and 6/24), the appropriate minimum
restrictions are as follows
a. “Any accompanying pilot must be made aware of the holder’s substandard vision in one eye”.
(This must remain as a permanent restriction);
b. “Not valid for flight as pilot-in-command by night until a satisfactory flight test has been completed
the results of the flight test).
acuity of 6/9, 20/30.
available”.
4. This means that these must be available for immediate use when exercising the privileges of licence.
This limitation may be satisfied by the availability of appropriate bifocal, trifocal or multifocal which
permit the reading of instruments and a chart or manual held in one hand, without impeding the use of
distance vision through the windscreen when wearing the spectacles. Single vision near correction
(full lenses of one power only, appropriate to reading) is not acceptable, since wearing these
significantly reduces distance visual acuity.
5. Near vision and intermediate vision should be recorded by ticking in the appropriate box if the pilot is
able to see N5 at 30-50 cm and N14 at a distance of 100 cm respectively.
6. Near vision and intermediate vision should be tested using a Pocket Vision Screener.

Distant vision
1. Distant vision is to be examined with a 6m Snellen Chart. A different chart is to be used for each eye.
Visual acuity with and without correction must be recorded at each examination.
2. Distant visual acuity with or without correction shall be 6/12 or better in each eye separately, and
binocular visual acuity shall be 6/9 or better. No limits apply to uncorrected visual acuity. Where this
standard of visual acuity can be obtained only with correcting lenses, the applicant may be assessed
as fit provided that:
a. the medical certificate is endorsed with the following limitation: “Suitable corrective lenses
must be worn for distance vision”.
b. such correcting lenses are worn during the exercise of the privileges of the licence or rating
applied for or held; and
c. in addition, a pair of suitable correcting spectacles is kept readily available during the exercise
of the privileges of the applicant’s licence.
3. An applicant accepted as meeting these provisions is deemed to continue to do so unless there is

reason to suspect otherwise, in which case an ophthalmic report is required at the discretion of the
SACAA. Both uncorrected and corrected visual acuity are normally measured and recorded at each
re-examination. Conditions which indicate a need to obtain an ophthalmic report include: a substantial
decrease in the uncorrected visual acuity, any decrease in best corrected visual acuity, and the
occurrence of eye disease, eye injury or eye surgery.
4. Applicants may use contact lenses to meet this requirement provided that:
a. the lenses are monofocal and non-tinted.
b. the lenses are well tolerated; and
c. a pair of suitable correcting spectacles is kept readily available during the exercise of the
licence privileges.
provide a full ophthalmic report prior to the initial medical assessment and every five years thereafter.
The purpose of the required ophthalmic examination is to ascertain normal visual performance and to
9. The applicant shall have the ability to read, while wearing the correcting lenses, if any, required by (2),
the N5 chart or its equivalent at a distance of 30-50 cm. If this requirement is met only by the use of
near correction, the applicant may be assessed as fit provided that this near correction is added to the
spectacle correction already prescribed in accordance with (2) ; if no such correction is prescribed, a
pair of spectacles for near use shall be kept readily available during the exercise of the privileges of
the licence. When near correction is required, the applicant shall demonstrate that one pair of
spectacles is sufficient to meet both distant and near visual requirements.
10. An applicant who needs near correction to meet this requirement will require “look-over”, bifocal, or
disqualifying.
Dioptre limits
may be accepted, provided that the visual acuity without correction is not worse than 6/60 in each eye
will be, where appropriate, endorsed with the following:
a. “Contact lenses only must be worn”; and
9.16.3. Class III medical certificates
Visual standards
General
An applicant may not have –

b. any abnormality of visual fields or binocular function;
c. any manifest squint, or large errors of eye muscle balance (phoria).
d. any anatomical or functional monocularity or substandard vision in one eye at initial issue of a Class 3
medical certificate. However, medical conclusion may permit experienced licence holders who develop
monocularity or substandard vision to be granted a medical certificate with appropriate restrictions
after an adaptation period of at least 6 months following the loss of vision.
Fitness to be licensed will be determined on a case-by-case basis. Practical testing in the Air Traffic
Control environment is a requirement.
vision better than 6/24 but worse than 6/12, with normal visual fields. Such applicants require
evaluation by an ophthalmologist to determine the cause of the visual loss. Fitness to be licenced will
be determined on a case-by-case basis. Practical testing in the Air Traffic Control environment may be
required.
acuity of 6/9, 20/30.
available”.
4. This means that these must be available for immediate use when exercising the privileges of the
licence. This limitation may be satisfied by the availability of appropriate bifocal, trifocal, or multifocal
spectacles, which permit the reading of displays and a chart or manual held in one hand, without
impeding the use of distance vision when wearing the spectacles. The wearing of single vision near
correction (full lenses of one power only, appropriate to reading), significantly reduces distance visual
acuity and is not acceptable in an air traffic control tower. Nevertheless, full lenses may be acceptable
in a radar room in which case the medical certificate must be endorsed with the following:

provide a full ophthalmic report prior to initial medical assessment and every five years thereafter. The
purpose of the required ophthalmic examination is to ascertain normal visual performance, and to
9. The applicant shall have the ability to read, while wearing the correcting lenses, if any, required by (2),
the N5 chart or its equivalent at a distance of 30-50 cm and the ability to read the N14 chart or its
equivalent at a distance of 100 cm. If this requirement is met only by the use of near correction, the
applicant may be assessed as fit provided that this near correction is added to the spectacle correction
already prescribed in accordance with (2) ; if no such correction is prescribed, a pair of spectacles for
near use shall be kept readily available during the exercise of the privileges of the licence. When near
correction is required, the applicant shall demonstrate that one pair of spectacles is sufficient to meet
both distant and near visual requirements.
10. An applicant who needs near correction to meet this requirement will require “look-over”, bifocal, or
disqualifying.
Dioptre limits
may be accepted, provided that the visual acuity without correction is not worse than 6/60 in each eye

will be, where appropriate, endorsed with the following:
a. “Contact lenses only must be worn”; and
Colour Vision Standards (Class I and II Pilots)
Colour perception standards Class III
1. Applicants are required to undergo the Ishihara Test (24 and 38 Plates) as per the Colour Vision
Protocol.
2. Applicants who fail the Ishihara Plates are required to undergo Lantern Testing at the Institute of
Aviation Medicine.
Note: Research for ATC for Colour Assessment Diagnosis (CAD) is still under investigation.
Colour perception standards (Class 4)
Not applicable.
Ear, nose and throat and hearing standards
9.16.4. Class I medical certificate
Ear, nose and throat and hearing standards
1. Applicants must have no established medical history or clinical diagnosis of the following:
a. Any pathological process, acute or chronic, of the internal ear or middle ear cavities;
b. Any unhealed (unclosed) perforation of the tympanic membranes, except that an applicant with a
single dry perforation may be eligible for a certificate if the defect does not prevent compliance
with the hearing standards;
c. Any chronic or serious recurrent obstruction of the Eustachian tubes;
d. Any serious or recurrent disturbance of the vestibular system;
e. Any obstruction to free nasal air entry to both sides;

f. Any serious malformation, or serious acute or chronic condition of the buccal cavity or upper
respiratory tract;
g. Any speech defect likely to interfere with the safe performance or duties in exercising the
privileges of the licence.
2. Applicants must be free from any hearing defect, which would interfere with the safe exercise of the
privileges of the licence.
3. Applicants for Class 1 medical certificate shall be tested by pure-tone audiometry at first issue of the
assessment, not less than once every five years up to the age of 40 years, and thereafter not less
than once every two years.
4. Alternatively, other methods providing equivalent results may be used.
5. Applicants shall demonstrate a hearing performance sufficient for the safe exercise of their licence
and rating privileges;
6. At medical intervals prescribed in subsection (3), where audiometry is not performed, applicants shall
be tested in a quiet room by a whispered and spoken voice test.
7. For the purpose of a hearing test, a quiet room is a room in which intensity of background noise is less
than 35db(A).
8. For the purpose of a hearing test, the sound level of an average conversational voice at 1 m from the
point of output (lower lip of the speakers) is c.60dB(A) and that of a whispered voice c.45dB(A), at 2
cm from the speaker, is 6 dB(A) lower.
9. The pure-tone audiometry shall be calibrated as per the standard of the current Audiometric Test
Method.
10. Applicants who are unable to hear an average conversational voice in a quiet room, using both ears,
at a distance of 2 m from the examiner and with the back turned to the examiner, shall be assessed as
unfit.
11. When tested by pure-tone audiometry, an applicant with a hearing loss in either ear separately, of
more than 35 dB at any of the frequencies 500, 1 000 or 2 000 Hz, or more than 50 dB at 3 000 Hz,
shall be assessed as unfit.
12. An applicant with a hearing loss greater than the one prescribed in subsection (11) may be declared
fit, provided that the applicant has normal hearing performance against a background noise that
reproduces or simulates the masking properties of flight deck noise upon speech and beacon signals.
13. It is important that the background noise be representative of the noise in the cockpit of the type of
aircraft for which the applicant’s licence and ratings are valid.

14. In the speech material for discrimination testing, both aviation relevant phrases and phonetically
balanced words shall be used.
15. Alternatively, a practical hearing test conducted in-flight in the cockpit of an aircraft of the type for
which the applicant’s licence and ratings are valid may be used.
Electrocardiography
Applicability
This protocol is applicable to classes I, II and III applicants.
Resting ECG
Resting ECG shall be performed at the following intervals: Class 1
a. at initial medical examination;
b. every 2 years between the age of thirty (30) and fifty (50);
c. annually after the age of fifty (50).
Resting ECG shall be performed at the following intervals Class 2
b. first exam after the age of 40;
c. every 2 years after the age of fifty (50).
Resting ECG shall be performed at the following intervals Class 3
b. every 2 years after the age of fifty (50).
Procedure for resting ECG
1. A resting ECG shall be recorded with the subject at rest in a warm environment.
2. The skin should be prepared with spirit or abrasive, or both.
3. A resting ECG is performed using a 12-lead standard ECG machine, and chest leads should be
placed accurately.
4. Leads V1 and V2 should be placed in the fourth inter-costal spaces on either side of the sternum.

5. Lead V4 is placed at the position of the apex of the normal heart – the fifth inter-costal space in the
mid-clavicular line.
6. Lead V3 is placed midway between V2 and V4. Leads V5 and V6 are placed at the same level as V4
in the anterior and mid-axillary lines, respectively.
7. The limb leads are placed on the right and left arms, and the right and left legs, respectively.
Interpretation
1. All ECGs are to be interpreted by a DAME trained in ECG reading who would refer to a cardiologist or
specialist physician when in doubt.
Stress ECG:Indications for stress ECG
a. Stress ECG shall be performed in the following circumstances:
b. Any abnormal resting ECG;
c. The following risk indications should be considered in determining the necessity of a stress ECG:
Hypertension, Smoking, Dyslipidaemia, Diabetes Mellitus, Raised BMI, waist circumference/abdominal
obesity, family history of early onset of cardiovascular disease.
d. In accordance with the cardiovascular risk assessment algorithm: for all applicants classified as
moderate, high or very high risk in accordance with the algorithm, provided that:
i. Stress ECG for moderate risk applicants may be performed by a DAME; and
ii. Stress ECG for high or very high-risk applicants shall only be performed by a cardiologist or a
specialist physician.
Procedure for Stress ECG
1. Stress ECG is performed using a 12-lead standard ECG machine displaying at least three leads
simultaneously and optimally filtered and damped. The leads should be placed as for a standard
resting ECG, except that the limb leads are positioned on the shoulders and the iliac crests on each
side.
2. Recordings should be made at rest in the erect and supine positions, and after hyperventilation for 10
seconds. The subject should be exercised to 85% of maximal heart rate or symptom limitation,
whichever comes first, and be expected to complete at least three stages (nine minutes) of the Bruce
Protocol or achieve an oxygen uptake equivalent to 11 metabolic equivalents (METs). The age-
predicted maximum heart rate is calculated by subtracting the age in years from 220 beats per minute
(bpm). The test is most sensitive when taken to symptom limitation rather than any percentage of the
age-predicted maximum. If exercise needs to be terminated due to symptom development, the licence
holder should be referred to a cardiologist (if stress is performed by DAME). The reason for
discontinuing the test should be recorded together with the presence or absence of any symptom.

3. Immediately post-stress, while the license holder is in the upright position, twelve (12) second
recordings should be made at the following intervals: 0, 3, 5 and 7 minutes. If there is any indication,
recordings can be taken at two (2) minute intervals up to 11 minutes. Any abnormalities on stress
ECG shall be referred to a cardiologist if the stress ECG is performed by a DAME.
4. A standardised protocol, such as the Bruce treadmill protocol 3 or equivalent, should be employed.
The Bruce protocol is not the only one available, but it is the most widely used.
Intervals
1. Stress ECG shall be performed in accordance with the cardiovascular risk assessment algorithm.
2. Applicants classified as moderate, high, or very high risk shall have an annual stress-ECG (if some
positive actions are taken to reduce or mitigate the risk of those classified as moderate, an annual
stress-ECG is probably not necessary, assuming the first one was negative).
Chest Radiography Requirements: Class I medical certificates
1. Chest radiography, anterior-posterior, and lateral views must form part of the respiratory system
assessment for the initial issue of a Class 1 medical certificate.
2. Periodic chest radiography is usually not necessary but may be a necessity in situations where
asymptomatic pulmonary disease can be expected.
3. It is, however, understood that a degree of interpretation and flexibility must always be exercised at
the discretion of the medical examiner and the medical assessor, taking into consideration not only
medical but also operational and environmental factors of relevance for the overall aviation medical
fitness of an applicant.
4. All licence holders who have a clinical indication for chest radiography may be required to submit
chest radiography at more frequent intervals.
5. Licence holders may be referred to the relevant protocols.
Class II medical certificates
1. Chest radiography, anterior-posterior, and lateral views must form part of the respiratory system

Class III medical certificates
1. Chest radiography, anterior-posterior, and lateral views, must form part of the respiratory system
Flow-Volume Lung Function Test -Class I medical certificates
1. Flow-volume lung function testing must form part of the respiratory assessment for the initial issue of a
Class I medical certificate under the age of 40 years.
2. The flow-volume lung function testing shall be done again at the first medical examination after the
age 40, and again at the first medical examination after the age of 50.
3. For active smokers*, the requirement for flow-volume lung function testing shall be not less than every
24 months (biennially) for licence holders under the age of 40 and not more than every 12 months
(annually) after the age of 40.
4. All licence holders who have a clinical indication for lung function testing will be required to submit a
lung function test at more frequent intervals.
Class II medical certificates
Class 2 medical certificate under the age of 40 years.

Class III medical certificates
Class IV medical certificates
*Note: Active smoker refers to an individual who engages in the act of intentional inhalation of tobacco smoke from any
tobacco product, including but not limited to, manufactured and hand rolled cigarettes, cigars, pipe tobacco and
cigarillos. Active smoking does not refer to passive smoking which is the unintentional inhalation by non-smokers of
tobacco smoke introduced into the atmosphere by smokers or smoking of any other substances such as herbal
cigarettes or marijuana. The consumption of tobacco products by other means, such as chewing, is also excluded from
this standard.

10. SECTION 4: TECHNICAL STANDARDS (MEDICAL PROTOCOLS)
10.1. Neurological or Neuropsychological Protocols
a. Head injuries
b. Post-traumatic epilepsy (PTE)
c. The post-traumatic syndrome
d. Epilepsy
e. Syncope
f. Narcolepsy
g. Transient memory loss
h. Headache
i. migraine
ii. cluster
iii. tension
iv. other
i. Stroke
j. Brain tumours
k. Parkinson's disease
10.2. Cardiovascular Protocols
a. Hypertension
b. Coronary artery disease protocol
c. Atrial Flutter & Atrial Fibrillation
d. Incomplete Right Bundle Branch Block
e. Complete Right Bundle Branch Block
f. Partial Complete Left Bundle Branch Block
g. Left Anterosuperior and Left Anterosuperior Fascicular Hemiblocks
h. Antero-Ventricular Block
i. Mobitz Type 2 Atrioventricular Block and Complete Anterosuperior Block
j. Abnormal ECG Tracing
k. Brugada Syndrome
l. Brugada Pattern

m. Prolonged QT Syndrome
n. Ventricular Tachycardia & Supraventricular Tachycardia
o. Radio-Frequency Ablation
p. Uncorrected Aortic Stenosis
q. Corrected Aortic Stenosis
r. Uncorrected Aortic Incompetence
s. Corrected Aortic Incompetence
t. Rheumatic Mitral Stenosis /Mitral Valve Regurgitation
u. Non-Rheumatic & Non-Ischaemic Mitral Regugitation
v. Aortic Valve Replacement
w. Mitral Valve Replacement
10.3. Respiratory Protocols
a. Asthma
b. Spontaneous Pneumothorax
c. Traumatic Pneumothorax
d. Chronic obstructive airways disease
e. Thoracic Surgery
f. Obstructive Sleep Apnoe
g. Pulmonary tuberculosis
h. Obesity
10.4. Endocrinology
a. Diabetes mellitus
b. Addison's disease
c. Type 1 Diabetic Mellitus Class 2 & 3
d. Type 1 Diabetes Class 1
10.5. Oncology
a. Malignant melanoma
b. Oesophageal cancer
c. Colorectal cancer
d. Breast cancer
e. Testicular cancer
f. Prostate cancer
g. Renal carcinoma
h. Bladder cancer
i. Lymphomas
j. Leukaemia
10.6. Psychiatry
a. Mood disorder protocol
10.7. Others
a. Obstetrics and gynaecology

b. Single kidney protocol
c. HIV/AIDS protocol
d. Substance abuse
e. Warfarin protocol
f. Colour perception deficiency protocol
g. Lasik
h. Rheumatoid arthritis
i. The use of Plavix
j. Bone marrow transplant
11. SECTION 5
Protocol on Neurological or Neurosurgical Problems
11.1. Epilepsy
Applicability
Section 1 of this Schedule 1 Protocol is only applicable to classes I, II, III and IV medical certificates and it
excludes cabin crew.
Aeromedical considerations
An applicant diagnosed with epilepsy is medical unfit to be granted a medical certificate to fly.
Important concepts
a. Diagnosis of a single epileptic attack means that the applicant is permanently unfit to fly.
b. No applicant who has had a convulsion after the age of 5 years shall be considered for pilot training.
c. Any inexplicable loss of consciousness (LOC) shall be regarded as epilepsy until otherwise
diagnosed.
d. An applicant with a history of a single, uncomplicated febrile convulsion between the ages of one and
five years shall be eligible for pilot training. If, however, the convulsion was complicated, the applicant
shall no longer be eligible for pilot training under the following conditions:
i. a convulsion before the age of one year. This holds the risk for mental retardation and epilepsy
later in life;
ii. multiple febrile convulsions;
iii. duration of convulsions longer than 5 minutes; or
iv. lateralising signs during febrile convulsions.
11.1.1. Epilepsy for Cabin Crew
Applicability
Section 2 of this Schedule 1 Protocol is applicable to cabin crew only.
General medical requirements
1. Any cabin crew member diagnosed with epilepsy is medical unfit to fly.
2. Cabin crew applicant may be considered for recertification by the Aeromedical Committee after a one
(1) year period has lapsed following initiation of medication.
3. On application for recertification the applicant shall be required to submit the following:
a. A neurologist report stating that he or she is adequately functional on acceptable medication

without significant side effects;
b. A brain CT scan film/MRI scan; and
c. A 16 lead EEG.
4. If an applicant suffers a seizure while on medication, he or she is medically unfit to fly and shall be
submit the reports referred in subsection 3).
5. If there is a change in medication, the applicant shall be grounded for six (6) months and shall be
required to provide a neurologist report stating stability on the new medication.

Restrictions
The cabin crew with epilepsy is restricted to operate under the following conditions:
a. short haul flights only;
b. under supervision or in pairs.
11.1.2. Benign Rolandic Epilepsy of childhood
Applicability
This medical standard is applicable to classes I, II, III, and IV medical certificates.
Operational considerations
Diagnosis of Benign Rolandic Epilepsy is disqualifying for classes I, II, III and IV medical certification.
Operational restrictions
The following are applicable operational restrictions:
i. Class I: Multi-crew, or with a co-pilot;

ii. Class II: Safety pilot;
iii. Class III: With constant supervision; and
iv. Class IV and cabin crew: No restriction
General information on Benign Rolandic Epilepsy of childhood
a) Benign Rolandic Epilepsy with centro-temporal spike is another type of childhood seizure disorder. It is
derived from the Rolandic area of the brain and common in children with a close family history of
epilepsy.
b) This seizure disorder is benign with the average age of 6-8 years and most children outgrow it during
adolescence. It typically involves twitching, numbness, tingling of the child’s face or tongue occurring
mostly during sleep.
c) The symptoms may interfere with speech and cause drooling, and they last no longer than two
minutes. The child remains fully conscious with EEG spikes on motor and temporal lobes of the brain.
Medical Requirements
a) An applicant with Benign Rolandic Epilepsy with centro-temporal spikes may be considered for
medical certification after a minimum observation period of five (5) years or more, as the condition is
self-limiting.
b) An applicant shall be seizure free and not using medication for this period.
c) The applicant shall be required to submit a comprehensive neurologist report:
d) A 16 lead EEG with provocation;
e) Brain CT/MRI scan film; and
f) All cases shall be presented to the Aeromedical Committee for consideration.
Febrile Childhood Seizures/Convulsions
General
1) The occurrence of a single seizure is disqualifying for all classes of medical certification unless it is a
proven febrile seizure of childhood.
2) One seizure under between the age of 1 to 5 years, clearly associated with an episode of febrile illness is
acceptable.
3) The following complications shall render an applicant medically unfit to fly:
a) A seizure that occurred under the age of 1 year;

b) Multiple seizures;
c) A seizure that lasted more than 5 minutes; and
d) Lateralising signs associated with a seizure.
4)A neurologist report is mandatory for all cases with febrile childhood seizures/convulsions.
Operational implications
The occurrence of a single seizure is disqualifying for all classes of medical certification.
Aeromedical implications
Medical certification may be granted following a single uncomplicated febrile seizure when all studies are
normal and there are no risk factors for recurrence.
1. An applicant with a history of febrile convulsions may be considered for certification provided it was a
single uncomplicated seizure.
2. The applicant with a history of febrile convulsions shall provide the following:
a. A comprehensive neurologist report;

b. A 16 lead EEG; and
c. A brain CT/MRI scan film.

11.1.3. Single Seizure
Applicability
This medical standard is applicable to classes I, II, III and IV medical certificates.
Cabin crew with a single seizure may be considered by the Medical Assessor on a case-by-case basis.
Operational Implications
The occurrence of a single seizure is disqualifying for all classes of medical certification with the exception of
cabin.
11.1.4. General information in relation to classification of seizures
Classification of Seizures
a) Cryptogenic seizures: These seizures were previously classified as idiopathic, and the aetiology is
unknown with no associated previous brain insult. These applicants are known to have a high risk of
developing epilepsy.
b) Symptomatic seizures: These are seizures that are caused by a previously known or suspected
disorder of the brain known to increase the risk to develop epilepsy. It can be acute, following an acute
disorder like metabolic disturbances (i.e. hypoglycemia, hypernatremia, infections, toxins and brain
trauma).
c) It is subdivided into: Acute symptomatic (occurring less than a week after the brain insult) and remote
symptomatic (occurring a week or more after the brain insult).
11.1.5. Risk factors for developing a Second Seizure or Epilepsy
a. Age younger than 16 years at first seizure presentation.

b. Remote symptomatic seizures following a stroke or lesion location.
c. Seizures occurring between midnight and 08:59 am.
d. Previous provoked seizures and previous febrile seizures.
e. Family history of epilepsy.
f. Status epilepticus or multiple seizures within 24 hours as the remote symptomatic seizures.
g. History of neurological deficit at birth, e.g. cerebral palsy or mental retardation.
h. EEG that shows epileptiform discharges.
i. Brain tumour on CT scan.
Requirements for consideration
1) An applicant shall be presented to the Aeromedical Committee for consideration on a case-by-case

basis.
2) When an applicant suffers from his or her first ever seizure, a thorough search for cause and risk
factor stratification is appropriate and the following information or medical record shall be required:

a. History of seizures in immediate family;

b. History of febrile seizures;
c. Prior acute symptomatic seizure;
d. History of remote neurological insult;
e. Neurologist report;
f. Cerebral imaging study (CT scan film); and
g. Abnormal EEG.
3) Applicant’s recurrence risk shall be approximately 30% over five years.
4) In the case of an applicant with absence of recurrence without medication in five years (5), his or her risk
may then become acceptable for medical certification and the applicant shall submit the following:
a) A comprehensive neurologist;
b) 16 channel EEG for 15 minutes, with provocation; and
c) An MRI/CT scan.
5) If a cause for a seizure is not found, the pilots or ATCs shall be temporarily taken off from their safety
operations duties for a duration of not less than five years (5) years.
6) The medical certificate applied for by the applicant referred to in paragraph 5 above hall not be granted
until the applicant is five-years seizure-free and a medication-free observation period has been achieved.
7) If a cause for a seizure is not found, the recreational pilot shall be temporarily taken off from his or her
safety operations duties for a duration of not less than two (2) years and the medical certificate applied for
shall not be granted until a two-year seizure-free and medication-free observation period has been
achieved.
8) If a cause is found for the seizure, such a cause shall be treated, and the grounding period shall be
determined by the cause of the seizure and the risks associated with the underlying cause by the
aeromedical committee.
9) An applicant who complies with the requirements of section 5.3 may be declared medical fit to fly.
10) Such applicant shall be restricted to fly “As or with co-pilot” for two years.
11) An applicant shall be required to repeat all investigations referred to in subsection 4) after 5 years.
11.1.6. Follow-Up Requirements
1) The applicant shall submit the following reports for a follow-up:
2) A 6-monthly comprehensive neurologist report for the first two years;
i. A 16 lead EEG;

ii. A CT brain film;

iii. Any report on new symptoms or change in medical status immediately; and
iv. An annual neurologist report after the third year.
11.2. Migraines
Applicability
1. This medical standard is applicable to classes I, II, III and IV medical certificates.
2. Cabin crew with migraine may be considered on a case-by-case basis.
11.2.1. Classification of migraines
Migraine with aura (classic)
Focal neurological phenomena preceding or accompanying the attack 5-20 minutes lasting 60 minutes.
i. Visual aura:
ii. Photopsia;
iii. Geometric forms;
iv. Objects seem to rotate;
v. Macropsia;
vi. Scotomata; and
vii. Mosaic vision.
Sensory: Paraesthesia, often migratory, lasting for minutes and can be bilateral.
i. Motor: Weakness; and Ataxia.

ii. Language: Dysarthria or aphasia.
iii. Headache usually follows within 60 minutes.
iv. If the headache is delayed, most people do not return to normal/pre-aura state.
v. Migraine without aura (common)
vi. General information on migraine without headache or migraine equivalents
vii. Periodic neurologic phenomena not followed by headache;Must be differentiated from TIA and focal
seizures;
viii. Transient visual disturbances with flickering and scotomata; and
ix. Generally associated with cerebrovascular embolic or thromboembolic disease.

Medical Requirements for Applicants with Migraines
1) Any applicant diagnosed with migraine shall be declared medically unfit to fly and shall provide the
following upon diagnosis:
i) A comprehensive neurologist report confirming the diagnosis and stating the frequency of
attacks, type of aura, duration of prodromal period;
ii) A brain CT scan; and
iii) A 16 lead EEG.
2) Applicant may be considered for recertification by the Medical Assessor after a minimum of six (6)
months’ observation period.
3) On application for recertification the applicant shall provide a comprehensive neurologist report,
stating the following:
i. The applicant is stable on acceptable medication with documented effectiveness for

prevention or treatment of migraine attack;
ii. The applicant does not suffer from visual auras;
iii. The applicant does not suffer from severe incapacitating headaches;
iv. The frequency of headaches is low, featuring one to two migraine episodes a year with
gradual onset; and
v. The applicant does not need unacceptable medication to abort, treat or prevent the migraine.
11.2.2. Cluster Headache
Applicability
a) This medical standard is applicable to classes I, II, III and IV medical certificates.
b) Cabin crew with cluster headache may be considered on a case-by-case basis and may be fit for their
duties
General information on Cluster Headache
The disorder is characterised by:
i. Severe, strictly unilateral pain, typically in the retro-orbital and fronto-temporal areas;
ii. Association with symptoms and signs of cranial autonomic dysfunction (tearing, conjunctival injection,
rhinorrhea/nasal congestion, and Horner’s syndrome), ipsilateral to the pain;
iii. A duration of 15-180 minutes if untreated;
iv. Pain of cluster headaches which may be intolerable and unpredictable; and
v.Anxiety and depression, which are common among people with cluster headaches, which may affect
functioning and quality of life.
General information on two (2) variants:
i. Episodic cluster headache: at least two cluster periods lasting from seven days to one year, separated
by a one-month remission period; and
ii. Chronic cluster headache: occurring without remission or remission of < one month for over a year.
Medical Requirement for Cluster Headache
1) An applicant diagnosed with cluster headache shall be declared medically unfit to fly and shall provide
the following upon diagnosis:
i. A comprehensive neurologist report stating the frequency of attacks, severity of attacks and
medication used for the headache;
ii. A brain CT Scan; and
iii. A 16 lead EEG.
2) An applicant may be considered for recertification after a one-year observation period has lapsed.
3) The applicant shall be on acceptable medication for the treatment of the cluster headache attacks.
11.2.3. Mild Head Injury or Traumatic Brain Injury (TBI)
Applicability
1) The requirement for mild head injury or traumatic brain injury (TBI) shall be applicable to classes I, II,
III and IV medical certificates.
2) General information on characteristics of mild head injury or traumatic brain injury
3) A mild head injury or traumatic brain injury (TBI) shall be characterised by the following features:
i. Loss of consciousness: 0-30 minutes;

ii. Alteration of consciousness: from a moment up to 24 hours;
iii. Post-traumatic amnesia (PTA): 0-1 day;
iv. Glasgow Coma Scale (GCS – best score in first 24 hours): 13-15; and
v. No neurological deficits or skull fracture.
a) The applicant shall be grounded for seven days (7) following the head injury.
b) Any fleeting loss of consciousness or altered consciousness shall deem the applicant to be medically
unfit and the applicant shall be grounded for six weeks (6) .

c) A mild traumatic brain injury with no alteration of consciousness and normal examination by a
neurologist may be considered for medical recertification.
d) The applicant shall be required to submit a brain CT scan and may be certified by the Aeromedical
Committee.
11.2.4. Moderate head injury or traumatic brain injury (TBI)
Applicability
a) This requirement is applicable to classes I, II, III and IV medical certificates.

b) Cabin crew with moderate head injury may be considered on a case-by-case basis.
General
Characteristics of moderate head injury or traumatic brain injury are as follows:
i. Loss of consciousness of between 30 minutes and 24 hours;

ii. Alteration of consciousness of more than 24 hours;
iii. Post-traumatic amnesia of more than one (1) day but less than seven (7) days; and
iv. Best Glasgow Coma Scale of nine to twelve (9-12) in 24 hours.
1) Upon diagnosis, the applicant is grounded and shall submit the following for consideration:
i. A neurologist report;
ii. A brain CT Scan film; and
iii. A 16 lead EEG with provocation.
2) The applicant diagnosed with moderate traumatic head injury may be considered for recertification by the
Aeromedical Committee, provided the observation period of at least two (2) years following injury has
lapsed.
3) On application for recertification, the applicant shall provide the following:
i. A comprehensive neurologist report stating that the applicant has been stable, and no seizures
were reported;
ii. A brain CT scan film; and
iii. A 16 lead EEG with provocation.

11.2.5. Severe head injury or traumatic brain injury (TBI)
Applicability
a) This medical standard for severe head injury or traumatic brain injury (TBI) shall be applicable to
classes I, II, III and IV medical certificates.
b) Cabin crew with severe head injury may be considered on a case-by-case basis.
General information for Severe Head Injury or Traumatic Brain Injury (TBI)
The characteristics of severe head injury or traumatic brain injury (TBI) shall be as follows:
i. Neurological and intellectual impairment;

ii. Loss of consciousness of more than twenty-four (24) hours;
iii. Alteration of consciousness of more than twenty-four (24) hours;
iv. Post-traumatic amnesia lasting more than seven (7) days; and
v. Best Glasgow Coma Scale of less than nine (9) in 24 hours.
Medical Requirements Head Injury
1) Upon diagnosis, the applicant will be deemed unfit, and the applicant will be required to submit the
following:
i. An MRI scan (brain)

ii. A 16 lead EEG with standard provocation;
iii. A neuropsychometric evaluation by a Clinical Psychologist; and
iv. A neurologist report.
2) An applicant diagnosed with severe traumatic brain injury shall be deemed to be temporary unfit for a
period of at least five (5) years;
3) The applicant may be considered for recertification by the Aeromedical Committee after a five-years
observation period has lapsed
Follow-Up Reports following withdrawal of medical certificate
1) Following the five-years observation period, the applicant shall provide the following for recertification
consideration:
ii. A 16 lead EEG with provocation;
iii. A brain MRI scan film; and
iv. A neuropsychometric evaluation from a clinical psychologist.

2) The applicant’s cognitive function and risk of seizure shall not compromise aviation safety.
11.2.6. Post-Traumatic Syndrome (Concussion)
The requirements for post-traumatic syndrome (concussion) shall be applicable to classes I, II, III and IV
medical certificates.
General
a) Each case in relation to post-traumatic syndrome (concussion) shall be considered on its own merits
by the Aeromedical Committee.
b) An applicant with concussion without any neurological sequelae may be considered for recertification
after one (1) month and shall provide the following:
iii. A 16 lead EEG report.
11.2.7. Syncope
1) The medical standard for syncope shall be applicable to classes I, II, III and IV medical certificates.
2) Cabin crew with syncope may be considered on a case-by-case basis.
General information on Syncope
a) Syncope is a loss of consciousness (usually fleeting) due to decreased cerebral perfusion.
b) Applicant who has a history of syncope shall be fully assessed, as there are many organic
(cardiovascular, neurological) diseases that may cause syncope.
Medical Requirements following q diagnosis of Syncope
Applicant presenting with syncope shall comply with the following requirements:
i. The applicant shall declared be temporarily medical unfit upon diagnosis;

ii. The applicant may be considered by the Aeromedical Committee for recertification after a period of at
least three (3) months has lapsed if there were two (2) or less attacks and after least six (6) months if
there were multiple attacks;
iii. A comprehensive neurologist report with clinical history and the circumstances surrounding it and the
cause of the syncope shall be fully investigated;
iv. A comprehensive cardiologist report with an ECG; and
v. Blood including, Full Blood Count (FBC), Urea and Electrolytes (U&E) and Pregnancy Studies.

11.2.8. Transient Memory Loss or Global Amnesia
Applicability
This medical standard for transient memory loss or global amnesia shall be applicable to classes I, II, II and IV
medical certificates.
Cabin crew with transient memory loss or global amnesia shall be considered on a case-by-case basis.
a) The applicant presenting with Transient Global Amnesia shall comply with the following requirements:
b) An applicant shall be declared medical unfit for a minimum period of one (1) year;
c) The cause of the amnesia shall be investigated;
d) An investigation shall include an EEG and an MRI Scan of the brain and to exclude ischaemic brain
injuries and epilepsy; and
e) An applicant may be declared medical fit to fly after one (1) year if all investigations are normal.
11.2.9. Brain Tumours
i. The medical standards for brain tumours shall be applicable to classes I, II, III and IV medical
certificates.
ii. Cabin crew with brain tumours may be considered on a case-by-case basis.
Benign Supra-Tentorial Tumours (meningioma)
a) An applicant presenting with benign supra-tentorial tumours shall be declared temporary medical unfit
upon diagnosis, for a period of two (2) years.
b) Following successful surgery, the applicant may be considered for recertification by the Aeromedical
Committee after at least two (2) years of observation.
c) On application for recertification the applicant shall provide the following:
i. A Brain MRI scan film;

ii. A Neurologist report; and
iii. An Oncologist report.
d) After successful recertification, the applicant must submit the following:
i. An annual Neurologist report; and

ii. An annual Oncologist report.
e) Following radiation therapy, the Aeromedical Committee may review each case on its own merit and
consider recertification after a ten (10) year observation period has lapsed, provided the therapy was
focal radiotherapy.
Benign Infra-Tentorial Tumours
a) An applicant presenting with benign infra-tentorial tumours shall be declared temporary medical unfit
upon diagnosis.
b) The applicant may be considered for recertification by the Aeromedical Committee after one (1) year,
following successful removal, and the applicant shall provide the following:
i. A Brain MRI scan film;

ii. A Neurologist report; and
iii. An Oncologist report.
c) Follow-Up Requirements for Benign Infra-Tentorial Tumours
d) After successful recertification, the applicant shall submit the following:
e) The applicant shall be declared medical unfit upon diagnosis and shall provide the following:
i. A neurologist report confirming the diagnosis;

iii. An ophthalmologist report with comment on visual fields.
f) The applicant may be considered for recertification after six (6) months provided he or she has no
headaches, is off medication or on acceptable medication and the visual fields are normal.
Follow-Up Requirements for Pseudo-Tumor Cerebri
On application for recertification, the applicant shall provide the following:
i. A Neurologist report; and

ii. An Ophthalmologist report.
Malignant Tumour of the Brain
An applicant diagnosed with malignant intra-cranial tumour is medically unfit to fly.

16.1.10 Multiple Sclerosis
a) The multi sclerosis (MS) medical standard shall be applicable to classes I, II, III and IV medical
certificates.
b) General information on multiple sclerosis
c) It is an immune-mediated disease of the central nervous system characterised by multiple white

matter plaques of demyelination that pose a major threat to neurological functions.
d) Symptoms vary widely depending on the nerve involved and the amount of nerve damage.
e) Some people may lose the ability to function independently while others may be on remission for long
periods. Most diagnoses are made in the 20s and 30s.
f) The common presenting symptoms are optic neuritis or visual disturbances and/or sensory
disturbances and sufferers may also present with tremor, ataxia, cognitive problems and bowel and
bladder disturbances.
g) There is a relapsing-remitting course and new symptoms develop over days or weeks and remit for
months.
h) Small increases in temperature may worsen the symptoms.
There are two types:
a) Primary progressive MS: This type has a gradual onset and steady progression of symptoms without
relapse; and
b) Secondary progressive MS: relapsing remitting MS, eventually develop a steady progression of
symptoms with some periods of remission.
c) Complications include muscle stiffness or spasms, paralysis, depression, epilepsy, mood and memory
problems.
Operational Considerations
Any renewal applicant diagnosed with multiple sclerosis is declared temporarily unfit.
Aeromedical Considerations
a) The applicant may be considered for recertification by the Aeromedical Committee after an
observation period of six (6) months has lapsed.
b) On application for recertification the applicant shall submit the following:
ii. Blood and cerebro-spinal fluid oligoclonal bands;

iii. An IGG index;

iv. A Brain and Spinal cord MRI scan film;
v. An Ophthalmologist report; and
vi. A Neuropsychologist report.
c) After successful recertification, the applicant shall provide a neurologist and ophthalmologist report
every six (6) months.
d) The applicant shall be declared medically unfit on follow-up if the following develops:
i. Neurological deficit after exacerbation;

ii. Visual loss;
iii. Sensory disturbances on hands;
iv. Mood instability;
v. Vertigo; and
vi. Any convulsions.
vii. Infections
16.1.11 Meningitis and Encephalitis
Applicability
The medical standard for infections shall be applicable to classes I, II, III and IV medical certificates.
General
a) An applicant diagnosed with meningitis or encephalitis shall be declared medically temporarily unfit.
b) The applicant may be considered for recertification by the Aeromedical Committee after an
observation period of six (6) month has lapsed.
c) Recertification shall depend on the degree of deficit or recovery and the risk of developing
hydrocephalus.
d) On application for recertification the applicant shall provide a neurologist report.
11.2.10. Brain abscess
a) Each case shall be assessed on its merit considering the location of the abscess (infra-tentorial or
supra-tentorial) and the nature of the neurological deficit.
b) There shall be a high incidence of seizures.

c) The decision to recertify shall be referred to the Aeromedical Committee after an observation period of
at least six (6) months has lapsed.
d) On application for recertification the applicant must submit the following:
i. Neurologist report; and

ii. Brain MRI scan film
11.2.11. Neurosyphilis
a) Neurological deficits usually persist even after successful treatment.
b) An applicant shall be assessed for neurological deficit or degree of recovery.
c) Recertification shall depend on the functional capacity following treatment and shall be referred to the
Medical Assessor.
d) Recertification may be considered after an observation period of six (6) months has lapsed.
e) On application for recertification the applicant shall submit the following:
i. A Neurologist report; and
ii. In the case of a specific occupation, a functional assessment report from the Occupational
Therapist shall also be considered.
11.2.12. Dementia
Applicability
The medical standards for dementia shall be applicable to classes I, II, III and IV medical certificates.
General Requirements
i. An applicant with dementia shall be declared medically unfit to fly.

ii. In the small number of cases where the cause of the dementia is known and the condition has been
resolved, the applicant may be considered for recertification.\
11.2.13. Stroke
16.1.15.1 Transient Ischaemic Attack (TIA)

Applicability
This protocol is applicable to classes I, II, III and IV medical certificates.
General Medical Requirement
1) Any applicant presented with symptoms of suggestive of a TIA shall be assessed thoroughly to
exclude risk of sudden medical incapacitation.
2) The applicant may be considered for recertification by the Authority at least after at least six (6)
months of observation.
3) The applicant shall be unfit upon diagnosis and shall provide the following for reconsideration of his or
her medical fitness:
i. A Comprehensive Neurologist report; and

ii. A Brain CT Scan Film.
4) The diagnosis of a TIA may be difficult to be determined with certainty and an applicant who presents
with symptoms suggestive of a TIA should be thoroughly assessed.
5) The presence of an asymptomatic bruit is associated with an increased risk for a stroke, and 6-
monthly examinations shall be done thereafter. The following conditions are disqualifying –
i. Cerebral infarct, embolism, or haemorrhage; and

ii. Cerebral aneurysm or A-V malformation, and the applicant may be made fit after surgical
repair (not proximal ligation or “packing”) if an angiogram done after 1 year shows
successful repair.
6) The incidental discovery of an asymptomatic occlusion of a cerebral vessel shall not make an
applicant unfit, but the applicant shall be fully assessed.
16.1.15.2 Ischaemic Stroke
Applicability
1) An applicant diagnosed with ischaemic stroke shall be declared medically unfit.
2) The cause shall be addressed, and risk of recurrence shall be minimal.

3) There shall be no neurological deficit.
4) The applicant may be considered for recertification by the Authority after an observation period of two
(2) years has lapsed.
5) Flexibility shall be applied by the Authority to the applicant with a history of ischaemic stroke who is
applying for a cabin crew and Class 4 medical certificate: and
6) On application the applicant shall provide the following:
ii. A brain CT scan film;
iii. A 16 lead EEG; and
iv. A clinical psychologist report .
16.1.15.3 Haemorrhagic Stroke
Applicability
This technical standard is applicable to classes I, II, III and IV medical certificates.
1) An applicant diagnosed with a haemorrhagic stroke shall be declared medically unfit and shall provide the
following upon diagnosis:
i. A Neurologist report;
ii. A Brain CT scan;
iii. A 16 Lead EEG; and
iv. A Clinical Psychologist report.
2) The applicant may be considered for recertification by the Authority after an observation period of two (2)
years has lapsed;
3) An applicant with subarachnoid bleeding may be considered by the Authority after an observation period of
at least one (1) year, following a successful isolation of the source with no neurological deficit.
4) Flexibility on the period of observation shall be applied by the Authority in respect of applicants with a
history of ischaemic stroke who is applying for a cabin crew and Class 4 medical certificate.
11.2.14. Parkinson’s Disease
Applicability

General
a) An applicant diagnosed with Parkinson’s disease shall be declared medically unfit upon diagnosis.
b) The applicant may be considered by the Authority after an observation period of six (6) months has
lapsed and the applicant is stable on acceptable medication.
c) On application for recertification the applicant shall provide the following:
i. A Neurologist report;
ii. A Clinical Psychologist report on neurocognitive functioning; and
iii. An undertaking to undergo the Authority’s supervised Simulator Test.
d) After successful recertification, the applicant shall provide a neurologist report to the Authority every
six (6) months.
1. ATRIAL FIBRILLATION AND ATRIAL FLUTTER
Applicability
This protocol applies to Class 1, 2 and 3.
Initial Medical Requirements
On initial diagnosis, an applicant or a holder of a medical certificate shall:
(a) be declared as temporary medically unfit for at least 3 months post successful ablation.
(b) submit a Cardiologist assessment report’
(c) be required to submit a 24 Hour Holter (3 Holter’s over 2 to 3 months showing no AF);
(d) submit Doppler Echocardiogram (The Left Atrial Internal Diameter shall be < 4.5cm);
(e) submit Stress ECG (walking time >10 min; Max HR <230bpm; longest pauses <3,5sec);
(f) submit biochemical profile: Liver function Test; Thyroid function studies, serum magnesium and
potassium levels, fasting blood glucose (FBG); Mean Copular Volume (MCV) ; Haemoglobin
(Hb) ;
(g) not have underlying structural heart disease.
(h) not have a history of Transient Ischemic Attack (TIA);
(i) be on acceptable medication with no side effects.
(j) be symptom free; and
(k) follow the Warfarin protocol or other suitable anticoagulant protocols where indicated.
Annual follow-up reports
An applicant or a holder of a medical certificate shall:
(a) submit 6 monthly Cardiologist review for at least 4 – 5 years (post ablation) and annually
thereafter.
(b) submit 24-Hour Holter; and
(c) submit Echocardiogram annually
2. INCOMPLETE RIGHT BUNDLE BRANCH BLOCK CONDITIONS
Applicability
This protocol is applies to Class 1, 2 and 3.
(1) An applicant or a holder of a medical certificate shall submit medical reports from a Cardiologist
addressing the underlying cause of the Incomplete Right Bundle Branch Block and the treatment if
applicable.
(2) Each case will be reviewed on its own merit”.”
3. COMPLETE RIGHT BUNDLE BRANCH BLOCK
Applicability
This protocol applies to Class 1, 2 and 3
Class 1 Restrictions
i. Multicrew - If acquired > 40 years of age.

ii. Satisfactory Cardiological review at 12 months, - may apply for multicrew restriction to be removed
Class 2 Restrictions
i. Certification as or with co-pilot.

ii. Satisfactory Cardiological review at 12 months, - may apply for multicrew restriction to be removed.
Initial Medical Reports Requirements
(a) Be declared temporary medically unfit on diagnosis of the complete right bundle branch block.
(b) submit a Cardiologist Report which must contain the underlying cause and treatment.

(c) submit Stress ECG (at least Stage 3 Bruce protocol).

(d) submit 24-hour Holter ECG (showing no significant rhythm or conduction disturbance apart from
RBBB.
(e) submit an Echocardiogram (normal structure and LV, RV function; LVEF > 50%)
(f) submit an Electrophysiological study; and
(g) have at least two attempts on atrioventricular pathway ablation.
Follow -Up Requirements

Annual Cardiologist report
4. PARTIAL/COMPLETE LEFT BUNDLE BRANCH BLOCK
Applicability
This protocol applies to Class 1, 2, and 3.
Restrictions
i. Class 1 – Multicrew
ii. Class 2 – May need co-pilot restriction.
Initial requirements following diagnosis.
i. be declared temporary medically unfit on diagnosis of the partial / complete Left Bundle Branch Block.
ii. submit Cardiologist’s report.
iii. submit Stress ECG and must complete a stage 4 Bruce protocol);
iv. submit Echocardiogram (LVEF >50%)
v. submit 24-hour Holter ECG; and
vi. pharmacological stress thallium MPI or Coronary angiography – (<50% stenosis in any major
untreated vessel/in any venous/arterial graft remote from any infarction; <30% if the proximal left
anterior descending or left main stem vessels are involved).
Follow-Up Reports (Annual)
An applicant or a holder of a medical certificate shall undergo routine aviation medical examination and submit
Cardiologist report annually”.

5. LEFT ANTEROSUPERIOR AND LEFT ANTEROPOSTERIOR FASCICULAR HEMIBLOCKS
Applicability
Initial requirements following diagnosis
An applicant or a holders of a medical certificate shall:
(a) submit a Cardiologist report.

(b) submit Stress ECG which is compliant to (at least Stage 3 Bruce protocol).
(c) submit a Cardiologist reports 24-hour Holter ECG.
(d) submit a Cardiologist reports Echocardiogram; and
(e) submit a Cardiologist reports Coronary angiography if indicated.
Follow-Up Reports
Normal investigations (24-hour Holter, Echo, Coronary Angiography), with no symptoms – no further
reviews”.”
6. ATRIO-VENTRICULAR BLOCKS
Applicability
6.1 1ST DEGREE ATRIO-VENTRICULAR BLOCK
(a) be declared temporary medically unfit on diagnosis.

(b) submit a Cardiologist Report; and
(c) submit a Resting and Stress ECG.
1) If the previous attempt on two episodes of ablation has failed, then an atrioventricular pacemaker shall
be inserted.
2) Once declared medically fit, an applicant or a holder of a medical certificate shall be reviewed every 6
months.
6.3. 2ND DEGREE ATRIO-VENTRICULAR BLOCK
An applicant or a holder of a medical certificate diagnosed with a Second Degree Atrio-Ventricular Block shall:
(a) be declared temporary medical unfit on initial diagnosis.

(b) submit Cardiologist Reports.
(c) submit a 24 Hour Holter; and
(d) submit a Stress ECG.
(1) An applicant or a holder of a medical certificate with untreated heart blocks of 2:1 or > shall not be
recertified for any class of medical certificate (risk of AV block and syncope).
(2) An applicant or a holder of a medical who meets the requirement shall be declared medically fit for not
more than 12 months and shall be reviewed annually”.
6.4 MOBITZ TYPE II -ATRIOVENTRICULAR BLOCK AND COMPLETE ATRIOVENTRICULAR BLOCK
Applicability
Initial requirements
Applicant or a holder of a medical certificate diagnosed with Mobitz type II, 2:1 atrioventricular block and
complete atrioventricular block shall be declared medically unfit for all medical classes”.
6.5 THIRD DEGREE HEART BLOCK
Applicability
General
a) An applicant or a holder of a medical certificate diagnosed with third degree heart block shall be
declared medically unfit for all classes.
b) An applicant or a holder of a medical certificate may apply for recertification after successful
pacemaker implant.
6.5.3 Initial medical requirements
(1) An applicant or a holder of a medical certificate diagnosed with a Third Degree Atrio-Ventricular Blocks
may apply for recertification after successful intervention with pacemaker.
(2) An applicant or a holder of a medical certificate shall submit a Cardiologist Report.
(3) An applicant or a holder of a medical certificate shall submit a 24 Hour Holter.
(4) An applicant or a holder of a medical certificate shall submit a Stress ECG Report.
(5) An applicant or a holder of a medical certificates shall submit a Pacemaker interrogation report.

(6) The pacemaker is to be dual pacemaker with bipolar leads due to the unacceptable risk of electrical
interference with pacemakers that have unipolar leads.
(7) Annual pacemaker is to have a technical check every 12 months.
6.5.4 Follow-Up Reports
(1) Applicant or a holder of a medical certificate shall submit 3 monthly Cardiologist reports for 6 months,
then 6 monthly Cardiologist reports for a year, then annual Cardiologist review thereafter.
(2) An applicant or a holder of a medical certificate shall submit annual Pacemaker interrogation report”.
7. 1 ABNORMAL ECG TRACINGS
Applicability
This protocol applies to Class 1, 2, 3, and 4.
Initial medical requirements
An applicant or a holder of a medical certificate:
(a) when presenting with an abnormal ECG tracing shall provide a Cardiology report.
(b) shall submit a stress ECG report
(c) shall submit a 24-hour Holter
(d) shall submit an Echocardiogram; and
(e) shall be assessed on a case-by-case basis”.
7.2 BRUGADA SYNDROME
Applicability
This protocol applies to Class 1, 2, 3, and 4.
General
Fibrillation/ atrial flutter/ flutter fibrillation/ some other super-ventricular tachycardia with various degrees of
block shall be declared medically fit provided an applicant or a holder of a medical certificate holder:

(a) is asymptomatic.
(b has a satisfactory Cardiology evaluation;
(c) has no family history of sudden Cardiac Death;
(d) has minimal ECG features seen only intermittently or following pharmacological provocation; and
(e) has no evidence of complex ventricular rhythm disturbances on regular Holter monitoring”.
7.2 BRUGADA PATTERN
(1) An applicant or a holder of a medical certificate with symptomatic Brugada pattern Type 1 with
evidence of tachyarrhythmia shall be declared medically unfit.
(2) An applicant or a holder of a medical certificate with asymptomatic Brugada pattern type 1 and 2 may
be declared medically fit provided such an applicant or a holder of a medical certificate have
satisfactory Cardiology evaluation and investigations (stress ECG, 24-hour Holter, Echocardiogram).
(3) An applicant or a holder of a medical certificate who is asymptomatic and has persistent or intermittent
Brugada Pattern type 3 may be declared medically fit with no restriction provided have a satisfactory
Cardiology evaluation and investigations (stress ECG, 24-hour Holter, Echocardiogram).
(4) An applicant or a holder of a medical certificate who is declared medically fit on initial assessment,
must provide annual Cardiologist reports.
(5) An applicant or a holder of a medical certificate shall be reviewed on a case-by-case basis.
7.3 PROLONGED QT SYNDROME
(1) An applicant or a holder of a medical certificate diagnosed with prolonged QT syndrome shall be
declared ‘medically unfit for all classes due to the risk of sudden death.
(2) An applicant or a holder of a medical certificate shall be assessed on a case-by-case basis
7.4 VENTRICULAR TACHYCARDIA AND SUPRAVENTRICULAR TACHYCARDIA
(1) An applicant or a holder of a medical certificate with ventricular or supraventricular tachycardia shall
be assessed on a case-by-case basis”.
7.5 WOLFF-PARKINSON-WHITE SYNDROME
Applicability

General
(1) Following a diagnosis of Wolff-Parkinson-White syndrome an applicant or a holder of a medical

certificate shall be declared temporary medically unfit.
(2) An applicant or a holder of a medical certificate may only apply for recertification 3 months after
successful ablation.
Initial recertification reports
(a) undergo annual routine aviation medical examination.
(b) submit a Cardiologist’s assessment.
(c) submit a report indicating the successful ablation.
(d) submit a Stress ECG report.
(e) submit an Echocardiogram; and
(f) submit a 24-hour Holter.
Follow-Up Reports
a) shall submit a Cardiologist review at the following intervals, 6 months and 12 months post successful
radiofrequency ablation of aberrant conduction pathways.
b) shall submit Annual Cardiologist’s review; and
c) if he or she did not experience a recurrence of abnormal conduction within 24 months of a successful
radiofrequency ablation, further recertification without restriction shall follow the normal pattern for an
applicant or a holder of a medical certificate’s age and class of medical certificate”.
7.6 RADIO-FREQUENCY ABLATION
Applicability
Restrictions
i. Multicrew Restriction

ii. Following an event-free period of 2 years, the restriction may be considered for removal subject to
review.
Initial Recertification Reports
1) An applicant or a holder of a medical certificate shall be considered at least 3 months following

successful ablation with demonstrated bidirectional block.
2) An applicant or a holder of a medical shall provide a Cardiologist report indicating that he or she have
not had arrhythmias in at least 3 months post ablation.
Annual Follow-Up Reports
a) submit a Cardiologist’s Report.
b) submit a Cardiologist’s 24-hour Holter; and
c) submit Echocardiogram”.
7.6 PROTOCOL FOR VALVULAR HEART DESEASES
UNCORRECTED AORTIC STENOSIS
Applicability
Restrictions
An applicant or a holder of a medical certificate who presents with any evidence of valvular calcification shall
be restricted to multicrew operation.
General
An applicant or a holder of a medical certificate diagnosed with uncorrected Aortic stenosis shall be declared
temporary medically unfit on initial diagnosis.
General Medical Requirements
An applicant or a holder of a medical certificate shall submit:
(a) a Cardiologist reports.
(b) an ECG report;
(c) a Doppler Echocardiogram report; and

(d) submit a Chest X-Ray report; and
(1) The medical reports shall be considered satisfactory if they meet the following criteria for solo
operation for a period of one (1) year when an applicant or a holder of a medical certificate :
i. is asymptomatic;
ii. have an Aortic valve calcification grade of 1 / 2.
iii. have a Valvular Doppler peak aortic velocity <3m/s; and
iv. have a Valve area > 1,0 cm sq.
Follow-Up Reports Annually
An applicant or a holder of a medical certificate shall submit:
(b) an ECG Report; and
(c) an Echocardiogram.
Disqualifying conditions for uncorrected Aortic Stenosis
An applicant or a holder of a medical certificate who present with:
(a) any evidence attributable symptoms.
(b) any evidence of any increase in LV wall thickness (>1,1cm) ;
(c) a history of cerebral embolic event; and
(d) aortic dilatation of >5 cm.
CORRECTED AORTIC STENOSIS
General
An applicant or a holder of a medical certificate diagnosed with a diagnosis of corrected aortic stenosis
shall be declared temporary medically unfit on initial diagnosis for at least 6 months post operation.
General Medical Requirements
(1) An applicant or a holder of a medical certificate:
a) shall undergo annual aviation medical examinations.

b) shall submit a Cardiologist report.
c) shall submit an ECG Report;
d) shall submit an Echocardiogram Report.
e) who underwent tissue valve replacement and there is no requirement for anticoagulation therapy,
certification may be issued for a period of one (1) year unrestricted to multicrew; and yearly
thereafter if the annual reports are satisfactory.
f) who underwent mechanical valve replacement and there is evidence of clinically satisfactory, well-
controlled anticoagulation, he or she may be issued with a Class 1 medical certification –restricted
to multi-crew operations for a period of one (1) year; and
g) submit a yearly thereafter if the annual reports are satisfactory.
Follow-Up Reports
An applicant or a holder of a medical certificate shall submit a Cardiologist report annually”.”
3. UNCORRECTED AORTIC INCOMPETENCE
Applicability
General
An applicant or a holder of a medical certificate diagnosed with uncorrected Aortic Incompetence shall be
declared temporary medical unfit on initial diagnosis.
(a) submit a Cardiology Report; and
(b) submit an ECG submit a Doppler Echocardiogram.
(1) If the reports are satisfactory, an applicant or a holder of a medical certificate shall be declared
medically fit for a period of one (1) year depending on the severity of the condition and the rate of the
deterioration.
3.4. Disqualifying conditions for Uncorrected Aortic Incompetence
An applicant or a holder of a medical certificate with the following conditions shall be disqualified:

(a) significant increase in the LV End-Systolic Diameter (LVEDD) (>6,0cm);
(b) increase of (LVEDD) LV End-Systolic Diameter of >4,1cm.
(c) significant arrhythmia.
(d) abnormal effort performance.
(e) Aortic root diameter of >5,0cm; and
(f) significant increase in the end-systolic (>4,4cm) and/or end-diastolic (>6,5 cm) diameter of the
Left ventricle, with or without evidence of impairment of systolic/diastolic function.
Follow-Up Reports (Annual)
(1) An applicant or a holder of a medical certificate shall submit an annual Cardiac Report.
(2) An applicant or a holder of a medical certificate shall submit an annual Echocardiogram”.
4. CORRECTED AORTIC INCOMPETENCE
Applicability
General
(1) An applicant or a holder of a medical certificate diagnosed with a diagnosis of Corrected Aortic
Incompetence will be declared temporary medically unfit on initial diagnosis for at least 6 months post
operation.
(2) An applicant or a holder of a medical certificate cases shall be reviewed by the Aeromedical
Committee.
(a) shall undergo routine medical examinations annually.
(b) shall submit a Cardiology Report.
(c) shall submit an ECG.
(d) shall submit a Doppler Echocardiogram.
(e) shall submit a Chest -X-Ray.

(f) shall declared medically fit for a period of 12 months if the reports are satisfactory and shall be
reviewed annually.
(g) who underwent tissue valve replacement and there is no requirement for anticoagulation
therapy, certification may be issued for a period of one (1) year unrestricted to multicrew; and
yearly thereafter if the annual reports are satisfactory; and
(h) who underwent mechanical valve replacement and there is evidence of clinically satisfactory,
well-controlled anticoagulation, they may be issued with a Class 1 medical certification –
restricted to multi-crew operations for a period of one (1) year and yearly thereafter if the annual
reports are satisfactory.
Follow-up reports (Annually)
(1) An applicant or a holder of a medical certificate shall submit an annual Cardiology report.
(2) An applicant or a holder of a medical certificate shall be required to submit an Echocardiogram”.
5. RHEUMATIC MITRAL STENOSIS OR MITRAL REGURGITATION
Applicability
General
(1) An applicant or a holder of a medical certificate diagnosed with a Rheumatic Mitral Stenosis OR
Rheumatic Mitral Regurgitation shall be declared medically unfit on initial diagnosis for all classes
unless the condition is minimal and is in sinus rhythm.
(2) An applicant or a holder of a medical certificate shall be assessed by the Aeromedical Committee
(3) An applicant or a holder of a medical certificate shall:
(a) submit a Cardiology assessment report.

(b) submit an Echocardiogram.
(c) submit an ECG and
(d) submit a Chest X-ray”.
6. NON –RHEUMATIC NON-ISCHAEMIC MITRAL REGURGITATION
Applicability

Restrictions
An applicant or a holder of a medical certificate who are declared medically fit, with the condition, shall be
restricted to operate in a multicrew environment.
General
(1) An applicant or a holder of a medical certificate with a diagnosis of non –rheumatic non-Ischaemic
mitral regurgitation shall be declared medically unfit on initial diagnosis for all classes.
(2) An applicant or a holder of a medical certificate shall be assessed on a case-by case basis.
(3) An applicant or a holder of a medical certificate shall submit:
(b) Resting and Stress ECG Report.
(c) an Echocardiogram report; and
(d) a 24-hour Holter report.
Disqualifying conditions following diagnosis of Non –Rheumatic Non-Ischaemic Mitral Regurgitation
(a) Left Ventricular systolic diameter >4,1 cm and/or an end-diastolic diameter > 6,0 cm.
(b) Atrial Fibrillation; and
(c) diagnosis of non –rheumatic non-Ischaemic mitral regurgitation will disqualify the applicants or
holders of of a medical certificate from medical certification to fly. (Class I and II)
Follow-up reports (Annually)
An applicant or a holder of a medical certificate shall:’
(a) undergo annual aviation medical examination.
(b) submit a Cardiologist report.
(c) submit an ECG report; and
(d) submit an Echocardiogram”.

“SCHEDULE 47: PROTOCOL FOR CARDIAC VALVE REPLACEMENT
1. AORTIC VALVE REPLACEMENT
Applicability
This protocol applies to Class 1, 2, and 3
General
(1) An applicant or a holder of a medical certificate who have undergone a Cadaver Homograft or possibly
a Carpentier-Edwards or similar Xenograft may be considered for certification.
(2) Medical certification may be considered in the best risk subjects for an applicant or a holder of a
medical certificate who have undergone aortic valve replacement with a bioprosthetic /mitral valve
repair at least 6 months previously with the following conditions:
(a) an applicant or a holder of a medical certificate shall:
i) be free of symptoms and shall be in sinus rhythm and not require warfarin therapy.
ii) have no significant Left Ventricular Hypertrophy on Echocardiogram (>1,3vm, septum
and free wall) or dilation (>6,0 cm End Diastole/ 4,1 cm end systole), nor dilatation of
the aortic root (>4,5 cm);
iii) have no abnormality of wall motion on Echocardiography (except that due to LBBB)
iv) have no significant (un-grafted) coronary artery disease.
v) have no significant rhythm disturbance on Holter monitoring.
vi) shall be required to submit annual Cardiologist report; and
(b) an applicant or a holder of a medical certificate who is declared medically fit shall be restricted
to multi-crew operations”.”
2. MITRAL VALVE REPLACEMENT
Applicability
Class 1, 2, and 3
(a) who have undergone mitral valve replacement shall be declared medically unfit on diagnosis.
(b) shall undergone mitral valve replacement may only be considered for recertification at least 6
months post operation; and

(c) shall be considered on a case-by-case basis.
Follow-up reports (Annual)
(a) undergo annual aviation medical.

(b) submit a Cardiologist report.
(c) submit an ECG report; and
(d) submit an Echocardiogram
Disqualification conditions
(a) any history of associated thrombo-embolic is disqualifying.

(b) sinus rhythm may be considered for certification; and
(c) undergone amputation of the left appendage may be at an advantage; and
(1) An applicant or a holder of a medical certificate shall be considered on a case-by-case basis”.
11.2.15. Protocols on Hypertension
A blood pressure which is consistently >160/100 mmHg disqualifies a person from all classes of medical
certification. A person is deemed unfit, until such time as the person can prove control on acceptable
medication.
Mild Hypertension
1) A person is considered to be having mild hypertension if his or her systolic BP is 140–159 or diastolic
BP is 90–99.
2) In the case of a mild hypertension referred to in paragraph 1), a person shall –
i. Undergo regular three-monthly BP checks for a year;

ii. Undergo Lifestyle Modification (according to the National Guidelines on the Management of
Hypertension);
iii. Adjust or alter medication if already on therapy;
iv. Undergo Cardiovascular Risk Assessment; and
v. May continue to fly, in the case of a pilot.

Moderate Hypertension
1) A person is considered to be having moderate hypertension if his or her systolic BP is 160-179 or

diastolic BP is 100-109.
2) In the case of a moderate hypertension referred to in paragraph (1), a person shall –
3) Exclude reactive hypertension;
4) If hypertension is established, submit the following:
i. Urine Dipstix for Microalbuminurea

ii. Clinical examination
iii. Blood tests:
iv. Urea and Electrolytes
v. Fasting Glucose
vi. Fasting Total Cholesterol, and if Total Cholesterol is >5.00 a fasting Lipogram should be done;
vii. Begin therapy with an acceptable agent;
viii. Undergo cardiovascular risk assessment;
ix. Be grounded for two weeks; and
x. Undergo a clinical evaluation after one month.
Moderate/severe Hypertension
1) A person is considered to be having moderate/severe hypertension if his or her Systollic BP is 160-

179 mmHg or Diastollic BP is 100-109 mm Hg (for moderate), or a Systolic BP of >180 or Diastolic BP
of >110 (for severe).
2) In the case of a moderate/severe hypertension referred to in paragraph 1), a person shall –
i. Review medication (therapy); and

ii. Be considered medically fit and not exercise the privileges of his or her licence until
hypertension is adequately controlled on acceptable medication.
Normotensive/Diagnosed reactive Hypertension
1) A person is considered to be normotensive if his or her Systolic BP is120-129 or Diastolic BP is 80-84.
2) Once the licence holder is normotensive or diagnosed to have reactive hypertension as per paragraph
1), a person shall –
3) be deemed fit to fly, with a 6-monthly follow-up for one year, consisting of –
4) Clinical examination
5) Resting ECG (<40 or falls into the Blue or Green Risk Categories – see Table 2)
6) Stress ECG (>40 or falls into the Yellow, Orange, or Red Risk Categories – see Table 2) See note*
Blood tests:
i. U & E including creatinine

ii. Fasting glucose
iii. Fasting lipogram
Note *Stress ECG for Yellow Risk Category to be done by AME. Stress ECG for Orange and Red Risk
Categories to be done by a cardiologist. Risk categories as per Table 2.,undergo annual follow-up thereafter
consisting of:
i. Clinical examination
ii. Resting ECG (<40 or falls into the Blue or Green Risk Categories – see Table 2)
iii. Stress ECG (>40 or falls into the Yellow, Orange, or Red Risk Categories – see Table 2) See
note*
iv. Blood tests (U&E including Creatinine, Fasting Glucose, Fasting Lipogram).
v. Note *Stress ECG for Yellow Risk Category to be done by AME. Stress ECG for Orange and
Red Risk Categories to be done by a Cardiologist. Risk categories as per Table 2.
ii. Cardiovascular Risk Assessment
Cardiovascular risk assessment shall be done based on the South African Hypertension Guidelines.
Cardiovascular risk assessment shall be done in accordance with the tables below.

Table 1: Major risk factors, target organ damage, and associated clinical conditions.
MAJOR RISK FACTORS, TARGET ORGAN DAMAGE, AND ASSOCIATED CLINICAL CONDITIONS
ASSOCIATED CLINICAL
MAJOR RISK FACTORS TARGET ORGAN DAMAGE
CONDITIONS
Levels of systolic and diastolic BP Left ventricular hypertrophy: based Coronary heart disease
on ECG
Smoking Microalbuminuria: albumin/ Heart failure
creatinine ratio
3 -30 mg/mmol
Dyslipidaemia Slightly elevated creatinine Chronic kidney disease: albumin
Total cholesterol >6.5 mmol/l, OR Men 115-133 μmol/l creatinine ratio >30 mg/mmol
creatinine ratio >30 mg/mmol Women 107-124 μmol/l
LDL >4 mmol/l, OR
HDL men <1 and women
<1.2 mmol/l
Diabetes mellitus Stroke or transient ischaemic attack
Men >55 years
Women >65 years
Family history of early onset of: Peripheral arterial disease
cardiovascular disease
Men aged <55 years
Women aged <65 years
Waist circumference – abdominal Advanced retinopathy
obesity Haemorrhages OR
Men ≥102 cm Exudates
Women ≥88 cm Papilloedema
The exceptions are South Asians
and Chinese: men >90 cm and
women >80 cm

Table 2: Stratification of risk to quantify prognosis
STRATIFICATION OF RISK TO QUANTIFY PROGNOSIS

Other risk factors BP (mmHg)
and disease Normal High-normal Stage 1 Stage 2 Stage 3
history SBP 120-129 SBP 130-139 Mild hypertension Moderate Severe
or or SBP 140-159 hypertension hypertension
DBP 80-84 DBP 85-89 or SBP 160-179 SBP >180
DBP 90-99 or or
DBP 100-109 DBP >110
No other major risk Average risk Average risk Low added risk Moderate added High added risk
Factors risk
1-2 major risk Low added risk Low added risk Moderate added Moderate added Very high added
Factors risk risk risk
≥ 3major risk Moderate High added risk High added risk High added risk Very high added
factors added risk risk
or target-organ
damage
or diabetes
mellitus
Associated clinical Very high Very high added Very high added Very high added Very high added
conditions added risk risk risk risk risk
* Legend
Average Risk and Low Added Risk

Bloods (Fasting Glucose, Fasting Lipogram, U&E-including Creatinine)
Resting ECG: less than the age of 40 years
Stress ECG: 40 years of age and above (to be done by a DAME)
Moderate Added Risk

Annual Stress ECG (done by a DAME-Designated Medical Examiner)
Annual Bloods (U&E – including Creatinine, Fasting Glucose, Fasting Lipo-gram) for all Classes.
Applicable Protocol for Co-morbidity
High Added Risk

Stress ECG (to be done by a Cardiologist – minimum stress level should be 85%)
Annual Bloods (U&E – including Creatinine, Fasting Glucose, Fasting Lipo-gram)
Applicable Protocol for Co-morbidity

Very High Added Risk

Stress ECG (to be done by a Cardiologist – minimum stress level should be 85%)
Annual Bloods (U&E – including Creatinine, Fasting Glucose, Fasting Lipo-gram)
Cardiovascular risk assessment shall be done based on the South African Hypertension Guidelines. (Refer to
Table 1: Major risk factors, target organ damage, and associated clinical conditions, and Table 2: Stratification
of risk to quantify prognosis.)
iii. Coronary Artery Disease Protocol
General
Aviation medical standards as laid down in Annex 1 of the Convention on International Civil Aviation by the
International Civil Aviation Organisation to which South Africa is a contracting State, have identified broad
medical conditions that, on the basis of expected risk of incapacitation, disqualify aviation personnel from
flying. South Africa is one of the countries that previously applied strict standards to initial applicants with a
history of coronary heart disease who applied for a medical certificate. This previous protocol was also applied
to aviation personnel regarding whom the risk of sudden incapacitation was reduced as a result of risk factor
modification or rehabilitation, including therapeutic interventions.
The SACAA has since reviewed this protocol and is now making provision for aviation personnel with a history
of coronary artery disease. Initial and experienced applicants may be considered for any class of medical
certificate. This consideration will be based on the individual medical condition of the applicant and risk factor
involved. This protocol applies to all applicants (initial and experienced) presenting with coronary artery
disease (such as Myocardial Infarction, Angina Pectoris or asymptomatic coronary artery disease detected on
investigation following assessment of risk factors). The protocol is applicable to isolated coronary artery
disease and its risk factors only. The presence of ischaemia/inducible ischaemia remains an exclusion factor.
Operational Restrictions
CLASS I
ATPL Multi-crew – As/or with a co-pilot
Commercial pilots
Instructor – Student must have completed first solo flying
Game capturing – Applicant can fly solo only if there are no passengers.
Crop spraying – Applicant can fly solo if there are no passengers.
CLASS II – no restrictions
CLASS III – no restrictions
CLASS IV – no restrictions
General medical requirements applicable to all applicants
1) Applicants will be temporarily taken off flying or controlling duties for a duration of not less than six
months following the index event.
2) Applicants must be asymptomatic for at least six months following adequate intervention; the medical
certificate will be withdrawn during this period.

3) Applicants on medication will be considered only if the medication is approved by the Medicine Control
Council of South Africa and is compatible with flying.
4) All initial medical reports must be submitted to a panel of specialists for consideration, and should
include the following –
a) Hospital admission summary (History and Physical).
b) If catherisation and/or angiography have been performed, all reports and actual films/CDs
must be submitted for review.
c) A cardiothoracic report, in cases of CABG/PTCI, detailing the cardiac event and procedures,
must be submitted.
d) Applicants presenting with more than two stenoses of more than 30% within a vascular tree
shall be assessed as unfit.
e) An angiogram shall not reveal stenosis of greater than 50% in any major untreated vessel, in
any vein/artery graft or at the site of an angioplasty/stent, except in a vessel supplying the
infarct.
f) The medical certificate of applicants presenting with any major vessel stenosis of 50% will be
withdrawn, until appropriate intervention is undertaken.
Cardiovascular Evaluation
a) General physical and clinical cardiology assessment.
b) Family and medical history.
c) Functional capacity using New York Heart Association Functional Classification or Canadian
Cardiovascular Score.
Prognosis of Incapacitation.
a) Treatment.
b) Blood chemistry (fasting Lipid Profile, Urea, Urate and Creatinine and Fasting Blood Glucose).
c) The following are major modifiable risk factor for ischaemic heart disease and should be under control:
d) Smoking: An applicant with known ischaemic heart disease who continues to smoke should be
assessed as “medically unfit”.
e) Weight reduction: Weight reduction in obese and overweight patients should be encouraged.
Applicants are theoretically encouraged to set a goal to achieve a body mass index (BMI) <25kg/m or
a waist circumference <102cm in men and 88cm in women.

f) Abnormal lipid profile: Applicants are encountered to be aware of their serum cholesterol levels and to
maintain a normal level. Statins are recommended early for all applicants with a history of Non-ST
elevation acute coronary syndrome (NSTE-ACS) in the absence contraindications, irrespective of
cholesterol levels, with the aim of achieving Low Density Lipoprotein (LDL) levels <2.6mmol\L.
g) Blood pressure control: Applicants are required to have a blood pressure control of <140/90, and
<130/80 mmHg for those suffering from diabetes mellitus or renal dysfunction.
h) Maximal stress ECG:
i) Applicants are required to be symptom-free and must complete a minimum of Bruce Stage 3 or 8.5
metabolic equivalents (METS).
j) A minimum of 85% of the required target rate must be achieved
5) The applicant must be free from inducible myocardial ischaemia or significant rhythm disturbances
during the study. A 24-hour Holter ECG tracing is necessary to assess any significant rhythm
disturbances.
6) A stress Echocardiogram/Stress MRI/MIBI Scan or Coronary CT scan will be required six months after
the incident.
7) If any of the above-mentioned tests show any significant abnormality, a Coronary Angiogram will be
required; it must be within previously described limits.
8) The left ventricular ejection fraction as a measure of left ventricular function using echocardiogram or
gated radionuclide scintigraphy should be 50% or more at rest and should not show a decrease of
more than 5% with satisfactory exertion (85% predicted maximum heart rate or >8 (METS).
9) A threshold ejection fraction of 45% applies with the use of single proton emission computerised
tomography (SPECT).
i. In applicants with an ejection fraction of between 40% and 50%, restricted medical
certification may be considered after review of a 24-hour Holter.
ii. This should reveal no more 30 ventricular ectopic beats per hour in the absence of anti-
arrhythmic medication, with no more than three consecutive beats and a cycle length that is
not less than 500 msec.
iii. A Myocardial Perfusion Scan shall be required at least six months after Angioplasty/Stenting,
but not necessarily after other events (Myocardial Infarction or Coronary Artery Bypass
Grafting), unless there is doubt about the diagnosis Myocardial Infarction or adequacy of
Bypass Grafting.
iv. Therapeutic considerations
v. Only medication that is compatible with flying will be allowed.

Follow-up certification
i. An annual cardiologist’s report, including –
ii. Resting and Maximal Stress ECG 12 lead ECG, symptom limited, with no evidence of myocardial
ischaemia or ischaemia equivalent. (Some applicants will continue to have an “abnormal” stress test.
iii. A cardiologist’s opinion should be sought for these cases and, if necessary, MIBI or stress ECHO may
be required);
iv. A normal 24 -hour Holter ECG will be required.
Blood chemistry shall include –
i. Urea & Creatinine;
ii. Fasting Lipid Profile;
iii. Fasting Blood Glucose; and
iv. Haemoglobin & Platelets.
An angiogram will be required –
a) If there is any cardiac abnormality detected, including symptom relapse.
b) Chest pain –
c) Regardless of whether typical or atypical for ischaemic heart disease, precludes medical certification
insofar as it indicates an elevated probability of significant coronary artery disease and an increased
risk of an incapacitating cardiac event.
d) An applicant may be considered fit if diagnostic testing indicates that the chest pain is not due to
myocardial ischaemia.
e) The initial assessment, including a review of the symptom history, must be without the effect of anti-
ischaemic meditation that could possibly mark adverse findings; and
f) If coronary arteriography reveals normal coronary arteries, coronary vasospasm should be excluded.
Four-yearly – Follow-Up Requirements
i. A Stress Cardiolite/MIBI Scan/Stress MRI/Stress Echo or coronary scan will be required.
ii. If any of the tests show any abnormality, a repeat angiogram will be required.

PROTOCOLS FOR THE RESPIRATORY SYSTEM
Protocol on Asthma
ICAO Annex 1 – Personnel Licensing 6.3.2.8. states: “There shall be no acute disability of the lungs nor any
active disease of the structures of the lungs, mediastinum or pleura.”In the ICAO Guidelines on Medical
Assessment of the Respiratory System – Chapter 2, the following is stated: “Applicants with bronchial asthma
should in general be assessed as unfit unless the clinical course is extremely mild and drug treatment is not
required.” In South Africa there is a slightly more lenient approach. Although applicants who comply with the
following protocols are able to fly, all cases that fall outside the minimum standards must be referred to the
Aviation Medical Panel for certification.
Special Medical Requirements
a) Lung function tests –

b) Interval: Same as ECG or more frequently on indication.
c) Chest X-ray: PA and Lateral on initial examination. Subsequent CXRs on indication only.
Minimum lung function standards
FEV1 and FVC ≥ 70% of predicted values (to exclude restrictive lung disease). N.B. If one or both values are
<70%, refer for X-ray and pulmonologists report.
FEV1/FVC ≥ 70% to exclude obstructive airways disease. N.B. Do not use % predicted values here.
Initial pilots
a) If FEV1/FVC ≤ 75%
b) Determine cause –
c) Infection (e.g. bronchitis):
d) Temporarily unfit. Repeat after 7 to 14 days when cured and off medication.
e) Reactive airways:
f) Any form of asthma in the last five years or previous hospitalisation due to asthma: Temporarily unfit.
Pulmonologists report.
g) Exercise induced asthma only: Temporarily unfit. Inhaled steroids for 4 weeks. Re-examine with
provocation test (e.g. stress ECG).
h) Acceptable lung function with –
i) History of asthma in past 5 years. Temporarily unfit. Pulmonologists report.

j) Use of bronchodilators. Unfit to fly with bronchodilators. Pulmonologists report.
Experienced Pilots
a) If FEV1/FVC ≤ 70%
b) Manage according to the cause:
c) Infection (e.g. bronchitis):
d) Temporarily unfit. Repeat after 7 to 14 days when cured and off medication
e) Reactive airways:
f) Treated for asthma in the last 5 years or previous hospitalisation due to asthma. Temporarily unfit.
Pulmonologists report.
g) Exercise induced asthma:
h) Unless severe (e.g. FEV1/FVC ≤ 70%) provisionally fit. Inhaled steroids for 4 weeks. Re-examine after
provocation test.
i) Acceptable lung function with:
j) History of wheezing in the absence of infection,not t taking medication and never admitted to hospital
due to asthma.
k) Provisionally fit (if medication is taken – temporarily unfit), pending the pulmonologist’s report.
l) Use of bronchodilators: Unfit to fly with bronchodilators. Pulmonologists report.
m) Any applicant who has had an FEV1/FVC ≤ 70% for reasons other than infections, should have an
initial pulmonologists report followed by an annual lung function test.
n) The only medication that may be used in the management of asthma is –
o) Inhalation steroids (e.g. Becotide ™, Becloforte™, Becodisks™, Pulmicort™, Clenil™, Inflammide™,

Flixotide™, Viarox™, Ventzone™, etc.)
p) Sodium cromoglycate (i.e. Lomudal ™) and Nedocromil (Tilade™) – are also acceptable.
Protocol on Pneumothorax
Traumatic Pneumothorax
a) Uncomplicated cases. Fit to fly six weeks after discharge from hospital. Confirmatory chest x-ray and
lung function test required.
b) Complicated cases (e.g. empyema, chronic pneumothorax, other serious injuries, etc.) – refer to
pulmonologist.
c) Case referred to Medical Assessor for specialists consideration
Spontaneous Pneumothorax
a) Initial pilots –
b) History of previous spontaneous pneumothorax. Temporarily unfit. Refer to pulmonologist.
c) Experienced pilots –
d) First episode –
e) May be considered for recertification six weeks after discharge from hospital. Confirmatory chest x-ray,
lung function and pulmonologists report (stipulating state of recovery, chance of recurrence and
underlying pathology) required.
f) More than one episode –
g) Temporarily unfit. May be recertified six to 12 weeks following successful pleurodesis.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Applicability
This protocol is applicable to an applicant for a to Class 1,2,3 and 4 Medical Certificate.
General
All case requires medical assessor consideration if the applicant is taking steroid doses equivalent to more
than 5 mg of prednisone per day.
1. Initial certificate eligibility
a) An applicant with Chronic Obstructive Pulmonary Disease should be assessed as Temporary

Medically Unfit upon diagnosis until they have been worked up by a Pulmonologists/Physician.
b) An applicant with only minor impairment of pulmonary function may be assessed as medically fit
by the Aeromedical Committee.
2. Initial considerations for monitoring of applicant
a) A Comprehensive Report from a treating specialist reporting on symptoms, cardiac assessment, and
Lung Function Test .
b) Treating specialist is required to stage the disease.
c) An applicant presenting with stage 2 and above must submit an Oxygen Saturation and Diffusion Test.
d) An applicant must present with a 6 Minute Walk Test.

e) An applicant shall be required to submit a Pulmonologist/Physician if FEV1 or FEV1/FVC is less than

70%..
f) An applicant shall be required to submit a Chest X-Ray.
g) Medical fitness must be assessed when an applicant has developed an associated cardiac condition.
h) An applicant is taking steroid doses equivalent to more than 10 mg of prednisone per day is
disqualifying on diagnosis.
i) A treatment regime and side effect profile shall be required.
j) (10)An applicant who is smoking shall be required to stop smoking.
3. Follow up Requirements
(1) An applicant shall be required to submit an Annual Pulmonologist Report.

(2) An applicant shall be required to submit Lung Function Test annually.
(a) the substitution of Schedule 9 of the following schedule
SPONTANEOUS PNEUMOTHORAX
Applicability
This protocol is applicable to an applicant for Class 1,2,3 and 4 medical certificates.
Initial certification eligibility
An application shall be assessed on a case-by-case basis and presented to the Medical Assessors for medical
consideration.
(a) An applicant shall be declared Temporary Medical Unfit upon diagnosis and may be considered for
issuance of a medical certificate 6 weeks after resolution of one episode.
(b) A Pulmonologist /Thoracic Surgeon report shall be required for the confirmation of the diagnosis (traumatic
versus spontaneous, primary, or secondary) and clinical status; and
(c) All high-risk patients require surgical intervention (surgical pleurodesis) before they can be considered for
recertification
INITIAL REQUIREMENTS
An applicant shall be required to :
1. Submit a High-Resolution CT Chest to rule out abnormalities.

2. Applicant to submit a follow-up of Chest Xray post pleurodesis.
a) Submit proof of cessation of smoking, a rapid nicotine test conducted by the treating doctor
b) Specialist report which t include follow-up recommendations and the risk of recurrence; and
c) Submit a Lung Function Tests (if clinically relevant).
Follow up Medical Requirements
a) An applicant shall be required to submit a Pulmonologist/ Physician/Thoracic Surgeon report one (1)
year following the incident, and if satisfactory, follow-up may be stopped.
TRAUMATIC PNEUMOTHORAX
Applicability
General
a) An applicant may be declared medically Temporary Unfit upon diagnosis and may be considered for
issuance of medical 6 weeks after an incident if one episode by the Medical Assessor Authority.
b) An applicant shall be required to submit a Pulmonologist /Thoracic Surgeon report, confirming the
diagnosis (traumatic & clinical status).
c) An applicant shall be required to submit a Lung function test (if clinically relevant -) management.
d) An applicant shall be required to submit a Chest X-ray, not necessary if HRCT is available.
e) An applicant shall be required to submit a specialist report with follow-up recommendations and the
risk of recurrence.
Follow up Medical Reports Requirements
An applicant shall be required to submit a Pulmonologist /Thoracic Surgeon report one (1) year following the
incident, and if satisfactory, the follow-up required may be stopped”.”
SARCOIDOSIS
Applicability
This protocol applies an applicant for to Class 1,2,3 and 4 medical certificates.
General

(1) An application for this protocol shall be assessed on a case-by-case basis and presented by a Medical
Assessors to ensure Accredited Medical Conclusion prior to initial certification.
(2) An applicant with active sarcoidosis shall be assessed and declared temporary medical unfit on diagnosis
for a period of 3 months, and an investigation shall be undertaken with respect to the possibility of
systemic, particularly cardiac, involvement.
(3) The disease shall be inactive clinically or until disease progression/stability has been demonstrated for a
minimum of 3 months before consideration for a medical certificate by the Authority.
(4) Clinical activity is defined as worsening or new organ involvement within a system.
(5) A medical fit assessment may be considered if there is no medication is required, and the disease is
investigated and shown to be limited to hilar lymphadenopathy and inactive.
(6) The need for treatment is normally disqualifying; however, up to 5mg of prednisone may, in individual
cases, be acceptable following Medical Assessor /Panel case assessment
Initial considerations for monitoring of applicant
(1) An applicant shall be required to submit a Cardiology review which shall include a 12-lead resting
ECG.
(2) An applicant shall be required to submit a 24-Hour Holter ECG and an Echocardiogram.
(3) An applicant who presents with any of the abnormalities of investigations referred to in subsection (2)
will require further evaluation including Cardiac Magnetic Resonance Imaging.
(4) A Neurologist assessment shall be conducted to exclude neurological involvement of sarcoidosis.
(5) Review to include Chest Xray if clinically indicated.
(6) Lung Function Tests remains fit if (<10%/yr fall in FEV or <15% fall in gas transfer using diffusion
studies and FEV1/FVC be no lower than 70% of predicted value)-Physician or Pulmonologist .
(7) The following blood test shall be required after 3 months in remission of angiotensin-converting
enzyme (ACE):
Follow up Medical Requirements
(i) a 24-Hour Holter Electrocardiogram;
(ii) a comprehensive respiratory assessment including a Lung Function Test by either a Pulmonologist or
a Physician;
(iii) a Chest X-Ray if clinically indicated;
(iv) a Clinical Psychologist, if clinically indicated; and

(v) Class 1 applicant with being required to do a follow-up shall be 6 monthly for the 1st 2 years after
diagnosis, then annually follow-up for 3 years;
(vi) Class 2 applicant shall be required to submit annually; and
(vii) Following 3 years, compliance shall be based on organ involvement, and the applicant may be
considered for removal of the Protocol by the Medical Assessor of the Authority”.”
OBSTRUCTIVE SLEEP APNEA
Applicability
Initial certification and requirements
1. An application shall be assessed on a case-by-case basis and presented by the Medical Assessor
prior to initial certification.
2. An applicant shall be declared temporary medical unfit upon diagnosis.
3. The following medical reports shall be submitted by an applicant for consideration of a medical
certificate:
i. Symptoms of Obstructive Sleep Apnea;

ii. Body Mass Index > 40;
iii. Epworth Sleep Score >10; and
iv. Neck circumference >42cm for men and > 40cm in women.
4.An applicant shall be required to monitor side-effects of CPAP or surgical procedures and report them to the
Aviation Medical Examiner.
5. An applicant shall submit:
(a) A sleep Physician report incorporating the following information: history of presenting
symptoms, Epworth Sleep Scale result, clinical status, and investigations conducted (Sleep
study / Maintenance of Wakefulness Test/Sleep Latency Test);
(b) A report on the progress and management of the condition from the treating specialist;
(c) A review of the Continuous Positive Airway Pressure (CPAP) download (usage statistics);
CPAP should be utilized for at least 5 hours per night and for 6 nights per week) and it must
be used during the sleep period just prior to flight;
(d) An objective measure of sleep apnea control (Apnea-Hypopnea Index (AHI)).
(e) Repeat sleep study following weight loss or surgery;

(f) A repeat sleep study following initiation of CPAP treatment or CPAP download; and
(g) A Clinical Psychologist report if clinically indicated.
Follow up Medical Requirements.
i. An applicant will be required to submit a copy of the cumulative annual CPAP device report, which
shows actual time used.
ii. Target goal should show use for at least 75% of sleep periods and an average minimum of 5 hours
per sleep period.
iii. An applicant shall after successful treatment by surgery, submit a statement attesting to the continued
absence of Obstructive Sleep Apnea symptoms.
iv. An applicant will submit a signed Airman Compliance with Treatment form or equivalent from the
airman attesting to the absence of Obstructive Sleep Apnea (OSA) symptoms and continued daily use
of prescribed therapy.
v. An applicant shall submit a status report from the treating physician, indicating that OSA treatment is
still effective”.”
PROTOCOL ON OBESITY
Applicability
Initial certification and requirements

(1) Initial applicant for a medical certificate shall be referred for further assessment if his or her BMI is 35
or above.
(2) A pilot whose BMI exceeds 35 require investigation within 2 months.
(3) The following medical reports shall be submitted for consideration of a medical certificate:
(a) Medical history & risk factors to include,

(b) BMI, waist & neck circumference,
(c) lipid profile, blood glucose, urinalysis,
(d) blood pressure,
(e) Epworth score
(f) ECG (full cardiology report if abnormalities are found)
(g) Sleep studies if BMI exceeds 40; and
(h) Medical practical flight test if BMI above 35

(4) An applicant may be issued a medical certificate if he or she complies with all of the following:
(a) obesity is not complicated and is responding to diet and exercise; and
(b) if bariatric surgery is undertaken, the applicant/licence holder will be grounded for a minimum period
of 3 months following the surgery. Upon submission of the surgeon’s report which includes information
pertaining to any complications that may have been experienced and the results of an updated BMI
assessment, the grounding will be reviewed.
5) The use of all appetite suppressants is prohibited, unless prior approval to use a specific suppressant is
obtained in writing from the medical assessor prior to the commencement of therapy. presenting with a
Body Mass Index increased by 2.5 points since the last Medical Fight Test (MFT); the MFT shall be
repeated; and shall be subjected to 6 monthly reviews until BMI is below 35.
Tuberculosis
Applicability & Restrictions
i. Class 1: May be assessed as fit as a multi-pilot (Class 1 ‘OML’)

ii. Class 2: May be assessed as fit as a safety pilot (Class 2 ‘OSL’)
iii. Class 3: May be assessed as fit as with or as second controller
iv. Class 4: May be assessed as fit in a multi-crew (cabin crew), and recreational pilots: no restriction
a) In case of an applicant undergoing treatment, a special waiver after three months may be given if:
b) The applicant does not have open cavitatory TB and the sputum is negative for TB;
c) He/she is on appropriate medication and demonstrates no drug resistance;
d) The medication exhibits no undesirable side effects that may impair flight safety;
e) The pulmonologist report is favourable; and
f) Underlying medical conditions are evaluated and appropriately managed.
g) Applicants with recurrent or re-activation tuberculosis, post TB-bronchiectasis with recurrent chest
infections or large cavities and MDR and XDR TB shall be deemed unfit pending a pulmonologist report,
and special waivers may be given on a case-to-case basis by the Aeromedical Committee and on re-
certification will require a pulmonologist report.
Endocrinology System
Type 2 Diabetes Mellitus
General medical examination requirements applicable to all applicants

a) All initial applicants must submit their medical reports to the medical panel for assessment.
b) Applicants are required to monitor their blood glucose frequently, including daily fasting glucose
measurements.
c) Extra snacks and glucagon should be readily available.
d) Applicants are required to test and record blood glucose levels before and during all flights and
present the information to the SACAA on a six-monthly basis.
e) Protocol for Diabetes Mellitus Type II controlled by diet and exercise
f) A blood glucose test is not a routine part of the SACAA medical evaluation; however, the examination
includes routine urine test.
g) Applicants with a history of diabetes mellitus controlled on diet alone are considered medically fit for all
the classes of medical certificates, provided that they have no evidence of associated disqualifying
cardiovascular, neurological, renal, or ophthalmological disease.
h) These applicants are required to submit an annual comprehensive endocrinologist/physician report.
Protocol for Diabetes Mellitus Type II controlled by oral medication
1. Applicants requiring oral hypoglycaemic agents to control their blood glucose may be assessed as fit
for all categories of licence, provided they have no cardiovascular, neurological, ophthalmological or
renal complications of diabetes, or any condition which could result in sudden or subtle incapacitation
while exercising the privileges of their license.
2. Acceptable oral medication
i. Biguinaides
ii. Arcabose
iii. Thiozolidenediones
Initial Follow up for Medical Certification
a) Following initiation of medication, the applicant’s medical certificate will be withdrawn for a period of
three (3) months;
b) this is to ensure stabilisation, adequate control, the absence of side effects, or complications from side
effects.
c) Should the applicant’s medication be changed, a comprehensive endocrinologist report indicating the
reason to change the medication and stating the name of the new information will be required.
d) The following conditions must be adhered to –
i. An initial report from a treating physician, confirming no complications of diabetes including

cardiovascular, neurological, ophthalmological or renal complications of diabetes;

ii. A statement regarding medication used dosage, presence or absence of side effects or
complications, clinical significant episode of hypoglycaemia and an indication of a satisfactory
of the diabetes;
iii. The applicant must not experience any adverse symptoms or effects from the oral
hypoglycemic agent; or
iv. The applicant may not use any medication interacting with the oral hypoglycemic agent;
v. Glucose: Fasting, Post-prandial peak <6.7 mmol/L <9.0 mmol/L;
vi. HbA1c <7.0% with risks, HbA1c <7.5% with no other risk factors.
vii. Cardiovascular assessment including:
viii. Symptom limited exercise ECG
ix. Clinical review by cardiologists
CVD risk factor profile; see the proposed optimal risk factor profile below:
Traditional CVD Risk Factors Targets

Cigarette Smoking Cessation
Dyslipidaemia
Total Cholestrol < 4,5 mmol/l
LDL Cholestrol < 1,8 mmol/l
HDL Cholestrol >1,0 mmol/l (men) > 1,2 mmol/l (women)
Triglycerides < 1,7 mmol/l
Obesity
Waist Circumference < 94 cms (men)
< 90 cms (men of South Asian Descent)
< 80 cm (women)
Body Mass Index < 25 kg/m2
Hypertension
Systolic Blood Pressure < 140 mm Hg
Diastolic Blood Pressure < 80 mm Hg
A complete fasting Lipid Profile must be submitted. The ideal Lipid Profile for a patient with Diabetes is as
above and should be strived for.
Protocol for Diabetes Mellitus Type II on Insulin Treatment
Applicability
Class I
Operational Restrictions
i. ATPL/CPL with a multi-crew – as/or with a co-pilot only, restricted to fly in the South African airspace
only

ii. Class II
iii. Only applicable to cabin crew.
iv. This protocol is currently not applicable to Private Pilots and Student Pilots.
v. Class III :Air Traffic Controllers – Required to inform their supervisors of the medical condition.
vi. Class IV:Protocol not applicable to Class IV applicants
Initial follow-up for Medical Certification
1) The applicant must have been on insulin for a minimum of one (1) year and the dosage should have
been stable for at least six months; this is to ensure stabilisation, adequate control, the absence of
side effects, or complications from side effects.
2) An initial report from a treating physician, confirming no complications of diabetes including

cardiovascular, neurological, ophthalmological, or renal complications of diabetes should be
submitted.
3) The following considerations must be adhered to –
a) The applicant will be required to carry and use a blood glucose monitoring device with memory and
report to the treating physician any hypoglycemic incidents.
b) The applicant must not have a history of hypoglycemic episode requiring intervention of another party,
during the previous one year.
c) The applicant must have no history of recurrent (2 or more) hypoglycemic reactions resulting in a loss
of consciousness or seizure within the past five years.
d) The applicant must have no evidence of hypoglycemic unawareness, and a good diabetes education
and understanding.
e) The applicant is required to have a satisfactory HBA1c of 7–7.5% within the past 30 days.
f) The applicant should have a positive attitude and practise monitoring and self-care.
g) The applicant is required to have adequate blood glucose self-monitoring using a calibrated memory
chip glucose meter.
h) The applicant is required to maintain 90% of blood glucose measurements >5.5mmo/L.
Annual follow-up for Medical Certification
1) The applicant will be required to carry and use a blood glucose monitoring device with memory and
report to the treating physician any hypoglycaemic incidents.
2) Quarterly (three monthly) interval evaluation reports by treating physician for –

i. Physical examination
ii. HbA1c
iii. Review of daily blood glucose measurements
iv. Results of the quarterly evaluations must be accumulated and submitted annually to the medical
panel.
v. Glucose: Fasting, Postprandial peak <6.7mmol/l <9.0mmol/l respectively.
vi. HbA1c <7.0% with risks, HbA1c <7.5% with no other risk factors.
vii. A complete fasting Lipid Profile must be submitted,the ideal Lipid Profile for a patient with diabetes
is as above and should be strived for.
viii. An annual report from a treating physician must be provided to confirm no complications of
diabetes including renal, neurological and visual complications.
Cardiovascular assessment including:

Cigarette smoking Cessation
Dyslipidemia
LDL Cholesterol < 1,8 mmol/l
Obesity
< 80 cm (women)
Hypertension
Monitoring and actions required during flight operations
a) A regularly calibrated glucometer with a memory chip and 10g portions of readily absorbable
carbohydrate (cho) should be included on the treatment pack to cover duration of flight.
b) Applicants must measure blood glucose prior to flight, blood glucose must be >6.0mmol/L .

c) During flight, the applicants blood glucose should be monitored every 30-60 minutes, if the blood
glucose <6.0mmol/l, then 10g absorbable carbohydrate should be ingested.
d) The frequency of glucose monitoring on flight duty periods over two hours may be reduced depending
on the individual circumstances, in consultation with the endocrinologist and the designated
Aeromedical Committee.
e) Applicants involved in short-haul operations are required to monitor their blood glucose at midpoint of
flight. Blood sugar will fluctuate slightly over one to two hours.
f) For applicants presenting with blood glucose of >15mmol/l, appropriate corrective measures should be
applied.
g) Blood glucose should be monitored 30-45 minutes prior to landing and should measurement reading
fall <6.0mmol/l, 10g of cho should be consumed.
h) The crew members would need to be made aware of the potential for hypoglycaemic events because
of insulin use and should be trained on management strategies.
i) Applicants are required to test and record blood glucose levels before and during all flights and
present the information to the SACAA on a six-monthly basis.
Acceptable insulin
i. Basal Insulin
ii. Bolus Insulin
Diabetes Type 1 Protocol
Applicability
Class II:
Applicable to Private Pilots and Students Pilots (with operational Safety Pilot Limitation)
Class III
i. Air Traffic Controllers – with another ATC in close proximity.

ii. Required to inform their supervisors of the medical condition.
Class IV
Applicable to cabin crew.
Protocol not applicable to Class IV applicants (may be considered on a case by case basis)

Initial follow-up for Medical Certification
i. The following conditions must be adhered to: An initial report from a treating physician confirming:
ii. No complications of diabetes, including cardiovascular, neurological, ophthalmological or renal

complications of diabetes;
iii. A statement regarding medication used, dosage, presence or absence of side effects or
complications;
iv. Clinical significant episodes of hypoglycaemia; and
v. Indication of diabetes control being satisfactory.
Cardiovascular assessment must include :
i. Symptom limited exercise ECG

ii. Clinical review by cardiologists
iii. CVD risk factor profile; see the proposed optimal risk factor profile below:

Cigarette smoking Cessation
Dyslipidaemia
LDL Cholesterol < 1,8 mmol/l
Obesity
< 80 cm (women)
Hypertension
a) A complete fasting Lipid Profile must be submitted. The ideal Lipid Profile for a patient with diabetes is
as above and should be strived for.
b) An opthalmologist report must be provided confirming the absence of clinically significant diabetic eye
disease.
c) Applicants are required to have a satisfactory HBA1c of < 6, 5 to 8, 0 % within the past 30 days. If
HBA1C < 6,5 then there should be no clinically significant hypoglycaemic events in the last year.

d) The following considerations must be adhered to:
e) The applicant will be required to carry and use a calibrated memory chip glucose meter and report to
the treating physician any hypoglycaemic incidents.
f) The applicant must not have a history of hypoglycaemic episode requiring intervention of another
party, during the previous one year.
g) The applicant must have no history of recurrent (two or more) hypoglycaemic reactions resulting in a
loss of consciousness or seizure within the past five years.
h) The applicant must have no evidence of hypoglycaemic unawareness, and a good diabetes education
and understanding.
i) The applicant should have a positive attitude and practise monitoring and self-care.
j) Acceptable glucose: Fasting < 7 mmol/l and Postpandrial Peak: < 10 mmol/l.
k) Applicants are required to maintain 90% of blood glucose measurements >5.5mmo/L.
Annual follow-up for medical certification
a) The applicant will be required to carry and use a blood glucose monitoring device with memory and
report to the treating physician any hypoglycaemic incidents.
b) Quarterly (three monthly) interval evaluation reports by treating physician for –
i. Physical Examination
ii. HbA1c
iii. Review of daily blood glucose measurements
iv. Results of the quarterly evaluations must be accumulated and submitted annually to the
medical panel.
v. Annual report from a treating physician as detailed above under initial certification.
vi. Annual cardiovascular assessment, including Lipogram, as detailed above under initial
certification.
vii. Acceptable Glucose: Fasting < 7 mmol/l and Post pandrial Peak: < 10 mmol/l.
viii. Applicants are required to maintain 90% of blood glucose measurements >5.5mmo/L.
Monitoring and actions required during Flight Operations.
a) To ensure safe flight, the insulin-using diabetic aviator must carry:
b) Two recording devices during flight, a regularly calibrated glucometer with a memory chip and a
backup glucometer;
c) Adequate supplies to obtain blood glucose samples (lancets, swabs, etc.); and

d) An amount of rapidly absorbable glucose, in 10g portions of readily absorbable carbohydrate (cho),
which should be appropriate to the planned duration of the flight.
The following actions shall be taken in connection with flight operations:
a) Applicants must measure blood glucose prior to flight, at least 1 hour before reporting for flight/duty
period or at least two hours before commencing flight/controlling.
b) Blood glucose must be >6.0mmol/L and glucose must be checked < 30 mins before flight duty period.
c) During flight, the applicants blood glucose should be monitored every 60 minutes, if the blood glucose
<6.0mmol/l, then 10g absorbable carbohydrate must be ingested and a retest performed within 30
mins.
d) The frequency of glucose monitoring during flight duty periods over two hours may be reduced
depending on the individual circumstances, in consultation with the endocrinologist and the designated
aeromedical committee.
e) Applicants involved in short-haul operations, are required to monitor their blood glucose at midpoint of
flight. Blood sugar will fluctuate slightly over one to two hours.
f) Blood glucose should be monitored 30-45 minutes prior to landing, should measurement reading fall
<6.0mmol/l, 10g of cho consumed.
g) Applicants presenting with blood glucose of >15mmol/l, appropriate corrective measures should be
applied. If >15 mmol/l, should not commence flight/controlling and/or cease carbohydrate ingestion
until blood sugar reduces.
h) Episodes of severe hypoglycaemia must be reported to the SACAA.
i) The crew members would need to be made aware of the potential for hypoglycaemic events because
of insulin use and should be trained on management strategies.
j) Applicants are required to test and record blood glucose levels before and during all flights and
present the information to DAME on a three-monthly basis and to the SACAA on a yearly basis.
INSULIN DEPENDANT DIABETES MELLITUS (FOR CLASS 1)
Applicability
Class 1 Medical Certificate
1. General
a) An application shall be assessed on a case-by-case basis and presented to a Medical Assessor and
Medical Expert prior to consideration of the initial and recurrent medical certification.

b) A holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) shall brief his or her co-
pilot fully prior to the flight regarding:
i. nature of his or her diabetes;

ii. blood glucose testing protocol;
iii. timing and method of blood glucose testing;
iv. actions to ensure the blood glucose remains in the acceptable range;
v. medication that may be required during the flight;
vi. symptoms of high or low blood glucose; and
vii. actions to be taken in the event of incapacitation.
c) A holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) shall cross check his or her
blood glucose test value with his or her co-pilot and shall always announce the blood glucose results
aloud so that it is recorded on the cockpit voice recorder (CVR) if installed, or an alternative approved
method.
2. Restrictions to be applied
OML: Operational Multi-pilot Limitation
3. Initial certification eligibility
a) An applicant may be considered for an initial certification after a period of one (1) year has elapsed
after the diagnosis of Type I Diabetes Mellitus.
b) An applicant shall have successfully completed solo flight training (i.e., towards a PPL or a higher
license) and already be in possession of at least a Class 2 medical certificate.
c) An applicant is required to have in his or her possession a Continuous Glucose Monitoring device
(CGM) approved by the South African Health Products Regulatory Authority (SAHPRA) or CE marked
(Europe) or FDA (US) approved or ISO 9000 certified or device approved by other relevant
authorities).
d) The CGM device referred to in section 4.3 shall not interfere with the aircraft avionics and a report
shall be submitted to a DAME or Medical Assessor of the Authority.
e) An applicant who utilises an insulin pump delivery system shall submit details of his or her ‘back-up’
non-pump regimen in the event of pump failure.
f) An applicant shall demonstrate evidence of hands-on training by the diabetic team regarding insulin
pump use which shall be submitted to the Authority at time of initial application.
g) An applicant shall demonstrate low risk of hypoglycaemia as evidenced by:

a. previous hypoglycaemic events requiring emergency medical intervention including

assistance from non-medically trained bystanders.
b. a stable glucose control as measured by HbA1C 6% - 7.5%.
c. submission of an Ambulatory Glucose Profile (AGP) and Time-In-Range (TIR) data over a
three (3) month period preceding initial certification that reflects the following blood glucose
control criteria:
o CGM Sensor Wear: at least 90% of the time or greater:

o Time in Range (TIR) of 4,5-10 mmol/L: 70% or greater;
o Overall glucose readings 3,9 - 13,9 mmol/L: 90% or greater;
o Glucose readings < 3,9 mmol/L: less than 4%;
o Glucose readings < 3,0 mmol/L: less than 1%;
o Glucose readings > 13,9 mmol/L: less than 5%;
o Coefficient of Variation (CV): < 33%, but will consider 33 - 36%;
o Glucose Management Index (GMI);
g) an applicant shall demonstrate adequate glucose monitoring with the Continuous Glucose Monitoring
(CGM) device;
h) an applicant shall demonstrate good diabetes education and understanding as evidenced by hands on
training by a diabetic team as well as a practical flight test demonstrating compliance with the
Authority blood glucose testing protocol);
i) an applicant shall not demonstrate evidence of hypoglycaemia unawareness;
j) an applicant shall have a positive attitude towards monitoring and self-care as reported by his or her
treating physician;
k) the CGM device shall be checked pre-flight and confirmed to be in a working condition. A spare finger
prick glucose monitoring device shall be carried by an applicant;
l) a holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) with a confirmed diagnosis
of a Type 1 Diabetes Mellitus medical certification shall have a validity period of one (1) year if the
holder thereof is under the age of 40 years, alternatively the requirements of regulation 67.00.6
relating to period of validity of aviation personnel shall apply;
m) a holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) shall ensure that blood
glucose monitoring is pre-planned, and alerts/reminders are set up for testing as per the relevant
schedule;
n) due to the lag in interstitial readings when blood glucose is either rising or falling rapidly, a finger prick
blood glucose measuring method shall be available on all flights;

o) a holder of a Class 1 medical certificate for a Schedule 13A protocol shall ensure that there is
adequate quantity of insulin and rapidly absorbing glucose available on every flight; and
p) a holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) shall ensure that a
Glucagon pen (hypokit) is available on every flight in case of a serious hypoglycaemic event with a
loss of consciousness.
Disqualifying conditions for initial medical certification
1) An applicant who presents with any history within the past two (2) years of hypoglycaemia attack
requiring the intervention of another person.
2) An applicant who presents with hypoglycaemia in the absence of warning symptoms (hypoglycaemic
unawareness).
3) An applicant who presents with inadequate blood glucose control as indicated by Ambulatory Glucose
Profile (AGP), Time-in-Range (TIR) data and glycated haemoglobin results.
4) An applicant who presents with significant visual, neurological or cardiovascular complications.
Initial considerations: medication and blood glucose control
1) An applicant who presents for consideration shall be stable for a minimum of six (6) months.
2) An applicant’s insulin pumps for drug delivery may be authorised with a precaution for the risk of over
delivery in the event of a rapid decompression.
3) An applicant shall carry a finger prick glucose monitoring device and non-pump insulin delivery system
for use during in-flight emergencies.
4) An applicant shall carry a back-up insulin delivery method in the event of pump failure.
5) An applicant shall submit an Endocrinologist assessment to a Medical Assessor and DAME with the
following information:
i. documentation of any history of being symptomatic; or

ii. biochemical hypoglycaemia in the preceding 12 months is required along with details of any
ensuing intervention.
6) An applicant shall provide evidence of stable blood glucose control for at least 3 months as measured
by:
a) HbA1C (Generally between 6% and 7.5%);

b) the submission of an Ambulatory Glucose Profile (AGP) and Time-In-Range (TIR) data
reflecting the blood glucose control criteria as per subpart 4.6 (c) of this schedule; and

c) having in his or her possession a CGM device approved by the South African Health Products
Regulatory Authority (SAHPRA) and/or CE marked (Europe) and/or FDA (US) approved or ISO
9000 certified or device approved by other relevant authorities).
Specialists reports and complications of Type 1 Diabetes Mellitus
1) An applicant shall have no neurological or renal complications of diabetes mellitus that may result in
sudden or subtle incapacitation.
2) Measurements of renal function such as eGFR > 90 and Albumin to Creatinine ratio < 30.
3) An Endocrinologist shall assess the neurology and renal system. If possible diabetic complications
exist, a nephrology or neurology assessment is required.
4) An applicant shall have no evidence of significant diabetic retinopathy and an Ophthalmologist

assessment is required.
5) An applicant shall have an initial cardiovascular assessment conducted by a cardiologist.
6) An applicant shall do an exercise electrocardiogram and shall reach 8.5 METS on the Bruce protocol.
7) An applicant over 40 years of age shall be screened for cardiovascular disease, unless there is a co-
morbid cardiovascular risk factor, then it shall be done annually.
Cardiovascular risk factor control
The following cardiovascular risk control measures shall be under control.
Lipid profile:
a) Total Cholesterol: < 4,5 mmol/1;
b) LDL Cholesterol: < 1,8 mmol/1;
c) HDL Cholesterol: > 1,0 mmol/1 (men), > 1,2 mmol/1 (women); and
d) Triglycerides: < 1,7 mmol/1.
Blood pressure:
The systolic blood pressure < 135 mm Hg, Diastolic Blood Pressure < 85 mm Hg
Smoking status:
An applicant shall have a history of never smoking or smoking cessation if he or she is a former smoker. If
currently smoking, initial certification shall only be considered after cessation.

Obesity:
An applicant is required to have a Body Mass Index: < 28kg/m2
Blood glucose testing protocol
1. Pre-flight monitoring
(a) a holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) shall conduct a glucose
test two (2) hours before commencing flight;
(b) One (1) hour before reporting for flight; and
(c) less than 30 minutes before take-off.
2. During flight monitoring
(a) a holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) shall conduct a blood
glucose test at least every hour whilst flying;
(b) in the event of experiencing any diabetic symptoms; and
(c) prior to resuming flying after a period of rest or period after corrective action was taken for an out-of-
range blood
glucose result.
3. On approach flight approach monitoring
A holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) shall within 30 minutes of
anticipated landing time conduct a glucose test.
4. Corrective actions in the event of an out-of-range blood glucose:
The corrective actions indicated in the diagram and notes below shall be taken in the event of an out of range
blood glucose level.

High readings
Priority action (>20.0mmol/l) Corrective action (>15.0mmol/l)
1.Check continuous glucose monitoring system 1.Check continuous glucose monitoring system
2.Shall hand over duties
3.take appropriate insulin and/or modify
carbohydrate 2.If still >15.0mmol/l review insulin dosing
intake and/or modify planned carbohydrate intake
4.Resume full duties when blood glucose
<20.0mmol/l
Low readings:
Priority action (<4.0mmol/l) Corrective action (<5.0mmol/l)
1.Check continuous glucose monitoring system 1.Check continuous glucose monitoring system
2.If still <4.0mmol/l shall hand over duties 2.If still <5.0mmol/l ingest 10-15g readily
3.Ingest 10-15g readily absorbed carbohydrate absorbed carbohydrate and retest after 30
and retest after 15mins mins
4.Review insulin dosing and/or modify
carbohydrate intake
5.If test after ingestion is still <4.0 then ingest
3.Review insulin dosing and/or modify
further 10-15g carbohydrate and retest after
carbohydrate intake
15 min
6.Wait for 45 mins after the blood glucose returns
to the ‘green’ range before resuming duties.
Insulin delivery in pumps functionality

1. An insulin pump system shall have an automatic function suspending insulin delivery if a rapid decrease
in blood glucose value is anticipated by the CGM device and insulin pump system (also known as a
“suspend before low” feature).
2. In the event of a rapid decompression for a pilot using insulin pump delivery systems:
a. atmospheric pressure reduction causes unpredictable, unintended insulin delivery in pumps by

bubble formation and expansion of existing bubbles;
b. therefore, the insulin pump shall be disabled (disconnected) immediately and 15g readily
absorbed carbohydrate ingested as soon as possible, within 15 minutes of the decompression;
c. more frequent blood glucose monitoring shall be carried out thereafter;
d. the insulin pump may be enabled (reconnected) after landing or when blood glucose levels and
stability of glycaemic control can be verified; and
e. a similar procedure shall be followed for all other emergency situations.
Issues of consideration
1. In the unlikely event of any symptoms of cognitive impairment a pilot shall not resume duties for the
duration of the flight.
2. If crew assistance is required or a pilot becomes incapacitated, then an incidence report shall be
completed and submitted to the Authority and the pilot shall be certified temporary unfit by a Medical
Assessor and the pilot’s medical fitness status shall be reviewed by the Aeromedical Committee to
determine an applicant’s medical fitness.
3. A holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) who hasto take action for a
high or low reading shall always record an entry in his or her logbook, documenting the action taken.
4. The blood glucose data shall be periodically reviewed by a DAME and such data shall be submitted to
the Medical Assessor against the flying/controlling log to ensure protocol compliance.
5. Failure to demonstrate compliance with the schedule of testing may result in suspension of the
6. A holder of a Class 1 medical certificate for Schedule 13A protocol (pilot) shall adhere to the fail-safe
position which is to always take rapidly absorbed carbohydrate if unable to test.
Medical certification renewal requirements
A holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot):
1. shall submit an endocrinologist report every six (6) months.
2. shall submit an HbA1C review every three (3) months for the first two (2) years, then six (6) monthly
thereafter.
3. is required to submit a cardiologist review every five (5) years if a pilot is under the age of 40 years
and annually if a pilot is over 40 years.

4. has cardiovascular risk factors in addition to diabetes, an annual cardiology report shall be submitted.
5. shall submit the ophthalmology report annually.
Requirements for change in the medical status
A holder of a Class 1 medical certificate for a Schedule 13A protocol (pilot) with changes in his or her medical
status falling outside the required criteria shall be required to submit medical reports to a Medical Assessor for
consideration and these changes include, but not limited to the following:
a) an HbA1C between 8.5% -10% should trigger a diabetes review and review of treatment and a period
of unfitness may be required to re-stabilise treatment;
b) an HbA1C of greater than 10% indicates poor control and shall normally entail an unfit assessment;
c) change of insulin regimen (including new use of pump) shall result in a pilot being declared temporary
medically unfit for a minimum period of one (1) month;
d) a medical report by an endocrinologist detailing stability, symptoms, satisfactory blood glucose and
monitoring is required before return to flying;
e) episodes of severe hypoglycaemia shall be reported and such occurrences including but not limited to
severe hypoglycaemia requiring the assistance of another person shall normally entail an unfit
assessment;
f) the development of any retinopathy requires ophthalmological assessment and is likely to result in
further restriction or medical unfitness if there is any field loss or reduction in visual acuity;
g) the presence of significant nephropathy significantly increases cardiovascular risk and is likely to entail
unfitness; and
h) non-declaration of symptoms, medical history or provision of incomplete testing records/flying

logbook is likely to entail unfitness. [Schedule 13A inserted by the Director of Civil Aviation
through SA-CATS 1/2023 w.e.f. 1 March 2023.]
Protocol on diagnosed Addison’s disease.
Before an applicant for a pilot licence may be considered, he/she must comply with the following standards:
a) Normal physical examination.
b) The following blood test results must be normal before exercise:
c) Urea and electrolyte
d) Blood glucose (random)

e) Serum cortisol
f) Liver function test
g) Exercise must then be undertaken, and a series of blood samples must be taken, both during and
after the exercise.
h) The exercise must be on a treadmill, with the applicant running until he/she is exhausted, or until a
heart rate equivalent to a 100% stress ECG is achieved.
i) The blood test results required during exercise are the following:
i. Urea and electrolyte screen (X 1)

ii. Blood glucose (X 3)
iii. Serum cortisol (X 1)
iv. The blood tests must be repeated after exercise.
v. The blood pressure and pulse rate must be monitored throughout the exercise, and any
changes must be appropriate for the intensity of the exercise.
Restriction
1. If all the above standards are achieved, the applicant may be certified, but with the following
restrictions:
i. May only fly with or as a co-pilot; and

ii. May not fly when suffering from any infection, or when pyrexial. Must be re-examined following
resolution of the infection before he/she can resume flying.
2. All surgical procedures will result in the applicant becoming unfit, until cleared by the designated body
or institution. Will remain unfit for at least six weeks following surgery.
3. Must always wear a Medic Alert disk specifying that he/she has Addison's Disease.
4. Must always carry an emergency supply of Cortisone when flying.
5. The following blood tests must be performed at least three times a year:
i. Urea and electrolyte;

ii. Blood glucose (random);
iii. Serum cortisol;
iv. Liver function test; and
v. Serum renin determination.

6. The applicant must be fully informed as to the disease, its treatment, and possible complications.
7. The applicant is required to submit an annual specialist physician’s report to the designated body or
institution.
Oncology Protocols
1. Aeromedical consideration
Impairment or sudden or subtle incapacitation:
i. Applicants must be free from any risk factor, disease or disability which renders them either
unable, or likely to become suddenly unable, to perform assigned duties safely.
ii. These may include effects and/or adverse effects from the treatment of any condition and drugs or
substances of abuse.
2. Medical Deficiency
a) Applicants must be free from any of the following, should these result in a degree of functional
incapacity likely to interfere with the safe operation of an aircraft of with the safe performance of their
duties:
b) Congenital or acquired abnormality;
c) Active, latent, acute or chronic disability, disease or illness; and
d) Wound, injury, or outcome of operation.
e) Every applicant who has been treated for malignant disease will need an individual assessment before
exercising licence privileges. Recovery from surgery or radiotherapy should be assessed.
f) Current curative or adjuvant chemotherapy is incompatible with certification, and recovery from the
effects of such treatments will demand a period of unfit assessment after the treatment.
g) If the pilot has recovered from the primary treatment and, as far as can be assessed with available
techniques, there is no residual tumour, then the level of certification will depend on the likelihood of
recurrent disease.
h) In addition to ensuring that treatment has been effective, pre-requisites for certification after treatment
for malignant disease include satisfactory haematological parameters and no on-going side effects
from therapy.
i) Treatment modalities available for cancer
Surgery
Surgery is the commonest primary treatment for malignant disease and is frequently the only treatment. A
return to flying, from the purely surgical aspect, depends on the extent of the surgical operation.

Radiotherapy
a) This is usually given as an intensive course.
b) The aim of radiotherapy may be curative, for example when given to an isolated group of lymph nodes
which have proved by biopsy to contain lymphoma; or as adjuvant treatment, for example to the
abdominal nodes following orchidectomy for a seminoma of the testis, on the assumption that they
may contain metastatic tumours.
c) Many patients undergoing radiotherapy suffer non-specific systemic effects (tiredness, malaise and
nausea), which make it inadvisable for any pilot to fly whilst receiving such treatment.
Chemotherapy
a) Pilots, ATC’s, CCM’s and other aviators should be assessed as unfit during any period of treatment
with cytotoxic chemical agents.
b) The only exception to an unfit assessment during adjuvant treatment for malignancy is endocrine
therapy.
c) Certain adjuvant hormone and anti-hormone treatments following (for example) breast or prostate
cancer treatment may be acceptable if there are no side effects.
d) Stem cell transplantation
e) It is possible to return to flying after stem cell transplantation if there is sustained remission.
Complementary and alternative medicine
i. Where such treatments are used in the presence of continued active disease, the applicant is
assessed as unfit.
ii. Where the treatment is used to prevent onset of malignancy or recurrence, the treatment will be
considered on a case-by-case basis, with regard to the individual’s overall health and the potential
effect of the treatment.
Hormonal Therapy
Endocrine therapy is used as part of the treatment of some cancers (such as hormone and anti-hormone
treatment following breast and prostate cancer). Pilots, ATCs, CCM’s and other aviators may be returned to
flying or controlling if there are no side effects from their hormonal therapy.
Acceptable aviation risk
The primary treatment, be it surgery, radiotherapy, chemotherapy, or a combination of these, should have
removed all signs of tumour/malignancy when measured clinically or by investigation. Thus, the risk to flight
safety is the possibility that local or metastatic recurrence will cause sudden or insidious incapacitation whilst

the pilot is flying. After treatment of malignancy, the prognosis improves with recurrence-free time after the
original episode.
Following “successful” primary treatment, the risk that tumour/malignancy will cause an insidious or sudden
incapacitation depends on two factors:
a) The actual risk of recurrence, which will depend on the pathological stage of the tumour or its TNM
classification; and
b) The site of that recurrence and this will depend on the primary tumour type.
c) Principle of Aeromedical Certification of Pilots, ATC’s, CCM’s and other aviators with malignancy
d) When considering the aero-medical risk (and therefore the risk to aviation safety) posed by a pilot,
CCM or ATC suffering from a malignancy, the SACAA will evaluate the following:
e) Cancer specific issues: This includes the type of cancer (tissue and histological diagnosis), the
likelihood of recurrence, site of recurrence, presence of any para-neoplastic syndromes, potential for a
recurrence to cause overt or subtle in-flight incapacitation.
f) Issues related to the treatment of the cancer: When assessing the aero-medical risk of a pilot, ATC, or
CCM with a malignancy, accurate tissue diagnosis of the malignancy is essential.
g) Complications of malignancy: The common complications of the malignancy are usually pain, wasting,
neuropathy, nausea, anorexia, seizures, hypercalcaemia, hyperuricaemia, viscus obstruction, organ
failure, and para-neoplastic syndromes.
Likelihood of recurrence: The overall survival curve for individuals diagnosed with a theoretical malignancy
must be considered. For most cancer types, annual recurrence rates can be calculated from survival curves.
(As cure following recurrence is rare, overall survival approximates recurrence).Staging: Recurrence rates are
greatly influenced by the stage of disease when primary treatment occurred. Many cancers are staged using a
TNM (Tumour, Node, and Metastasis) classification. The variation in survival rates for a theoretical cancer
according to the degree of spread evident at diagnosis.Site of recurrence: Each tumour has a characteristic
pattern of recurrence. Thus for a theoretical tumour, metastases might occur according to the distribution.
Risk of particular metastasis causing incapacitation: Several assumptions are made when assessing the risk of
a particular metastasis causing incapacitation (either subtle or overt). For a theoretical cancer, recurrence in a
regional lymph node carries a relatively small risk of incapacitation. On the other hand, brain metastasis has a
near-100% potential for incapacitation (whether sudden due to a fit or bleed, or subtle as a result of pressure
effects or headache, etc.).Tumour markers: The relapse or active progression of certain tumours may be
effectively followed by measuring tumour markers.
ii. Protocol for specific cancers
The following cancers/malignancies are discussed for the purpose of this protocol:

The rest of the cancers not discussed here will be considered by the Aeromedical Committee on a case-by-
case basis using the similar principles of certification.
Malignant Melanoma
A diagnosis of Malignant Melanoma is disqualifying and upon diagnosis, and applicants shall be deemed
medically unfit to exercise the privileges of the class of the licence they hold.
PROTOCOL ON DIAGNOSED ADDISON’S DISEASE
1.Before an applicant for a pilot licence may be considered, he/she must comply with the following
standards :
i. Normal physical examination.
2.The following blood test results must be normal before exercise –
i. Urea and electrolyte screen.

ii. Blood glucose (random).
iii. Serum cortisol.
3.Liver Function Test screen (this is necessary in order to ensure that the applicant is not abusing alcohol,
which would
predispose him to developing hypoglycaemia).
4.Exercise must then be undertaken, and a series of blood samples must be taken, both during and after
the exercise. The exercise must be on a treadmill, with the applicant running until he/she is exhausted,
or until a heart rate equivalent to a 100% stress ECG is achieved.
5.The blood test results required during exercise are the following:
i. Urea and electrolyte screen (X 1).
ii. Blood glucose (X 3).
iii. Serum cortisol (X 1).
6.The blood pressure and pulse rate must be monitored throughout the exercise, and any changes must be
appropriate for the intensity of the exercise.
7 .If all the above standards are achieved, the applicant may be certified, but with the following restrictions –

1) May only fly with or as a co-pilot.
2) May not fly when suffering from any infection, or when pyrexial (including “flu” or a common cold). Must be re-
examined by the designated body or institution following resolution of the infection before he/she can resume
flying.
3) All surgical procedures, operations or use of medication, whatever the reason, will result in the applicant
becoming unfit, until cleared by the designated body or institution. Will remain unfit for at least 6 weeks
following surgery.
4) Must always wear a Medic Alert disk specifying that he/she has Addison’s Disease.
5) Must always carry an emergency supply of Cortisone when flying.
6) The following blood tests must be performed at least 3 times during the year (i.e. approximately every 4
months) in order to determine whether the applicant is complying with treatment –
i. Urea and electrolyte screen.
ii. Blood glucose (random).
iii. Serum cortisol.

iv. Liver Function Test screen.
v. Serum Renin determination.
7) The applicant must be fully informed as to the disease, its treatment and possible complications.
8) The applicant is required to submit an annual specialist Physician’s report to the designated body or institution.
Oesophageal Cancer
A diagnosis of oesophageal cancer is disqualifying, and upon diagnosis, the applicant shall be deemed
medically unfit to exercise the privileges of the class of the licence they hold. Oesophageal cancer is
uncommon but is not rare. It is more common over the age of 55, with the average age of diagnosis being 72.
Oesophageal cancer does not usually cause any noticeable symptoms until the cancer has spread beyond the
oesophagus and into nearby tissue. Therefore, the outlook for oesophageal cancer is poor compared with
other types of cancer. On average, 30% of people with oesophageal cancer will live for one year after
diagnosis. An average of 8% will live for five years after the diagnosis. Even with early diagnosis an estimation
of 34% to 42% of people will live for two years after the diagnosis.
Two main types of oesophageal cancer are:

i. Squamous cell carcinoma (90%-95%) – upper part of the oesophagus; and

ii. Adenocarcinoma of the oesophagus (50%-80%) – lower part of the oesophagus.
Medical Requirements Oesophageal Cancer
1) Recertification is possible as most patients return to their regular level of activities within two months
after surgery.
2) The following examinations and procedure reports are required before the applicant’s case can be
considered regarding medical certification/recertification:
i. Specialist report including Staging and/or with Tumour Grading

ii. Histology report
iii. Radiological reports: Barium swallow, CXR, CT/MRI/PET scan (PET scan is the preferred
investigation)
iv. Bloods: e.g. FBC, LFT, U&E (Creat), Ca2+
Stage 1 & 2 Oesophageal Cancer
a) Patients without lymph node involvement have a significantly better prognosis and five-year survival
rate compared to patients with involved lymph nodes.
b) Follow-up treatment may include evaluation with CT scans and upper endoscopy to watch for possible
recurrence. In stage 0, the cancer is confined to the superficial lining of the oesophagus.
c) In stage I, the cancer has not invaded the outer muscle layer of the oesophagus and surgery to
remove the tumour offers the best chance for cure.
d) If the disease is caught early, the five-year survival rate is much higher – 75% for patients diagnosed
in stage 0 and 50% for those diagnosed in stage I.
Follow-Up Requirements Oesophageal Cancer
i. Six-monthly specialist report

ii. Six-monthly radiological reports for three years, then annually till year five
iii. Barium swallow, CXR, CT/MRI/PET scan (PET scan is a preferred investigation)
iv. Endoscopic examination at six-monthly to yearly intervals as per clinical indication
v. Bloods, e.g. FBC, LFT, U&E (Creat), Ca2+
vi. Restriction Applicable to the Medical Certificate
vii. Licence holders will be required to operate under a multi-crew environment, as or with co-pilot, or
under supervision (depending on their environment) etc., until the aeromedical risk has been assessed
and deemed favourable for a restriction to be lifted.

Stage 3 Oesophageal Cancer
i. Stage 3 oesophageal cancer is generally disqualifying.

ii. The five-year survival rate is about 20% to 30%.
iii. Recertification may be considered on a case-by-case basis if the cancer is operable, there is no lymph
node involvement, and the applicant is at least six months post treatment.
iv. Follow-Up Requirements Oesophageal Cancer
v. Six monthly specialist report
vi. Six monthly radiological reports for three years, then annually till year five
vii. Barium swallow, CXR, CT/MRI/PET scan (PET scan is a preferred investigation)
viii. Endoscopic examination at six-monthly to yearly intervals as per clinical indication
ix. Bloods e.g. FBC, LFT, U&E (Creat), Ca2+
x. Restriction in the Medical Certificate
xi. Licence holders will be required to operate under a multi-crew environment, as or with co-pilot or
under supervision (depending on their environment) etc., until the aeromedical risk has been assessed
and deemed favourable for the restriction to be lifted.
Stage 4 Oesophageal Cancer
i. Stage 4 lesions are associated with a 5-year survival rate of less than 5% and is disqualifying.
Colorectal Cancer
A diagnosis of colorectal cancer is disqualifying and upon diagnosis, the applicant shall be deemed medically
unfit to exercise the privileges of the class of the licence they hold.
Medical Requirements for Colorectal Cancer
i. The following examinations and procedure reports are required before the applicant’s case can be
ii. Specialists’ reports, which must include clinical staging, and /or with tumour grade, colonoscopy
findings and an indication whether adjuvant therapy is indicated or not;
iii. Histology report including Duke’s/TNM Staging;
iv. Blood test results: FBC, ESR; LFT including LDH & ALP;
v. Tumour markers, e.g. CEA;

vi. Presence of occult blood in the faeces – Haemoccult;
vii. Radiological reports: CXR; and
viii. If clinically indicated according to the colonoscopy and CEA findings, a CT scan of the abdomen,
lungs and brain will be required.
ix. A minimum period of three months is required following colectomy before an applicant can be
considered for recertification.
x. If Dukes A/Stage 1, requiring no adjuvant therapy- Colorectal Cancer
xi. Recertification is possible after three months (3) post-surgery and the following medical requirements
must be submitted:
a) The applicant must submit six-monthly specialist’s reports for two years, thereafter annually for five
years;
b) Radiological assessments: Annual CXR/CT chest, CT Abdomen and Pelvis for five years (stage 1, 2,
3);
c) Colonoscopy to be done one year after completion of treatment and repeated annually if new polyps
are noted or every three years if no polyps are noted; and
d) Six-monthly laboratory tests; FBC, and ESR; LFT including: LDH & ALP; and tumour markers, i.e.
CEA.
Restriction for Colorectal Cancer
Licence holders will be required to operate under a multi-crew environment, as or with co-pilot, or under
supervision (depending on their environment) etc., until the aeromedical risk has been assessed and deemed
favourable for the restriction to be lifted.
Dukes B&C/Stage 2&3 Requirements- Colorectal Cancer
1) The applicant is required to complete full course of chemotherapy and radiotherapy.
2) Recertification is possible after three months(3) post-surgery and the following information will be
required :
i. The applicant is clinically disease free and fully recovered from all treatments; and
ii. The applicant has no side effects including cardiac side effects.
Follow-Up Reports Colorectal Cancer

i. Must submit six-monthly detailed specialists’ reports (surgeon, radiologist, oncologist, etc.);
ii. Must do a faecal occult blood test six monthly;
iii. Report from radiation oncologist specifying exposure areas and any sequalae;
iv. CXR, CT/MRI scan; colonoscopy or adequate air-contrast Ba Enema annually; and
v. Six-monthly Bloods: FBC, ESR, LFT including LDH, Serum CEA.
vi. Restriction on the Medical Certificate - Colorectal Cancer
Duke’s D/Stage 4- Colorectal Cancer
Stage 4 Colorectal Cancer is Disqualifying.
Breast Cancer
1) A diagnosis of breast cancer is disqualifying, and upon diagnosis, the applicants shall be deemed
2) Clinical management of patients with early breast cancer is determined on an individual basis, taking
into account many factors, including the risk of cancer recurrence.
3) The clinical management of breast cancer is directly linked to pathological assessment of the cancer.
So, accurate pathological assessment of the breast cancer specimen is vital.
4) Common factors have been identified for predicting the risk of recurrence in patients with breast
cancer.
5) Node negative status at diagnosis has commonly been associated with a favourable outcome.
6) But the risk of recurrence still exists for women with early breast cancer regardless of nodal status,
oestrogen receptor status, age, chemotherapy regimen, time on Tamoxifen or time from initial
diagnosis.
7) Adjuvant Tamoxifen therapy has significantly improved patient outcomes.
8) However, even with adjuvant therapy, more than 20% of node-negative patients had their disease
recur within 15 years after diagnosis.
9) Recurrences can occur after five years of being disease free, even with the successfully treated early
breast cancer.
10) Risk of recurrence is greatest during the first two years following surgery. After two years, there is a
steady decrease in the risk of recurrence until five years.
11) After five years, the risk of recurrence averages 4.3% per year.
12) Up to at least 12 years, the risk of recurrence remains appreciable and even some patients considered
low risk have some risk of the cancer coming back.

a) Specialist reports including clinical staging;

b) Histology reports;
c) Radiological assessment: CXR, CT/MRI/PET scan/mammograms;
d) Nodal assessment: lymph node biopsies;
e) Bloods, e.g. FBC, LFT, U&E (Creat); and
f) Tumour markers such as HER2.
Restriction on the Medical Certificate
Testicular Cancer
A diagnosis of testicular cancer is disqualifying, and upon diagnosis, the applicants shall be deemed medically
Medical Requirements- Testicular Cancer
a) An orchidectomy must have been performed successfully, without complications.

b) The following examinations and procedure reports are required before the applicant’s case can be
c) A specialist report from an oncologist or urologist, including staging;
d) Radiological reports: CXR and/or CT/MRI/PET scan reports (if considered necessary by the
specialist); and
e) Tumour marker levels: α fetoprotein; Lactate dehydrogenase (LDH); Human chorionic gonadotropin
(HCG).
f) The applicant is temporarily unfit to fly while on chemotherapy (and for at least one week after
cessation of medication).
Stage 1 (Non-metastatic disease): Testicular Cancer
a) Certification will be considered after full recovery and cure rates of 100% are possible.
b) Follow-Up Requirements - Testicular Cancer
c) Due to the great differences in the management of the multiple types of testicular carcinomas, the
follow-up requirements will be as per the oncologist/urologist plan.
d) The applicant will be required to submit:

e) Specialist’s reports (oncologist or urologist) along with tumour marker levels 3 to 4 monthly or as per
specialist follow-up plan for two years, then six monthly for three years thereafter, with annual
submissions submit util year 10.
Stage 2 (Pelvic and Abdomen L/N spread): Testicular Cancer
Certification will be after full recovery; survival rates of 97% are possible.
Follow-Up Requirements - Testicular Cancer
a) Due to the great differences in the management of the multiple types of testicular carcinomas, the
follow-up requirements will be as per oncologist/urologist plan.
b) The applicant will be required to submit specialist’s reports (oncologist or urologist) along with tumour
marker levels 3 to 4 monthly or as per specialist follow-up plan for two years, then six monthly for
three years thereafter annually until year 10.
Restriction on Medical Certificate
Stage 3/4 (local and distant metastatic disease)
Certification will be after full recovery; Prognosis remains good (65%-85% cure rates).
Follow-Up- Testicular Cancer
a) Due to the great differences in the management of the multiple types of testicular carcinomas, the
follow-up requirements will be as per the oncologist plan.
b) The applicant will be required to submit Specialist’s reports (oncologist or urologist) along with tumour
marker levels 3 to 4 monthly or as per specialist follow-up plan for two years, then six monthly for
three years thereafter annually until year 10.
c) Applicants on will not be considered while recertification while on chemotherapy

Restriction on Medical Certificates

Prostate Cancer
a) A diagnosis of prostate cancer is disqualifying, and upon diagnosis, the applicants shall be deemed
b) The outcome of prostate cancer varies greatly.
c) It is mostly affected by whether the cancer has spread outside the prostate gland and how abnormal
the cancer cells are (the Gleason score) upon diagnosis.
d) Many patients with prostate cancer that has not spread can be cured, as well as some patients whose
cancer has not spread very much outside the prostate gland.
e) Even for patients who cannot be cured, hormone treatment can extend their life by many years.
Medical Requirements- Prostate Cancer
a) Cancer of the prostate has a generally good prognosis and tends to metastasize locally or to bone.
Once primary treatment has been completed, unrestricted certification will be possible where:
b) There is no evidence of metastatic spread;

c) PSA has returned to acceptable limits; and
d) There are no significant consequences of treatment, such as incontinence.
e) The following examinations and procedure reports are required before the applicant’s case can be
considered with regard to medical certification/recertification:
a) Specialist report, which must include clinical staging and/or with Gleason score;
b) Histology report;
c) Blood test results: PSA (usually every three months to one year); and
d) Initial radiological reports, CXR/bone scans/CT/MRI (done during diagnosis or staging).
e) Should there be metastatic spread which has been controlled and PSA has returned to less than 10,
certification may also be considered.
f) Should the medical waiver be granted in cases of metastatic spread mentioned above, the follow-up
medical examinations and reports must be accompanied by:
g) A six-monthly progress report from a urologist or oncologist for 3 years; and
h) Annual PSA level for three years.
i) If the applicant shows no signs of recurrence after three years from initial diagnosis, no further follow-
up is required.

Renal Cancer
A diagnosis of renal cancer is disqualifying, and upon diagnosis, the applicants shall be deemed medically
Medical Requirements- Renal Cancer
1) As the outcome of renal cancer is unpredictable, and as cerebral metastases are common, the
SACAA will determine aero-medical disposition on a case-by-case basis.
2) There would at least be a six-month grounding period following completion of treatment.
a) Detailed specialist’s reports including staging;

b) Radiological reports;
c) CXR, Abdominal CT/MRI /PET scan reports, renal arteriography, bone scan, U/S;
d) Bloods: FBC, LFT, U&E, GFR; and
e) Urine tests.
Bladder Cancer
1) A diagnosis of bladder cancer is disqualifying and upon diagnosis, the applicants shall be deemed
2) Impairment to flying may result from urinary frequency/urgency and tumour(s) or clots causing urinary
tract obstruction with resultant pain. Metastatic disease could cause any number of symptoms,
including sudden incapacitation or subtle decrement of higher cognitive function.
3) The clinical course of bladder cancer carries a broad spectrum of aggressiveness and risk. Low grade,
superficial bladder cancers have minimal risk of progression to death. However, high-grade non-
muscle invasive cancers frequently progress to death. Muscle-invasive cancers are often lethal.

4) Upon presentation, 55%-60% of patients have a low-grade non-invasive disease, which is usually
treated conservatively with transurethral resection and periodic cystoscopy.
5) The remainder of patients have a high-grade disease, of which 50% is muscle invasive and is typically
treated with radical cystectomy.
6) Carcinoma in situ is managed by instilling chemotherapeutic or immunotherapeutic agents.
7) Bladder cancer has the highest recurrence rate of any malignancy, thus creating a great need for
accurate and diligent surveillance. Because of a fairly high risk of recurrence for both invasive and
non-invasive disease, there will always be a need for scheduled follow-up evaluation.
8) Early after treatment, the patient may be required to undergo urologic evaluation (urinalysis, cytology,
cystoscopy, imaging, and additional labs) every three months.
9) After two years without recurrence, indefinite annual examinations are usually recommended.
Medical Requirements- Bladder Cancer
a) A minimum of a six-month (6) grounding period is applicable to an applicant.

b) The following examinations and procedure reports are required before the applicant’s case can be
c) Specialist reports including staging;
d) Bladder exams every three to six months after treatment;
e) Urological evaluation;
f) Urinalysis (if bladder not removed);
g) Cytology (urine cytology);
h) Cystoscopy; and
i) IVP.
After two years without recurrence, indefinite annual examinations are required along with the following:
a) Histology reports;
b) Radiological and imaging;
c) CXR, Bone scans/CT; and
d) Lab tests; FBC.
Stage 1 & 2 Bladder Cancer
The outlook for stage 1 or 2 cancers is fairly good. Although the risk of the cancer returning is high, most
bladder cancers that return can be surgically removed and cured.
Follow-Up- Bladder Cancer
a) Applicant will be required to submit a three- to six-monthly Urologist

b) After two years without recurrence, indefinite annual examinations are required along with the
following:
c) Annual radiological reports; and
d) CXR, bone scans/CT.
Restriction on Medical Certificate
3 Bladder Cancer
The cure rates for people with stage 3 tumours are less than 50% and patients with stage IV bladder cancer
are rarely cured. Stage 3 and 4 are disqualifying.
Renal Transplantation
Applicability
Medical Requirement
Requirements for consideration of a medical certificate following renal transplantation:
1) An applicant shall be declared medically unfit following renal transplantation.

2) An applicant shall be referred to an Aeromedical Committee 12 months post-transplantation for
recertification, and each case shall be considered on its own merit.
3) An applicant may be considered for medical certification if he or she submits a nephrologist’s report with the
following information:
a) Renal function is stable, with no underlying systemic disorder likely to cause sudden change;
b) Blood pressure is well controlled on approved medication;
c) Steroid dosage is below 10mg/day;
d) Anti-rejection drugs levels are within therapeutic ranges, to minimise side effects; and
e) Cardiovascular risk has been assessed by a cardiologist as minimal.
Protocol on Renal Cell Carcinoma
Applicability
Requirements for consideration of a medical certificate:
1) An applicant who is asymptomatic and has no other conditions may be declared medically fit subject to the

following conditions:
a) The primary lesion (tumour) shall be monitored with six-monthly CT scans for two years; and
b) An applicant with a lesion not demonstrating growth after two years (threshold 4 cm) shall be monitored with
annual CT scans.
2) An applicant who is symptomatic or with lesions (tumour) > 4cm:
a) Shall be declared medically unfit for a period of two years; a recommended treatment is nephrectomy;
b) When presenting himself or herself for recertification after two years, an applicant shall be required to submit a
urologist’s report which is not older than three months with the following:
(i) Disease-specific history such as symptom-free period, surgery complications, further anticipated treatment;
(ii) Function of the remaining kidney;
(iii) CT reports, mainly on brain and abdomen; and
(iv) Confirmation that the applicant is off all medication.
3) An applicant with early recertification with multi-crew limitation may be declared medically fit if a specialist’s advice
indicates an acceptable low risk.
Follow-Up Reports Renal Cell Carcinoma
An applicant shall be required to submit the following urologist report:
a) One report every three months in the first year;

b) Two reports in the second year; and
c) One report annually after the second year for an indefinite period.
Protocol on Benign Prostatic Hyperplasia
Applicability
This protocol is applicable to the classes I, II, III and IV medical certificates.
Requirements for consideration of a medical certificate
1) An applicant presenting with benign prostatic hyperplasia who is asymptomatic may be declared medically
fit provided that he or she has submitted the required medical reports.
2) An applicant presenting with benign prostatic hyperplasia who is asymptomatic shall be required to submit a
six-monthly urologist’s report, including a Prostate Specific Antigen (PSA) blood test.
3) An applicant presenting with benign prostatic hyperplasia who is symptomatic shall be declared medically
unfit up to a period of three months post-commencement of medical treatment.
4) An applicant presenting with benign prostatic hyperplasia who is symptomatic shall be medically unfit from
the time of diagnosis up to a period of six weeks post-surgery.
5) An applicant may be considered for medical certification only if no treatment or surgery complications and
symptoms are completely resolved.
Follow-up Reports
An applicant shall submit a six-monthly urologist’s report which shall include Prostate Specific Antigen (PSA)
values and a disease-specific history such as any deterioration of symptoms, any complications and planned
future treatment.
Kidney Diseases
Chronic Kidney Disease
Applicability
1) An applicant presenting with chronic kidney disease shall have ongoing surveillance with a physician to prevent
deterioration and development of complications.
2) An applicant with a diagnosis of chronic kidney disease, with Creatinine < 200 micromol/L, shall be declared medically
unfit if symptomatic, until he or she is treated and is stable.
3) An applicant presented with chronic kidney disease, with Creatinine < 200 micromol/L, may be considered for
recertification if a physician’s report provides the following:
a) An applicant has been treated fully or has recovered with no current illness likely to cause instability;
b) Renal function is stable with normal electrolytes; and
c) Underlying chronic medical conditions are well controlled on current medication.
4) An applicant with a diagnosis of chronic kidney disease, with Creatinine 200-500 micromol/L, shall be considered on a
case-by-case basis after recovery.
5) An applicant shall submit a six-monthly physician’s report, which shall not be older than three months and shall
include results for:
a) Urea, Creatinine and Electrolytes;
b) Haemoglobin; and
c) Urinalysis.
6)An applicant considered for recertification shall submit a physician’s report which shall not older than three
months, and shall include the following information:
a) Normal Electrolytes;
b) Haemoglobin is at least 10g/dL;
c) Confirmation that the underlying chronic medical conditions are well controlled; and
d) Conformation that an applicant condition is asymptomatic and stable on current treatment.
7) An applicant presenting with chronic kidney disease, with Creatinine > 500 micromol/L, shall be declared
medically unfit.
8) An applicant presenting with chronic kidney disease, with Creatinine > 500 micromol/L, may be referred to a
medical assessor to be considered for recertification.
9) An applicant who requires dialysis shall be declared medically unfit.
HIV/AIDS PROTOCOL-Class 1,2 & 3
General and Medical Requirements
1) Following an initial diagnosis of HIV seropositivity, the applicant will be assessed as temporarily unfit for a
period of three months, pending submission of the following favourable reports –
a) HIV specialist* review with following –
b) History of infection and current and previous symptoms;
c) Stability of condition and history of opportunistic infections or associated illnesses;
d) History of CD4+ T cell counts ;
e) History of viral load measurements;
f) Medication history (including “over-the-counter” medications and alternative medicines);
g) Report concerning side effects of medications;
h) Laboratory testing to include –
i) Hepatitis B and C, cytomegalovirus, toxoplasma, tuberculosis;
j) Full blood count, urea, creatinine and electrolytes, liver function tests, fasting glucose, lipogram.
2.Neurological review – can be undertaken by a neurologist or specialist or physician.
3.Assessment for neurological sequelae including assessment of primitive reflexes because of their
association with cognitive decline.
a) Neuropsychological review.
b) Baseline neuropsychological assessment.

4.Tests should include timed psychomotor tasks and memory tasks requiring attention, learning, active
monitoring and retrieval of information.
5.Psychiatric review (only if clinically indicated)
6.Assessment for psychiatric sequelae related to HIV seropositivity and antiretroviral treatment.
7.Cardiologist review (only if indicated) and Cardiologist review is recommended if the following exist –
8.Lipodystrophy or metabolic syndrome (dyslipidaemia - raised total cholesterol, low high density lipoprotein
cholesterol and raised triglycerides or insulin resistance with hyperglycaemia);
i. Cardiac risk factors are present, including –
ii. Hypertension, evidence of left ventricular hypertrophy, smoking, raised lipids, diabetes and age over
40 years.
2. Medications include –
a) Acceptable medications abacavir, didanosine, emtricitabine, lamivudine, tenofovir, zidovudine,

atazanavir, fosamprenavir, lopinavir/ritonavir, nelfinavir, saquinavir, nevirapine.
b) Unacceptable medications include enfuvirtide, zalcitabine, indinavir, efivarenz and stavudine.
c) Recently available medication, e.g. tipranavir, darunavir, raltegravir and maraviroc, may be acceptable
on an individual basis.
d) Particular attention needs to be given to the toxicity and side effect profile of such medications.
e) A “temporary unfit” assessment should be made when initiating, modifying, or discontinuing ART.
f) When stable, recertification after three months of monitoring may be permitted providing that –
i. There has been an acceptable serological response (as evidenced by increase CD4 count and a
decrease in the viral load)
ii. No on-going side effects
iii. Full blood count (FBC), liver function tests (LFTs), lipids and fasting blood glucose are within normal
limits.
iv. Reviews should take account of any over-the-counter medications and alternative therapies being
taken.

v. Applicants whose condition is stable, asymptomatic, with an acceptable CD4+ count of > 350, viral
load of < 1000 copies per millilitre of plasma and acceptable co-infection can be considered for any
class of the medical certificate.
9.All cases will be assessed individually taking into consideration a favourable clinical and serological
response.
Regular follow-up is required, to include:
a) 3-monthly CD4 count and viral load measurements
b) 6-monthly neurological assessment (by HIV specialist or neurologist including consideration of the
need for psychiatric evaluation – for follow-up assessment a specialist physician may conduct the
neurological examination).
c) If taking ART: 6-monthly LFTs, FBC with minimum Haemoglobin of 12g/dl, Renal Function, Lipogram
and Fasting glucose.
Annual cognitive function assessment.
a) Impaired performance will require further neuropsychological assessment to be compared with

baseline testing, and any deficits will require that the pilot is declared temporarily unfit.
b) Neuropsychological assessment should be undertaken if there are any clinical concerns about
cognitive impairment.
c) Further co-infection testing should be undertaken where clinically indicated and those with new
positive tests must be deferred for further evaluation.
d) If an applicant develops new symptoms and/or fails to achieve the nominal levels listed above he must
be declared temporarily unfit and referred to the Aeromedical Committee.
7. Withdrawal of the medical certificate
The medical certificates of applicants presenting with the following complications/side effects will be withdrawn
if there is –
a) Presence of acute or serious opportunistic infection

b) The use of any substance or medication that is not compatible with flying
c) Safety threatening side effects of any medication
d) Co-existing disqualifying medical conditions or disease
e) Very low CD4 count of 350 or less and Viral load of more than 5 000 copies per millilitre of plasma.*
f) HIV Specialist is any medical practitioner with training in HIV Medicine

Protocol on Lymphomas
Applicability
This protocol shall be applicable to classes I, II, III and IV medical certificates.
Hodgkin’s lymphoma
a) Class I applications may be considered after six months post-treatment for an operational multi-crew
environment and an applicant may apply for the removal of restriction after two years.
b) Class II applications may be considered after six months post-treatment for an unrestricted medical
certificate.
c) Class III and Class IV applicants may be considered by a medical assessor upon submission of the
required medical reports.
Requirements for medical certification
1) An applicant shall complete a minimum of six weeks of radiotherapy for consideration. If radiotherapy
treatment has been conducted to the chest and cardiac tissue, cardiac evaluation shall be considered
as satisfactory.
2) An applicant shall be required to complete a minimum of two months of chemotherapy (excluding

anthracyclines) before being considered for a medical certificate.
3) An applicant shall be considered for a medical certificate upon completing a minimum of six months of
anthracycline chemotherapy after presenting a cardiac evaluation report relating to the side effects of
the medication.
4) An applicant shall submit satisfactory haematological parameters >12g/dl (male) or >11.5g/dl (female)
and platelets.
5) An applicant shall demonstrate continuing clinical remission without symptoms of potential flight safety
importance.
6) An applicant shall not have a history of central nervous system involvement.
7) An applicant shall not have continuing side-effects from treatment.
8) An applicant shall submit the following medical reports which shall not be older than three months:
i. A current status report and all pertinent medical reports such as a haematologist/oncologist report;
ii. Blood results for FBC & ESR, U&E and LFT;
iii. A medical report which includes past and present treatment(s);

iv. Chest X-ray.

v. ECG;
vi. Lung function test; and
vii. Any other report that may be requested.
Requirements for regular follow-ups
1) An applicant shall submit a six-monthly haematologist /oncologist report, which shall include a full
blood count, white cell count (WCC) and differential, and a biochemical profile including a liver function
test, for the first five years.
2) After five years, an applicant shall be required to submit a haematologist/oncologist report annually.
3) Bone marrow transplantation
4) An applicant may apply for medical recertification after a bone marrow transplantation.
5) Autologous stem cell transplantation
6) An applicant for medical recertification after one year of autologous stem cell transplantation shall be
restricted to Class I OML (valid only as or with qualified co-pilot).
7) An applicant for medical recertification after two years of autologous stem cell transplantation may
apply for an unrestricted medical certificate.
8) An applicant for medical recertification after one year of autologous stem cell transplantation for Class
II shall be eligible to apply for unrestricted medical certificate.
Allogeneic Transplantation
1) An applicant applying for medical recertification after two years of allogeneic transplantation shall be
eligible to apply for a restricted to Class I OML (valid only as or with qualified co-pilot) and after three
years for an unrestricted Class I.
2) An applicant applying for medical recertification after one year of an allogeneic transplantation for a
Class 2 medical certificate shall be eligible to apply for a restricted to Operational Safety Pilot medical
certificate and after two years for an unrestricted medical certificate.
3) Lack of adverse prognostic features and the underlying diagnosis shall be important and, in the case
of allogeneic transplantation, the lack of continuing graft-versus-host disease or immunosuppression.
General
1. An applicant with an active Hodgkin’s disease or an applicant undergoing therapy for Hodgkin’s
disease shall be declared medically unfit due to the risk of sudden incapacitation.

2. An applicant with Stage I and II-A with no evidence of the disease for two years after completion of
treatment may be declared medically fit.
3. An applicant with Stage II-B through to IV-B shall be free of the disease after completion of therapy for
at least five years before consideration of being declared medically fit and shall be re-evaluated every
six months for 10 years.
4. Numerous long-term complications of treatment for Hodgkin’s disease include the development of
acute leukaemia and second malignancies of other types, radiation-related heart disease, pulmonary
fibrosis, and hypothyroidism.
5. Subsequent to frequent re-evaluation after 10 years, an applicant shall be subjected to annual.

appraisals.
Non-Hodgkin’s lymphoma
a) Requirements for consideration of a medical certificate
b) Applicants with well-differentiated and poorly differentiated lymphocytic lymphoma, mixed lymphocytic
lymphoma and histiocytic lymphoma of either nodular or diffuse type, are usually not curable, and
these applicants should be disqualified permanently.
c) B-cell, diffuse histiocytic lymphoma, particularly in the early stages, may be cured by radiation therapy
and/or chemotherapy and, if applicants are free from disease without therapy for at least three years,
they may be certified with re-evaluation to occur every three months for three years and then every six
months.
d) Applicants with T-cell, diffuse histolytic lymphoma, including immunoblastic lymphoma and T-cell
lymphoblastic sarcoma, should not be certified because of their unpredictability. Burkitt’s lymphoma
should not be certified.
Plasma-cell dyscrasia
1) Applicants with multiple myeloma, Waldenstrom’s macroglobulinemia or multiple plasmacytomas

should not be certified.
2) These disorders are not curable, require frequent therapy that is toxic, and are associated with sick
effects such as neurological impairment that may lead to sudden incapacitation.
3) Applicants with a single plasmacytoma may be cured and, if they are free of disease for more than
three years after therapy has been discontinued, they may be considered for certification with frequent
follow-up.

4) Applicants with benign monoclonal gammopathy with a monoclonal spike comprising less than 2 g/dl
of protein, with fewer than 55 plasma cells in the bone marrow, and with a haematopoietic
compromise or osteolytic lesions may be certified if they have no evidence of progression of the
disease for three years; they should be recertified every six months.
5) The major risks of monoclonal gammopathy are progression to multiple myeloma and an increase in
serum viscosity leading to neurological impairment.
6) Applicants with amyloidosis associated with plasma cell dyscrasia should not be certified because of
the high incidence of organ infiltration and the risk of sudden impairment.
7) Applicants with gammopathy of alpha chain disease should not be certified. The median survival is
approximately 12 months for gamma heavy chain disease, and the alpha chain disease is often
associated with abdominal lymphoma, which is a progressive and fatal disorder.
8) Applicants with cold agglutinin disease should not be certified because of the risk of sudden
haemolysis. Applicants with cryoglobulinemia syndrome should not be certified because of the risk of
sudden vascular incidents and neurological dysfunction.
Protocol on previously diagnosed Acute Leukaemia
Applicability
This protocol shall be applicable to classes I, II, III and IV medical certificates.
1) Any applicant who has a previous history of having had any type of acute leukaemia in the past will be
required to comply with the following requirements before recertification may be considered –
2) The applicant must comply with the criteria for complete remission, i.e.:
3) Clinical: the disappearance of any abnormal clinical findings due to the leukaemia and return to good
physical health.
4) Haematological:
5) The peripheral blood must have returned to normal, with reference to:
6) Haemoglobin (Hb);
7) Total, and differential, white cell count; and
8) Platelet count.

9) Recognisable leukaemia cells may not be present in a bone marrow preparation, and there may have
been not more than 5% normal blast cells present in a marrow preparation of normal cellularity.
10) The applicant must have completed his/her last treatment at least two years before submitting his/her
application to the designated body or institution. (This includes all modalities of treatment for
leukaemia.)
11) The applicant must have undergone at least six-monthly medical follow-ups in an appropriate
specialised unit. A report detailing the follow-up programme and the applicant’s medical record must
be submitted with the application to the designated body or institution.
12) During the initial post-remission period of two years the applicant’s blood picture should have been
closely monitored. Although the specific results are unlikely to be required by the designated body or
institution, it is necessary that the applicant has been monitored as follows:
13) During the first year after treatment has been stopped –
14) A six-weekly blood profile;
15) A 12-weekly bone marrow evaluation; and
16) A 12-weekly lumbar puncture.
17) During the second year after treatment has been stopped –
18) An eight-weekly blood profile; and
19) A 16-weekly bone marrow evaluation.
20) After two years of documented remission, the applicant may submit an application for certification. If
the results of the above tests are within acceptable limits, the applicant may be granted certification,
with the following restrictions –
21) Must continue with follow-up at a suitable specialist unit, and submit six monthly reports to the
designated body or institution;
22) Must continue to have blood profile monitored at 8-12 weekly intervals (for a year, then six monthly);
23) Must undergo an Aviation Medical Examination at least annually (or more frequently if indicated); and
24) Must do an ECG and stress ECG with each aviation medical examination.
Protocol for Obstetrics and Gynaecology
General requirements
The provision for aviation personnel with obstetrics and gynaecology medical conditions to obtain a medical
certificate may be considered for any class of medical certificate based on the individual medical condition of
the applicant and risk factor management.

Background
Approximately thirty per cent of pregnant women experience nausea and vomiting, and this can result in
dehydration and malnutrition. Approximately fifteen per cent of embryos will abort in the first trimester. Cardiac
output rises in early pregnancy, accompanied by an increase in stroke volume, heart rate, and plasma volume.
Haemoglobin (and haematocrit) begins to fall between the third and fifth month of pregnancy and is lowest by
the eighth month. Adequate diet with supplementary iron and folic acid is necessary, but self-medication and
prescribed medicine should be avoided. The incidence of venous varicosities is three times higher in females
than males and deep venous thrombosis and pulmonary embolism are among the most common serious
vascular diseases occurring during pregnancy.
As the uterus enlarges, it compresses and obstructs the flow through the vena cava. Progressive growth of the
foetus, placenta, uterus and breasts, and the vasculature of these organs, leads to an increased oxygen
demand; and increased blood volume and oxygen demands produce a progressive increase in workload on
both the heart and lungs. Hormonal changes affect pulmonary function by lowering the threshold of the
respiratory centre to carbon dioxide, thereby influencing the respiratory rate.
In order to overcome pressure on the diaphragm, the increased effort of breathing leads to greater
consciousness of breathing and possibly greater cost in oxygen consumption. The effect of hypoxia at
increased altitude further increases the ventilatory effort required to provide for increasing demands of oxygen
in all tissue.Aviation personnel must inform their Designated Aviation Medical Examiner (DAME) if they
become aware of any medical condition that would make them unable to meet the requirements of the licence
they are applying for or if they are taking medication that is not compatible with flying. The medical examiner
should consider the important physiological changes associated with pregnancy, which might interfere with the
safe operation of an aircraft at any altitude throughout a prolonged or difficult flight –
Factors which may considerably reduce flight safety and classify an “abnormal” pregnancy include:
a) A history of multiple pregnancies;

b) Previous pre-term deliveries;
c) Cervical incompetence;
d) Bleeding, increased uterine activity;
e) Reduced oxygen carrying capacity in the blood (anemia);
f) Reduced placental respiratory reserve such as intrauterine growth retardation;
g) Post maturity;
h) Pre-eclampsia;
i) Chronic hypertension;
j) Placental infarction; and
k) Flight during pregnancy increases the risk for oedema (swelling) and blood clot formation due to
obstruction of the vena cava from uterine compression and lack of mobility.
6.6.1 Menstrual Disturbances
1) Applicants for all classes of medical assessments, with gynaecological disorders that are likely to
interfere with the safe exercise of their licence and rating privileges shall be assessed as unfit to fly.

2) Dysmenorrhea is a common condition with symptoms ranging from mild discomfort to severe
abdominal pain, headache and backache, nausea and vomiting, diarrhea, dizziness and fatigue.
Usually, the condition is limited to 24-48 hours around the onset of the menstrual flow, and fitness for
aviation duties is rarely reduced to a significant degree. Treatment with oral contraceptives and
NSAIDs (non-steroidal anti-inflammatory drugs) is very efficient and is generally well tolerated.
3) The use of oral contraceptives is acceptable in the aviation environment, but when medication with a
NSAID is first used, an initial off-duty trial should take place so that the medical examiner can
ascertain that there are no significant side effects such as gastro-intestinal symptoms, visual
disturbances, and drowsiness. In severe cases, especially when an underlying disease such as
endometriosis or pelvic inflammatory disease is suspected (secondary dysmenorrhea), appropriate
diagnostic evaluation is important and specialist opinion should be sought.
4) Premenstrual syndrome (PMS) may occur during the week before the onset of menstruation. The
symptoms are partly mental such as mood swings, anxiety and depression, and partly physical such
as bloating, headache and poor coordination. Because of the broad spectrum of symptoms and their
varying severity and the many different kinds of medication usually prescribed, each case has to be
assessed on its own merits. In most cases pharmaceutical therapy will prove unsatisfactory, and
fitness for aviation duties is often reduced for a number of days every month.
6.6.2 Endometriosis
Endometriosis can cause quite severe discomfort such as lower abdominal or suprapubic pain, usually just
before or during the first days of the menstruation period. There are several medical and surgical treatment
options. If symptoms are well controlled by oral contraceptives or mild analgesics, this condition is usually
compatible with aviation duties. Those who undergo surgical treatment with a successful outcome will normally
be cured and able to fly safely after a suitable period of recovery.The middle group, consisting of patients with
moderate symptoms but on medication and with decreased fitness several days per month, is more difficult to
evaluate and assess. Usually, the final decision should be deferred to the medical panel for further evaluation.
The medical panel, in consultation with a gynaecologist, should weigh all relevant factors carefully before
making a recommendation.
6.6.3 Genitourinary system
1) Applicants for all classes of medical assessments with sequelae of disease of or surgical procedures
on the kidneys or the genito-urinary tract, in particular obstructions due to stricture or compression,
shall be assessed as unfit to fly unless the applicant’s condition has been investigated and evaluated
in accordance with the best medical practice and is assessed not likely to interfere with the safe
exercise of the applicant’s licence or rating privileges.

2) Major gynaecological surgery will normally entail unfitness to fly for a period of two to three months
and some procedures such as hysterectomy may require more extensive periods of recovery.
3) Applicants who are pregnant shall be assessed as unfit to fly, unless obstetrical evaluation and
continued medical supervision indicate a low-risk uncomplicated pregnancy.
4) Once pregnant, a report from a gynaecologist and an aviation medical examiner to confirm the
pregnancy.
5) It is advisable that a treating obstetrician is aware of the type of flying the applicant intends to carry
out. Common complications of pregnancy can be detected and treated, by careful prenatal evaluation,
observation, and care.
6) Low-risk uncomplicated pregnancy must be evaluated and supervised. Pregnancy is considered a

normal, uncomplicated and low risk, if there is supporting medical information from her obstetrician,
family physician and/or midwife supporting that the applicant may continue to exercise the privileges of
her licence.
7) Close medical supervision must be established for the part of the pregnancy where the applicant
continues to carry out their duties, and all abnormalities should be reported to the medical examiner.
Pregnancy
Applicability
Medical requirements for pregnancy for classes I, II & IV medical certificates

a) Applicant may continue to exercise the privileges of her licence from the end of the 12th week (first
trimester) until the end of the 26th week of the gestational period –
b) Applicant will be declared to be medically fit to fly if her pregnancy is considered normal,
uncomplicated and low risk.
c) A medical report from a treating obstetrician, family physician and/or midwife will be required.
d) Close medical supervision where the pilot continues flying, and all abnormalities should be reported to
the medical examiner.
e) Medical requirements for pregnancy for Class III medical certificate
f) During the gestational period, precautions should be taken for the timely relief of an air traffic controller
in the event of early onset of labour or other complications –
g) The fit assessment should be limited to the period until the end of the 34th week of gestation.
h) Once pregnancy is confirmed, the pregnant air traffic controller should report to the medical examiner.
If declared fit, she may continue to exercise the privileges of her licence.
Medical requirements following confinement or termination of pregnancy
1) Miscarriage (spontaneous abortion) occurs in about fifteen per cent of all pregnancies and is
terminated spontaneously. Observation for a few days to ensure that bleeding has stopped may be all

that is needed, but vacuum suction or dilatation and curettage to ensure completion of the abortion is
frequently performed.
2) Induced abortion, usually by vacuum suction or by dilatation and curettage, will in the majority of cases
entail unfitness for less than a week as these procedures are generally very safe, the rate of serious
complications is <1% and the mortality rate is <1 in 100 000 cases. Complication rates increase as
gestational age increases. Although uncommon, post abortion bleeding and pelvic inflammation,
peritonitis and septicemia may occur.
3) The “abortion pill” (mifepristone, a progesterone-receptor blocker) is used within the first seven weeks
of pregnancy. A second drug (prostaglandin) is given two days later to start uterine contractions and
complete the abortion. This method is very safe, and unfitness is limited to a few days.
4) For most women, abortion has no adverse mental sequelae but for those who have a desired
pregnancy terminated for medical reasons (maternal or fetal) or who have considerable ambivalence,
the mental sequelae may be pronounced. The medical examiner should therefore pay particular
attention to the psychological effects of induced abortion before allowing return to aviation duties.
5) The applicant shall not be permitted to exercise the privileges of her licence, until she has undergone
re-evaluation in accordance with best medical practice and it has been determined that she is able to
safely exercise the privileges of her licence and ratings.
6) Uncomplicated pueperium and full recovery: able to resume aviation duties six weeks after
confinement.
Protocol on Warfarin Anticoagulant Drug
General
Aviation personnel presenting with coagulation disorders should be disqualified if there is a history of a serious
bleeding episode and factor replacement.
The provision of medical certification for aviation personnel on Warfarin may be considered for any class of
medical certificate based on the individual medical condition of the applicant and risk factor management.
Applicants on Warfarin may not take part in aerobatic activities.
Applicability
Class I ATP:
The applicant will only be considered with a restriction as a part of a multi-crew, with or as a co-pilot.
Class I COMM:
A. An applicant may fly solo if they comply with the following restrictions:
i. The applicant must not have associated co-morbidities; and
ii. Proof of INR control, 80% of the time in three months after initiation of Warfarin, while grounded.

B. An applicant may fly with a safety pilot if:

The applicant has associated co-morbidities that are poorly controlled;
There are no restrictions other than for corrective lenses or glasses; and
Proof of INR control is provided, 80% of the time in three months after initiation of Warfarin, while grounded.
Class II:
A. An applicant may fly solo if:
There are no associated co-morbidities; and
Proof of INR control is provided, 80% of the time in three months while grounded.
B. An applicant may fly with a safety pilot if:
i. The applicant has associated co-morbidities that are poorly controlled;
ii. There are no restrictions other than corrective lenses/glasses; and
iii. Proof of INR control is provided, 80% of the time in three months after initiation of Warfarin, while
grounded.
Class III: Applicants will be considered if they meet the prescribed criteria.
Class IV: Applicants will be considered if they meet the prescribed criteria.
General medical examination requirements applicable to all certificate holders
i. All initial medical reports will be submitted to the panel of specialists for approval.
ii. Applicants will be required to submit the initial baseline INR and a cardiologist report before the
initiation of Warfarin, and thereafter he/she will submit a weekly INR report after initiation of Warfarin
until there is proof of stability; the applicant can then submit one monthly INR reports.
iii. The applicant will submit his/her INR reports to the DAME on a monthly basis.
iv. The applicant will submit a full medical examination report, including INR and a cardiologist report to
the medical panel on a six-monthly basis.
v. Medication must be well-tolerated by the aviation personnel for a three-month observation period
(during which the applicant will be grounded to ensure safety).
vi. All applicants must submit proof of stability of the INR, 80% of the time in three months, prior to
consideration for medical certification.
vii. Licensed aviation personnel presenting with INR outside the required range will be grounded for a
four-week observation period, in which he/she will be required to submit four reports separately
(weekly) to prove INR stability to the panel.
viii. Applicants should not take any other medication without approval, either by the DAME, or by the
specialist managing his condition.
ix. Applicants who present with an acute illness will be grounded until they are fully recovered, and their
INR re-assessed.
x.
General Medical Conditions
A. Deep Vein Thrombosis

i. Certification should be denied for the period of the episode, and for three months post initiation of
anticoagulation therapy
ii. The applicant will be grounded for a three-month observation period, in which he/she will be required
to submit three months’ INR reports (baseline INR reports, weekly INR report until stability is reached,
then one monthly reports) the levels of which must be between 2 and 3, 80% of the time.
iii. The applicant will submit his/her monthly INR reports to the DAME.
iv. Underlying contributing factors such as malignancies must be evaluated according to the guidelines
set for those conditions.
B. Atrial fibrillation
i. Certification should be denied for the initial period of the episode, while the condition is being
investigated
iii. The applicant will submit his/her monthly INR reports to the DAME.
iv. Underlying contributing factors must be evaluated according to the guidelines set for those conditions.
C. Valvular replacement
v. Certification should be denied for the period of the episode.
vi. The applicant will be grounded for a three-month observation period, in which he/she will be required

vii. The applicant will submit his/her monthly INR reports to the DAME.
viii. Underlying contributing factors must be evaluated according to the guidelines set for those conditions.
D. Pulmonary Embolism
i. Certification should be denied for the initial period of the episode, while the condition is being
investigated.
iii. Underlying contributing factors must be evaluated according to the guidelines set for those conditions.
iv. Recurrent atrial emboli is disqualifying under any circumstances.
v. A single episode of pulmonary embolism, not associated with chronic deep venous thrombosis, should
be considered disqualifying from the date of the embolisation and for at least three months after anti-
coagulation treatment has been initiated.
vi. More than one episode of pulmonary embolisation documented by a CT scan method should be
denied certification permanently.
vii. The applicant will submit his/her monthly INR reports to the DAME.
Bone Marrow Protocol
The holder of a medical certificate is to be grounded from the date of harvesting.

The date of harvesting is calculated from the date of when the first injection of Granulocyte-Colony Stimulating
Factor (G-CSF) is given.
The holder of a medical certificate shall submit a full blood count two weeks after completion of the procedure.
If the full blood count is normal, the holders of a medical certificate may be considered to exercise the
privileges of their license they are applying for; if the full blood count is abnormal, the holder of a medical
certificate will remain grounded until all abnormalities have been corrected.

Protocol on Plavix Prescription Drug
General
The provision of medical certificate for aviation personnel on Plavix may be considered for any class of
medical certificate based on individual medical condition of the applicant and risk factor management.
Applicants on Plavix may not take part in aerobatic activities.
Applicability
Class I ATP
Any restrictions placed on the pilot would be in keeping with the underlying condition for which Plavix was
prescribed.
Class I Comm
prescribed.
Class II PPL
prescribed.
Class III and Class IV
prescribed.
General medical examination requirements
i. All initial medical reports should be submitted to the Panel of Specialists for approval.
ii. Medication must be well tolerated by the aviation personnel for a three-month observation period
(during which the applicant will be grounded to ensure safety).
iii. Each case can be dealt with on a case-to-case basis.
iv. If any severe side effects develop, the relevant Specialist Report will be required (i.e.
Neurology/Psychiatry for CNS/Psychiatric S/E).

Protocol on Mood Disorder (Depressions)

General
i. Aviation medical standards as laid down in Annex 1 of the convention on International Civil Aviation by
the International Civil Aviation Organisation, to which South Africa is a contracting State, have
identified broad medical conditions that, on the basis of expected risk of incapacitation, disqualify
aviation personnel from flying.
ii. South Africa is one of the countries that previously applied strict standards to applicants with a history
of depression.
iii. The previous protocol did not take into consideration new therapeutic interventions, risk factor
modification or rehabilitation, all of which may reduce the risk of sudden incapacitation.
iv. The SACAA has since reviewed this protocol and is now making provision for aviation personnel with
a history of depression to apply for the privileges of the license they wish to apply for.
v. This consideration will be based on the individual medical condition of the applicant and risk factors
involved.
Background
Depression is a disorder that defines a certain component of psychopathology that is grouped as “Mood
Disorders”. Mood disorders are psychopathologic states in which a disturbance of mood is either a primary
determinant or constitutes the core manifestation of the condition. These conditions, especially the depressive
forms, are heterogeneous and are common in both psychiatry and general medicine. These conditions are
becoming even more common as the stigmata associated with such a diagnosis are having less impact in the
social spectrum of life. The methods used to treat patients suffering from mood disorders have improved over
recent years, and individuals that require pharmacotherapy may apply, or re-apply, for a license to fly or to
undertake air traffic control work.The key areas of concern in certification of aircrew with mood disorders are
the risk of suicidal ideation, suicide, lack of concentration, chronic tiredness, insomnia/hypersomnia, and
general malaise, with all the ramifications resulting in a detrimental effect on global functioning of an individual.
Estimated incapacity risk The lifetime prevalence of major depression in males is about 5% to 12% and in
females about 10% to 25%. There is no specific association with ethnicity, social status, income or marital
status. The risk for a second episode after remission is 60%, 70% for a third episode and 90% for a fourth
episode.

This leads to the clinical conclusion that for the purpose of risk management in the aviation industry, a person
should be treated optimally and permanently with the appropriate pharmacologicals, thereby reducing the risk
of recurrence. During the initial phase of therapy there may be a higher incidence of suicidal tendencies
brought on by the appropriate therapeutic interventions.Without diligent care by the professional therapist and
adequate protocol parameters disallowing the privileges of execution of an aviation-related license in the initial
phase of treatment, the incapacity risk would be unacceptably high.
Mood Disorder
Class Applicability
Any class of certification may be applied for, subject to the following requirements:
Class I
i. Commercial passenger air transport operations – multi-crew restriction
ii. Flight instruction – student must have completed first solo flight
iii. Class II – no restriction
iv. Class III – may operate under supervision
v. Class IV – no restriction
General medical requirements applicable to all applicants for initial consideration
i. All symptoms of the psychiatric condition for which treatment is indicated must be eliminated by the
single medication and the applicant must be symptom-free for four weeks prior to application for
certification.
ii. An applicant must have no aeromedically significant side effects of the prescribed medication for a
period of four (4) weeks.
iii. Applicants will be required to submit psychiatrist and clinical psychologist reports to the Aeromedical
Committee for consideration.

iv. A consultation status report from the treating psychiatrist must attest to and describe the applicant’s
diagnosis, length and course of treatment, type and dosage of the antidepressant medication taken,
Hamilton Scale (HAMD 17) score (must be consistently below 7) and presence of any side effects
from the antidepressant the applicant takes or has taken in the past.
v. Any additional information that may be required by the Aeromedical Committee.
vi. Applicants who meet the requirements prescribed above will be required to submit a monthly
psychiatrist report for a period of six (6) months following initial certification.
vii. A follow-up psychiatrist report will be required at nine (9) months, and then at twelve months (12) post-
certification.
viii. Should other co-morbidities exist or develop after the issuing of a certificate of fitness, then
certification will not be granted (in the case of existing) or will be withdrawn by the Aeromedical
Committee without re-assessment.
F. Diagnostic inclusions
The following mood disorders are acceptable for the purpose of this protocol:
Major depressive disorder (mild to moderate degree), either single episode or recurrent episode before
commencement of therapy;
Dysthymic disorder;
Adjustment disorder with depressed mood.
G. Disqualifying conditions
Any history of depressive disorder of a severe degree is disqualifying.

The following conditions will, by virtue of their risk profile, exclude a person from obtaining a certificate of
aviation medical fitness:
History of psychosis;
Impairment of arousal;
History of electro-convulsive therapy;
Concurrent treatment with multiple antidepressant medications;
History of multi-agent drug use (prior use of other psychiatric drugs in conjunction with antidepressant
medications);
History of discontinuation of acceptable medication and then a subsequent onset of depression; and
Any other manifestation of mood disorder as specified at the time of promulgation, or at the discretion of the
treating psychiatrist.
H. Acceptable oral medication
Fluoxetine
Sertraline
Citalopram
Escitalopram
Other oral medication deemed acceptable by the Director.
I. Annual follow-up for medical certification
After twelve (12) months, the applicant will be required to submit a psychiatrist report at six-monthly intervals to
the Aviation Medical Department, until the time of cancellation of his/her license.
b. Protocol on Rheumatoid Arthritis

All pilots suffering from rheumatoid arthritis need a rheumatologists report stating whether or not the
disease is in remission or controllable on acceptable medication.
The only acceptable medication at present is MethotrexateTM in dosages not exceeding 5 mg per day.
Gold salts, NSAID's, anti-malarials (in anti-rheumatic dosages), etc. are not compatible with flying.
The DAME must determine whether the arthritic damage already incurred would compromise the pilot's
flying safety.
c. Protocol on Coagulation and Thrombotic Disorders
General
Inherited disorders of coagulation should be disqualified if there is any history of factor replacement or serious
bleeding episodes.
Haemophilia:
Factor VIII deficiency should be denied certification.

Von Willebrand's disease, as well as other specific factor deficiencies, should be denied certification if there is
a history of factor replacement or serious bleeding episodes.
Haemorrhagic platelet abnormalities
Decreased circulating platelet count due to any cause may result in debilitating haemorrhagic episodes.
Haemorrhage can also occur when platelet counts are normal but platelet function is abnormal.
Congenital/Genetic Disorders, e.g. Protein S or Protein C Deficiency will render applicants medically unfit.
d. Monocular/Amblyopic Protocol
To be applicable if optimally corrected vision in the weak eye is 6/12 or worse.

Preconditions:
There must be no active ocular pathology.
Vision (uncorrected or corrected) in the better eye must be 6/6 or better (distance vision) and 6/9 or better
(near vision).
Initial applicants: In addition to the required standards, initial applicants must pass a practical flight test by a
CAA-approved instructor before being declared fit according to the protocol.
e. Colour Vision Protocol
Applicability
This technical standard is applicable to the following categories:
Class I
Air Transport Pilots
Commercial Pilots
Class II
Private Pilots with the following:
Night Flying
IF Rating
Flying a Glass Cockpit Aircraft
Ishihara test
All applicants will be required to submit themselves for an Ishihara test;

Applicants must be able to demonstrate ability to perceive readily those colours the perception of which is
necessary for the safe performance of duties;
The use of tinted lenses to obtain adequate colour perception is not permitted;
The medical examiner shall instruct the person being tested to report the number on a plate they can see and
warns the subject that on some occasions they may not see a number;
Ishihara test to be conducted as per manufacturer’s instructions test at a distance 75 cm with plane of plates at
right angles to line of vision under daylight or daylight simulated light;
Applicants should see this number with a viewing time of about three seconds allowed for each plate, undue
hesitation on the part of the subject may be the first indication of colour deficiency;
Ishihara plates should be updated periodically or if showing any signs of fading;
The SACAA will only allow a 24 or 38 plates test version to be used for screening of colour vision;
The Ishihara test is to be considered passed for the 24 plates, if the 1st to the 15th is identified correctly, with
no errors, presented in a random order;
The Ishihara test is to be considered passed for the 38 plates, if the 1st to the 24th are identified correctly, with
no errors presented in a random order.
Class II medical certificate applicants who fail to obtain a satisfactory score of the Ishihara tests may
nevertheless be assessed as fit.
A medical certificate may be issued if medical conclusion indicates that the applicant has a colour perception
defect which is compatible with the safe exercise of the privileges of the license, provided the certificate is
endorsed with the following limitations and the applicant meets the following conditions:
“For private pilot licence privileges only”;
Not valid for night flying;
Not valid for IFR flying or flying of EFIS-equipped aircraft where the EFIS is the primary flight instrument;
Meet visual criteria for a Class II Medical Certificate: and
The applicant shall submit a satisfactory report from an ophthalmologist every 2 years if the if < 40 years of
age and every year if > 40 years of age.
Applicants who fail to pass the Ishihara test and who wish to apply for a Class II PPL without restrictions and a
Class I medical certificate shall undergo further colour perception testing to establish whether they are colour
safe using the Colour Assessment Diagnosis (CAD).

For Class I and Class II PPL without restrictions
CAD tests should be conducted under CAA protocols as indicated below.

The CAD test will only pass those individuals as colour safe who perform as well as individuals with colour
vision in the normal range on the most difficult aviation colour vision tasks.
Ishihara test requirements
The definitive CAD will assess red/green colour vision and yellow/blue colour vision. The test can be done
simultaneously or individually but will run somewhat faster if you only assess one type of colour vision at a
time. The CAD will establish class of colour vision loss and whether pass (colour safe) or fail (colour unsafe).
Applicants will be required to produce identity documents prior to examination.
Applicants may not wear coloured contact lenses.
A report from an ophthalmologist that confirm that there are no visual defects must be submitted, which must
include:
Refraction errors
Peripheral vision
Exclusion of any acute or chronic eye disease
Lens abnormality
Absence of any medication that may cause colour vision defect
The procedure for testing for colour deficiency using the Colour Assessment and Diagnosis (CAD) shall be as
follows:
The applicant’s eye will be positioned at display height and at a distance of 1.4 meters.
The illumination in the room will be arranged such that no light falls directly on the display.
The ambient illumination on the display surface will not exceed 1 lux.
During this test, the applicant will see a coloured target moving diagonally across a central square in one of
four possible directions (top-right, top-left, bottom-right, or bottom-left).
The response box has four buttons laid out to form a square.
The applicant’s task is to press the appropriate button to indicate the corresponding direction of movement.
When unsure, the applicant must make their best guess.

For best results, the applicant will be instructed to maintain fixation on the centre of the square and not to track
the moving target.
The applicant can request for representation of the current presentation if, for any reason, the subject failed to
attend to the task, but not more than twice.
The applicant will start with the learning mode to familiarise him/herself with the fools before being exposed to
the definitive test.
Interpretation of the CAD results
In the case of Class 1 medical certificates, applicants shall have normal perception of colours or be colour
safe.
Colour Assessment and Diagnosis (CAD) test is considered passed if the threshold is equal to or less than
6SU for deutan deficiency, or equal or less than 12 SU for protan deficiency;
A threshold greater than 2 SU for tritan deficiency will be disqualifying;
A threshold greater than 2 SU for tritan deficiency indicates an acquired cause which should be investigated.
Applicants who fail further colour perception testing shall be assessed as unfit.
A medical certificate may be issued if medical conclusion indicates that the applicant has a colour perception
defect which is compatible with the safe exercise of the privileges of the license, provided the certificate is
endorsed with the following limitations and the following conditions are met:
“For private pilot license privileges only”;
Not valid for night flying;
Not valid for IFR flying or flying of EFIS-equipped aircraft where the EFIS is the primary flight instrument;
The applicant meets the visual criteria for a Class II medical certificate; and
The applicant shall submit a satisfactory report from an ophthalmologist every two years if the if < 40 years of
age and every year if > 40 years of age.
Operational colour vision test and medical practical flight test
Applicability
Class I – Commercial Pilots only
Class II – with no colour vision restrictions on the medical certificate
Operational colour vision test (OCVT)

An applicant for a Class I (Commercial) or Class II who has defective colour vision must demonstrate the the
ability to pass an OCVT, which includes:
The ability to read and correctly interpret in a timely manner aeronautical chart and Jeppesen chart legends:
Including print in various sizes, colours, and typefaces; conventional markings in several colours; and terrain
colours.
Aeronautical chart reading may be performed under any light condition where the chart will normally be read.
Medical practical flight test (PMFT)

The Director may require applicants to demonstrate their ability to perceive colour in a EFIS-equipped aircraft
or EFIS Cockpit Simulator with the panel lighting set to the comfort of the applicant day and night and must
include the interval from dawn to dusk;
The medical practical flight test shall be conducted in a Level C or D simulator, or such lessor device as
determined by the Director .
The test shall be conducted by a panel of specialists appointed by the Director and will be coordinated by
authorised officers (medical assessors) of the SACAA;
The panel shall comprise of the following:
A representative authorised officer from the CAA;
A designated aviation medical examiner, preferably with experience in flying;
An ophthalmologist;
A designated flight examiner as determined by the Director; and
The procedure for the medical practical flight test shall be approved by the Directors.
Applicants must have the ability to demonstrate the following:
Must read and correctly interpret in a timely manner aviation instruments or displays, particularly those with
coloured limitation marks;
Must read and interpret coloured instrument panel lights, especially marker beacon lights, warning or caution
lights, weather displays, etc.;
Must recognise terrain and obstructions in a timely manner, have the applicant select several emergency
landing fields, preferably under marginal conditions, and describe the surface;
Must visually identify in a timely manner the location, colour and significance of aeronautical lights.

An applicant may be issued a medical certificate with operational limitations should the panel appointed by the
Director deem it for safety.
Applicants will be afforded a single opportunity for a medical practical flight test.
Operating limitations required by physical deficiencies may restrict holders to certain aircraft types, special
equipment or control arrangements, or special operating conditions.
16.14.4 Considerations for applicants with Class I Comm who fail a CAD and pass the OCVT and PMFT tests
To fly as CPL in a multi-crew environment by day and night as a deuteranope with the following restrictions:
The holder does not meet the ICAO medical standard as per Annex 1 and is therefore restricted to fly within
the South African borders on a South African registered aircraft only.
Applicants who fail the CAD will not qualify for Air Transport Pilot Licence operations.
Annual ophthalmological assessment will be required to determine any refractory, visual field or lens
translucency change every two years if < 40 years and annually if > 40 years.
The applicant must inform his/her employer and cockpit crew members of his/her red-green colour deficiency.
The holder is restricted to a cabin altitude of maximum 8000 ft AMSL at night or during IFR conditions.
The holder may not perform any CAT II approaches.
A minimum required flight hours as prescribed in SA-CARS/CATS Part 61 will be applied before allowing the
applicant as PIC with CPL.
The decision and restrictions will be reviewed, should there be a change in the applicant’s condition or new
evidence becomes available regarding deuteranopia and flight safety.
16.14.5 Radial Keratotomy/PRK/Lasik protocol
General
Applicants contemplating refractive surgery must take cognisance of the risks involved and shall be aware that
having the surgery might result in a delay in return to duties as aircrew or air traffic controller or, if
complications occur, that it may result in the permanent loss of medical certification.
The visual acuity result meets the visual requirements of technical standard 67.00.3 and the assessment must
be based on measurements made by an ophthalmologist.
An applicant presenting with a pre-operative refractive error of up to 10.00 D spherical equivalent at initial
application will be considered medically unfit for the periods prescribed below:
An applicant who has undergone a Radial Keratotomy (RK) procedure, for a period of six months;
An applicant who has undergone a Photorefractive Keratectomy (PRK) procedure, for a period of six months;
An applicant who has undergone a laser-assisted in situ Keratomileusis (LASIK) procedure, for a period of two
months.
An applicant with pre-operative refractive error greater than 10.00 D spherical equivalent will be considered
medically unfit for the periods prescribed below:
An applicant who has undergone a Radial Keratomy (RK) procedure, for a period of six months;
An applicant who has undergone a Photorefractive Keratectomy (PRK) procedure, for a period of six months;
An applicant who has undergone a laser-assisted in situ Keratomileusis (LASIK) procedure, for a period of six
months.
An applicant who has had refractive surgery and who is considered for medical certification or recertification
shall meet the following criteria:
The surgery must have been without complications;
The vision must be stable; and
There must be no corneal haze or complaints of glare, halos or “ghosting”.
Follow-up requirements: An applicant shall submit a post-operative assessment report by an ophthalmologist
at the following intervals:
At six (6) weeks after the procedure;
At six (6) months after return duty; and
Annually, thereafter.
f. Substance Abuse
General
These technical standards are based on the general principles that have been established internationally and
are designed to ensure that the entire drug and alcohol testing process is conducted to give accurate and
reliable information about a donor's drug and alcohol use.
6.15.1 Procedure for substance and alcohol testing

1. Specimens must be collected by suitably trained personnel (collecting officers) who have a thorough
understanding of the principles of chain of custody.
2. Collecting officers must be able to provide evidence of their training, and/or the instructions that they
must follow during the collection process.
3. The following restrictions apply:
4. The immediate supervisor of a donor may not serve as the collector when that donor is tested, unless
there is no feasible alternative.
5. A co-worker who is in the same testing pool or who works with a donor on a daily basis may not serve
as a collector when that donor is tested, unless there is no feasible alternative.
6. An individual who has a personal relationship with the donor (e.g., spouse, ex-spouse, relative, close
personal friend) may not serve as the collector, unless there is no feasible alternative.
7. The collector should have identification with his/her name address, and telephone number and be able
to provide it upon request of the donor.
8. The following items should be available to the collecting officer before specimen donation occurs:
9. Chain-of-Custody form:
10. The original copy accompanies the sample to the confirmatory laboratory and all persons involved in
the transport and receiving of the sample should record their name and signature on the chain- of-
custody form; and
11. A copy should be handed to the licence holder, the medical review officer (MRO) and the collecting
officer.
12. A link between the chain-of-custody form and collection cup;
13. A demonstrably clean and unused collection cup which can hold a minimum of 50 mL;
14. At least two collection cups for split specimen collection;
15. Each cup must be able to hold a minimum of 20 mL;
16. In the case of single specimen collection, the cup must be able to hold a minimum of 40 mL;
NOTE: In case of the use of immunoassay integrated test cup kits (also referred to as an “integrated split
specimen cup”), the collection cup and sample bottle is integrated into the same device, hence a single
specimen collection may be performed.
1. Blueing agent that must be added to toilet bowl water/tank before donor enters the collection area;
2. Temperature measurement device able to determine temperatures between 32-38°C;
3. Secure tamper-evident seal for each bottle;
4. Leak-resistant plastic bag;

5. Disposable gloves for collector when handling donor specimens; and
6. Packaging components that satisfy current mail and courier regulations.
7. Collection site requirements
8. A collection site is a permanent or temporary facility where a donor provides a urine specimen for a
drug test.
9. The site must have all necessary personnel, supplies, equipment, facilities, and supervision to provide
for specimen collection, security, and temporary storage.
10. A urine specimen collection site must provide for donor privacy while he or she provides the urine
specimen.
11. An observed collection must only be performed when required (e.g. as part of a recollection in
adulteration suspicion).
12. The following facilities provide adequate privacy for urine collections:
13. A single-toilet restroom with a full-length door.
14. A multi-stall restroom with partial-length doors.
15. A mobile restroom (e.g. a vehicle with an enclosed toilet stall).
16. A source of water for washing hands must be provided.
17. The water source should be external to the restroom where urination occurs.
18. If the only source of water available is inside the restroom, the collector must secure the water source
before the collection, and restore the water source to allow the donor to wash his or her hands after
the collection.
19. If a water source is not available, providing moist towelettes outside the restroom is a suitable
alternative.
20. A suitable clean surface for the collector to use as a work area must be available.
21. The collector work area may be located outside the restroom or inside the restroom, only if the donor
can have privacy while providing the urine specimen.
22. The collector must maintain line-of-sight custody or provide for the secure temporary storage of
specimens from the time the specimen is collected until it is sealed in a shipping container prior to
transfer to an express carrier or courier for shipment to a laboratory.
23. Either the collection officer or the donor, with both of them present, must unwrap or break the seal of
the collection container.

24. During the collection process the collection site must be dedicated solely to drug testing and comply
with all local health and safety requirements.
25. The collection officer and the donor must be present throughout all the procedures outlined in the
paragraphs of this section and the entire process must be transparent.
26. When a donor arrives at the collection site, the collection officer will request that the donor presents
photographic identification (passport, national identity document, driver’s licence, SACAA licence, etc).
27. If the donor does not have proper photographic identification, the collection officer will obtain a positive
identification of the donor by an authorised supervisor or manager within the parent organisation.
28. If the donor's identity cannot be established, the collection officer will not proceed with the collection
and notify an authority.
29. The collection officer will ask the donor to provide voluntary written informed consent before the
collection commences.
30. The following minimum precautions shall be taken to ensure that unadulterated specimens are
obtained and correctly identified:
31. To deter the dilution of specimens at the collection site, toilet water colouring agents should be placed
in toilet tanks wherever accessible or in the toilet bowl, so the reservoir of water in the toilet bowl
always remains coloured.
32. Any other sources of water in the enclosure where urination occurs (e.g. taps, shower) will be secured
prior to collection.
33. The collection officer will ask the donor to remove any unnecessary outer garments that might conceal
items or substances that could be used to tamper with or adulterate the donor's urine specimen
34. The donor will be instructed to wash and dry his or her hands prior to urination with inspection of the
hands afterwards by the collection officer.
35. After washing hands, the donor will remain in the presence of the collection officer and will not have
access to any unregulated source of water, soap dispenser, cleaning agent, or any other materials
that could be used to adulterate the specimen.
36. The collection officer will give the donor a clean specimen collection cup.
37. The donor will be instructed not to flush the toilet until the specimen is handed to the collection officer.
38. The collection officer will note any unusual behaviour of the donor on the chain of custody form.
39. Upon receiving the specimen from the donor, the collection officer shall comply with the following:

40. Check the volume of urine in the specimen container and check the temperature of the urine
specimen.
41. The temperature-measuring device used must accurately reflect the temperature of the specimen and
not contaminate the specimen.
42. If a thermometer is used it may only be done on the residual urine in the collection cup after the
specimen has been transferred to the sample bottles earmarked and secured for possible confirmatory
analysis (split or single).
43. The thermometer may under no circumstances be brought into contact with the urine that is
designated for possible confirmatory analysis.
44. The time from urination to temperature measurement should not exceed four minutes.
45. Inspect the specimen to determine its colour and appearance for any signs of contaminants.
46. Any unusual findings will be noted on the chain of custody form.
47. A re-collection may be performed and both specimens forwarded for testing by a laboratory with
special notice on the chain of custody form.
48. For a split specimen collection, the volume must be approx. 50 millilitres (mL) or more and the
temperature within the acceptable range of 32°C-38°C, the collection officer may then proceed with
step
49. If the volume is less than 50 ml, the specimen will be discarded, and a second specimen will be
collected.
50. For a single specimen collection, the volume must be approx. 20 millilitres (mL) or more and the
temperature within the acceptable range of 32°C-38°C, the collection officer may then proceed with
step
51. The donor may be offered a reasonable amount of liquid to drink for the purpose of re-collection (e.g.
250ml of water every 30 min, but not to exceed a maximum of 1 litre).
52. If the temperature of the urine specimen is outside the acceptable range of 32°C-8°C, a second
specimen will be collected (as above).
53. If there is any reason to believe (temperature outside of range, visible contamination, etc.) that a donor
may have adulterated, diluted, altered or substituted the specimen, another specimen will be obtained
as soon as possible and both specimens will be forwarded to the laboratory for testing.
54. Both the donor and the collection officer will keep the specimen container/specimen bottles in view at
all times prior to the urine specimen being sealed and labelled.

55. For a split collection, the specimen is split into a minimum of two specimen bottles (Sample A and
Sample B).
56. When the specimen is transferred from the specimen container to the specimen bottles, it will be
poured and the collection officer will request the donor to observe the transfer of the specimen and the
attachment of the tamper-evident seal/tape on the bottles.
57. The sealed specimens together with the corresponding chain of custody documentation in a tamper
evident container must be dispatched to the laboratory.
58. In split collections one bottle will be used for the drug test (Sample A) while the second bottle (Sample
B) will remain sealed at the analytical laboratory in case the donor wishes to challenge a positive
confirmation result.
59. In single collections (including integrated test cups) the specimen is split immediately after reception at
the laboratory, before any testing, into a sample for analysis (Sample A) and a stored challenge
specimen (Sample B)
60. At an appropriate time after the urine specimen has been collected and sealed into the transport
bottles the collection officer will invite the donor to wash his/her hands.
61. The specimen bottle will have an identification label that contains at a minimum the date, the donor's
specimen number and the donor’s signature/initials.
62. The collection officer will enter all information on the chain of custody form to identify the origin of the
specimen.
63. Specimen bottles and all pages of the chain of custody will be labelled at the time of collection with a
unique identifier.
64. The donor will be asked to read and sign a statement on the chain-of-custody form certifying that the
specimen identified on the form was in fact the specimen provided by the donor and giving informed
consent. The collection officer will complete the specimen chain-of-custody form and package with the
urine specimen ready for dispatch as soon as possible.
65. Packaging and storage of specimens
66. Specimens should be stored at 4°C (do not freeze).
67. The specimens will be placed in containers designed to minimise the possibility of damage during
shipment.
68. The collection officer will keep a register of the transfer of the specimens to the courier from the
collector.

Laboratory urine analysis: Specimens are received at the laboratory where initial checks on the chain of
custody documents and sample appearance are done.
The following specimens will be deemed invalid:

1. No chain of custody documentation accompanied the sample.
2. Chain of custody documentation incomplete (collector/donor details not filled in, donor consent
absent).
3. Identification parameters (name/ID/barcode/numerical) mismatched on sample and documentation.
4. No seals on specimens or seals broken/tampered with on any sample bottle.
5. Insufficient sample volume.
6. After the initial checks are complete samples may be placed in temporary storage at 2°C-10°C before
further analysis.
7. Upon reception of a split specimen (Sample A and Sample B) samples are separated and one sample
is placed in long term storage at -20°C (only Sample B) for possible challenges to results by the
donor.
8. Upon reception of a single specimen (only Sample A) the sample is documented on the chain of
custody and opened for a split performed by the laboratory before any further analysis.
9. The sample is poured from Sample A into a clean sample bottle (Sample B) containing the unique
identifier of Sample A, sealed and placed in long term storage at -20°C for possible challenges to
results by the donor.
10. NOTE: The basic protocol of specimen collection, sample validity testing, initial drug screen test (on-
site or laboratory) and confirmation of all non-negative results must be followed.
11. Analysis performed by the laboratory is done utilising separate aliquots from the testing sample
(Sample A).
12. Aliquots are taken in a manner to exclude contamination of the sample.
The following validity tests must be performed to ensure the collected specimen is unadulterated urine:
1. Temperature
2. pH
3. Specific gravity/creatinine
4. Nitrite
5. Oxidants (e.g. halogens, chromium (VI), pyridinium chlorochromate)
6. Gluteraldehyde
7. Surfactants (e.g. benzalkonium chloride)
8. Any result that indicates adulteration (non-negatives) should be reported to the customer who may
request additional confirmatory testing for adulterants.
9. All preliminary drug tests must fulfil the following minimum requirements:
10. All preliminary test results must be reviewed with regard to the validity of the results.
11. All assays must be calibrated against appropriate analytical standards.
12. Where the assay has significant cross-reactivity or selectivity to related compounds, the assay must
be calibrated against one named standard, and, where necessary, the sensitivity to other compounds
must be indicated.
13. The SACAA must be informed of the expected sensitivity and specificity to assayed compounds of
interest.
14. Suitable cut-offs from Substance Abuse and Mental Health Services Administration (SAMHSA) are to
be employed (Table 1).
15. Additional drug classes may be included at cut-offs established in scientific literature as long as the
above-mentioned minimum criteria are applied.
Table 3: SAMHSA recommended cut-off concentrations for preliminary drug tests
NOTE: All prescription medication needs to be declared at all times by the licence holder and it is then the
prerogative and responsibility of the employer to withdraw him/her from any safety sensitive duties.
Prescription medication should be declared upfront before a drug test commences and should be noted on
either of the “voluntary informed consent form” or the “chain-of-custody form”.

1. All non-negative results from initial drug screen tests (on-site and laboratory) must be confirmed by a
reference method such as Gas Chromatography-Mass spectrometry (GCMS).
2. Immunoassay and enzymatic assays (automated or point-of-care testing devices) are not regarded as
confirmatory techniques for ethanol in blood but rather as preliminary testing techniques.
3. The confirmatory drug test must provide a quantitative result from laboratory established standard
operating procedures (SOP) that are in line with international standards and quality assurance
programs.
4. These include, but are not limited to, the use of pure analytical standards, calibrators and quality
control samples.
5. Suitable cut-off concentration values established by the Substance Abuse and Mental Health Services
Administration (SAMHSA) are to be employed (Table 2).
6. Additional drugs/metabolites may be included at cut-off concentration levels established in scientific
literature as long as they are closely associated with cut-off concentration levels utilised in preliminary
testing.
Table 4: SAMHSA recommended cut-off concentrations for confirmatory drug tests
1 6-Acetylmorphine as evidence for heroin use is better associated (reduced false-negatives) within the
unconjugated fraction of opiate metabolites. Analysis of un-conjugated morphine and codeine allows better
discernment between codeine and morphine usage (from scientific literature).
2 Positive confirmation of methamphetamine use at this cut-off requires amphetamine concentration greater or
equal to 200 ng/mL.

1. Only drugs which have been confirmed by a recognised confirmation test (like GC-MS) can be
reported as positive.
2. Before any laboratory test result is released, the results are reviewed and certified as accurate by an
authorising scientist.
3. The laboratory must report all non-negative test results for a specimen. For example, a specimen can
be positive for a specific drug in addition to being adulterated.
4. An analytical positive result may be due to medication (prescribed or over-the-counter) or to dietary
causes.
5. Interpretation is best carried out by a qualified toxicologist who may consult with the MRO, the donor,
and the donor's GP.
6. The toxicologist cannot issue a negative report for a positive analytical result even if the test result is
likely to be due to the use of declared medication.
7. Results are reported to the MRO within a maximum of five working days.
8. The laboratory report must include:
9. The specimen identification number;
10. The quantitative result/s for each sample submitted as well as the 99% confidence interval; and
11. The limit of detection (LOD) and the limit of quantitation (LOQ).

12. Challenges to results by the donor for re-testing must be made within 72 hours of reporting results to
the MRO.
13. The stored sample (Sample B) should be released for analysis to a drug-testing laboratory able to
demonstrate that they can accurately determine the concentration of a drug or metabolite at 50% of
the confirmation cut-off concentration employed.
14. The release must be supported by a chain of custody that can withstand legal scrutiny and requires
authorisation from the customer and the donor.
15. Long-term frozen storage (-20°C or below) ensures that positive urine samples will remain suitable for
a retest.
16. Unless otherwise authorised in writing by the SACAA, the laboratory will retain all samples confirmed
positive in properly secured long-term frozen storage for a minimum of one year.
17. Within this one-year period the SACAA may request the laboratory to retain the sample for an
additional period of time.
18. If no such request is received, the laboratory may discard the sample after the end of one year, except
that the laboratory shall be required to maintain any samples known to be under legal challenge for a
further agreed period.
19. The laboratory will maintain and make available for an agreed period (minimum two years),
documentation of all aspects of the testing process involved in the generation of a positive result
including the following:
20. Chain-of-custody forms
21. Quality assurance records
22. Computer generated data
23. Breath specimen collection for alcohol testing
24. The SST or the BAT who administers the alcohol must have qualification training and demonstrated
proficiency in the alcohol testing device he or she will be using.
25. The qualification training for BAT’s and STT’s must contain the following elements:
26. In depth knowledge in the operation of the alcohol testing device to be used. Their responsibility for
maintaining the integrity and credibility of the testing process, ensuring privacy of the donors being
tested, and avoiding conduct or statements that could be viewed as offensive or inappropriate.
27. Trainers should provide their students with certificate of completion.
28. The BAT student should successfully demonstrate that he/she can:
29. Respond to the device’s messages and commands or displays;
30. Take appropriate actions when an error message or malfunction occurs within the device;
31. Recognise that an air blank has been conducted;
32. Identify and explain actions the technician will take when the device does not function properly;
33. Explain when an external calibration check is required, if applicable to the device being used, and
identify the procedures used to perform the check;
Mock tests:
1. After completion of training, the student must complete at least seven consecutive error-free mock
tests for initial BAT qualification and at least five consecutive error-free mock test for initial STT
qualification.
2. The mock tests must be conducted on the same device(s) the BAT/STT will use.
3. If the device involves colour changes, contrasts, or colour readings, the technician must demonstrate
that he/she can see the changes.
4. The mock tests must portray a real event conducted with someone acting as the test subject
5. The BAT and STT should go for refresher training every three years to remain eligible to conduct
alcohol tests.
6. The content of the refresher training must include material equivalent to the initial training but updated
as needed.
7. The refresher training includes conducting error-free mock tests monitored by the trainer.
8. Error correction training:
9. A BAT or STT who makes an error causing a screening test/confirmatory test to be invalid or
cancelled must undergo correction training within 30 days of notification of the error. (He/she may
continue with the normal testing duties; however, the goal is to complete the error correction training
as soon as practical after the error occurred).
10. The employer or agent designated by the SACAA should be responsible for notifying the alcohol
testing site of the error and the retraining requirement and for ensuring that the training takes place.
11. Error correction training is not required for errors related to equipment failure, unless the failure is
related to the BAT’s failure to maintain EBT.
12. Error correction failure is also required if, in the event of equipment failure, the BAT does not try to
accomplish the test using another, alternative device, provided that the device is reasonably available.
13. Error correction training should focus on the mistake(s) made and must include three error-free mock
collections (at least two of which are related to the area in which the error was made.

14. Breath and blood specimens for legally defensible alcohol testing need to be collected under
circumstances which respect the dignity of the individual.
15. Suitable records must be made when the specimen is collected to prove that:
16. Breath alcohol test result can be traced back to the donor.
17. The blood specimen collected and the sample received by the blood alcohol testing laboratory is one
and the same.
18. This is the first link in the chain of custody process which, when reconstructed at a later date, can be
used to prove that the final result belongs to the specimen collected.
19. The following restrictions apply to collecting officers:
20. The immediate supervisor of an employee may not serve as the collector when that employee is
tested, unless there is no feasible alternative.
21. A co-worker who is in the same testing pool or who works with an employee on a daily basis may not
serve as a collector when that employee is tested, unless there is no feasible alternative.
22. An individual who has a personal relationship with the employee (e.g., spouse, ex-spouse, relative,
close personal friend) may not serve as the collector, unless there is no feasible alternative.
23. The collector should have identification with his/her name and his/her employer’s name, address, and
telephone number and be able to provide it upon request of the donor.
24. A breath alcohol test site requires setup to an extend that ensure the testing devices are fully
functional.
25. Each alcohol test should be conducted with reasonable visual and auditory privacy so that bystanders
cannot know or infer the results.
26. A breath alcohol technician (BAT) is authorised to perform both screening and confirmation test.
27. A screening test technician (SST) is authorised only to perform screening tests for alcohol.
28. When a donor arrives at the collection site, the collection officer will request that the donor presents
photographic identification (passport, national identity document, driver’s licence, etc).
29. If the donor does not have proper photographic identification, the collection officer will obtain a positive
identification of the donor by an authorised supervisor or manager within the parent organisation.
30. If the donor's identity cannot be established, the collection officer will not proceed with the collection
and notify an authority.
31. The collection officer will ask the licence holder to provide voluntary written informed consent before
the collection commences.
32. Only one donor is tested at a time.
33. The BAT explains the procedure and shows the donor the instructions on the back of the alcohol
testing form.
34. The BAT completes Step 1 of the ATF and asks the donor to complete Step 2.
35. If the donor refuses to sign Step 2 this is a refusal to test and the BAT documents the refusal to test on
the ATF, then notify the SACAA.
36. The alcohol test is initially performed with an ASD or EBT.
37. If the initial concentration is at or above 0.10 mg ethanol/1000 mL exhaled breath, the test is repeated
15-30 minutes later using an EBT.
38. During the 15-20-minute interval, the BAT tells the donor to not eat, drink or belch, and to wait nearby
within view of the BAT or another employer representative who will watch the donor to help ensure he
or she complies.
39. Prior to the confirmation test the BAT must ensure that an air blank reading zero is displayed,
demonstrating that no alcohol is present in the EBT.
40. The BAT should complete the confirmation test prior to collecting a urine specimen or conducting
other tasks in which the donor cannot remain under direct observation of the BAT.
41. If circumstances delay confirmatory testing beyond 30 minutes, the BAT still performs a confirmation
test and not another screening test and notes why the delay occurred.
42. The breath sample may be screened (preliminarily tested) for the presence of alcohol with an alcohol
screening device (ASD).
43. If the screen results are negative no further analysis is necessary.
44. If the screen/preliminary test resulted to be non-negative for the possible presence of alcohol above a
predefined cut-off level, a confirmation test to obtain the exact breath alcohol concentration must be
carried out utilizing an evidentiary breath testing device (EBT).
45. Oral fluid preliminary testing may also be performed for preliminary testing purposes:
47. The BAT shows the donor the result as displayed on the EBT and the EBT then prints the test result.
48. The BAT ensures that the results are affixed or directly printed on all three copies of the ATF,
preferably in the designated space on the front of the ATF.
49. Fixing of the result printout can take place by means of:
50. A label that is tamper evident;
51. Affixing the printout to the ATF with tamper evident tape;
52. The BAT signs and dates Step 3 of the ATF; and
53. Expressing the result on these copies as a number, rather than as positive or negative.
54. If the confirmation test is at or above 0.10 mg ethanol/1000 mL exhaled breath, the BAT must ask the
donor to sign Step 4 of the ATF.
55. If the donor refuses to sign Step 4, the BAT makes a note of the refusal on the ATF (but this is not a
refusal to test).
56. The BAT then immediately sends/faxes the ATF to the SACAA.
57. The donor may ask for a blood alcohol test that should be performed by a recognized confirmatory
analytical technique like HS-GC-FID.
58. If the result is at or above 0.10 mg ethanol/1000 mL exhaled breath, the BAT should instruct the donor
to remain at the testing site until the employer arranges transportation for the donor.
Analytical procedure:
1. An evidential breath test device (EBT) must be able to print the result on triple ply paper or on three
labels after an analysis.
2. EBT devices to be utilised should be listed in the National Road Traffic Act, 1996 (Act No. 93 of 1996).
3. The manufacturer of each ASD or EBT should have a quality assurance plan (QAP) that describes the
accuracy checks, 95% confidence intervals or tolerance ranges, maintenance requirements and
quality control procedures according to ISO 17025 guide.
4. Each EBT’s QAP should include external calibration checks for accuracy.
5. An accuracy check is performed with known alcohol standards in a liquid solution or compressed dry
gas.
6. These standards should originate from laboratories complying to ISO 17025 for calibration.
7. The EBT’s measured value when analysing the standards must be within the tolerance limits
designated by the manufacturers QAP, which is typically ± 0.005mg / 1000ml exhaled air. The site
should perform an accuracy check once a month and as soon as conveniently possible after every
positive test.
8. If the EBT fails a check, it should be taken out of service according to the manufacturer’s QAP.
9. Every result of 0.01mg/ 1000ml or above obtained on the EBT since the last valid check will be
declared invalid.
10. A logbook of calibration records needs to be kept with each device for a minimum of two years.

Table 5: Scheme of a breath alcohol analysis with integral scientific safeguard steps
.
Shy-Lung
The term “Shy-Lung” refers to a situation where the donor does not provide a sufficient amount of breath to
permit a valid breath test.
The donor must be given a minimum of two attempts to provide an adequate sample.
If the donor does not provide an adequate sample based on the EBT requirement, the BAT should:
Repeat the procedure if the BAT believes there is a strong likelihood of success with additional attempts.
Try to conduct the test in annual mode if the EBT has this capability.
Consider using an oral fluid device if the donor fails after two attempts, and the BAT is also a qualified STT.
Breath will still be required if confirmation testing is necessary.
Records the circumstances on the ATF and immediately informs the SACAA.
If the BAT believes the donor is purposefully not blowing adequately or forcefully into the breath testing device,
then the BAT notes in Step 3 “Refusal to Test”.
Alternatively, a blood alcohol test may be performed as confirmation, after an elevated screening result.
The donor shall be sent for a Shy-Lung assessment to be conducted by a Specialist Physician or experienced
MRO.
The evaluating physician will communicate his/her determination directly to the SACAA.
If the physician states that there was a valid medical condition for the insufficient amount of breath, the test is
deemed invalid.
If the physician identifies no valid medical reason, the donor is deemed to have refused testing.
6.15.5 Alcohol test errors

1. If a BAT or STT becomes aware of an event that will cause the test to be deemed invalid, he/she must
try to correct the problem promptly, if practicable.
2. This may require repeating the test, using a new ATF and, if needed, a new alcohol screening device
or different EBT.
3. Some errors cannot be corrected, and some errors are potentially correctable by amending the ATF.
4. If a valid test cannot be performed, the BAT or STT cancels the test and immediately informs the
SACAA.
5. If the error is a fatal flaw, the test must be deemed invalid and the SACAA must be informed within 48
hours of the cancellation.
6. An invalid test is neither positive nor negative and does not count toward any required random rate or
number of follow-up tests.
7. All results are to be communicated to the donor and to the SACAA.
8. The BAT should notify the SACAA within 48 hours of any test that had a fatal flaw.
9. If the alcohol testing result is confirmed to be at or above 0.1 mg/1000 mL:
10. The licence holder shall be removed from all duties.
11. The BAT should instruct the licence to remain at the testing site until transportation for the donor is
arranged.
6.15.6 Blood specimen collection
12. The collecting officer must be a medical/health professional registered at the Health Provisions
Council of South Africa (HPCSA), including a medical doctor, phlebotomist, nursing sister, etc.
13. The collector should have identification with his/her name and his/her employer’s name, address and
telephone number and be able to provide it upon request of the donor.
14. The following restrictions apply to collecting officers:
15. The immediate supervisor of an employee may not serve as the collector when that employee is
tested, unless there is no feasible alternative.
16. A co-worker who is in the same testing pool or who works with an employee on a daily basis may not
serve as a collector when that employee is tested, unless there is no feasible alternative.
17. An individual who has a personal relationship with the employee (e.g. spouse, ex-spouse, relative,
close personal friend) may not serve as the collector, unless there is no feasible alternative.
18. The collection site must have the following:
19. All necessary personnel, supplies, equipment, facilities, and supervision to provide for specimen
collection, security and temporary storage.
20. A blood specimen collection site must provide for donor privacy while the blood is drawn.
21. A suitable clean clinically sterile surface for the collector to use as a work area must be available.
22. A bed for the donor to lie down.
23. For the collection of blood specimens for alcohol analysis:
24. Blood is collected from the cubital veins of the forearm.
25. Needles should be clean and dry and not contaminated in any manner, including water (as per
standard clinical practice).
26. The disinfectant used to clean the arm should not contain ethanol, isopropanol, or other volatile
compounds.
27. Sodium fluoride (1%) is effective as preservative.
28. Alcohol testing should be performed in whole blood.
29. Potassium oxalate or EDTA will suffice as an anticoagulant.
30. After properly labelling the two (2) tubes with all the required information, the specimen, a laboratory
request form, and a chain-of-custody form should be sealed in an appropriate container.
31. The samples must be stored in a fridge as soon as possible (2-4ºC) until collection by the courier.
32. The collector must maintain line-of-sight custody or provide for the secure temporary storage of
specimens from the time the specimen is collected until it is sealed in a shipping container prior to
transfer to an express carrier or courier for shipment to a laboratory.
33. Suitable records must be made when the specimen is collected to prove that:

34. The blood specimen collected and the sample received by the blood alcohol testing laboratory is one
and the same.
35. This is the first link in the chain of custody process which, when reconstructed at a later date, can be
used to prove that the final result belongs to the specimen collected.
36. The original copy accompanies the sample to the confirmatory laboratory and all persons involved in
the transport and receiving of the sample should record their name and signature on the chain-of-
custody form.
37. One of three carbon copies of the chain-of-custody forms should be handed to each of the following:
38. The licence holder;
39. The medical review officer (MRO); and
40. The collection officer.
41. Requirements for dispatch of collected blood specimens:
42. The specimens and accompanying documents should be sent to the laboratory as soon as possible.
43. On receipt by the laboratory, specimens should be stored in a fridge by the laboratory and after
analysis kept in a frozen or refrigerated state
44. Collection officers will arrange to dispatch the collected specimens to the drug-testing laboratory.
45. The specimens will be placed in containers designed to minimise the possibility of damage during
shipment.
46. Transfer of the specimens to the courier from the collector, and in turn from the courier to the
laboratory, should be documented on the chain of custody.
47. Laboratory analysis of a blood specimen:
49. Preliminary blood alcohol testing may be performed by immuno-assay and enzymatic assays.
50. If the screen/preliminary tests are non-negative, a confirmation test to obtain the exact alcohol
concentration must be carried out on another portion of the same blood sample.
51. A screening/preliminary test is not required if the client prefers the blood sample to be subjected to the
confirmatory analytical procedure directly.
52. The confirmatory test should not involve a repetition of the same analytical technology as was
employed for the preliminary testing, but has to be performed by an internationally recognised
confirmatory technique (typically head-space gas chromatography with flame ionisation detection, HS-
GC-FID).
53. Positive results are only reported after laboratory confirmation and may require further interpretation.
NOTE: It is of prime importance to note that immune-assay and enzymatic assays are not regarded as
confirmatory techniques for ethanol in blood but rather as preliminary testing techniques.
54. Requirements for blood alcohol test results higher than 0.02 g ethanol/100 mL:
55. If a laboratory performs the analysis (e.g. blood testing), the result may be reported to the MRO or
directly to the SACAA if the test results is higher than 0.02 g ethanol/100 mL blood.
56. If the MRO receives the result, he/she relays it to the SACAA without interpretation.
57. Challenges to results by the licence holder for re-testing must be made within 72 hours of reporting
results to the MRO or the SACAA.
58. The stored sample (Sample B) should be released for analysis to a drug-testing laboratory able to
demonstrate that they can accurately determine the concentration of a drug or metabolite at 50% of
the confirmation cut-off concentration employed.
59. The release must be supported by a chain of custody and requires authorisation from the customer
and the donor.
60. Suitable records must be made during the analytical process to prove that the sample received by the
laboratory and the sample, about which the final report is written, are one and the same.
61. All blood samples which prove positive above the cut-off concentration of 0.02 g/100mL and all
records of the analytical process must be kept as follows:
62. One year – Records of alcohol tests with a concentration of less than the company cut-off
concentration and cancelled alcohol tests.
63. Two years – Documentation of the inspection, maintenance, and calibration of EBT’s.
64. Five years – Alcohol test results for both blood and breath at or above the SACAA cut-off, and
documentation of refusals and follow-up alcohol tests.
65. If the customer requires an independent toxicological review, the laboratory must make available, if
requested, the analytical data upon which it based its final report.
66. Long-term frozen storage of samples will be at 0°C-4°C or below.
67. The laboratory will retain all samples confirmed positive in properly secured long-term cold storage for
a minimum of three months.
68. Within this three-month period the SACAA or licence holder may request the laboratory to retain the
sample for an additional period of time.
69. If no such request is received, the laboratory may discard the sample after the end of three months,
except that the laboratory shall be required to maintain any samples known to be under legal
challenge for a further agreed period.
Class VI Medical Standards-Protocols -Cabin Crew and Recreational Pilots

4.1.18 Class IV medical certificates
Psychiatric
1) Any of the following conditions that are of a severity which renders the applicant incapable of safely
exercising the privileges of the licence, or makes it likely that within two years of the assessment the applicant
will be unable to safely exercise the privileges of the licence, will be disqualifying unless acceptable and
effective treatment has controlled any additional risk of functional disorder or sudden or subtle incapacitation:
a) a psychotic disorder, unless the psychosis was of toxic origin and there has been complete recovery;
b) alcohol or other psychoactive substance abuse or dependence;
c) character or behaviour disorder, severe enough to have resulted in an overt act;
d) any other psychiatric disorder;
e) an organic mental disorder;
f) a mental or behavioural disorder due to use of psychoactive substance; this includes dependence
g) schizophrenia or schizotypal or delusional disorder;
h) a mood (affective) disorder;
i) a neurotic, stress related or somatoform disorder;
j) a behavioural syndrome associated with physiological disturbance or physical factors;
k) a disorder of adult personality or behaviour, particularly if manifested by repeated overt acts;
l) mental retardation;
m) a disorder of psychological development;
n) a behavioural or emotional disorder with onset in childhood or adolescence, or
o) a mental disorder not otherwise specified.
An applicant who has a history of psychoactive substance abuse or dependence may apply for an
1. exemption to the designated body or institution if the following circumstances exist –
2. The applicant has been under medical treatment for psychoactive substance abuse and the medical
practitioner concerned, approved by the designated body or institution, certifies that the applicant is
free from the effects of psychoactive substance abuse;

3. the applicant provides the name of a sponsor who is prepared to certify that the applicant no longer
takes a psychoactive substance in any form. Such a sponsor must be a person acceptable to the
designated body or institution for this purpose;
4. the applicant signs an undertaking not to take any psychoactive substance while holding a valid
licence.
5. Any of the following conditions that are of a severity which renders the applicant incapable of
safely exercising the privileges of the licence, or makes it likely that within two years of the
assessment the applicant will be unable to safely exercise the privileges of the licence, will be
disqualifying unless acceptable and effective treatment has controlled any additional risk of
functional disorder or sudden or subtle incapacitation:
6. A psychotic disorder, unless the psychosis was of toxic origin and there has been complete recovery;
7. Alcohol or other psychoactive substance abuse or dependence;
8. Character or behaviour disorder, severe enough to have resulted in an overt act;
9. Any other psychiatric disorder.
Neurological
Any disease, injury or abnormality of the nervous system, the effects of which, according to medical
conclusion, are likely to interfere with the safe exercise of the privileges of the licence or cause sudden or
subtle incapacitation, will be disqualifying unless acceptable and effective treatment has controlled any
additional risk of functional disorder or sudden or subtle incapacitation. In particular, the following are not
acceptable:
1. Epilepsy;
2. Any seizure disorder;
3. Any disturbance of consciousness without satisfactory medical explanation of the cause;
4. Migraine; and
5. Incapacitating headaches.
Musculoskeletal
Any active disease of the bones, joints, muscles, or tendons, or any significant functional limitation from
any previous congenital or acquired disease or injury will be disqualifying unless acceptable and effective
treatment has controlled any additional risk of functional disorder or sudden or subtle incapacitation.

Functional abnormalities affecting the bones, joints, muscles, or tendons, compatible with the safe exercise of
the privileges of the licence, may be assessed as fit.
An appropriate demonstration of ability via a practical test may be required.
Gastrointestinal
Any disease or abnormality, or result of disease or surgical operation, affecting the digestive tract and its
attachments, including the biliary system and hernial orifices, of a severity likely to cause obstruction,
significant functional disorder or infection, or sudden or subtle incapacitation, will be disqualifying unless
acceptable and effective treatment has controlled any additional risk of functional disorder or sudden or subtle
incapacitation. An applicant who has undergone a major surgical operation on the biliary passages or the
digestive tract or its adnexa with a total or partial excision or a diversion of any of the organs should be
assessed as medically unfit until such time as the medical assessor, having access to the details of the
operation concerned, considers that the effects of the operation are not likely to cause incapacitation in flight.
The relevant protocol is contained in Schedule 5.
Respiratory
Any disease or abnormality, or result of disease or surgical operation, affecting the lungs, mediastinum, pleura,
chest wall or respiratory passages of a severity likely to cause infection, functional disorder or sudden or subtle
incapacitation at altitude, will be disqualifying unless acceptable and effective treatment has controlled any
additional risk of functional disorder or sudden or subtle incapacitation.
Cardiovascular
Any disease or abnormality, or result of disease or surgical operation, which affects the heart or circulatory
system and is of a severity likely to cause functional disorder or sudden or subtle incapacitation. Evidence of
myocardial infarction, or significant hypertension, will be disqualifying unless acceptable and effective
treatment has controlled any additional risk of functional disorder or sudden or subtle incapacitation. Disorders
of cardiac rhythm requiring a pacemaker will be disqualifying unless acceptable and effective treatment has
controlled any additional risk of functional disorder or sudden or subtle incapacitation. Applicants with an
abnormal cardiac rhythm shall be assessed as unfit unless the cardiac arrhythmia has been investigated and
evaluated in accordance with the best medical practice and is assessed as not likely to interfere with the safe
exercise of the privileges of the applicants’ license or ratings.

Applicants with evidence strongly suggestive of coronary artery disease, including the presence of excessive
cardiovascular risk factors, will be assessed as unfit unless adequate myocardial perfusion can be
demonstrated and reversible risk factors controlled.
Metabolic, nutritional and endocrine

Any metabolic, nutritional or endocrine disorders likely to interfere with the safe exercise of the privileges of the
licence, or to cause sudden or subtle incapacitation, will be disqualifying unless acceptable and effective
treatment has controlled any additional risk of functional disorder or sudden or subtle incapacitation.
Any applicant with a diagnosis of metabolic, nutritional or endocrine disorder will generally be assessed as
unfit but may be considered for special certification by the SACAA Aeromedical Committee.
Haematologic and immunologic

Any active disease of the lymphatic system or of the blood will be disqualifying unless acceptable and effective
treatment has controlled any additional risk of functional disorder or sudden or subtle incapacitation. Those
with chronic diseases of these systems in a state of remission may be assessed as fit, provided
appropriate specialist reports permit medical conclusion that the condition is not likely to affect the safe
exercise of the privileges of the licence. Applicants with any infectious diseases, the effects of which are likely
to impede the safe exercise of the privileges of the licence or cause sudden or subtle incapacitation, must be
assessed as unfit until such time as effective and acceptable treatment has removed such effects.
Applicants with sickle-cell trait or other haemoglobinopathic traits are usually compatible with flying provided
they submit a favourable Haematologist report and their condition is unlikely to cause sudden or subtle
incapacitation. Splenic infarctions have repeatedly been reported occurring due to sickling of red blood cells.
Sickle-cell disease, which includes sickle-cell anemia (SS), sickle-cell haemoglobin C disease (SC), sickle-cell
thalassemia (STh), sickle-cell haemoglobin D disease (SD) and other pathological genotypes involving
haemoglobin S with other genetic variants, is disqualifying for flying. A clear distinction must be made between
sickle-cell disease (SS, SC, SD and STh) and sickle-cell trait (AS). The diagnosis of sickle-cell trait should be
based on the following findings (including results from sickling tests): the patient should not be anaemic, and
should have normal red cell morphology, normal levels of haemoglobin F, and a haemoglobin electrophoretic
pattern of haemoglobins A and S in which A predominates for example the concentration of Hb S is less than
45% of total haemoglobin.

The relevant protocols are contained in Schedules 15, 16, 17 and 18.
Genitourinary
Any active disease or abnormality, or result of disease or surgical operation, affecting the kidneys, urine,
urinary tract, menstrual function or genital organs, to a degree likely to impede the safe exercise of the
privileges of the licence, or cause sudden or subtle incapacitation such that the applicant will be unable to
safely exercise the privileges of the licence will be disqualifying unless acceptable and effective
treatment has controlled any additional risk of functional disorder or sudden or subtle incapacitation. Urine
examination shall form part of the medical examination and abnormalities shall be adequately investigated.
Ophthalmology
All cases should be referred to the SACAA Aeromedical Committee for consideration. Refer to the relevant
protocols.

An applicant shall have no established medical history or clinical diagnosis of –
5.1.1 Psychiatric
Any of the following conditions that are of severity which render an applicant incapable of safely exercising the
privileges of the licence or makes it likely that within two years of the assessment an applicant shall be unable
to safely exercise the privileges of the licence, shall be disqualifying unless acceptable and effective treatment
has controlled any additional risk of functional disorder or sudden or subtle incapacitation.
I. a psychotic disorder, unless the psychosis was of toxic origin and there has been complete recovery;
II. alcohol or other psychoactive substance abuse or dependence;
III. character or behaviour disorder, severe enough to have resulted in an overt act;
IV. any other psychiatric disorder;
V. an organic mental disorder;
VI. a mental or behavioural disorder due to use of psychoactive substance; this includes dependence
VII. schizophrenia or schizotypal or delusional disorder;
VIII. a mood (affective) disorder;
IX. a neurotic, stress related or somatoform disorder;
X. a behavioural syndrome associated with physiological disturbance or physical factors;
XI. a disorder of adult personality or behaviour, particularly if manifested by repeated overt acts;
XII. mental retardation;
XIII. a disorder of psychological development;
XIV. a behavioural or emotional disorder with onset in childhood or adolescence; or
XV. a mental disorder not otherwise specified.
Brief Psychotic Disorder

1) An applicant who is presented with psychotic symptoms shall be declared medically unfit while the
underlying causes are being identified. An applicant with a brief psychotic disorder shall be assessed on
case-by-case basis.
An applicant who applied for medical recertification shall submit a comprehensive psychiatric report detailing
the following –
I. the presence and severity of symptoms;
II. the duration shall be less than one month;
III. full return to the premorbid level of functioning; and
IV. the use of any medication.
V. Adjustment Disorder
VI. An applicant with adjustment disorder shall be assessed on a case by case basis.
VII. An applicant shall be deemed temporarily medically unfit while suffering from symptoms.
VIII. Applicant is required to submit a comprehensive psychiatrist’s report detailing the following –
IX. the applicant is currently asymptomatic; and
X. the applicant is not on any medication that is not compatible with flying.
Personality Disorders
An applicant with a confirmed diagnosis of personality disorder shall be considered medically unfit.
Attention deficit hyperactivity disorder.
An applicant with attention deficit hyperactivity disorder may be considered medically fit, if the applicant
submits the following –

a favourable comprehensive psychiatric report detailing the signs, symptoms and diagnosis of the applicant;
and a favourable comprehensive clinical psychologist assessment.
2)An applicant showing evidence of persisting deficiencies in cognitive ability or behavioural aberrancy
shall be declared medically unfit.
3) An applicant shall be required to be on medication for a minimum of one month off therapy and clinically
stable.
(4) An applicant who continually use amphetamine medication shall be declared medically unfit.
Substance Abuse or Substance Dependence

1)An applicant who has a history of psychoactive substance abuse may be declared medically fit if –
I. an applicant has been under medical treatment for psychoactive substance abuse and the
DAME or a medical practitioner concerned certifies that the applicant is free from the effects
of psychoactive substance abuse;
II. an applicant provides the name of a sponsor who is prepared to certify that the applicant no
longer takes a psychoactive substance in any form and such a sponsor shall be a person
acceptable to the Medical Assessor for this purpose; and
III. an applicant declares under oath not to take any psychoactive substance while holding a
licence.
2)An applicant with a history of alcohol dependency may be assessed as fit provided that he or she
meets the following requirements –
I. applicant abstained from alcohol for at least 6 months;
II. applicant submit blood parameters (MCV- Mean Corpuscular Volume, GGT- Gamma Glutamyl
Transpeptidase and CDT- Carbohydrate deficient Transferrin) normalised;
III. applicants submit normal urine drug screening samples; and
IV. applicant submit a report detailing successful completion of an in-patient rehabilitation.
V. The requirements prescribed in subsection (2) are applicable to an applicant who is presenting with
the first episode of alcohol dependency.
VI. An applicant who presents two episodes of alcohol dependency shall be required to meet the
requirements prescribed in subsection (2) and comply with the following –
VII. applicant shall be subjected to random drug testing for a 2 years period; and
VIII. applicant who relapse after the second episode shall be declared medically unfit.

IX. Applicant presenting with a second episode shall be restricted to operating without carrying
passengers or operating in multi crew environment for a minimum period of 6 months.
(6)The restriction referred in subsection (4) may be lifted after two years of proven sobriety.
I. Alcohol related seizure
II. Applicant presenting with an alcohol-related seizure shall be assessed as medically unfit for a
minimum period of two (2) years, and until such time that freedom from substance use has been
established and can be demonstrated.
An applicant may be considered after two (2) years and shall be restricted to the following operations
restrictions –
I. may not carry passengers; and
II. shall operate in a multi-crew environment.
An applicant shall be required to submit the following favourable reports:

I. a report stating proven attendance of a rehabilitation programme and quarterly after-care reports;
II. a comprehensive clinical psychologist report;
III. a comprehensive neurologist’s report;
IV. an EEG report with provocation; and
V. a CT scan or MRI report.
VI. An applicant shall be subjected to random alcohol testing.
The limitations prescribed in subsection (3) may be lifted in 5 years after the seizure, provided sobriety is
proven and an applicant has been free from seizures.
I. Anxiety Disorders
II. Generalised Anxiety Disorder
III. Applicant with generalised anxiety disorders shall be assessed on a case-by-case basis by the
Medical Assessor.
IV. Applicant shall be required to submit a comprehensive psychiatrist report containing the following
information –
V. diagnosis and prognosis;
VI. presence and severity of symptoms;
VII. medication and side effects is any experienced; and

VIII. applicant shall be required to be asymptomatic without medication for a minimum of 6 months.
IX. Post-traumatic Stress Disorder.
Applicant with post-traumatic stress disorder shall be assessed on a case-by-case basis by the Medical
Assessor.
Applicant shall be required to submit a comprehensive psychiatrist report containing the following information –
I. diagnosis and prognosis;
II. presence and severity of symptoms;
III. applicant shall be symptom free; and
IV. medication used and side effects if any.
C. Mild to Moderate Anxiety

Applicant with a history of mild to moderate anxiety may be assessed as medically fit if he or she meet the
following criteria –
I. if the psychiatrist’s and the psychologist’s reports are favourable;
II. is well and stable for a minimum of period one month; and
III. the medication used is acceptable for flight duties.
Mild to Moderate Depression
1. Applicant with a history of mild to moderate depression shall comply with the Mood Disorder Protocol
prescribed in the SA-CATS-MR Schedule 30:
2. Hypomania and bipolar mood disorder II
3. Applicant presented with a diagnosis of hypomania and bipolar mood disorder II shall be declared
medically unfit for period of 3 years.
4. Applicant may be considered after three years if a psychiatrist report indicates that the applicant has
been well and stable for a period of 3 years.
5. If the psychiatrist’s report states that the applicant has experienced a full level of functional recovery
with insight into the illness and fully adheres to the agreed treatment plan.
6. If a Clinical Psychologist report finds no alertness, concentration and motor performance deficits.
7. An applicant use medication that is compatible with flight duties.
Requirements for renewal of the medical certificates are as follows –

an applicant shall be required to submit a 6-monthly Psychiatric and Psychological report, with a YMRA
(Young mania rating scale); and an applicant shall be required to submit a 6-monthly biochemical profile
including drug levels.
Bipolar Mood Disorder Type 1

Applicant with a confirmed diagnosis of Mania with or without major depression shall be declared medically
unfit.
Bipolar mood disorder type 2

(1) Applicant with a confirmed diagnosis of Hypomania with Major Depression shall be declared medically
unfit
1. Para-Suicide
2. Applicant presenting with a diagnosis of para-suicide shall be referred to the Medical Assessor for
consideration.
3. Applicant shall be required to submit a comprehensive Psychiatrist report indicating the following:
4. multi-axis diagnosis; and presence or absence of substance and alcohol dependent/abuse
Organic Mental Disorders

Applicant presented with a diagnosis of organic mental disorders shall be declared temporary medically unfit
and referred to the Medical Assessor for consideration.
Applicant shall be required to submit a comprehensive Psychiatrist report indicating the following –
I. the underlying cause;
II. the diagnosis and prognosis;
III. the presence and severity of symptoms;
IV. stipulate whether the underlying cause has been identified and remedied; and
V. indicate whether the client has reached full recovery to baseline acceptable level of functioning.
Delirium
Applicant presenting with a diagnosis of Delirium shall be declared temporary medically unfit and referred to
the Medical Assessor for consideration on a case-by-case basis.

I. the underlying cause;
II. the diagnosis and prognosis;
III. stipulate whether the underlying cause identified and remedied;
IV. the presence and severity of symptoms;
V. full recovery from the delirious state; and
VI. examination done to confirm the underlying cause and a prognosis or likelihood of recurrence.
Dementia
Applicant with a confirmed diagnosis of dementia shall be declared medically unfit. However; in the small
number of cases where the cause of dementia is known and the condition has been resolved, the applicant
may be considered for recertification.
I. the presence and severity of symptoms;
II. full recovery from the delirious state;
III. examinations done to confirm the underlying cause and a prognosis likelihood of recurrence; and
IV. stipulate whether the underlying cause has been identified and remedied.
Schizophrenia
Applicant presenting with a diagnosis of schizophrenia shall be declared medically unfit.
Delusional Disorder
Applicant presenting with a diagnosis of delusional disorder shall be declared medically unfit
Neurology system
An applicant shall have no established medical history or clinical diagnosis of any disease, injury or
abnormality of the nervous system that –
is of a severity that renders the applicant incapable of safely exercising the privileges of the licence; or makes
it likely that within the specified period of time of the assessment an applicant is unable to safely exercise the
privileges of the licence; or if an acceptable and effective treatment has any additional risk of functional
disorder or sudden or subtle incapacitation.
Malignant Brain Tumours

Applicant presenting with a diagnosis of malignant brain tumours shall be declared medically unfit.
Hereditary, degenerative and demyelinating disorders. Applicant presenting with a diagnosis of hereditary,
degenerative and demyelinating disorders shall be declared temporary medically unfit and be referred to the
Medical Assessor for consideration on a case-by-case basis.
Applicant presenting with progressive or disabling shall be declared medically unfit.
Applicant considered shall be required to submit the following comprehensive report –

I. a neurological report;
II. a neuro-ophthalmological report;
III. an MRI of the brain and the spinal cord; and
IV. a clinical psychologist report.
Primary and Central Hypersomnia

Applicant presenting with a diagnosis of primary and central hypersomnia shall be declared temporary
medically unfit and be referred to the Medical Assessor for consideration.
An applicant to considered medically fit shall be required to submit the following –

I. a comprehensive neurological report; and
II. a Polysomnogram from an HPCSA accredited practitioner.
Epilepsy
Applicant may be declared medically fit if he or she has been free from epileptic attacks for at least 10 years
without anticonvulsant medication during that time.
Specific self-limited conditions such a Benign Rolandic Seizure with centro-temporal spikes shall allow medical
certification after 5 years.

Epilepsy for Cabin Crew

A cabin crew member who is diagnosed with epilepsy is medically unfit to fly. Cabin crew member may be
considered for recertification by the Medical Assessor after a year period has lapsed following initiation of
medication.
On application for recertification an applicant shall be required to submit the following reports which are not
older than 3 months –
I. a Neurologist report stating that he or she is adequately functional on acceptable medication without
significant side effects;
II. a Brain CT scan film/MRI scan; and
III. a 16 Lead EEG.
If an applicant suffers a seizure while on medication, he or she is deemed to be medically unfit to fly and shall
submit the reports referred to in subsection (3). If there is a change in medication, an applicant shall be
grounded for 6 months and shall be required to provide a Neurologist report stating that an applicant is stable
on the new medication.
Restrictions on Medical Certificate

A cabin crew member with epilepsy is restricted to operate under the following conditions –
I. short haul flights which are not more than 3 hours; and
II. operate under supervision or in pairs.
Single Seizure
An applicant presented with a diagnosis of single seizure shall be declared temporary medically unfit and
referred to the Medical Assessor for consideration.
An applicant shall be deemed medically fit pending a favourable neurological report that stipulates that –
applicant has had no further episodes of a seizure for the past four years preceding the application; and
clinical examination and supporting medical reports quantify the risk of seizure to be at 2% per annum.
Solitary loss of consciousness or loss or altered awareness likely to be cardiovascular in origin

Applicant presenting with a diagnosis of solitary loss of consciousness or loss or altered awareness likely to be
cardiovascular in origin shall declared medically unfit for period of one year;
Applicant may be deemed temporarily medically unfit for a minimum of three months if the underlying cause is
identified and treated.
Applicant to be considered medically fit shall be required to submit the following comprehensive reports for
consideration –
I. a Cardiologist’s report;
II. an Echocardiography;
III. a resting and exercise ECG; and
IV. a Tilt-table test.
Cardiovascular System
The applicant shall have no current cardiovascular conditions likely to interfere with the safe operation of an
aircraft.
The resting ECG shall form part of the examination –
I. at the initial examination;
II. after the applicant has attained the age of 40 years;
III. after the applicant has attained the age of 50 years;
IV. after the attainment 50 years, the applicant shall submit four yearly; and
V. when clinically indicated.
Blood Pressure
Applicant presented with a blood pressure at examination consistently exceeds 160 mmHg systolic and/or 95
mmHg diastolic, with or without treatment shall be declared medically unfit.
I. The initiation of medication to control blood pressure requires a period of at least two weeks’
temporary medical suspension of the medical certificate to establish control and the absence of side
effects.
II. Applicant presented with hypertension shall be assessed for potential risk factors.
III. Applicant with symptomatic hypotension shall be declared as medically unfit.

Applicant shall be required to use a medication which is compatible with flying and shall be required to submit
the following reports –
I. a comprehensive report from the treating Doctor or DAME; and
II. applicant required to submit the following blood tests;
III. U&E and Creatinine Fasting glucose;
IV. Random Lipogram; and
V. resting and stress ECG.
Coronary Artery Diseases

Acute Myocardial Infarctions
Applicant shall not have a confirmed diagnosis of an Acute Myocardial Infarctions within the preceding 6
weeks.
Applicant who have had a satisfactory cardiological evaluation, including an exercise or equivalent test that is
negative for ischemia, may be declared as medically fit pending submission of the following favourable reports-
I. a resting and maximal stress ECG;
II. a 24-Hour Holter ECG;
III. an Angiogram (initial);
IV. an Echocardiogram;
V. a Stress MRI/MIBI Scan or Coronary CT Scan; and
VI. bloods (FBC, U&E, Lipogram, Fasting Glucose).
Coronary Artery Bypass Graft

An applicant shall not be assessed if he or she has undergone coronary artery bypass graft within the
preceding 3 months.
Applicant who had a satisfactory cardiological evaluation, including an exercise or equivalent test that is
negative for ischemia may be assessed as medically fit pending submission of the following favourable
reports-
III. an Angiogram (initial);
V. a stress MRI/MIBI Scan or Coronary CT Scan; and
VI. bloods (FBC, U&E, Lipogram, Fasting Glucose).

VII. Elective Angioplasty
Applicant shall not be considered for medical certification if he or she have had an elective Angioplasty within
the preceding 6 weeks.
Applicant with a satisfactory cardiological evaluation, including an exercise or equivalent test that is negative
for ischemia, may be declared medically fit pending submission of the following favourable reports –
III. an Angiogram;
V. a Stress MRI/MIBI Scan or Coronary CT scan; and
VI. loods (FBC, U&E, Lipogram, Fasting Glucose).
Angina
Applicant who has been free from angina for 6 weeks with or without treatment and who had a satisfactory
cardiological evaluation, including an exercise or equivalent test that is negative for ischemia, may be declared
medically fit. The tests shall be determined by treating specialist and the Medical Assessor.
Rhythm and Conduction Disturbances

Applicant with a significant disturbance of cardiac rhythm shall be declared medically unfit unless the rhythm
disturbance is assessed by a Physician or Cardiologist and is not likely to interfere with the safe exercise of the
privilege of the licence the applicant is applying for.
Applicant shall be required to submit the following reports:

I. an exercise ECG;
II. a 24-Hour Holter ECG; and
III. an Echocardiogram.

Rate and Rhythm Disturbances

Applicant presented with the diagnosis above may be considered medically fit only if the arrhythmia has been
controlled for 3 months and the LV ejection fraction is >40%.
Pacemaker Implant
Applicant who has undergone a pacemaker implant may be considered medically fit 3 months following the
pacemaker implantation. Applicant shall be required to submit a satisfactory cardiologist including pacemaker
interrogation report.Applicant to be referred to the Medical Assessor for consideration.
Successful Catheter Ablation

Applicant who has undergone a Catheter Ablation may be considered medically fit 3 months following the
ablation pending a favourable cardiologist report.
Left Bundle Branch Block

Applicant with a Left Bundle Branch Block may be considered medically fit following submission of a
satisfactory Cardiologist evaluation, which shall include an exercise or equivalent test. The tests shall be
determined by treating specialist and a Medical Assessor on a case-by-case basis. Applicant who do not meet
the exercise test requirement may be declared medically fit with the OPL limitation to operate only without
passenger or in a multi crew environment.
Pre-Excitation
Applicant may be considered medically fit subject to a satisfactory cardiological evaluation, unless if the Pre-
excitation associated with an arrhythmia.
Applicant with any of the following conditions shall be assessed as medically unfit or have his or her privileges
limited to operations without carrying passengers or operating in a multi crew environment –
I. a left ventricular ejection fraction known to be less than 40%;
II. applicant Blood Pressure (with or without treatment) at examination consistently exceeding 160 mmHg
systolic and/or 95 mmHg diastolic;
III. an unsatisfactory exercise test;
IV. an aortic aneurysm in the range of 5,5 cm to 6,5 cm';
V. pre-excitation associated with a significant arrhythmia;
VI. aneurysms greater than 6,5 cm; and

VII. symptomatic Hypertrophic Cardiomyopathy.
Respiratory System (Check the other requirements)
Chest radiography requirements

Chest Radiography, anterior, posterior and lateral view, shall form part of the respiratory system assessment
for the initial issue of a Class 4 medical certificate. Periodic chest radiography is usually not necessary, but
may be a necessity in situations where asymptomatic pulmonary disease can be expected.A licence holder
who has a clinical indication for chest radiography may be required to undergo chest radiography at more
frequent intervals.
Flow-Volume Lung Function

Flow-volume lung function testing shall form part of the respiratory assessment for the initial issue of a Class 4
medical certificate under the age of 40 years. The flow-volume lung function testing shall be done again at the
first medical examination after the age 40, and again at the first medical examination after the age of 50. For
an applicant who is an active smoker, the requirement for flow-volume lung function testing shall be not less
than every 24 months (biannually) for licence holders under the age of 40 and not more than every 12 months
(annually) after the age of 40. A licence holder who has a clinical indication for lung function testing may be
required to submit a lung function tests at more frequent intervals.
Class IV medical certificates

Chest radiography, anterior-posterior, and lateral views, must form part of the respiratory system assessment
for the initial issue of a Class 4 medical certificate. Periodic chest radiography is usually not necessary but may
be a necessity in situations where asymptomatic pulmonary disease can be expected. It is, however,
understood that a degree of interpretation and flexibility must always be exercised at the discretion of the
medical examiner and the medical assessor, taking into consideration not only medical but also operational
and environmental factors of relevance for the overall aviation medical fitness of an applicant.
All licence holders who have a clinical indication for chest radiography may be required to submit chest
radiography at more frequent intervals. Licence holders may be referred to the relevant protocols.

Asthma
1)An applicant with a history of pre-existent asthma may be declared medically fit if he or she complies with
the following –
I. submit a Lung Function Test which demonstrates FEV1 / FVC Ratio >= 70% of predicted value;
II. applicant does not present with bronchospasm on clinical examination or associated with mild
respiratory infection;
III. applicant has not in the 3 months preceding the examination required treatment with an oral
corticosteroid or a short acting beta-2-agonist;
IV. applicant has not visited an emergency room or healthcare centre for symptoms of asthma in the
preceding 3 months;
V. treatment is limited to medication compatible with flight safety; and
VI. the applicant has submitted a favourable DAME or Specialist Physician report.
An applicant may be declared temporarily medically unfit in the following cases –

I. the FEV1 / FVC Ratio <=70% of predicted value, and there is a determined cause;
II. the applicant currently has lung infection;
III. applicant presenting with acute bronchospasm shall be declared temporarily medically unfit until
appropriate management is instituted and, on review, licence holder demonstrates acceptable lung
function test (FEV1 / FVC ratio >= 70% of predicted value) and absence of bronchospasm (wheezing)
on clinical examination;
IV. this means reversibility on a pre and post lung function test shall be less than 12% and/or 200ml;
V. any form of asthma attack requiring emergency room treatment in the past 2 years, shall be declared
temporarily unfit pending pulmonologist’s report; and
VI. use of short-acting beta-2-bronchodilators, subject to pulmonologist’s report.
Exercise-Induced Asthma
Applicant presenting with a diagnosis of exercise-Induced Asthma shall be declared temporary medically unfit
until appropriate management is instituted. Applicant shall be required to submit a provocation test such as a
Stress Lung Function Test, and he or she shall be required to demonstrates acceptable lung function test
(FEV1/ FVC ratio >= 70%) and there is absence of bronchospasm (wheezing) on clinical examination.
Applicant to provide a Pulmonologist /Physicians report.
Chronic Obstructive Airway Disease

Applicant with COAD is assessed according to the minimum lung function standards.
Applicant presented with irreversible airways obstruction outside the minimum standard shall be referred to a
pulmonologist for assessment of –
I. vital capacity reduction;
II. increased residual volume;
III. presence of bullae;
IV. diffusion capacity;
V. oxygen saturation and carbon dioxide retention.
Applicant shall be required to submit a CXRs Biennially or as frequent as stated in the pulmonologist’s report if
the applicant continues smoking. Applicant presenting with acute symptoms or requiring continuous
medication to relieve symptoms shall be deemed medically unfit. Applicant declared medically unfit may apply
to the Medical Assessor for a special waiver.
Applicant with inter-current infections shall be deemed temporarily medically unfit until the appropriate
treatment is instituted. Applicant presenting with mild disease may be declared medically fit if –
I. the lung impairment is mild;
II. the applicant is asymptomatic;
III. the applicant does not require treatment; and
IV. the Chest- X-ray has no evidence of bullae.
V. Pulmonary Tuberculosis
An initial applicant with active tuberculosis or undergoing treatment shall be declared as temporarily medically
unfit for a minimum period of 3 months from the date of confirmation of disease and initiation of treatment.
The applicant may be declared medically fit following completion of treatment and if the following reports are
favourable –
I. a lung function tests is normal;
II. the chest radiograph shows no significant lung damage;
III. a recognised course of medication has been completed; and
IV. a favourable physician report;
V. the applicant does not have open cavitatory TB and the sputum is negative for TB;
VI. the applicant is on appropriate medication and demonstrates no drug resistance;
VII. the medication provokes no undesirable side effects that may impair flight safety;
VIII. the pulmonologist’s report is favourable; and
IX. the underlying medical conditions are evaluated and appropriately managed.
Applicant with recurrent or re-activation tuberculosis, post TB bronchiectasis with recurrent chest infections or
large cavities and MDR and XDR TB shall be declared medically unfit pending a pulmonologist’s report.
Special waiver may be granted on a case-to-case basis by the Medical Assessor.
For recertification of an applicant, a pulmonologist’s report shall be required.
Pulmonary Sarcoidosis
Applicant with a diagnosis of active Sarcoidosis symptomatology shall be declared as medically unfit. Applicant
with a history of multisystem Sarcoidosis shall be declared as medically unfit.
Applicant with a history of Sarcoidosis confined to hilar lymphadenopathy may be declared as medically fit
provided that –
I. a full clinical evaluation is normal; tests shall include a chest x-ray, resting and exercise ECG, 24-hour
ambulatory ECG monitoring and, if needed, myocardial scintigraphy or perfusion scanning;
II. a normal pulmonary function tests are demonstrated;
III. the applicant has no evidence of other organ or parenchymal involvement;
IV. the applicant is not on treatment;
V. OPL limitation for 6 months; and
VI. applicant submit a favourable specialist physicians report.
These investigations shall be repeated annually, and provided regression has occurred a fit assessment
without limitation may be permitted after 2 years’ observation. Blood tests (ESR- erythrocyte sedimentation
rate, Angiotensin Converting Enzyme, Ca2+, uric acid) and any necessary examinations shall be at the
discretion of the treating Physician. Applicant who has recovered from Multisystem Sarcoidosis with no
detectable cardiac involvement may be considered by the Medical Assessor.
I. Applicant with known Cardiac Sarcoidosis shall be declared as medically unfit.
II. Applicant with evidence of Neuro Sarcoidosis shall be declared as medically unfit.
Pneumothorax
Traumatic Pneumothorax
Applicant with a history of Traumatic Pneumothorax may be declared as medically fit if he or she meets the
following requirements:
I. six weeks shall have elapsed since full recovery;
II. full respiratory examination shall be normal;
III. acceptable lung function tests shall be demonstrated, i.e. FEV1/ FVC ratio >=70%; and
IV. chest radiograph changes shall have resolved.
V. Initial and experienced applicant with a history of recurrent episode(s) of traumatic or spontaneous
pneumothorax which is complicated shall be assessed as medically unfit unless the applicant has
undergone a bilateral pleurodesis, depending on the procedure.
Applicant may apply to the Medical Assessor for a waiver consideration and the following reports shall be
required,
I. Pulmonologist’s;
II. Cardiothoracic surgeon; and
III. Other supporting investigation reports.
IV. Spontaneous Pneumothorax
Initial applicant with a history of a single episode may be assessed as fit, provided that they submit the
following:
I. a period of 6 months has elapsed since full recovery after the episode and the applicant shall have
had bilateral pleurodesis, the applicant may be declared medically fit 12 weeks after the surgery
subject to the thoracic surgeon’s report;
II. a full respiratory examination and tests are normal;
III. there shall be no bullae shown on the CXR, CT scan or any other image; and
IV. applicant presenting with any bullae present shall have been treated by surgery and a no-smoking
status has been confirmed.
Applicant presenting with second episode of the spontaneous pneumothorax, may be medically declared
unfit.

A fit assessment at renewal may only be considered by the Medical Assessor following submission of a
satisfactory surgical treatment and full convalescence, usually three months.
I. Applicant shall be restricted to OPL for one year from the original occurrence.
II. Applicant may be declared as medically fit for certification provided that:
III. a full re-expansion of the lung has taken place;
IV. a full respiratory evaluation is normal; and
V. there shall be no bullae shown on the CXR, CT scan or any other image.
Acute Lower Respiratory Disease

Any acute active infectious disease of the respiratory system of any nature shall result in temporary unfitness
until –
I. the condition has fully resolved without sequelae;
II. there is no further medication is required;
III. the lung function tests are within normal range;
IV. the chest radiograph changes have resolved; and
V. the treating physician’s report is favourable.
Pulmonary Embolism
Applicant presenting with a confirmed diagnosis of Pulmonary embolism may be declared as medically fit if he
or she demonstrates, upon recovery with the following –
I. the lung function tests and diffusion test is normal;
II. the blood gases are acceptable after 10 minutes of exercise;
III. submission of favourable Pulmonary Angiogram/Pulmonary CT Angioqram/Pulmonary VQ Scan
report;
IV. coagulation studies are acceptable;
V. a satisfactory Physician report.
The applicant to be referred to the Medical Assessor for consideration on a case-by-case basis.
Post-Operative effects of Thoracic Surgery

Applicant who has had thoracic surgery shall be declared as temporarily medically unfit for a period of 6
months.

Unrestricted certification shall be considered where –

I. there is full recovery from the underlying condition(s) and supporting reports are submitted;
II. the surgery has no sequelae;
III. a full respiratory examination and chest radiological imaging are acceptable and minimum lung
function standards are met; and
IV. the specialists’ reports (pulmonologist and cardiothoracic surgeon) are favourable.
Visual System
An applicant may not have any condition or congenital abnormality of either eye or its attachments likely to
impede the safe exercise of the privileges of the licence. An applicant’s visual acuity and visual fields shall be
examined.
Acuity
An applicant’s visual acuity with or without corrective lenses shall be 6/12 binocularly and 6/18 in each eye.
Amblyopia or Monocularity
An applicant with Amblyopia or Monocular may be declared as medically fit, if the visual acuity in the
unaffected eye with or without correction is 6/6 or better.
Visual Field Defects

Applicant shall have a normal binocular visual field or a normal monocular visual field.
ENT System
Applicant shall have no established medical history or clinical diagnosis of the following –
I. any pathological process, acute or chronic, of the inner ear middle ear cavities or external ear canal;
II. any unhealed (unclosed) perforation of the tympanic membranes, except that an applicant with a
single dry perforation may be eligible for a certificate if the defect does not prevent compliance with
the hearing standards;
III. any chronic or serious recurrent obstruction of the Eustachian tubes;
IV. any serious or recurrent disturbance of the vestibular system;
V. any obstruction to free nasal air entry on both sides;

VI. any serious malformation, or serious acute or chronic condition of the buccal cavity or upper
respiratory tract; or any speech defect likely to interfere with the safe performance of duties in
exercising the privileges of the licence;
VII. profound deafness may be considered medically fit if there is proven ability to communicate in the
event of an emergency by speech or by using a device;
VIII. applicant unable to communicate with assisted devices shall be considered medically unfit;
IX. the applicant shall be able to hear a whispered voice in a quiet room; and
X. applicant to be referred to the Medical Assessor for consideration on a case-by-case basis.
Genitourinary System
Applicants with renal or genitourinary disease shall be assessed as medically unfit, unless an adequate
examination shows that their condition is unlikely to interfere with the safe exercise of their licence and rating
privileges. Urine examination shall form part of the medical examination and abnormalities shall be adequately
investigated.
Applicant with sequelae of disease of, or surgical procedures on the kidneys or the genitourinary tract, in
particular obstructions due to stricture or compression, shall be assessed as medically unfit unless the
applicant’s condition has been investigated and evaluated. Applicant who has undergone nephrectomy shall
be declared as medically unfit unless the condition is well compensated. Applicant to be referred to the
Medical Assessor for consideration on a case-by-case basis.
Nephrectomy
Applicant who has undergone a nephrectomy shall be assessed as medically unfit for a minimum period of 3
months or until such time as they are free from any abnormality, disability and/or sequelae from the operation
that is likely to interfere with the safe operation of an aircraft or with the safe performance of duties.
Requirements for medical certification –

I. upon recertification the condition shall be well compensated;
II. the treating specialist’s report detailing the underlying cause of the removal of the kidney; and
III. any other examinations deemed necessary by treating specialist shall be submitted.

3) Renal function testing includes the following –

I. Urea and electrolytes (U&E, Uric Acid);
II. Glomerular filtration rate (GFR); and
III. 24-hour urine creatinine clearance;
IV. the remaining kidney’s function and anatomy shall be normal.
Urinary Calculi
Single renal stone (passed or removed)
A medically fit assessment may be made with successful passage or removal of the stone.
I. Urologist report.
II. Follow-up: annual urine dipstix.
III. Modifiable risk factors are controlled.
Recurrent renal stones (passed or removed)

May be recertified if –
I. an applicant is proven to be free of all stones in kidney or renal tract;
II. the renal function is normal;
III. modifiable risk factors are controlled; and
IV. Urologist report.
V. Follow-up: annual urine dipstix and urate level.
Retained renal stones (asymptomatic)

Assessment shall be done on a case-by-case basis. An applicant shall be declared medically unfit while
suffering from any acute symptoms or complications.
An applicant may be assessed as medically fit if –
I. stones are located such that they are unlikely to pass into the calyx;
II. urinary studies do not reveal any underlying risk factors for recurrent stone formation;
III. annual urine dipstix and urate levels are normal;
IV. modifiable risk factors are controlled; and
V. favourable Urologist report.

HIV/AIDS Protocol for Cabin Crew and Recreational pilot

Applicability
This protocol shall be applicable to the cabin crew and recreational pilot.
General and medical requirements

1) All cases shall be assessed on a case-by-case basis, taking into consideration a favourable clinical and
serological response.
2) Subsequent to an initial diagnosis of HIV seropositivity, an applicant shall be declared temporarily medically
unfit.
3) An applicant shall submit the following reports, which are not older than three months, for recertification:
I. HIV specialist or a physician review with the following:
II. History of infection;
III. Current and previous symptoms;
IV. Full neurological examination to assess sequelae, including primitive reflexes;
V. Stability of condition;
VI. History of opportunistic infections or associated illnesses;
VII. History of CD4+ T cell counts;
VIII. History of viral load measurements;
IX. Medication history, including “over-the-counter” medications and alternative medication; and
X. A report concerning side effects of medications.
XI. The laboratory testing reports shall include the following:
XII. Hepatitis B and C, syphilis and tuberculosis screening;
XIII. Full blood count (minimum Hb of 12g/dL), urea, creatinine and electrolytes, liver function tests (LFTs);
XIV. Fasting glucose and lipogram, which may be required on clinical indication; and
XV. Cytomegalovirus and toxoplasma, which may be required when clinically indicated.
XVI. A clinical psychologist report with baseline cognitive assessment, including the following tests:
XVII. Timed psychomotor tasks and memory tasks requiring attention, learning, active monitoring and
retrieval of information.
XVIII. Other specialist reports as may be required on clinical indication.

Medication
1)An applicant shall use acceptable medication referred to on SA-CATS 67.00.9
2)If an applicant is using medication which is not on the acceptable list, he or she may apply for a waiver.
3)An application for a waiver referred to in paragraph 1) shall be accompanied by a treating physician’s report
stating the duration of treatment, and the side effects and profile specific to an applicant.
Requirements for regular follow-ups

1)Regular follow-ups shall include:
I. CD4 count and viral load measurements which shall be required initially at three months, six months
and then annually;
II. FBC (with minimum Hb of 12g/dL), Urea, Creatinine and Electrolytes, LFTs at three months and six-
monthly thereafter, with submission of reports; and
III. Fasting glucose and fasting lipogram may be required when clinically indicated.
2)A medical assessor may request that medical examinations or tests be performed at shorter intervals or
require additional examinations or tests to be performed when clinically indicated.
Medically unfit applicant

An applicant presenting with the following complications or side effects, shall be declared medically unfit:
I. presence of acute or serious opportunistic infection;
II. the use of any substance or medication that is not compatible with flying;
III. safety threatening side effects of any medication;
IV. evidence of resistance to antiretroviral treatment;
V. co-existing disqualifying medical conditions or disease; and
VI. any other medical condition which may be deemed unsafe for practice of aviation duties
.
6.17 Pharmacology-Acceptable Medication
General
This subsection outlines the general principles for the use of medications in flying.
Any intake of medicine or narcotic substance must be declared in the formal declaration signed by aviation
personnel and handed to physicians in charge of the evaluation of flying fitness at each medical examination.
In principle, pilots taking medication either prescribed or obtained ‘over the counter’ have to be regarded as
unfit unless a DAME/IAM/SACAA have been contacted and endorsed resumption of flying duties.
The use of herbal medication and alternative treatment modalities requires particular attention to possible side
effects and should also be reported to the DAME/IAM and the SACAA. The decision as to whether an aviation
personnel member is medically fit for the privileges of the licence they apply for whilst taking medication has
always to be taken in conjunction with knowledge of the applicant’s clinical situation and the dosage and side
effects associated with the medication.
The consumption of such substances may have consequences on qualification for three reasons:
The disease requiring treatment may be cause for disqualification;
Flight conditions may modify the reactions of the body to a treatment (e.g. jet lag, dehydration, moderate
hypoxia): and Most importantly, medication may cause adverse side effects that impair flight safety. It should
be noted that the effects of medication do not necessarily immediately appear when treatment is started or
disappear when the treatment is stopped, and that the subject may be temporarily disqualified during the
withdrawal period.
Flying personnel should nevertheless not be deprived of an efficient treatment because of their professional
occupation. What is important is to find a compromise between flying fitness requirements, medical treatment
and illness that is the most suitable, both for the patient and flying safety. Flying personnel must be declared fit
by their DAME according to the circumstances and not by their medical practitioner. One of the goals of the
DAME must be to make flying personnel aware of the problems caused by treatment so that they refrain from
taking unreported medication whose side effects may not have been assessed.
It is possible that new therapeutic agents will become available that offer significant treatment advantages. If
such agents are considered by the SACAA to be appropriate for use by aircrew, with due consideration given
to aero medical and safety aspects, their use may be approved. However, as a general rule, medication shall
only be endorsed by the DAME if the applicant has taken the respective medication whilst not on flying duty for
an appropriate period of time (temporary disqualification) with proven efficacy and without any side effects that
could interfere with flying duties.
Guidelines
The medical condition is the primary concern, and a clinical assessment of being unfit to exercise aviation-
related tasks will determine the period of unfitness.

The class of medical fitness determines which medical conditions will be allowable for the exercise of the
aviation licence, or how it may be waivered. Knowledge of existing criteria and protocols as produced by
SACAA is mandatory for proper interpretation of aviation medical fitness.
All drugs not published in the SA-CATS 67 need to be verified by SACAA before prescribing.
Central acting drugs generally are unacceptable and unsafe as medication for aviation personnel.
I. The side effect profile needs careful attention to determine acceptability.
II. The applicant’s co-morbidities may cause medical unfitness.
III. The applicant’s possible adverse reactions to the medication must be monitored before a decision
regarding fitness may be made.
IV. The period of being unfit after the use of unacceptable medications largely depends on the manner
and time of elimination of the drug.
Table 6: List of medication

CENTRAL NERVOUS SYSTEM STIMULANTS
Name Acceptable Unacceptable Comments
Benzodiazepines Tamazepam No flying within 72 hours;
this drug is addictive and
should not be used with
alcohol at the same time.
Other Zopiclone Applicants must wait 24-
Zolpidem 48 hours before flying
Zaleplon after these medications
have been taken. These
drugs must not be used
more than twice a week
to avoid habituation.
Food supplement Melatonin (not generally If considered, it should
recommended for flight crew be given a ‘ground trial’
and cabin crew) during a period when the
crew member will not be

engaged in flying duties

and any unwanted side
effects can be assessed.
SSIR Fluoxetine Selected non-sedating
Sertraline selective serotonin re-
Citalopram uptake inhibitors (SSIR)
Escitalopram require a minimum of
Paroxetine three (3) months
grounding period. The
SACAA will evaluate
affected applicants on a
case-by-case basis and
will issue medical
certificates based on
medical findings. Refer to
the protocol.
Barbiturates These agents are
unacceptable
Anxiolytics These agents are
unacceptable
Anti-psychotics These agents are
unacceptable
Anti-epileptics These agents are These medications may
unacceptable to Pilots be considered for cabin
and ATC, including crew, on a case-by-case
Gabapentin which is presentation. A three-
used for conditions other month stabilisation period
than epilepsy is required. Refer to the
protocol.
Anti-Parkinson agents These agents are
unacceptable

Anti-vertigo and anti- These agents are

emetics unacceptable
Anti-migraine agents Triptans Triptans The underlying condition
Maxalt is disqualifying. The
Authority will evaluate
affected applicants on a
case-by-case basis and
will issue medical
certificates based on the
medical findings.
Applicants allowed on
these medications may
not fly for 24 hours after
being treated with these
medications. Beta-
blockers may be
considered acceptable
for prophylaxis. Refer to
the protocol.
Agents for Alzheimer’s These agents are
disease unacceptable
Anaesthetics Acceptable A minimum of 24 hours
following local or regional
(including dental)
anaesthetics. (The
condition for which the
anaesthetic has been
administered must also
be considered prior to
returning an individual to
flying or controlling

duties).
A minimum of 72 hours
following general, spinal
or epidural anaesthetic.
This proscription includes
drug-induced sedation.
(The condition for which
the anaesthetic has been
administered must also
be considered prior to
returning an individual to
flying or controlling
duties).
ANALGESICS AND ANTI-INFLAMMATORIES
Central nervous Acceptable Unacceptable Central acting analgesics
system agents Morphine and narcotics morphine
Codeine opioid/analgesics are
Codethyline strictly incompatible with
Cocaine flying status.
Cannabis
Doxylamine
Promethazine
Meprobamate
Orphenadrine
Propoxyphene
Diphenhidramine
Tramadol
NSAIDS Acetyl Salicylic Acid
Peripheral analgesics
Non-Selective Cox- Acceptable Unacceptable
Inhibitors

Acetaminophen Paracetamol Sulindac These substances,

Phenlybutazone prescribed for short
Salicylates Acetyl Salicylic Acid periods at moderate
doses may be compatible
Propionic acid Ibuprofen with flying status if the
derivatives Naproxen condition which justifies
Fenoprofen their prescription is itself
Ketoprofen compatible with flying
Flurbiprofen status.
Indomethacin
Acetic acid derivatives Ketorolac

Diclofenac
Enolic acid (Oxicam) Diclofenac Nabumetone
Piroxicam
Meloxicam
Tenoxicam
Lornoxicam
Fenamic acid Mefenamic Acid

derivatives Meclofenamic Acid
Flufenamic Acid
Tolfenamic Acid
COX Inhibitors Meloxicam
SelectiveCOX2 Celecoxib
inhibitors Etoricoxib
Parecoxib
MUSCULOSKELETAL AGENTS

Anti-Gout Allopurinol Colchicine This medication may be

acceptable, each
application will be
considered on a case-by-
case basis
Flying prohibited while on
colchicine. Stable GIT
must be demonstrated
after discontinuation of
colchicine.
Topical agents These agents are
acceptable
Gold These agents are

unacceptable
Osteoporosis Biphosphonates Reserved on a case-by-
Alendronate by case basis
Risedronate
Calcium and Vit D
supplements
Other drugs:
Selective oestrogen receptor
Modulators –Raloxifene
Parathyroid hormone
Teriparatide
Autonomic Sympathomimetic All centrally acting agents are

Sympatholytics unacceptable.
Cholinergic
Anti-cholinergics
AUTOCOIDS

Antihistamines Ebastine Sedating oral antihistamines

Loratadine are not authorised for flying
Desloratadine personnel and incompatible
Acrivastine with flying status. New
Fexofenadine generation, non-sedating oral
(e.g. fexofenadine) and
topical antihistamines may be
acceptable.
Serotonin antagonists All agents in this group
are unacceptable
Methysergide
Cyproheptadine
Pizotifen
Ondansetron
Grinesatron
Neurokinin1 (NK1) All agents in this group Novel class of medications
Antagonists are unacceptable that possesses unique
Aprepitant antidepressant, anxiolytic,
Casopitant and antiemetic properties.
CARDIOVASCULAR AGENTS
Positive Inotropic All agents in this group

Agents are unacceptable
Anti-Arrhythmic Case-by case presentation,
individual medical may be
considered.
Anticoagulants Rivaroxabin The underlying condition
Dabigatran should be assessed on a
case-by-case basis.
ANTI-HYPERTENSIVE
Central acting All agents in this group
sympathetic nervous are unacceptable

system inhibitors
Alpha-receptor Tamsulosin – e.g. All agents in this group All L.U.T.S cases – cases
blockers Tamsul are unacceptable presentation, individual
medication will be considered.
Applicants on Tamsulosin
should be monitored for
postural hypotension with
every medical as per
underlying condition protocol
requirements.
Beta-receptor Atenolol Non-selective drugs are Cardio-selective beta
blockers Metoprolol unacceptable blockers are acceptable, but
Bisoprolol no longer first line or choice.
Sympathetic nervous These drugs are
blockers unacceptable as they
may impair alertness
Direct-acting Dihydralazine These drugs are
vasodilators Prazozine unacceptable because they
Uradipil frequently have adverse side
effects such as orthostatic
hypotension.
Calcium channel Diltiazem Short acting Nifedipines These medications may be
blockers Verapamil are unacceptable compatible with flying status.
Nicardipine They may induce peripheral
Nitrendipine oedema or headache, but
Long-acting Nifedipine they are generally well
tolerated. Preference shall be
given to medications with the
most flexible use.
If used for angina these

medications are not

compatible with flying status.
ACE inhibitors Captopril
Enalapril
Lisinopril
Benazepril
Fosinopril
Perindopril
Quinapril
Ramipril
Angiotensin Receptor Candesartan
Antagonists Eprosartan
Irbesartan
Losartan
Telmisartan
Valsartan
Anti-Angina Agent Angina pectoris per se is
disqualifying.
Diuretics Hydrochlorothiazide (< Furosemide Low dose diuretics are
25 mg/day) Bumetanide acceptable.
Potassium/ magnesium Torasemide
sparing diuretics such as Acetazolamide High dose kaliuretic diuretics
amiloride and Eplerenone (> 25 mg hydrochlorothiazide
spironolactone or equivalent) are
unacceptable.
Other vasodilators The indications for use are
disqualifying.
Vasoconstrictors The indications for use are
disqualifying.
HYPOLIPIDAEMIC AGENTS
Dyslipidaemia in flying personnel should be treated in conjunction with an appropriate diet and weight

reduction if appropriate.
Fibrates Treatment with fibric acids

(e.g. fenofibrate or
gemfibrozil) should be
discontinued in the case of
gastrointestinal side effects or
elevated transaminase
concentration.
Statins Cholestyramine] Fluvastatin HMG-CoA reductase
All except exclusions Lovastatin inhibitors are acceptable with
Combined formulas preference for hydrophilic
e.g. Ezetimibe & Statins molecules such as
pravastatin rather than
lipophilic substances such as
simvastatin, which may
induce sleep disorders.
Others Acipimox (niacin
derivative) used in low
doses and accepted on a
case-by-case basis
Plasma Expanders All agents in this group

are unacceptable
Blood and Anticoagulants-Warfarin Haemostatics, the
Haemopoeitic – refer to the protocol – indications for use are
acceptable disqualifying

Platelet aggregation Disprin/Aspirin in low- All agents in this group

Haematological dose (≤100mg/day) are unacceptable
agents acceptable
Platelet aggregation
inhibitors, Injectables
Sclerosing All agents in this group
are unacceptable
Haematinics Prophylactics in Anaemia has to be corrected
pregnancy are before consideration.
acceptable
Haemoglobin-based This medication is not

Oxygen carrier considered
RESPIRATORY SYSTEM
Coughs and Cold Drugs containing only Tripolidine
carbocysteine, Pseudoephedrine
guaifenesin or Ephedrine
acetylcysteine without an Codeine & modifieds
alcohol base are Theophylline
accepted Dextromethorphan
Diphenhydramine
Promethazine
Noscapine
Phenyltoloxamine
Methadone
Bronchodilators Spiriva Sympathomimetics: The use
of Short-acting Beta Agonists
(SABA)/Long-acting Beta
Agonists (LABA) should be
restricted to eight (8) hours or
more prior to flying, but may

be used in an unusual
asthmatic attack in flight to
allow the safe completion of
the flight.
Methylxanthines and All agents in this group
combinations are unacceptable
Anticholinergics All agents in this group
are unacceptable
Combinations Only acceptable
combinations are:
Salmeterol
Fluticasone
Budesonide
Formoterol.
Mucolytics Carbocysteine
Acetylcysteine
Bromhexidine
Anti-Asthmatics Inhaled Glucocorticoids
Leucotrine receptor
Antagonists
Chromones Cromolyn Sodium The drugs are also called
Nedocromil Sodium cromoglycates. They are
alternative choices when
initiating regular controller
therapy in patients with mild
asthma, although inhaled
corticosteroids (ICS) are the
preferred agents. They have
the advantage of having a
lower side effect profile than
ICS.

Other Anti-asthmatics All agents in this group

are unacceptable
Surfactants This medication is not
compatible with flying
EAR, NOSE AND THROAT
Topical nasal These medications are
preparations acceptable
Ear drops and These medications are
ointments acceptable
Mouth and throat These medications are
preparations acceptable
GASTRO-INTESTINAL TRACT
Digestants These medications are
acceptable
Appetite suppressants All agents in this group
are unacceptable
Anti-Spasmodics Mebeverine Hyoscine Antimuscarinics (e.g.
Alverine Diphenhidramine dicyclomicine, mepenzolate,
Peppermint Oil Alcohol substrates pipenzolate, poldine and
Belladonna propatheline) are used to
Chlordiazepoxide reduce smooth muscle spasm
Propantheline in non-ulcerative dyspepsia,
Methixene irritable bowel syndrome and
diverticular disease.
They all have atropine-like
side-effects of confusion, dry
mouth, reduced power of
accommodation, difficulty with
micturition and constipation,
which preclude their use.
ACID REDUCERS

Antacids Magnesium as a single

drug is unacceptable
Antacids and Dicyclomine
combinations Magnesium dominant
drugs
Oxethazaine
Bronchodilators Spiriva Sympathomimetic: The use of
Short-acting Beta Agonists
(SABA)/Long-acting Beta
Agonists (LABA) should be
restricted to eight (8) hours or
more prior to flying, but may
be used in an unusual
asthmatic attack in flight to
allow the safe completion of
the flight.
H2 receptor Cimetidine allowable if
antagonists taken more than 8 hours
before aviation activity
Ranitidine allowable if
taken more than 12
hours before aviation
activity
Proton pump Omeprazole
inhibitors
Cycloprotective Misoprostol
Motility Enhancers All agents in this group

are unacceptable
Laxatives Magnesium salts
Antidiarrhoeals Loperamide not to be Codeine phosphate

taken less than 6 hours [Cophenotrope]

before aviation activity Co phenotrope
Morphine
Atropine (Lomotil)
Aminopentamide
Liver, gall bladder and These agents are Treatment for the dissolution
bile unacceptable due to of gallstones is not
disease profile compatible with flying status
as it may cause diarrhoea
and cholecystitis.
Suppositories and These agents are Soothing preparations
anal ointments acceptable containing bismuth
subgallate, zinc oxide and
haemamelis, often mixed with
a small dose of corticosteroid,
may be acceptable in short
courses for topical
application.
Others Sulfasalazine enteric Sibutramine
coated may be used with Budesonide
6 monthly ophthalmology Infliximab
reporting, FBC, UKE, Orlistat
and urinalysis
Anti-inflammatory Mesalazine Humira Case-by-case presentation,
agents for Bowel Asacol: (5-aminosalicylic Salofalk individual medication may be
Disease acid) considered.
Sulfasalazine enteric coated
may be used with 6-monthly
ophthalmology reporting,
FBC, UKE, and urinalysis.
The use of sulfasalazine in

inflammatory bowel disease

has declined due mainly to
the fact that it yields the
metabolite sulfapyridine which
gives rise to side-effects such
as agranulocytosis and
hypospermia. However, the
other metabolite of
sulfasalazine, 5-
aminosalicylic acid (5-ASA) is
credited with causing the
drug's therapeutic effect.
Therefore, 5-ASA and other
derivatives of 5-ASA, are now
usually preferred and given
alone (as mesalazine),
despite their increased cost,
due to their more favourable
side-effect profile.
Sulfasalazine, and its
metabolite 5-ASA, are poorly
absorbed from the small
intestine. Its main mode of
action is therefore believed to
be inside the intestine.
Approximately one third of a
dose of sulfasalazine is
absorbed from the small
intestine. The remaining two
thirds pass into the colon
where it is split by bacteria

into 5-ASA and SP. SP is well

absorbed from the colon
(estimated bioavailability
60%); 5-ASA is less well
absorbed (estimated
bioavailability 10% to 30%).
ANTHELMINTICS
Anthelmintics Mebendazole Piperazine
Albendazole
Praziquantel
Dermatological
Anti-bacterial These medications are
antiseptic agents acceptable
Anti-parasitics These medications are
acceptable
Fungicides These medications are
acceptable
Cortico-steroids These medications are
acceptable
Psoriasis Systemic Etretinate Systemic etretinate for
Acitretin psoriasis may cause serious
drying of the skin and mucosa
and particularly of the
conjunctival tissues,
intensified by flying
conditions. It is not
recommended for aircrew.
Acne Tretinoin
Isotretinoin
Cyproterone acetate

Minocycline
Melanin inhibitors and These medications are
stimulants unacceptable
Emollients and These medications are
Protectives acceptable
Others Imiquimod
Minoxidil
OPTHALMICS
Aviation activities only to commence once all visual normality is regained
Anti-infective and Chloramphenicol Anti-infective and anti-
antiviral Ciprofloxacin inflammatory eye
Olfloxacin preparations are usually not
Oxytetracycline compatible with flying status
Fusidic Acid due to the underlying
Moxyfloxacin condition. The SACAA should
Acyclovir be consulted if there is any
doubt.
Corticoids These medications are
acceptable
Combinations All treatment containing
Aminoglycosides are
unacceptable
Decongestants These medications are
unacceptable
Mydriatics These agents are
unacceptable
Others Injectables
Verteporfin
Urinary System
Anti-diuretics This medication is not

Urinary alkalinizes The chronic use of this

medication is not
Urinary antiseptics Pipemidic Acid
Nalidixic Acid
Tamsulosin
Lanthanum
Flavoxate
Others Tamsulosin Lanthanum
Flavoxate
GENITAL SYSTEM
Contraceptives These medications are
acceptable
Vaginal Preparations These medications are
acceptable
Oxytocics These agents are
unacceptable
Uterine These agents are
Antispasmodics unacceptable
Sexual dysfunction Temporary colour vision
disturbance have been
reported after the use of
phosphodiesterase-type-5
inhibitors (e.g. vardenafil,
sildenafil). 72 hours should
elapse after use prior to
flying.
ANTI-VIRAL AGENTS
Anti-Viral Agents Acyclovir Anti-Retroviral – case-by

-case management, refer

to protocol
ANTI-MICROBIALS
Anti-Microbials Beta-lactams Telithromycin All antibiotics should be
Erythromycin (short course) Roxithromycin used for 48 hours without
Azithromycin (short course) Aminoglycosides any side effects before
Other Macrolides Tetracycline commencing aviation
Chloramphenicols activities. Injectables are
Sulphonamides and not acceptable.
combinations
Quinolones
Clindamycin (short course)
Na-Fusidate
Fosfomycin
Doxycyclin
ANTI-FUNGAL AGENTS
Anti-Fungal Agents Fluconazole
Itraconazole
Nystatin
Terbinafine
Griseofulvin
Ketoconazole
ANTI-PROTOZOA AGENTS
Anti-Protozoa Agents Metronidazole Pirimethamine
Atovaquone Tinidazole
Chloroquine Halofantrine
Mefloquine

Anti-retroviral agents
Nucleoside Zizovudine Efavirenz Initially monthly
Reverse Retrovir FBC for 6 months
Transcriptase Lamivudine
Inhibitors (NRTIs) Didanosine
Abacavir
Emtricitabine
Tenofovir
Non-Nucleoside Nevirapine Initially ALT & AST
Reverse – 2 weeks, 6
Transcriptase weeks
Inhibitors
Proteases Atazanavir Indinavir
Inhibitors (PI) Lopinavir/Ritonavir
Saquinavir
Nelfinavir
Others Raltegravir Tipranavir
Darunavir
Etravirine
Maraviroc
Amprenvir
Fosamprenavir
Fusion Inhibitors Fuzeon
ENDOCRINE SYSTEM
Anti-Diabetic Oral Insulin Oral Insulin Refer to Diabetic
agents Metformin Glargine Glipizide Neutral Protocol.
Thiazolidenediones Detemir Tolbutamide protamine
Pioglita Glulisine Gliclazide Hagedorn
Rosiglitazone Lispro Glibenclamide Premix
Acarbose Glimepiride analogues
Chlorpropamide (biphasic)

Repaglinide
Nateglinide
Thyroid Thyroxine Neo-Mercazole Refer to Protocol.
Parathyroid Corticosteroids, Calcitonin Refer to Protocol.
only low dose
Prednisone is
acceptable
HORMONES
Androgens and Testosterone Metenolone
Anabolic steroids Mesterolone Nandrolone
Oestrogens
Progestogens
Tibolone
Tropic Hormones Clomiphene Injectables and implants
Hormone Inhibitors Tamoxifen Case-by-case basis
Anastrazole and 3-months
stabilisation period
required.
VITAMINS, TONICS, MINERALS AND ELECTROLYTES
Vitamins These agents are acceptable In general, pilots, cabin
crew, and ATCs should
not exceed the
Recommended Daily
Allowances for these
products.
Tonics Alcohol based
combinations
unacceptable
Minerals and These agents are acceptable In general, pilots, cabin
electrolytes crew, and ATCs should
not exceed the

Recommended Daily
products.
Amino-Acids These agents are acceptable In general, pilots, cabin
crew, and ATCs should
not exceed the
Recommended Daily
products.
CYTOSTATICS
Immunological
Immunosuppressants
Immunostimulants
CHELATING AGENTS, ION EXCHANGE PREPARATIONS
Chelating agents, Ion These agents are
exchange unacceptable
preparations
BIOLOGICAL
Biological Immunisation regimens are No aviation-related

acceptable duties for 24 hours after
receiving the following
vaccinations (primary
and boosters):
Adult diphtheria and
tetanus
Poliomyelitis
Hepatitis A & B
Measles, mumps, rubella
Yellow fever
Typhoid
Tuberculosis (Mantoux
Test or Bacille Calmette-
Guerin)
Influenza
Varicella
Meningococcal
Pneumococcal
Cholera.
After receiving the
following immunisations
(primary and boosters)
there should be no
aviation-related duties
for a minimum of 72
hours: Japanese
Encephalitis.
Biologics Revellex
Humira
ENZYMES
Enzymes These agents are
unacceptable
POISON ANTIDOTES
Poison Antidotes Bupropion is
unacceptable
Others
Others Nicotine adjuvants are Bupropion is
acceptable unacceptable
Biological Immunisation regimens are No aviation-
acceptable related duties

for 24 hours
after receiving
the following
vaccinations
(primary and
boosters):
Adult
diphtheria and
tetanus
Poliomyelitis
Hepatitis A &
B
Measles,
mumps,
rubella
Yellow fever
Typhoid
Tuberculosis
(Mantoux Test
or Bacille
Calmette-
Guerin)
Influenza
Varicella
Meningococcal
Pneumococcal
Cholera.
After receiving
the following
immunisations
(primary and

boosters)
there should
be no aviation-
related duties
for a minimum
of 72 hours:
Japanese
Encephalitis.
The history section on the examination form has to be completed by the applicant in the presence of the
medical examiner. Alternatively, the medical examiner has to verify the information with the applicant prior to
performing the physical examination. The examiner must ask direct questions and must make use of this
opportunity to provide advice to the applicant.
Remarks such as "previously documented" or "refer to previous records", will not be accepted. The document
will be considered as incomplete. Incomplete forms will not be accepted and will be sent back to the medical
examiner.
The information on the following two pages should be considered carefully when completing the history
section:
Question Description
1 – 17 Self-explanatory
15 Only class i.e. class 1 or 2 or 3 or 4 (do not specify ATP, Comm, etc.)
18 ♦ Provide details of previous restrictions/protocols
♦ Include date of implementation
17 Hours must be provided by pilot
18 ♦ This refers to the ultimate intention and not short-term goal

♦ State present licence type, i.e. ATP, Comm, etc.
19 Applicant must present previous medical certificate to DAME to confirm
17 All types of medication must be noted, whether it is prescription medication, OTC drugs, herbs,
vitamins, etc.

22 (1-5) When recording family history, details of the family member, age and details of disease should
be supplied
22 (6-9) These questions should be answered to determine latent medical problems that may have an
effect on medical fitness
22 (10) The following should be noted:
♦ Number and type of cigarettes smoked daily
♦ Number of years that has elapsed since applicant started smoking
♦ If the applicant has stopped smoking, number of years since cessation should be noted
22 (11+19) ♦ Dates, frequency and type of drugs should be noted
♦ If applicant is still using drugs recreationally, he/she must be found temporary unfit and be
referred
22 (12-42) A detailed explanation must be provided with all affirmative questions
22 (20) The following should be noted:
♦ Number and type of alcohol used on a weekly basis
♦ Number of years that has elapsed since applicant started using alcohol
♦ If the applicant has been abusing alcohol, number of years since abuse has stopped should
be noted
22 (43) ♦ Make use of the opportunity to provide education to the applicant related to the disease and
the possible effects it might have on aviation safety
♦ Hand the applicant the document related to encouraging voluntary testing and disclosure as
well as a copy of the present HIV protocol
♦ Provide counselling or refer for counselling and testing if so requested by the applicant
♦ At this point in time, the applicant is not legally bound to disclose a positive HIV status
♦ However, it is important to remind the applicant that he/she may not fly while aware of any
22 (44-46) condition that might

These questions impact
should beon aviation to
answered safety
determine latent medical problems or forgotten facts
that may have an effect on medical fitness
23 + 24 ♦ Any affirmative answer must be documented fully by the aviation medical examiner in the
space provided
♦ If there is insufficient space, the examiner must attach a separate sheet to the examination
form

25 and 26 ♦ The DAME must bring the contents of these two paragraphs to the attention of the applicant
♦ The applicant should be aware that it is an offence to knowingly make a false declaration
♦ The declaration made by the applicant is a legal declaration that the applicant has supplied
complete and accurate information
♦ It also releases information to the Director of Civil Aviation for Civil Aviation
27 - 29 ♦ The applicant must read, date and sign the declaration and the signature must be
witnessed
♦ The DAME must sign as witness
Physical examination
A comprehensive physical examination must be performed. Any finding on the physical examination must be
documented fully by the aviation medical examiner in the space provided. If there is insufficient space, the
examiner must attach a separate sheet to the examination form.
Remarks such as "previously documented" or "refer to previous records", will not be accepted. The document
will be considered as incomplete. Incomplete forms will be sent back to the medical examiner.Should the
examiner decide that more tests are indicated, he/she should obtain informed consent and perform the test or
refer the applicant for further evaluation. The details must be provided on the form in the space provided.
The information on the following 2 pages should be carefully considered when completing the examination
section:
Question Description
31 ♦ BMI is calculated by dividing the weight of the applicant by the square of the height of the
applicant
♦ Underweight – less than 18,5
♦ Normal – 18,5 to 25
♦ Overweight – 25 to 30
33 ♦ Obese
Pulse rate– and
30 torhythm
40 must be noted
♦ Very obese – more than 40

45 ♦ The gynaecological examination and the rectal examination may be performed by the
applicant's gynaecologist, urologist or general practitioner
♦ Should this be the case, it should be remarked as such on the examination form
♦ The applicant should be made aware of the importance of these examinations
46 ♦ It is essential not to rush the examination and to engage the applicant in discussions to
enable the examiner to evaluate the applicant psychologically
♦ The medical examiner should inspire confidence in the applicant, create a trusting and
friendly environment and should get to know the applicant well to enable him/her to identify
possible problems or changes in behaviour during future examinations
63 If applicant has been referred for further evaluation, the name of the person as well as
the reasons for the referral should be provided
64-66 ♦ Distant and near vision for each eye separately as well as for binocular vision must be
determined
♦ Criteria for intermediate vision has not yet been determined, but may be required in future
67 ♦ Details of colour vision determination must be provided
♦ If a Lantern test has been performed on the applicant, the date and result of the test must be
provided as well
70 ♦ CVD risk factor assessment must be completed
♦ The result of this assessment may be used in future to determine the
necessity for a stress-ECG
♦ Medical examiners must make use of this assessment to educate the applicant about a
healthy lifestyle
71-75 All 4 columns must be completed even if test is marked as not applicable for this specific
examination date
76 ♦ Any finding must be documented fully by the aviation medical examiner in the space
provided
♦ If there is insufficient space, the examiner must attach a separate sheet to the
77 examination
♦ formthe medical examiner must document his/her findings and decisions
In this section
♦ It also serves as a summary of the aviation medical examination

78 The declaration made by the medical examiner is a legal declaration that the examiner
♦ Has personally reviewed the history
♦ Has personally examined the applicant
♦ Has supplied complete and accurate information
The medical examiner must supply all the details as requested in this section as this is a legal
document. Incomplete documents will not be accepted
79 This section should not be completed by the medical examiners. This is for official use by the
designated institution only
Operational restrictions and medical requirements
Examination form
The medical examiner must indicate all operational restrictions and medical requirements in detail on the
examination form.
Medical certificate
Operational restrictions should be documented clearly on the medical certificate according to the table below.
In order to maintain confidentiality of information, the medical examiner may not provide details of any medical
condition, requirement or protocol on the medical certificate. If medical reports are required for future
examinations, the following restriction must be documented:
"Medical reports to be submitted with next medical examination".
If the medical examiner has found the applicant to be temporary unfit, the following restriction must be
documented:
"Medical reports to be submitted before medical certificate can be issued".
Examination reminder
The medical examiner must issue the applicant with a separate document detailing the tests required for the
next aviation medical examination. This will be the property of the applicant and need not be presented to
anyone unless the applicant chooses to do so. The document will serve as a reminder to the applicant or as an
information sheet to a different aviation medical examiner, should the specific medical examiner be
unavailable.
Operational restrictions
1 With or as co-pilot only
2 With safety pilot only
3 Daylight flying only
4 Valid as PPL only
5 Suitable corrective lenses must be worn
6 A spare pair of lenses must be readily available
7 Monocular restrictions:
a. If flying open cockpit aircraft, protective goggles not restricting visual field must be worn
b. Any accompanying pilot must be made aware of the holder's monocular vision c. Not valid for
flight as pilot-in-command by day or night until a satisfactory flight test has been completed with a
8 Restricted to demonstrated
flight examiner in each case".aircraft type
9 Valid only with approved prosthesis
10 Hearing aid required
11 Altitude restricted to 10 000 feet maximum
12 Not to fly within 24 hours of using medication
13 No aerobatic flight
14 Valid only when another air traffic controller available to assume duties
15 Not valid for aircraft equipped with toe brakes
16 Valid for air traffic controller only
17 Valid for simulator instruction only
18 Medical reports to be submitted with next medical examination
19 Medical reports to be submitted before medical certificate can be issued
Practical flight tests

In some cases, it will be necessary to perform a practical medical flight test with an applicant to determine
medical fitness and ability to control the aircraft, e.g. pilots with monocular vision, disabled pilots, etc. In these
cases, the medical examiner must refer the case to the SACAA medical department of the SACAA to arrange
for a practical flight test with a SACAA flight inspector. Borderline medical conditions should first be referred to
a specialist for a thorough investigation as outlined in the following chapters of this manual. This should
include an evaluation of whether or not the condition is progressive, to what extent functions is impaired, and
whether there is any risk of future deterioration or sudden incapacitation. If the applicant fails to meet the
medical requirements but the condition, in the examiner’s opinion, does not affect the regular and safe
performance of duties, the SACAA might wish additionally to assess any skill and experience demonstrated
during practical flight tests, in order to make certain that the applicant is capable of performing duties without
endangering flight safety.

A practical flight test is usually most appropriate for assessing static physical conditions, and not for those with
normal physical function but who have an increased risk of rapid incapacitation. It is likely to be undertaken
mainly for private pilots, for whom the medical standards are less rigorous and where modification to aircraft
controls may be feasible, although professional pilots may also require practical testing for certain conditions.
Special medical flight testing, appropriate to the applicant’s deficiencies, is conducted to help the SACAA to
estimate the applicant’s ability to perform under normal as well as adverse flight conditions.
Therefore, testing of the applicant could include marginal or simulated marginal conditions such as might be
encountered in emergency operations, in adverse weather, in twilight or at night, in haze or cloudiness, and in
flight towards the sun as appropriate to the condition being assessed. The flight test report should comment on
the conditions under which tests were given. Reasonable simultaneous tasks should be introduced during
medical flight testing (such as map reading and navigation, operation of flight equipment, maintenance of
communications, and even equipment or engine malfunction) to estimate the applicant’s ability to perform
more than one task simultaneously. Specifications for such special medical flight tests provide guidelines to
help in determining the applicant’s abilities and limitations.
The SACAA medical department is currently in consultation with the relevant stakeholders to review the
practical flight test for the following conditions, however; in the meantime below is a guideline from ICAO:
Deformity or absence of extremities

An applicant might be assessed as fit if able to demonstrate: ability to reach readily and operate effectively all
controls that would normally require use of the deficient extremity (or extremities), noting any unusual body
position required to compensate for the deficiency; ability to perform satisfactorily emergency procedures in
flight, such as recovery from stalls and power-off control, as well as on the ground, including evacuation of the
aircraft.
Defective hearing
Defects in hearing need not normally necessitate tests under actual flight conditions since all pertinent factors
may be simulated. Whether conducted on the ground or in-flight conditions, the main considerations to be
assessed in such cases are:
ability to hear radio voice and signal communications;
ability to understand ordinary conversational voice on the ground, in the cockpit with engine on and engine off.
(The examiner should guard against the applicant lip-reading.)
Speech defects — stammering, stuttering

An applicant might be assessed as fit, if able to demonstrate ability to converse and be clearly understood in
direct conversation and over the radio.
END

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Department / Division: Aviation Safety Operations

Document Owner: E:ASO

Name of Document: GUIDE FOR MEDICAL EXAMINERS

Document Owner: E:ASO

Name of Document: GUIDE FOR MEDICAL EXAMINERS

DAMES GUIDE Revision March 2023 Page 3 of 303

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10.3. Respiratory Protocols .............................................................................................. 109

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11.4. Protocol on Plavix Prescription Drug ........................................................................... 211

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Name of Document: GUIDE FOR MEDICAL EXAMINERS

Compile By Senior Manager: AVMED

Signature Date 24th March 2023

Approved by Executive: Acting Air Safety Operations

Signature Date 24th March 2023

DAMES GUIDE Revision March 2023 Page 6 of 303

Document Owner: E:ASO

Name of Document: GUIDE FOR MEDICAL EXAMINERS

Amendment Approved By:

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3. LIST OF EFFECTIVE PAGES

Revision No.: Original

* PAGE REVISION DATED * PAGE REVISION DATED

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4. LIST OF DEFINITIONS AND ABBREVIATIONS USED IN THIS DOCUMENT

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abnormal attitude, or an abnormal variation in speed, which is not necessary

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also function as the Toxicologist (see under Toxicologist)

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order to ensure reliability and accuracy

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Note 1: Medical assessors evaluate medical reports submitted to the Licensing

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Document Owner: E:ASO

Name of Document: GUIDE FOR MEDICAL EXAMINERS

manipulating the controls

DAMES GUIDE Revision March 2023 Page 15 of 303

Document Owner: E:ASO

Name of Document: GUIDE FOR MEDICAL EXAMINERS