Risk Management – The Pilot Physician’s Perspective
Medical Risk and Flying: Perspective and Management
Matthew M. Cooper, MD MBA FACS FAsMA FCAMA CPL CFI
Medical conditions affect all of us at one time or another – rare is the exception. As pilots, we react especially because we grow concerned that our medical, our ticket to fly, may be jeopardized. The specter of “Special Issuance” and long periods without flying make us hesitant to report to our AME or to engage with the FAA at all if it is avoidable (e.g., BasicMed). This reaction is certainly understandable. However, let’s put a couple of things into perspective.
The first consideration should truly be your overall health, long-term survival, and quality of life. The ability to fly is a secondary consideration. Usually, if the former are assured, the latter follows. The statistics indicate that less than one half of one percent of all pilots applying to the FAA are ultimately and finally denied. The motivation and perspective of the FAA is safety of the air transport system. As such, their focus is on the statistical risk of a pilot sustaining acute total or partial incapacitation. It is true, as in many cases, the outcome of statistical analyses must be combined with a healthy dose of common sense. This perspective differs in some regards from that of the individual pilot. The FAA has pathways that may require the pilot to jump through additional hoops to potentially be granted a Special Issuance. This is best viewed as a time limited, able to be renewed, health monitoring program.
The relevant epidemiologic data available are limited. However, while one could argue about methodologic nuances, there are some striking findings in the data that should make us all take notice:
- FAA aeromedical waivers were associated with a 33% lower odds of death while holding a medical certificate and a 35% increased odds of death within 4 years after expiration of a medical certificate (1).
- With respect to medically related deaths, BasicMed pilots have an adjusted 53% higher mortality risk than the Third Class medical group (2).
- The adjusted risk of death from stroke or MI (myocardial infarction = heart attack) in BasicMed airmen was three times that of Third Class airmen; the risk of cancer-related death was two times higher among BasicMed pilots (2).
Yes, it is true that the average age of airmen flying under BasicMed is currently older than that of Third Class pilots. This post is not intended to argue either Pro or Con for BasicMed. Rather, it is intended to highlight the value in disciplined scrutiny, management, and surveillance of potential and actual medical issues.
As with health care in general, our system is so fragmented and otherwise challenging that it requires a savvy, persistent navigator to help make sure we get the right care in timely fashion. So too, a Senior AME with relevant medical specialty expertise and abundant experience consulting for, and working with the FAA, can most expeditiously assist the airman in maintaining their overall health while successfully navigating the path to maintaining their medical flight status. If a disqualifying medical condition exists, this may be managed with granting of a Special Issuance which then allows consideration of BasicMed in lieu of a Third Class medical if the airman so chooses. The caveat, as explained above, is that BasicMed requires an enhanced level of pilot-driven and managed surveillance to maintain health.
Reference
- Mills WD and Greenshaw RM. Association of Medical Certification Factors with All-Cause Mortality in U.S. Aviators. Aerospace Medicine and Human Performance. 2019; 90(11):938-944.
- Norris A et al. Assess Mortality Between the BasicMed Population and Third-Class Medically Certified Pilots. Report No. DOT/FAA/AM-22-03. FAA. March 2022
MORE from Dr. Cooper: Medications, Pilots & Flight
Contact Dr. Cooper at drcooper@leftseat.com or 405-787-0303
December 25, 2025
Very interesting stats on mortality in regards to active medical cert holders vs recently expired medical – perhaps the data also demonstrates that active pilots who experience some type of acute medical event give-up on maintaining an active medical which can further influence many other life behaviors that accelerate both physical and mental decay – with proper guidance, consultation and therapy following an acute change in medical condition a pilot should not make an immediate decision to void the maintenance of their pilot certificate or simply forego any attempt to pursue active possibilities to keep their medical certificate – It is very important to seek a consultation pathway of multiple possibilities not narrowed down to just a primary care provider, AME or a personal FAA interpretive – if I have ever gained anything from “LeftSeat’ it’s their multitude of consultation – Rarely does the Plane stop flying, but we stopped flying the Plane.
If basic med pilots are at that high of a risk of death- how is it based on the current system that the faa does not find them threatning enough to revoke the whole program?
[Submitted Via Linked-In]
Jennifer,
That is an excellent question.
When FAA looked at the initial comparison between pilots covered under Basic compared to Third Class Medical from 2017-2019 they reported to Congress in 2023: “No difference was found in the risk of BasicMed and third-class airmen having an aviation accident from the start of BasicMed in 2017 through the end of 2019. No difference was found between accident involved BasicMed and third-class airmen in the phase of flight in which their accident occurred. No difference was found between accident involved BasicMed and third-class airmen in fatal versus non-fatal outcomes. No difference was found between fatally injured BasicMed and third-class airmen in autopsy findings.”
Interpreting the results is complicated for several reasons. This study looked at accident rates during the first two years under Basic which lasts four years. It is my understanding that they did not look at medical issues per se – apples and oranges. In addition, as time goes on no longer under an FAA certificate, the data suggests increasing morbidity and mortality. So it may be that that initial comparative study didn’t follow airmen long enough. We do know that the Basic population of pilots has grown older with more comorbidities in general than Third Class pilots. So we will need to continue to follow all available data. The other issue to consider is the impact of insurance companies. Over age 40, Third Class pilots are reexamined every two years as compared with Basic, every four. As a result there is an element of potential increased risk for the insurer. It is not clear this has yet influenced premiums or willingness to insure. What is clear regardless of the route chosen by the pilot, they must robustly and honestly surveil their own health and performance.
PMSI has received a significant number of calls from pilots seeking FAA medical certification that would prefer to fly under basic med rules but the insurance company age-risk rating makes the cost coverage unaffordable, unless they obtained an medical certificate. DHale
As a first class certificate holder, it is a little different for me but the overall premise seems to be keep yourself healthy and then you will fly. However I completely disagree with flying being secondary. Not one pilot of any medical class is going to appreciate that approach.
I would say that flying is one way of staying healthy. Staying healthy includes doing all that is reasonable to be fit and prolong life. There are pilots who have avoided going to the doctor and died of preventable conditions before their time.