[Federal Register Volume 59, Number 203 (Friday, October 21, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-26047]


[[Page Unknown]]

[Federal Register: October 21, 1994]


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Part II





Department of Transportation





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Federal Aviation Administration



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14 CFR Parts 61 and 67




Revision of Medical Standards and Certification Procedures and Duration 
of Medical Certificates; Proposed Rule
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DEPARTMENT OF TRANSPORTATION
Federal Aviation Administration
14 CFR Parts 61 and 67

[Docket No. 27940; Notice No. 94-31]
RIN 2120-AA70

 
Revision of Medical Standards and Certification Procedures and 
Duration of Medical Certificates

AGENCY: Federal Aviation Administration (FAA), DOT.

ACTION: Notice of proposed rulemaking (NPRM).

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SUMMARY: This notice proposes an extensive amendment of part 67 of the 
Federal Aviation Regulations (FAR) to revise airman medical standards 
and medical certification procedures. This announcement, in part, 
proposes to implement a number of recommendations resulting from a 
comprehensive review of the medical standards announced in previous 
notices. As proposed, this revision of the standards for airman medical 
certification and associated administrative procedures of part 67 will 
better provide for safety in the aviation system and reflect current 
medical knowledge, practice, and terminology.
    This notice also proposes to amend Sec. 61.23 of part 61 to revise 
the duration of third-class airman medical certificates, based on the 
age of the airman, for operations requiring a private, recreational, or 
student pilot certificate.

DATES: Comments must be submitted on or before February 21, 1995.

ADDRESSES: Comments on this notice should be mailed or delivered, in 
triplicate, to: Federal Aviation Administration, Office of the Chief 
Counsel, Attention: Rules Docket (AGC-10), Docket No. 27940, 800 
Independence Avenue, SW., Washington, DC 20591. Comments mailed or 
delivered must be marked Docket No. 27940. Comments may be examined in 
Room 915G weekdays between 8:30 a.m. and 5 p.m., except on Federal 
holidays.

FOR FURTHER INFORMATION CONTACT: Carol A. Thomas or Dennis McEachen, 
Aeromedical Standards Branch, 800 Independence Avenue, SW., Washington, 
DC 20591; telephone (202) 493-4075.
SUPPLEMENTARY INFORMATION:
Comments Invited
    Interested persons are invited to participate in the making of the 
proposed rule by submitting such written data, views, or arguments as 
they may desire. Comments relating to the environmental, energy, 
federalism, or economic impact that might result from adopting the 
proposals in this notice are also invited. Substantive comments should 
be accompanied by cost estimates. Comments should identify regulatory 
docket or notice number and should be submitted in triplicate to the 
Rules Docket address specified above. All comments received on or 
before the closing date for comments specified will be considered by 
the Administrator before taking action on this proposed rulemaking. The 
proposals contained in this notice may be changed in light of comments 
received. All comments received will be available, both before and 
after the closing date for comments, in the Rules Docket for 
examination by interested persons. A report summarizing each 
substantive public contact with FAA personnel concerned with this 
rulemaking will be filed in the docket. Commenters wishing the FAA to 
acknowledge receipt of their comments submitted in response to this 
notice must include a preaddressed, stamped postcard on which the 
following statement is made: ``Comments to Docket No. 27940.'' The 
postcard will be date stamped and mailed to the commenter.

Public Meeting

    Public meetings will be held in Washington, DC, Seattle, WA, and 
Orlando, FL. A notice of the meeting times and locations will be 
published later in the Federal Register.

Availability of NPRM

    Any person may obtain a copy of this NPRM by submitting a request 
to the Federal Aviation Administration, Office of Public Affairs, 
Attention: Public Inquiry Center, APA-200, 800 Independence Avenue, 
S.W., Washington, D.C. 20591, or by calling (202) 267-3484. 
Communications must identify the notice number of this NPRM.
    Persons interested in being placed on the mailing list for future 
NPRM's should request from the above office a copy of Advisory Circular 
No. 11-2A, Notice of Proposed Rulemaking Distribution System, which 
describes the application procedure.

Background

    On April 15, 1982, the FAA announced the adoption of Amendment 67-
11 (47 FR 16298; April 15, 1982) to the FAR (14 CFR part 67). The 
amendment revised, among other things, the special discretionary 
procedures for issuing airman medical certificates to persons who do 
not qualify for certification under Secs. 67.13, 67.15, or 67.17 of the 
FAR. In the preamble to that amendment, the FAA announced that, in 
compliance with Executive Order 12291, Federal Regulation (February 17, 
1981), it intended to conduct an overall review of the medical 
standards in part 67 of the FAR. A complete review of the regulations 
was needed to bring the standards and procedures for airman medical 
certification up to date with advances in medical knowledge, practice, 
and technology. Therefore, Amendment 67-11 was considered interim 
clarification until a comprehensive review of the medical standards 
contained in part 67 could be concluded.
    The FAA began the review of the medical standards for airmen and of 
its certification practices and procedures (47 FR 30795; July 15, 1982) 
by requesting public comment. In addition, the FAA initiated a contract 
with the American Medical Association (AMA) to provide professional and 
technical information. The AMA presented its report, ``Review of Part 
67 of the Federal Air Regulations and the Medical Certification of 
Civilian Airmen'' (AMA Report), on March 26, 1986. The public was again 
invited to comment on part 67 in ``Announcement of the Availability of 
a Report'' (51 FR 19040; May 23, 1986). The AMA Report detailed the 
results of a comprehensive review of the standards for airman medical 
certification and of their application. The AMA Report considered 
pertinent advances in the field of medicine since 1959, recommended 
changes in FAA medical standards and explained the rationale for such 
changes.
    In a separate but related issue, on May 11, 1979, the Aircraft 
Owners and Pilots Association (AOPA) petitioned to amend Sec. 61.23 to 
require medical examinations for private pilots at 36-month intervals 
rather than at 24-month intervals. In response to the petition, the FAA 
reviewed the literature, surveyed the medical practices of the 
Department of Defense, and considered a preliminary analysis of its own 
aeromedical certification data. The FAA then contracted with Johns 
Hopkins University to prepare a detailed statistical analysis of 
information collected by the FAA from annual examinations on 
approximately 31,000 air traffic controllers over a 15-year period. The 
study sample was demographically similar and broadly comparable to the 
private pilot population, and the examinations were similar to airman 
medical examinations.
    The Johns Hopkins University analysis confirmed an increasing 
incidence of recorded pathology with increasing age, agreeing with the 
data from the AMA report, but a relatively low incidence in young 
individuals. Reducing the frequency of medical examinations could be 
expected to result in an increased prevalence of undetected pathology 
within the system. For the younger age groups, however, this effect 
would be small. The Johns Hopkins analysis did not identify exact ages 
at which the frequency of examinations should be changed.
    In response to the AOPA petition to amend Sec. 61.23, the FAA 
issued on October 29, 1982, NPRM No. 82-15 (47 FR 54414, December 2, 
1982) proposing to amend part 61 to revise the duration of validity of 
third-class privileges of airman medical certificates for operations 
requiring a private or student pilot certificate. As proposed by Notice 
No. 82-15, the requirement for a third-class medical examination would 
have been changed to every 5 years for the youngest pilots then 
increasing in frequency to the existing 2-year interval for older 
pilots.
    On September 27, 1985, prior to the issuance of the AMA Report on 
its review of the airman medical standards and certification procedures 
in part 67, the notice proposing to amend part 61 to revise the 
duration of third-class airman medical certificates was withdrawn (50 
FR 39619). The proposal was withdrawn, in part, because of issues 
raised by the medical community. In addition, a regulatory evaluation 
of Notice No. 82-15 suggested a slight increase in aircraft accident 
fatalities if the then proposed third-class medical certificate was set 
to 5 years for young airmen. Given the then pending issuance of the AMA 
Report and the possibility that the report would provide better data on 
which to base an evaluation of the safety concerns raised by the 
medical community, the FAA decided that any future consideration of 
examination frequency would be within the context of the outcome of the 
comprehensive review of part 67.
    On February 26, 1986, AOPA again petitioned the FAA to revise the 
duration of a third-class airman medical certificate to 36 calendar 
months for noncommercial operations requiring a private, recreational, 
or student pilot certificate. The petition (Docket No. 24932) was 
entered in the public docket and remains open.
    On September 24, 1993, AOPA once again petitioned the FAA to revise 
the duration of a third-class airman medical certificate to 48 calendar 
months for a specific trial period for noncommercial operations 
requiring a private or student pilot certificate. The petition (Docket 
No. 27473) was entered in the public docket and remains open.
    Based on the FAA's review of part 67, the FAA's judgment regarding 
recommendations contained in the AMA Report, and on consideration of 
all public comments in response to previous notices, the FAA proposes 
to revise part 67, ``Medical Standards and Certification.'' The 
proposed revision of part 67 will involve the incorporation of 
additions and changes to specific medical standards, the scope of 
examination, and the administrative procedures pertaining to airman 
medical certification. In consideration of pertinent advances in the 
field of medicine since the last significant revision of part 67, the 
medical standards and certification procedures that are being proposed 
reflect current medical knowledge, technology, and practice.
    As stated in the notice withdrawing Notice 82-15, the duration of 
airman medical certificates was to be reconsidered after the AMA's 
report; however, the report provided no duration recommendation. The 
proposal to revise airmen standards and certifications procedures and 
the duration of airmen medical certificates was also addressed in a 
January 1992 agency rulemaking review. The results of these events 
supported the revision of part 67 and duration of third-class airman 
medical certificates. A reevaluation of all studies and data collected 
since 1982 supports a revision of the duration of third-class medical 
certificates outlined in this proposal. Accordingly, the FAA is 
proposing revisions to part 67 and to Sec. 61.23 of part 61 of the FAR.

Summary of Proposed Amendments to Part 67

    The following is a summary of the substantive changes proposed in 
this rulemaking. Because the FAA is proposing a complete recodification 
of part 67, this summary states both the current and proposed section/
paragraph numbers.
    1. Distant visual acuity requirements for first- and second-class 
certification are changed to delete the uncorrected acuity standards. 
However, each eye must be corrected to 20/20 as in the current 
standard. [FAR Standards: Current Secs. 67.13(b) and 67.15(b); Proposed 
Secs. 67.103(a) and 67.203(a)]
    2. For third-class certification, the current 20/50, uncorrected, 
or 20/30, corrected, distant visual acuity standard is changed to 20/40 
in each eye, with or without correction. [FAR Standard: Current 
Sec. 67.17(b); Proposed Sec. 67.303(a)]
    3. For first- and second-class certification, minimum near visual 
acuity requirements are specified in terms of Snellen equivalents (20/
40), corrected or uncorrected, each eye, at 16 inches and, after age 
50, also include an intermediate standard (20/40) at 32 inches. This 
replaces the current standard of V=1.00 at 18 inches for first-class 
only. [FAR Standards: Current Secs. 67.13(b) and 67.15(b); Proposed 
Secs. 67.103(b) and 67.203(b)]
    4. A near visual acuity standard of P20/40, corrected or 
uncorrected, each eye, at 16 inches is added to the third-class visual 
requirements. [FAR Standard: Current (None); Proposed Sec. 67.303(b)]
    5. Color vision requirements are amended to read: ``ability to 
perceive those colors necessary for safe performance of airman 
duties,'' and are the same for all classes. Current standards require 
``normal color vision'' for first-class and the ability to distinguish 
aviation signal colors for second- and third-class applicants. [FAR 
Standards: Current Secs. 67.13(b), 67.15(b), and 67.17(b); Proposed 
Secs. 67.103(c), 67.203(c), and 67.303(c)]
    6. The current first-class standard pertaining to pathological 
conditions of the eye or adnexa that interfere or that may reasonably 
be expected to interfere with proper function is substituted in both 
the second- and third-class standards for the current standards which 
specify, respectively, ``no pathology of the eye'' and ``no serious 
pathology of the eye.'' [FAR Standards: Current Secs. 67.15(b) and 
67.17(b); Proposed Secs. 67.203(e) and 67.303(d)]
    7. The ``whispered voice test'' for hearing is deleted for all 
classes. Substituted are a conversational voice test using both ears at 
6 feet; an audiometric word (speech) discrimination test to a score of 
at least 70 percent obtained in one ear or in a sound field 
environment; or pure tone audiometry according to a table of acceptable 
thresholds (ANSI 1969). The amended standards for hearing are the same 
for all classes. [FAR Standards: Current Secs. 67.13(c), 67.15(c), and 
67.17(c); Proposed Secs. 67.105(a), 67.205(a), and 67.305(a)]
    8. The standards pertaining to the ear, nose, mouth, pharynx, and 
larynx are revised to more general terms and related to flying and 
speech communication. Specific references to the mastoid and eardrum 
are deleted. The current standard, ``No disturbance in equilibrium,'' 
is changed to, ``No ear disease or condition manifested by, or that may 
reasonably be expected to be manifested by, vertigo or a disturbance of 
equilibrium.'' The amended standards are the same for all classes. [FAR 
Standards: Current Secs. 67.13(c), 67.15(c), and 67.17(c); Proposed 
Secs. 67.105(b), 67.205(b), and 67.305(b)]
    9. ``Psychosis,'' as used in the proposed regulation, refers to ``a 
mental disorder in which the individual has manifested psychotic 
symptoms or to a mental disorder in which an individual may reasonably 
be expected to manifest psychotic symptoms.'' This alleviates some of 
the problems in interpreting the regulations created by changes in 
nomenclature and classification of mental conditions found in the 
Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM 
III). [FAR Standards: Current Secs. 67.13(d), 67.15(d), and 67.17(d); 
Proposed Secs. 67.107(a), 67.207(a), and 67.307(a)]
    10. Substance dependence and substance abuse are defined and 
specified as disqualifying medical conditions. Substance dependence is 
disqualifying unless there is clinical evidence, satisfactory to the 
Federal Air Surgeon, of recovery, including sustained total abstinence 
from alcohol for not less than the preceding 2 years in the case of 
alcohol dependence. In the case of other substance dependence, recovery 
would include sustained total abstinence from that substance for not 
less than the preceding 5 years. Substance abuse, in the case of 
alcohol within the preceding 2 years and in the case of other 
substances within the preceding 5 years, is disqualifying. Alcohol 
dependence and alcohol abuse are included in the terms ``substance 
dependence'' and ``substance abuse'', respectively. [FAR Standards: 
Current Secs. 67.13(d), 67.15(d), and 67.17(d); Proposed 
Secs. 67.107(a) and (b), 67.207(a) and (b), and 67.307(a) and (b)]
    11. ``Bipolar disorder'' is added as a specifically disqualifying 
condition. This corrects a regulatory problem created by the change in 
nomenclature contained in DSM III. [FAR Standards: Current (None); 
Proposed Secs. 67.107(a), 67.207(a), and 67.307(a)]
    12. The general mental standard is amended to add the word 
``other'' before ``mental.'' The proposed revised standard reads, ``No 
other personality disorder, neurosis, or other mental condition * * 
*.'' [FAR Standards: Current Secs. 67.13(d), 67.15(d), and 67.17(d); 
Proposed Secs. 67.107(c), 67.207(c), and 67.307(c)]
    13. ``A single seizure,'' and ``A transient loss of control of 
nervous system function(s) without satisfactory medical explanation of 
the cause,'' are added as specifically disqualifying neurologic 
conditions. [FAR Standards: Current (None); Proposed Secs. 67.109(a), 
67.209(a), and 67.309(a)]
    14. The word ``seizure,'' is substituted for ``convulsive.'' [FAR 
Standards: Current Secs. 67.13(d), 67.15(d), and 67.17(d); Proposed 
Secs. 67.109(b), 67.209(b), and 67.309(b)]
    15. ``Cardiac valve replacement,'' ``permanent cardiac pacemaker 
implantation,'' and ``heart replacement'' are added as specifically 
disqualifying cardiovascular conditions for all classes of 
certification. [FAR Standards: Current Secs. 67.13(e), 67.15(e), and 
67.17(e); Proposed Secs. 67.111(a), 67.211(a), and 67.311(a)]
    16. A requirement is added whereby all applicants for second-class 
airman medical certificates will be required to have a routine resting 
electrocardiogram (ECG) at the first application after reaching age 35 
and every 2 years after reaching age 40. An ECG requirement currently 
exists for first-class applicants; however, first-class applicants must 
have an annual ECG after reaching age 40. There is no requirement added 
for third-class. [FAR Standards: Current Sec. 67.13(e); Proposed 
Secs. 67.111(d) and 67.211(d)]
    17. The current table of age-related maximum blood pressure 
readings for applicants for first-class certificates and the reference 
to ``circulatory efficiency'' are deleted, and a requirement that 
average blood pressure while sitting not exceed 150/95 millimeters of 
mercury is added for applicants of all classes. A medical assessment is 
specified for all applicants who need or use antihypertensive 
medication to control blood pressure. [FAR Standards: Current 
Sec. 67.13(e); Proposed Secs. 67.111(b), 67.211(b), and 67.311(b)]
    18. For first-class applicants only, a total blood cholesterol 
determination after reaching age 50 is added. A cholesterol of 300 
milligrams per deciliter or more may require further evaluation 
although the applicant, if otherwise eligible, is issued a medical 
certificate pending the results. [FAR Standard: Current (None); 
Proposed Sec. 67.111(f)]
    19. The use of anticoagulant medication is made specifically 
disqualifying for applicants of all classes. [FAR Standards: Current 
(None); Proposed Secs. 67.111(c), 67.211(c), and 67.311(c)]
    20. Current Sec. 67.19 of the FAR, Special Issue of Medical 
Certificates, is rewritten [Proposed FAR Standard: Sec. 67.401(a)] to 
provide for, at the discretion of the Federal Air Surgeon, an 
``Authorization for Special Issuance of Medical Certificate'' 
(Authorization), valid for a specified period of time. An individual 
who does not meet the published standards of part 67 of the FAR may be 
issued a medical certificate of the appropriate class if he or she 
possesses a valid Authorization. The duration of any certificate issued 
in accordance with proposed Sec. 67.401 of the FAR is for the period 
specified at the time of its issuance or until withdrawal of the 
Authorization upon which it is based. A new Authorization is required 
after its expiration, and the applicant must show again that airman 
duties can be performed without endangering air commerce.
    Proposed FAR Standard, Sec. 67.401(b) also provides for a Statement 
of Demonstrated Ability (SODA) instead of an Authorization. The SODA 
will be issued to applicants whose disqualifying conditions are static 
or nonprogressive and who have been found capable of performing airman 
duties without endangering air commerce. The SODA authorizes an 
aviation medical examiner to issue a certificate if the applicant is 
otherwise eligible.
    Proposed Sec. 67.401(e) retains the language of current 
Sec. 67.19(c) regarding consideration of the freedom of a private pilot 
to accept reasonable risks to his or her own person or property that 
are not acceptable in the exercise of commercial or airline transport 
pilot privileges, and consideration at the same time of the need to 
protect the safety of persons and property in other aircraft and on the 
ground.
    Proposed Sec. 67.401(f) adds language that explicitly provides that 
the Federal Air Surgeon may withdraw the Authorization or SODA. An 
Authorization or SODA may be withdrawn at any time for (1) adverse 
change in medical condition, (2) failure to comply with its provisions, 
(3) potential endangerment of public safety, (4) failure to provide 
medical information, or (5) the making or causing to be made of a 
fraudulent or intentionally false statement or an incorrect statement 
in support of a request for an Authorization or SODA or in any entry in 
any logbook, record or report that is kept, made, or used to show 
compliance with any requirement for an Authorization or SODA.
    Proposed Sec. 67.401(i) allows a person to request that the Federal 
Air Surgeon review a decision to withdraw an Authorization or SODA. The 
request for a review would have to be made within 60 days of the 
service or mailing of the letter withdrawing the Authorization or SODA. 
The proposed review procedures would be on an expedited basis and would 
provide an affected holder of an Authorization or SODA a full 
opportunity to respond to a withdrawal by submitting supporting medical 
evidence.
    21. Proposed Sec. 67.403 amends current Sec. 67.20 to provide for 
denial of an airman medical certificate if the application for airman 
medical certificate is falsified. Though this consequence is implied, 
the current regulation specifically provides only for revocation or 
suspension of certificates. Additionally, Sec. 67.403 proposes to deny 
or withdraw any Authorization or SODA where information provided to 
obtain it is false, whether the statement was knowingly false or 
unknowingly incorrect. Finally, Sec. 67.403(c) proposes that the making 
of an unknowingly incorrect statement on an application for an airman 
medical certificate or on a request for an Authorization or SODA is a 
basis for denial, revocation, withdrawal, or suspension of an airman 
medical certificate and the denial or withdrawal of an Authorization or 
SODA. The making of an unknowingly incorrect statement is not a basis 
for revocation or suspension of other types of certificates or ratings 
issued under the FAR.
    22. A new Sec. 67.415 of the FAR is proposed to provide that the 
holder of any medical certificate that is suspended or revoked shall, 
upon the Administrator's request, return it to the Administrator. The 
FAA practice always has been to request return of the certificate in 
such circumstances.
    23. Where appropriate, changes are made to eliminate gender-
specific pronouns, to replace ``applicant'' with ``person,'' to use 
current position titles and addresses, to correct spelling and improve 
syntax, and to adjust section and sub-section references.

Summary of Proposed Amendments to Part 61

    Section 61.3(c) of the FAR provides, with some exceptions, that no 
person may serve as pilot in command or in any other capacity as a 
required pilot flight crewmember unless that person has in his or her 
personal possession an appropriate current medical certificate issued 
under part 67 of the FAR. The medical standards for issuing first-, 
second-, and third-class medical certificates are set forth in current 
Secs. 67.13, 67.15, and 67.17, respectively.
    Section 61.23 identifies the duration of validity and privileges of 
each class of medical certificate. Currently, a first-class medical 
certificate is valid for 6 months for operations requiring an airline 
transport pilot certificate, 12 months for operations requiring only a 
commercial pilot certificate, and 24 months for operations requiring 
only a private, recreational, or student pilot certificate. A second-
class medical certificate is valid for 12 months for operations 
requiring a commercial pilot or an air traffic control tower operator 
certificate and for 24 months for operations requiring only a private, 
recreational, or student pilot certificate. A third-class medical 
certificate currently is valid for 24 months for operations requiring a 
private, recreational, or student pilot certificate.
    Using the John Hopkins University analysis (raw data originated 
from the FAA), airman certification data, and annualized pilot exposure 
data, a decision model was prepared for the FAA that determined the 
best age-specific duration plan for the third-class medical certificate 
population. We determined that the best plan would provide for maximum 
regulatory relief without public safety decrement. For further 
discussion of duration analysis, see this docket's copy of the 
regulatory evaluation at pages 25-26, 58-64, and 77-80.
    Using the model and the decision criteria previously discussed, the 
FAA proposes to lengthen the validity period of third-class airman 
medical certificates for most persons under the age of 40. Persons 
under age 40 would be required to undergo a physical examination every 
3 years for a third-class medical certificate. Third-class medical 
certificates for persons age 40 but less than age 70 would continue to 
be valid for 2 years. Persons age 70 and older would be required to 
undergo a physical examination every year when applying for a third-
class medical certificate.
    These ages and examination periods were selected because they will 
allow no significant increase in undetected pathology between required 
examinations. Regulatory and economic relief can be provided without a 
significant effect on aviation safety.
    The FAA has determined that the frequency of routine examinations 
can be reduced in the case of younger airmen who are less likely to 
suffer medical disability and who have undergone an initial examination 
and certification prior to first solo flight. Those individuals 
manifesting conditions that represent a risk to safety will be denied 
certification or, after individual evaluation, will be restricted in 
their flying activities or examined more thoroughly and frequently, or 
both. Those individuals who meet the published medical standards but 
whose conditions require more frequent scrutiny will, under the new 
amendment, be issued medical certificates with a validity of 2 years 
rather than the longer period which they may otherwise be granted. With 
routine medical examination frequency increasing with age as proposed, 
aviation safety will be maintained.
    Both the AMA report and the Hopkins' analysis confirm the greater 
incidence of medical pathology in older persons. FAA analysis also 
confirms that the incident of accidents generally increase with an 
increase in age. It is prudent, therefore, to leave the current routine 
periodic examination requirement unchanged for persons age 40 but less 
than age 70 and to increase the frequency of examination for persons 
age 70 and older.
    All third-class airman medical certificates or third-class 
privileges of a first- or second-class medical certificate issued prior 
to the effective date of a final rule will remain valid for 2 years 
from the date of issuance unless the validity period has been otherwise 
limited by the FAA. The period of validity for all third-class airman 
medical certificates or third-class privileges of a first- or second-
class medical certificate issued on or after the date of a final rule 
will be calculated according to the provisions of the final rule unless 
the validity period has been otherwise limited by the FAA.
    Because of the increased public responsibilities associated with 
commercial pilot privileges, the FAA does not plan at this time to 
change the frequency of examinations for first- or second-class medical 
certificates for operations requiring an airline transport pilot, 
commercial pilot, or air traffic control tower operator certificate. 
Similarly, the agency does not plan now to revise the validity period 
of student pilot certificates, now 2 years as set forth in Sec. 61.19, 
though these are usually issued in combination with the third-class 
medical certificate. A student pilot whose student pilot certificate 
has expired but whose third-class medical certificate remains valid, 
may obtain a new student pilot certificate from an FAA operations 
inspector as provided in Sec. 61.85(b).
    Section 61.53 of the FAR provides that: ``No person may act as 
pilot in command, or in any other capacity as a required pilot flight 
crewmember while he [or she] has a known medical deficiency, or 
increase of a known medical deficiency, that would make him [or her] 
unable to meet the requirements for his [or her] current medical 
certificate.'' This amendment does not change Sec. 61.53, and the FAA 
continues to require airmen to comply with that rule. In reducing the 
frequency of required periodic contacts with knowledgeable health 
professionals, self-monitoring and personal attention to health become 
a more important part of the individual airman's responsibility for 
flight safety. This notice also proposes to amend Sec. 61.39 to require 
that applicants must possess at least a third-class medical certificate 
or the third-class privileges of a first- or second-class medical 
certificate valid under proposed Sec. 61.23 in order to be eligible for 
a flight test for a certificate, or an aircraft or instrument rating. 
The proposal amends Sec. 69.39 to coincide with the duration changes in 
Sec. 61.23, as discussed above.
    As noted above, the FAA developed its proposal through review of 
the literature, survey of the medical practices of the Department of 
Defense, analysis of National Transportation Safety Board (NTSB) 
accident data and its own aeromedical certification data, consideration 
of the data developed by the Johns Hopkins University, and in 
consideration of the part 67 proposal announced in this notice. The 
proposed examination spacing represents the agency's view of an optimum 
schedule in terms of estimated detectable pathology in the airman 
population and of the burden of required examinations.
    No change in the scope of required examinations was proposed by 
Notice 82-15, Duration of Medical Certificates. Where an applicant for 
medical certification demonstrates by history or by findings that 
additional or more detailed medical evaluation is required, current 
regulations permit the FAA to obtain it. The routine examination used 
for many years has proven adequate for the identification of those 
airmen who should be further evaluated yet places only minimum burden 
on that majority of persons who can be immediately certificated. 
Nevertheless, the FAA announced and conducted a complete review of the 
standards for airman medical certification (47 FR 16298, April 15, 1982 
and 47 FR 30795; July 15, 1982), and examination scope was one object 
of the review. The larger part of this notice announces proposals 
related to standards and administrative procedures for airman medical 
certification.

History of Medical Standards

    Airman medical standards have been in effect for many years. The 
1938 Code of Federal Regulations (14 CFR parts 20 and 21, 1938) under 
the authority of the Air Commerce Act contained minimum requirements 
for the physical condition of airmen. The early rules did not provide 
for the issuance of airman medical certificates. However, they did 
require that an appropriate physical examination be given before a 
pilot could be tested for a pilot certificate. In 1942, a system for 
the issuance of medical certificates was adopted that provided for the 
issuance of first-, second-, and third-class medical certificates.
    Discretion in the issuance of medical certificates has always been 
a feature of the FAA medical certification system. Over the years this 
feature has been modified but the basic provision for special issuance 
of a medical certificate to a person who does not meet the required 
medical standards has remained. To be granted a special issuance, an 
airman has had to demonstrate by operational experience, flight 
testing, special practical evaluation, or a special medical evaluation 
that he or she can carry out the appropriate airman duties without 
endangering public safety during the prescribed time period of the 
medical certificate.
    A number of specific changes to the medical standards took effect 
in 1959. Electrocardiographic examination was required of first-class 
certificate applicants. The ECG is to demonstrate the absence of 
myocardial infarction and to identify other cardiovascular conditions. 
A second amendment provided for additional medical standards related to 
a person's general physical condition and nervous system. These 
revisions were based primarily on a study conducted by the Flight 
Safety Foundation, Inc. (FSF). The study proposed that the existing 
certification criteria be expanded to cover the following specific 
medical conditions:
    (1) An established diagnosis of diabetes requiring insulin or other 
hypoglycemic treatment agents;
    (2) A history of myocardial infarction or other evidence of 
coronary artery disease; and,
    (3) A history of an established diagnosis of psychosis, severe 
psychoneurosis, severe personality abnormality, epilepsy, chronic 
alcoholism or drug addiction.
    The FSF position was that the existence of any of the above 
conditions was an appropriate basis for disqualification for any class 
of medical certificate. The FSF based its recommendation on the belief, 
at that time, that medical prognostication for these conditions was too 
imprecise to provide assurance that these conditions would not 
interfere with the safe piloting of an aircraft. The FSF found that the 
likelihood of an occurrence of a partially or totally incapacitating 
state directly related to these conditions was so great that an airman 
with one of these conditions posed a potential hazard to flight safety. 
As a result of the FSF's recommendations, the procedures were amended 
to prohibit the granting of special issuances to airmen with these 
conditions. The Federal Aviation Act of 1958, however, provided for the 
granting of exemptions by the Administrator. In 1960, the FAA specified 
that the existing general exemption procedures applied to the medical 
standards.
    Rapid developments in medical knowledge about the disqualifying 
conditions and the development of improved techniques for prediction of 
their risk for incapacitation led the FAA shortly afterwards to grant 
exemptions, with appropriate limitations, to many persons with these 
conditions. Though exemptions were available, requests from individuals 
with severe manifestations of some conditions were denied.
    In 1971, the authority to grant or deny petitions for exemption 
from part 67 was delegated to the Federal Air Surgeon (Amendment 11-11; 
36 FR 3462; February 25, 1971). This revision was designed to reduce 
administrative processing time and lower costs for the FAA in the 
granting of exemptions. The FAA granted over 3,000 medical exemptions 
in the ensuing years. Overall, the safety record of airmen who were 
granted exemptions has been at least as good as that of the general 
population of airmen who hold medical certificates issued under the 
medical standards.
    In 1982, the FAA amended part 67 in several areas (47 FR 16298; 
April 15, 1982). First, any disqualifying condition which previously 
required a formal petition for exemption was permitted to be considered 
for certification through special issuance procedures. Second, the 
prerequisite agency administrative review and decision process leading 
to eligibility for NTSB review of denial actions was streamlined. 
Third, authority was delegated to the Federal Air Surgeon to place 
functional limitations on medical certificates. Fourth, Sec. 67.19 was 
amended to state that the Federal Air Surgeon, in granting special 
issuances to applicants for private pilot certificates, considers the 
freedom of these applicants to accept reasonable risks to their person 
or property that are not acceptable in the exercise of commercial or 
airline transport privileges, and at the same time, considers the need 
to protect the safety of persons and property in other aircraft and on 
the ground. Fifth, clarifying interim cardiovascular standards were 
issued. Sixth, the alcoholism standard was revised to conform to the 
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and 
Rehabilitation Act of 1970. In addition to the amendments to part 67, 
the preamble to the 1982 final rule announced that in accordance with 
Executive Order 12291, Federal Regulations, the FAA would undertake an 
overall review of the medical standards in part 67. This total and 
comprehensive review was described as a major rulemaking effort that 
would involve obtaining the views of the medical profession and all 
other interested parties and result in significant revision of part 67.

Reference

    Review of Part 67 of the Federal Air Regulations and the Medical 
Certification of Civilian Airmen; Engelberg, A.L., Doege, T.C.; 
American Medical Association, under contract to DOT (DTFA01-83-C-
20066); March 1986.
    This document is available from the National Technical Information 
Service, 5285 Port Royal Rd., Springfield, VA 22161 (accession numbers 
AD A166 464, Volume I ($31), and AD A166 465, Volume II ($53). There is 
also a handling charge of $3 for purchase by wire or mail. A synopsis 
of the 750-page, 2-volume report was published in the Journal of the 
American Medical Association (JAMA Vol. 255, No. 12, pp. 1589-1599) on 
March 26, 1986, and is available at many libraries and has been placed 
in Docket No. 23190.

Current Requirements--Medical Certification of Airmen

    Part 67 of the FAR provides for the issuance of three classes of 
medical certificates. A first-class medical certificate is required to 
exercise the privileges of an airline transport pilot certificate. 
Second- and third-class medical certificates are needed to exercise the 
privileges of commercial and private pilot certificates, respectively.
    An applicant who is found to meet the appropriate medical 
standards, based on a medical examination and an evaluation of the 
applicant's history and condition, is entitled to a medical certificate 
without restrictions or limitations other than the prescribed 
limitation as to its duration. These medical standards are currently 
set forth in Secs. 67.13, 67.15, and 67.17 (14 CFR part 67).
    An applicant for a medical certificate who is unable to meet the 
standards in Secs. 67.13, 67.15, or 67.17 may, nevertheless, be issued 
a medical certificate. Procedures for granting special issuances or 
exemptions have always been available, and, thus, the standards have 
never been ``absolutely disqualifying,'' in the sense that 
certification is permanently denied all who do not meet the standards.
    Under Sec. 67.19, ``Special issue of medical certificates,'' at the 
discretion of the Federal Air Surgeon, acting on behalf of the 
Administrator under Sec. 67.25 of the FAR, a special flight test, 
practical test, or medical evaluation may be conducted to determine 
that, notwithstanding the applicant's inability to meet the applicable 
medical standard, airman duties can be performed, with appropriate 
limitations or conditions, without endangering public safety. If this 
determination can be made, a medical certificate may be issued with 
appropriate limitations to ensure safety.

Discussion of the Proposal

    The FAA proposes to amend part 67 to incorporate additions and 
changes in the specific medical standards and scope of examination and 
in the administrative procedures pertaining to airman medical 
certification. The FAA also proposes to recodify and partly reorganize 
part 67 to improve readers' accessibility to specific standards and 
procedural requirements. Additional changes are proposed to improve 
syntax and correct errors. Section and sub-section references are 
adjusted as necessary to reflect additions, deletions, and 
reorganization. Because the proposed medical standards are not meant to 
be exhaustive in naming all medical conditions that are disqualifying, 
the word ``includes'' rather than the word ``are'' is used in each 
section of the medical standards. Disqualifying medical conditions are 
not limited to those representative conditions listed in the proposed 
standards. Medical conditions may be identified during an examination 
which are related to a specific medical category of a section in the 
proposed standards but are not specifically named in the standards 
(e.g., respiratory malignancy). These medical conditions would be 
considered under the General Medical Condition section of the medical 
standards.
    The proposal is based on the FAA's review of part 67, on the FAA's 
judgment regarding the AMA Report recommendations, and on public 
comment relevant to those recommendations and to the standards 
generally. The following discussion of the proposal presents under each 
subject heading a discussion of the current rule, the AMA 
recommendations, and the proposed rule. Also included in this preamble 
is a response to the comments received on the review of part 67 (Docket 
No. 23190).

Distant Visual Acuity

    The current standards for applicants for first- or second-class 
airman medical certificates require that the uncorrected distant visual 
acuity be not poorer than 20/100 and the corrected acuity not poorer 
than 20/20 in each eye, separately. Applicants for third-class 
certificates are required to meet a standard of distant visual acuity 
of 20/50 or better in each eye, separately, without correction; or, if 
poorer than 20/50, a corrected distant visual acuity of 20/30. For 
third-class airman medical certification there is no standard for 
minimum acceptable uncorrected distant visual acuity.
    The FAA practice for many years has been to grant any class 
certificate requested, regardless of uncorrected distant acuity, if the 
required minimum vision is present or achieved through conventional 
corrective lenses (spectacles or contact lenses), there is no evidence 
of significant eye pathology, and the person is otherwise eligible. For 
first- and second-class certification, this has been accomplished 
through the special issuance process.
    Thousands of airmen exercising airline transport pilot, commercial 
pilot, private pilot, student pilot, and air traffic control tower 
operator certificates have demonstrated their ability to safely perform 
their jobs while using corrective lenses for distant visual acuity that 
is poorer than 20/100 in each eye.
    The AMA Report recognizes that the uncorrected distant visual 
acuity standards for first- and second-class certification may be too 
stringent and recommends that they be changed from 20/100 to 20/200 
without offering a rationale for the specific recommendation of 20/200. 
The FAA notes that this recommended standard is consistent, in part, 
with the standards of the International Civil Aviation Organization 
(ICAO).
    In response to the AMA recommendation, in mid-1986, the agency 
simplified the procedure for special issuance of certification in cases 
where the applicant for a first- or second-class certificate 
demonstrates uncorrected distant vision worse than 20/100 but not worse 
than 20/200. AME's were given permission to evaluate applicants without 
further referral to eye specialists or to the agency for decision. In 
the absence of significant eye pathology, the AME may, after telephone 
coordination with the agency, issue any class certificate. Individuals 
whose distant vision is poorer than 20/200 can be granted certification 
only by the FAA, after evaluation by an eye specialist. The FAA has 
found through experience that safety is not adversely affected by 
permitting medical certification at any level of uncorrected acuity. 
Little, if any, disqualifying eye pathology is found through the 
special evaluations of applicants whose vision corrects to acceptable 
levels, and AME's are able to identify those whose findings suggest the 
need for further examination by specialists. Therefore, the FAA 
proposes under Secs. 67.103(a) and 67.203(a) the deletion of the 
current uncorrected acuity standard for first- and second-class 
certification, thereby administratively simplifying the certification 
process and reducing costs to airmen and to the agency. The FAA 
intends, however, to retain the current requirement for first- and 
second-class certification that distant visual acuity be, or correct 
to, not poorer than 20/20 in each eye separately.
    For third-class certification the FAA proposes under Sec. 67.303(a) 
that the standard be amended to require a distant visual acuity of not 
poorer than 20/40 in each eye, separately, with or without correction. 
This amendment eliminates the confusing current minimum acuity standard 
(20/30 if corrective lenses are used and 20/50 if not used) and is 
consistent with safety and with the standards commonly used by state 
automobile driver licensing authorities. It also reflects the ICAO 
standards for private pilots, and it includes the AMA Report 
recommendation for minimum distant visual acuity without correction.

Near Visual Acuity

    The current near visual acuity standard for first-class medical 
certification is expressed as ``* * * at least v=1.00 at 18 inches with 
each eye separately, with or without corrective glasses.'' The near 
visual acuity standard for second-class medical certification is based 
on the ability to pass a test showing that the applicant can read 
official aeronautical maps. Currently the rules for third-class medical 
certification have no near visual acuity requirements.
    The AMA Report recommends several revisions to the near visual 
acuity standards. The AMA Report points out that the current vision 
terminology of first-class medical certification is antiquated and 
unfamiliar to most AME's and ophthalmologists. The AMA also notes that 
the Near Vision Acuity Test Card, FAA Form 8500-1, contains letters 
that are to be used at 16 inches while the current standards are 
established for 18 inches.
    The AMA Report recommends the same near visual acuity standards for 
all three classes of medical certification: a near vision of 20/40, 
Snellen equivalent, at 16 inches in each eye separately, with or 
without corrective lenses. In addition, the AMA Report recommends, at 
age 50 or older, a near vision standard of 20/40, Snellen equivalent, 
at both 16 inches and 32 inches in each eye separately, with or without 
corrective lenses.
    Additional requirements are imposed after age 50 because, with age, 
the eye loses the ability to accommodate for close viewing distances, a 
condition called ``presbyopia.'' The AMA Report states:

    It is important while piloting to be able to see clearly at 
close distances, as when looking at maps, and at intermediate 
distances, as when viewing the instrument panel. This is especially 
important in night flying. Diminished intermediate visual acuity due 
to presbyopia in an individual 50 years of age or older may be 
further compromised by bifocal correction. Trifocal or progressive 
power lenses may be necessary for clear vision at distance, 
intermediate, and near.

The AMA Report recommends that the appropriate necessary corrective 
lenses must be worn while exercising the privileges of the certificate.
    The proposed rule at Secs. 67.103(b) and 67.203(b) follows the AMA 
Report recommendations except that a standard for intermediate visual 
acuity is not proposed for third-class medical certification (see 
proposed Sec. 67.303(b)). Also, the proposed rule would require only 
that the corrective lenses be available while exercising the privileges 
of the certificate.
    The FAA is not proposing an intermediate visual acuity standard for 
third-class certification in recognition of the lower level of 
responsibility inherent in noncommercial flight operations.
    The proposal does not require that corrective lenses for near or 
intermediate visual acuity be worn during all flight operations because 
this is a matter better left to the discretion of the pilot. FAA 
practice and the FAR currently permit airmen to exercise their 
certificates when any required corrective lenses for near vision are in 
their possession. This permits, at the airman's option, use of separate 
near and distance spectacles; contact lenses for distance with the 
addition of spectacles for near; unifocal contact lenses that correct 
for both near and distance; bifocal spectacles; or continuously 
variable focus spectacles. If the airman requires correction only for 
near vision, spectacles, half-spectacles, or bifocal spectacles without 
power in the distance portion may be used.
    From among these options, an airman should be able to choose his or 
her method of visual correction while piloting an aircraft. A 
requirement that all airmen wear their correction for near vision while 
flying would significantly and, in the absence of demonstrated 
problems, unnecessarily limit their choice of visual aids. The FAA has 
no evidence that significant operational problems are occurring with 
the use of corrective lenses for near vision. Therefore, the proposed 
requirement for corrected intermediate vision in older airmen can be 
met through possession of additional spectacles of the appropriate 
power or by use of trifocal lenses or lenses of continuously variable 
focus, as desired.

Color Vision

    The current standards for first-class medical certification require 
``normal color vision'' (Sec. 67.13(b)(3)); second- and third-class 
certification require ``ability to distinguish aviation signal red, 
aviation signal green, and white.'' (Secs. 67.15(b)(5) and 
67.17(b)(3)).
    In current practice, applicants for certification are tested by use 
of standard pseudoisochromatic plates or by other approved devices. A 
passing score defines the applicant as not color deficient. Failure 
indicates a color deficiency and requires that any certificate issued 
be limited, prohibiting flight at night or by color signal control. 
This limitation can, however, be removed through the successful 
completion of a practical signal light test or of a medical flight 
test, as appropriate for the class certificate sought and the level of 
aviation experience of the applicant.
    Airmen are routinely granted second- or third-class medical 
certificates without restriction if they pass the signal light test. 
When they have the experience required for an airline transport pilot 
certificate and pass the medical flight test, first-class certification 
is granted. An experienced airman rarely fails a medical flight test 
given for deficient color vision.
    Safety is further enhanced by the thorough training and testing 
given airmen seeking authorization to pilot new aircraft. Through use 
of actual aircraft or of simulators, instructors, check airmen, and 
flight inspectors have an opportunity to identify and, if necessary, 
recommend restrictions for those individuals who encounter difficulty 
with color.
    The AMA Report states:

* * * the hazard to aviation safety of anomalous color vision is not 
clear. No studies have shown that color deficiency has been a direct 
cause of accidents. On the other hand, color is an important 
constituent of aircraft devices such as instrument panel gauges and 
warning lights, and of airport landmarks, such as beacons and runway 
lights.

The AMA Report recommends that testing for color vision remain part of 
the routine periodic examination of airmen. The suggested standards 
include the retention of ``normal color vision for first-class 
certification and ``ability to distinguish aviation signal red, 
aviation signal green, and white'' for third-class certification. The 
AMA Report suggests, however, that the standard for second-class 
certification be changed to that for first-class. The AMA Report notes 
an increasing use of color in instrument displays for advanced aircraft 
but less frequent use of colored signal lights in today's flight 
environment. Despite these diverging trends and the absence of accident 
data, prudence dictates some continued concern for the color perception 
of airmen.
    The FAA, therefore, proposes at Secs. 67.103(c), 67.203(c), and 
67.303(c) that testing at the time of the periodic medical examination 
be continued as recommended, but that the standard for all classes of 
certification be, ``Ability to perceive those colors necessary for the 
safe performance of airman duties.'' The standard is consistent with 
that of the ICAO and reflects the agency's experience and practice for 
many years. Tests, instructions, and scoring criteria are provided to 
AME's in the ``Guide for Aviation Medical Examiners.''
    Certification relative to deficient color vision ultimately is 
based on performance. It is appropriate, therefore, that the standard 
be related to the job requirement and that it be the same for each 
class of medical certificate.

Other Pathology of the Eye

    The current standard is worded differently for each class of 
certification but without significant difference of meaning. In 
accordance with the AMA recommendations, therefore, revision is made to 
correct the spelling of the plural word ``adnexa'' and to provide for 
the same standard for all classes of certification, at proposed 
Secs. 67.103(e), 67.203(e), and 67.303(d).

Eye Fusion

    This standard, which applies only to first- and second-class 
certification, is revised to correct spelling and to eliminate gender-
specific pronouns. No substantive revisions are proposed for this 
standard. (See proposed Secs. 67.103(f) and 67.203(f)).

Intraocular Pressure

    The AMA Report recommends for all three classes of certification 
the measurement of intraocular pressure after the age of 40 to identify 
glaucoma. The basis for this recommendation is that glaucoma may appear 
in two forms. One, closed-angle glaucoma, is acute, painful, and 
potentially impairing; the other, open-angle glaucoma, is subtle, 
painless, and progressive. Either form can be destructive to vision. 
Since, in many cases, open-angle glaucoma is not noticed by the 
individual until after permanent changes in visual fields have 
occurred, a search for it should be a part of any routine health 
maintenance examination.
    Current regulations have no standard for intraocular pressure, 
however, and the FAA is not proposing standards at this time. While the 
recommendations of the AMA Report suggest that everyone might benefit 
from regular measurement of intraocular pressure, the risk to flight 
safety appears minimal in comparison to the cost and difficulty of 
testing.

Hearing

    Current standards for hearing are as follows: (1) for first-class 
medical certification the person must be able to hear the whispered 
voice at 20 feet with each ear separately or demonstrate a hearing 
acuity of at least 50 percent of normal in each ear as shown by a 
standard audiometer; (2) for second-class certification, the person 
must be able to hear the whispered voice at 8 feet in each ear 
separately; and (3) for third-class certification, the person must be 
able to hear the whispered voice at 3 feet in one ear. The use of the 
whispered voice has raised questions of accuracy and validity in the 
aviation environment. Pure tone audiometry is considered a more 
scientific and accepted method for determining hearing capabilities and 
for documenting changes in that capability over a period of time. The 
present procedure, however, has served well in enabling AME's to 
identify for referral and evaluation those individuals whose hearing 
acuity is less than normal.
    Testing accomplished by the AME serves as a screen to identify 
those individuals who should receive more specialized initial and 
periodic future evaluations. Almost all hearing-impaired applicants, 
however, receive special issuance of a certificate after documentation 
of their condition. Many undergo practical testing to determine their 
functional aviation capabilities. In the absence of other significant 
pathologic conditions, the certification decision regarding hearing 
relates only to the individual's ability to safely exercise airman 
privileges. Medical flight tests are used frequently for this 
determination, and the subject may use hearing aids, if necessary. 
Though an airman may regularly use a hearing aid for activities not 
involving flight, the normal aircraft communication equipment may serve 
as well, and the agency does not, in such cases, mandate the wearing of 
an aid. Special issuance is possible, especially for applicants for 
third-class medical certification, in the presence of total deafness. 
Restrictions on the exercise of airman privileges are applied to 
maintain safety in cases of total or functionally significant deafness, 
and agency experience demonstrates that these practices have been 
successful and appropriate.
    The AMA Report recommends that speech discrimination be the basic 
screening examination used for certification for all three classes. If 
sound field or speech testing audiometry equipment is unavailable, pure 
tone audiometry is offered as an alternative. Speech testing would be 
accomplished either binaurally or monaurally, while pure tone 
audiometry would apply a ``better ear'' and ``poorer ear'' standard. 
The AMA Report suggests individual consideration when an applicant 
fails the standard tests.
    The FAA agrees with the AMA Report that the standards for hearing 
and for testing should be the same for all classes of medical 
certification.
    However, it is unlikely that equipment appropriate for speech 
discrimination testing, as proposed by the AMA Report, will be 
available to all AME's. In keeping with the intention of the AMA Report 
and in the interest of cost, availability, simplicity, and functional 
adequacy, the FAA believes and, therefore, proposes at Secs. 67.105(a), 
67.205(a), and 67.305(a) that the basic screening test administered to 
all applicants be a spoken voice test. This test is included as part of 
Hearing Requirement No. 1 and Hearing Requirement No. 2, Chapter 6.-- 
Medical Requirements, Personnel Licensing, International Standards and 
Recommended Practices, Annex 1 to the Convention on International Civil 
Aviation, ICAO. It has been implemented in many countries and is easily 
described and administered. The conversational voice test is not 
inconsistent with the AMA Report emphasis on speech discrimination. The 
proposed standards would require that a person be able (1) to hear an 
average conversational voice in a quiet room, using both ears, at a 
distance of 6 feet; (2) understand speech by audiometric speech 
discrimination testing to a score of at least 70 percent obtained in 
one ear or in a sound field environment; or (3) provide acceptable 
results of pure tone audiometric testing in accordance with a table 
that is provided in the rule.
    Audiometric speech discrimination or pure tone audiometric testing 
are proposed as alternatives or for the further evaluation of 
individuals who show reduced hearing acuity in the conversational voice 
test. The proposed standard would apply to the examination of 
applicants without use of their hearing aids. Need for these devices to 
meet the standard suggests that a more detailed evaluation is 
appropriate before certification, and that special issuance with 
periodic reevaluation may be necessary.

Ear, Nose, Throat, and Equilibrium

    In addition to hearing (discussed above), current ear, nose, 
throat, and equilibrium standards specify: no acute or chronic disease 
of the middle or internal ear; no disease of the mastoid; no unhealed 
perforation of the eardrum; no disease or malformation that would 
interfere with or be aggravated by flying; and no disturbance in 
equilibrium.
    The AMA Report recommends, for all three classes, a change of the 
standard to specify, ``No acute or chronic disease of the middle or 
internal ear that will cause acute paroxysms or unpredictable attacks 
of vertigo.'' Also, the AMA Report recommends an additional standard 
that specifies, ``No disease or malformation of the oral cavity, 
pharynx, or larynx that would interfere with clear and effective speech 
communication.'' All other standards in the current rule would be 
deleted.
    For the most part, the proposed rule at Secs. 67.105(b), 67.205(b), 
and 67.305(b) follows the AMA Report recommendations. It requires that 
there be no ``disease or condition of the middle or internal ear, nose, 
oral cavity, pharynx, or larynx'' that will interfere with or be 
aggravated by flying or that will interfere with clear and effective 
speech communication. In addition, in the proposed rule at 
Secs. 67.105(c), 67.205(c), and 67.305(c) there may be no disease or 
condition that may involve vertigo or a disturbance of equilibrium.
    Current standards reflect specific concerns about infections of the 
ear and mastoid and the damage caused by such infections to the ear 
drum and middle ear. The proposed standards more generally and properly 
address diseases, or conditions of the ear, nose, or throat that may 
interfere with speech communication or equilibrium, factors that are 
important for safety.

Mental

    Mental disorders may adversely affect judgment and behavior in ways 
that create potential hazards in aviation. The current standards for 
all three classes of airman medical certification, therefore, list 
certain psychiatric disorders for which medical certification would be 
denied. The list was derived from the recommendations made by the 
Flight Safety Foundation in 1959. These disorders are considered to 
constitute a definite hazard to safety in flight when determined to be 
present in an airman by established medical history or by clinical 
diagnosis. As listed in the current regulations, any of the following 
disorders is a cause for denial: (1) a personality disorder that 
manifests itself in overt acts; (2) a psychosis; (3) alcoholism; and 
(4) drug dependence. In addition, the current standards provide for 
denial of medical certification in the presence of any ``other 
personality disorder, neurosis, or mental condition that the Federal 
Air Surgeon finds makes the applicant unable to safely perform the 
duties or exercise the privileges of the airman certificate that he 
holds or for which he is applying; or may reasonably be expected, 
within two years after the finding, to make him unable to perform those 
duties or exercise those privileges.''
    The mental standards have been well accepted by the public and by 
the medical community as practical and effective. However, with 
publication of the authoritative reference, Diagnostic and Statistical 
Manual of Mental Disorders, Third Edition (DSM III), changes in the 
diagnostic terminology and classification of mental disorders have 
caused some confusion. Major illnesses, previously included in the 
category of ``psychosis,'' are separately described in the DSM III and 
are, therefore, no longer considered by some others as covered under 
the term ``psychosis'' in the FAR. Since these conditions are of 
concern in the context of airman medical certification and flight 
safety, the agency must amend the mental standards to clarify the 
position of the FAA.
    The AMA Report recommends amendment of the regulations to include a 
more extensive and specific list of disqualifying mental disorders: 
substance abuse or dependence; schizophrenic disorders; paranoid 
disorders; psychotic disorders; major affective disorders (including 
bipolar disorders and depression); anxiety disorders; dissociative 
disorders; impulse disorders; disorders first evident in infancy, 
childhood, and adolescence; and organic brain syndrome.
    The proposed rule at Secs. 67.107 (a) through (c), 67.207 (a) 
through (c), and 67.307 (a) through (c) would include all of these 
disorders but would not specifically list them. The current and 
proposed mental standard lists a psychosis as a disqualifying disorder. 
The proposed standard states that ``psychosis'' refers to ``a mental 
disorder in which the individual has manifested psychotic symptoms or 
to a mental disorder in which an individual may reasonably be expected 
to manifest psychotic symptoms.'' In this way, two types of persons 
would be disqualified under this standard: those who have manifested 
psychotic symptoms; and those who have not had psychotic symptoms but 
whose mental condition is one in which psychotic symptoms may 
reasonably be expected to develop. Psychotic symptoms are characterized 
by a failure to maintain adequate contact with reality. The failure to 
maintain adequate contact with reality results in or may reasonably be 
expected to result in the impairment of judgment, including bizarre, 
grossly disorganized behavior; out of control behavior; delusions; or 
hallucinations. ``Psychosis'' would include schizophrenic disorders, 
paranoid disorders, and other disorders such as mood disorders, that 
sometimes manifest psychotic symptoms. Also included would be such 
conditions as schizotypal and borderline personality disorders. Other 
disqualifying disorders listed in the AMA Report that are not 
specifically listed in the proposed rule, such as anxiety disorders and 
impulse disorders, may be disqualifying under the general mental 
provisions of the regulations as they are now, depending on the 
severity of the disorders. The particular circumstances of each 
individual history and medical condition are considered by the FAA in 
determining whether such history or condition is disqualifying.
    The FAA also proposes, as recommended in the AMA Report, that 
bipolar disorder be added to the list of disqualifying conditions. 
Previously called manic depressive psychosis, this common, major 
affective disorder now is separately classified by DSM III and may 
include individuals who have manifested only mania. Bipolar disorder is 
not specifically referenced in current part 67. In consideration of 
potential risk to flight safety, individuals with this diagnosis are 
rarely granted certification. Those few individuals who are determined 
to be eligible for certification through the special issuance 
provisions of the FAR must be followed closely for relapse and 
recurrence of symptoms. By including the new terminology, the standards 
will clearly reflect the agency's concern about this disorder. 
(Discussion of how a proposed disqualifying condition may affect a 
current medical certificate appears under ``Additional Standards for 
Disqualification.'')

Substance Abuse/Dependence

    Additional proposed changes in the mental standards for airmen are 
influenced by DSM III nomenclature for conditions involving dependence 
on or abuse of alcohol, drugs, or other chemical substances. Current 
regulations list as disqualifying ``alcoholism'' and ``drug 
dependence.'' The AMA Report points out that DSM III eliminates the 
term ``alcoholism'' and substitutes the diagnosis of ``substance 
dependence'' and ``substance abuse.'' As disqualifying conditions, the 
AMA Report recommends ``substance abuse, substance dependence and 
related substance use disorders, including but not limited to those 
associated with alcohol; barbiturates; other sedative/hypnotics; muscle 
relaxants; anxiolytics; opioids; central nervous system stimulants such 
as cocaine and amphetamines; and hallucinogens such as phencyclidine, 
cannabis, and volatile solvents and gases.''
    The proposed rule differs from the AMA recommendations in that (1) 
``barbiturates'' are not specified separately since they would be 
included with ``sedatives and hypnotics;'' (2) the phrase ``and 
similarly acting sympathomimetics'' would be added to the grouping of 
``cocaine'' and ``amphetamines;'' and (3) ``phencyclidine or similarly 
acting arylcyclohexylamines,'' ``cannabis,'' and ``volatile solvents 
and gases'' are listed separately rather than grouped under 
``hallucinogens.'' Additionally, the phrase ``related substance use 
disorders,'' as proposed, but not defined in the AMA Report, is not 
included in this proposal.
    The proposed standard defines ``substance dependence'' and 
``substance abuse.'' A medical history or clinical diagnosis of 
``substance dependence'' would disqualify a person for a medical 
certificate under the standards unless there is evidence of recovery 
satisfactory to the Federal Air Surgeon. The proposed changes also are 
intended to provide specific regulatory medical standards for excluding 
from aviation a person who, though not substance dependent, has abused 
alcohol within the preceding 2 years or other substances within the 
preceding 5 years. These proposed standards respond to the AMA Report 
as well as to national concerns about substance abuse. These standards 
would enhance the agency's ability to examine and to exclude, where 
medically appropriate, those airmen who have abused a substance within 
the time frames stated above or who have a medical history or a 
clinical diagnosis of substance dependence. The proposed mental 
standard retains, however, current language that permits medical 
certification under the standards upon presentation of acceptable 
evidence of recovery and a specified period of abstinence in the case 
of alcohol dependence. The proposed rule provides that clinical 
evidence of recovery would include sustained total abstinence from 
alcohol for not less than the preceding 2 years in the case of alcohol 
dependence, and in the case of other substance dependence, sustained 
total abstinence from the substance for not less than the preceding 5 
years. The time periods for sustained total abstinence are based on the 
AMA recommendations. Other factors considered in determining recovery 
include the natural history and severity of the problem; the period of 
satisfactory recovery since manifestation of the problem; any 
treatment, as well as any continuing requirements for treatment, and 
its nature; any current or recent psychiatric symptoms, aberrant 
behavior, or psychiatric or other medical findings; the need for or use 
of chemical agents; any personality traits or other recognized factors 
involving the risk of future recurrence of the problem or the risk of 
other adverse events; the period of the person's abstinence from the 
substance or substances; the number of times treatment was sought and 
relapse occurred; the quality of the final treatment effort; the 
presence of residual medical complications, especially neurologic 
manifestations; progress in marital, social, vocational, and 
educational areas, as appropriate, since rehabilitation began; 
commitment to rehabilitation by virtue of continuing contacts with 
social or professional agencies, or both, and their opinions and 
recommendations; and the findings of recent psychiatric and psychologic 
evaluations, if appropriate.
    The proposed definition of substance abuse includes two criteria 
(the first relates to alcohol, the second to other substances) that 
state a person would be disqualified if he or she demonstrated 
recurrent use of a substance in situations in which that use was 
physically hazardous. At least one of the uses would have to have taken 
place within the preceding 2 years in the case of alcohol or 5 years in 
the case of other substances. Under this criterion, use in physically 
hazardous situations need not involve the same substance or substances.
    A third criterion states that a person who used a prohibited drug 
as that term is defined in part 121, appendix I of the FAR would be 
disqualified. The prohibited drug use would have to have taken place 
within the preceding 5 years. ``Prohibited drugs'' as defined in the 
FAR do not include all substances; however, ``substances'' as defined 
in this proposal do include all prohibited drugs. Alcohol, for example, 
is a substance which may be abused but is not a prohibited drug as that 
term is defined under appendix I of part 121.
    A positive drug test result for a prohibited drug is one type of 
evidence of use. The FAA recognizes that the probative value of a drug 
test result varies depending on several factors, including the type of 
test, circumstances under which the test was conducted, and other 
corroborative evidence of drug use. The FAA considers a positive drug 
test conducted under any rule or internal program of the Department of 
Transportation (such as the FAA program required by Secs. 121.457 and 
135.251 or any other Administration within DOT) to be compelling proof 
of the use of a prohibited drug for which the drug test was positive.
    With respect to positive drug tests other than those conducted 
under rules or internal programs of the Department of Transportation, 
the FAA would evaluate such test results and the surrounding 
circumstances on a case-by-case basis to determine the weight to be 
accorded them. If one of these tests is positive for substance use, the 
individual could be disqualified under the criteria used in the 
definition of substance abuse or substance dependence.
    A fourth substance abuse criterion states that an individual is 
medically disqualified if he or she misused a substance that is found 
by the Federal Air Surgeon to make the person unable to safely perform 
the duties or exercise the privileges of the airman certificate applied 
for or held; or may reasonably be expected, within 2 years after the 
finding, to make the person unable to perform those duties or exercise 
those privileges. The finding of the Federal Air Surgeon is based on 
the case history and appropriate, qualified medical judgment. Again, as 
in the two previous criteria the misuse must have taken place within 
the preceding 2 years in the case of alcohol or 5 years in the case of 
other substances.
    As with the current regulation, certification before completion of 
the 2- or 5-year abstinence/recovery period is possible under the 
special issuance provisions of the FAR if an individual evaluation 
demonstrates that the applicant is able to perform airman duties 
without endangering public safety.

Neurological Conditions

    Current regulations on neurological conditions list as 
disqualifying for all three classes anyone with a history or clinical 
diagnosis of epilepsy or disturbance of consciousness without 
satisfactory medical explanation of cause. Nor may a person have any 
other convulsive disorder, disturbance of consciousness, or 
neurological condition that the Federal Air Surgeon finds makes the 
person unable to perform airman privileges safely, or may reasonably be 
expected, within 2 years after the finding to make the airman unable to 
perform airman privileges.
    A detailed discussion of neurological conditions, their evaluation, 
and prognosis is provided within the AMA Report. Additional information 
and recommendations are contained in ``Neurological and Neurosurgical 
Conditions Associated with Aviation Safety,'' a major report prepared 
in 1979 by representatives of the American Academy of Neurology and the 
American Association of Neurological Surgeons through an earlier 
contract between the FAA and the AMA. Neither report proposes detailed, 
objective criteria and tests that could be included in the standards 
and by which medical certification could be determined. They discuss 
the medical techniques now available for evaluation of individual 
airmen and the significance of the results obtained from their use.
    Both reports emphasize the significance of seizure disorders. The 
few changes to the standards suggested by the AMA Report are proposed 
by the FAA at Secs. 67.109, 67.209, and 67.309, for all three classes 
of airman medical certificates and include the addition of ``a single 
seizure'' to the list of disqualifying conditions; the use of 
``seizure'' rather than ``convulsive'' to describe disorders that may 
be found disqualifying by the Federal Air Surgeon; and the addition of 
a ``transient loss of control of nervous system function(s) without 
satisfactory explanation of the cause'' as a specific basis for 
disqualification. This last proposed addition clarifies the agency's 
aeromedical concern about such events whether or not they are 
characterized as disturbances of consciousness. (Discussion of how a 
proposed disqualifying condition may affect a current medical 
certificate appears under ``Additional Standards for 
Disqualification.'')
    Other neurological conditions described in the AMA Report, though 
of significance in questions of aeromedical certification, are not 
proposed as separate standards. The proposed regulatory provisions 
provide an adequate medical basis for assuring safety.
    The AMA Report recommended that an abbreviated mental examination 
of four questions be included in each airman medical certification 
examination. If one or more responses are incorrect, the Mini-Mental 
Status Examination of Folstein, Folstein and McHugh (Folstein) would be 
given. The FAA studied the feasibility of the AMA Report's 
recommendation. It found that neither the AMA-recommended test nor the 
test by Folstein provides a useful screening device, alone or in 
combination, for airman neurological status. There was an unacceptable 
incidence of false negatives. Additionally, neither test, alone or in 
combination, provides predictors of any skills known to be relevant to 
piloting.

Cardiovascular Conditions

    To meet its statutory responsibility to ensure public safety, on 
May 17, 1982 (47 FR 16298; April 15, 1982), the FAA amended part 67 of 
the FAR in part to clarify the cardiovascular standards. This change 
codified FAA policy that individuals with a history of coronary heart 
disease not be medically certificated for the exercise of airman 
privileges under Secs. 67.13, 67.15, or 67.17. These individuals would 
continue to be certificated through the discretionary special issuance 
procedures after a separate determination that their disease no longer 
represents a risk to aviation safety. During that rulemaking procedure, 
a number of commenters expressed the belief that the cardiovascular 
standards for medical certification should be relaxed. Commenters also 
suggested that those standards be revised to set forth more detailed, 
objective criteria and tests by which medical certification could be 
determined, and a group of concerned pilots submitted a petition for 
rulemaking (to be discussed later in this document) that was intended 
to accomplish such a revision. Many commenters contended that the 
standards failed to take into account the advances in medicine that had 
occurred since part 67 was issued. The FAA announced that these issues 
would be addressed in its review of part 67.
    Accordingly, the FAA specifically asked the committee of 
consultants assembled by the AMA to review the cardiovascular standards 
in light of recent advances and current concepts in cardiovascular 
medicine. Further, the FAA asked the physicians to develop suggestions 
for inclusion of diagnostic and prognostic techniques in the standards, 
if appropriate and feasible. The final AMA Report, however, indicates 
that the group could not establish, in the standards, qualifications 
for medical certification. Instead, the AMA Report suggests general 
retention of the current cardiovascular standards and format with 
additions to further improve their utility for ensuring aviation 
safety. In the presence of known cardiovascular disease, certification 
decisions still would require professional evaluation of multiple 
medical factors rather than verification of the results of a test 
specified in the published standards. The individual airman who fails 
to meet the published standards would continue to be considered in 
accordance with the discretionary special issuance provisions.
    The AMA Report does recommend a number of changes. Additional 
cardiac conditions are suggested for inclusion in the standards as 
rendering an airman unqualified for certification; revised standards 
for acceptable blood pressure are given; maximum levels of blood 
cholesterol are proposed for some commercial airmen; and routine 
periodic electrocardiography for all airmen is recommended. Rather than 
changes to the standards, the AMA Report emphasizes the need for 
careful evaluation of all applicants prior to certification. Where 
individuals are found either to have cardiovascular disease or to have 
factors or findings indicative of increased risk, more exhaustive 
evaluations are suggested before certification can be granted and 
before periodic renewal of certification. Recommendations for these 
evaluations are included in the AMA Report and are generally consistent 
with long-standing FAA practice.

Coronary Heart Disease

    The FAA proposes that the present standards pertaining to coronary 
heart disease and its manifestations remain unchanged. As amended in 
1982, these standards are clear and have provided a firm medical basis 
for denying airman privileges to individuals with significant, active 
coronary heart disease who might endanger public safety. This condition 
precludes routine airman medical certification because it is a 
documented cause of in-flight pilot incapacitation, and it is 
progressive in nature.
    The FAA will continue to evaluate airmen who fail to meet this 
standard to determine their eligibility for a discretionary special 
issuance of medical certification. Certification will be based upon 
acceptable evidence that the individual has recovered and that his or 
her anatomic and physiologic cardiac status would justify the 
subsequent exercise of airman privileges. Appropriate functional 
limitations of airman privileges may be applied, and periodic follow-up 
medical reevaluations may be required to detect any relapse or 
progression of disease. This procedure protects the public while 
providing a means of relief for those individuals whose heart disease 
has stabilized sufficiently to pose an acceptable risk. Since adoption 
of the amendments in 1982, an increasing number of airmen have been 
found eligible and granted certification.

Additional Standards for Disqualification

    The FAA also proposes additions to the standards in proposed 
paragraphs (a) (4), (5), and (6) of Secs. 67.111, 67.211, and 67.311, 
providing that a history or clinical diagnosis of cardiac valve 
replacement, implantation of a permanent cardiac pacemaker, or heart 
replacement would make the subject person unqualified for certification 
under the standards. These amendments are consistent with the AMA 
Report and the opinions of agency consultants and reflect the serious 
nature of each of the conditions. Among the agency's concerns are 
failure of prosthetic heart valves, pacemaker malfunction or 
progression of underlying disease that has required artificial cardiac 
pacing, organ rejection, or the complications of immunosuppression. 
While the FAA may determine that an airman with a history or clinical 
diagnosis of any of these conditions may be granted a discretionary 
special issuance of certification, such history would preclude 
certification until specialized medical evaluation confirms adequate 
recovery and function and the absence of significant risk in terms of 
the aviation environment. Where special issuance of certification is 
granted, the regulations will provide for periodic medical 
reevaluations, if appropriate, for subsequent certification.
    Under the proposed medical standards, a small number of airmen, who 
currently hold certificates as a result of an order of the NTSB, would 
become disqualified from further medical certification because of the 
addition of specifically disqualifying medical conditions. These airmen 
had been denied medical certification by the FAA under a current 
general medical standard. Under the general medical standards, an 
individual is denied certification by the FAA when he or she has a 
condition which the Federal Air Surgeon finds may reasonably be 
expected to make the individual unable to safely perform pilot duties. 
For example, the FAA has denied certification to airmen who have had 
cardiac valve replacement and the NTSB has ordered certification in 
some of these cases. Under the proposed standards a medical history of 
cardiac valve replacement would be specifically disqualifying and those 
airmen would no longer be entitled to certification. It is expected, 
however, that the possible certification of such individuals would be 
reviewed under the Federal Air Surgeon's special issuance authority 
once the FAA evaluates the case and is satisfied with the airman's 
condition since the NTSB ordered certification. Such a disposition of 
these cases would be consistent with the FAA's practice after the 1982 
amendment of the cardiovascular standards rendered several airmen 
disqualified whose certification under the old medical standards had 
been ordered by the NTSB.

Other AMA Recommendations

    The AMA Report also suggests that certain other cardiac diagnoses 
be added to the standards as specific disqualifications. FAA 
certification experience, however, has not indicated a need for 
regulatory change in cases of cardiomyopathy, congenital heart disease, 
valvular heart disease or murmurs, pericarditis, or disturbances of 
heart rhythm or conduction. The agency agrees with the AMA Report that 
these conditions pose a potential risk but has found that the existing 
standards and procedures provide adequate opportunity for 
identification and evaluation of the affected airmen and a regulatory 
basis for denial of airman privileges, if appropriate.

Electrocardiography

    Current standards require that applicants for first-class medical 
certificates submit a resting, 12-lead ECG at the time of their first 
examination after reaching age 35 and, annually, after reaching age 40. 
They must show by these ECG's, ``an absence of myocardial infarction.'' 
An ECG made within the 90 days before an examination for a first-class 
medical certificate is accepted as meeting the requirement. There now 
is no routine requirement for submission of ECG's by applicants for 
second- or third-class medical certificates.
    The AMA Report notes that it is well established that up to 20 
percent of myocardial infarctions (``heart attacks'') fail to produce 
symptoms that bring a person to a physician. The resting ECG often 
shows evidence of a prior myocardial infarction and patterns of 
anatomic change and other abnormalities that are also associated with 
an increased risk of coronary artery disease. The AMA Report adds that 
many of the most common alterations of cardiac conduction seen on the 
routine ECG are not associated with symptoms or with easily discerned 
physical findings. Yet, each of these electrocardiographic findings 
causes special concerns regarding medical certification and may result 
in recommendations for additional assessment.
    The AMA Cardiovascular Committee, in recognition of these facts, 
recommended that the requirement for electrocardiography be modified in 
an effort to increase the assurance that significant cardiac disease in 
pilots will be detected. The committee suggested that, in addition to 
the current requirement for first-class certificates, an ECG be made on 
all applicants for medical certification at the time they first apply. 
These ECG's would serve as a valuable medical baseline for future 
comparison. Further, the committee recommended that an ECG be made on 
applicants for second-class medical certificates at ages 35 and 40 
years and every 2 years thereafter, and on applicants for third-class 
certificates at age 40 years and every 6 years thereafter. The 
committee also suggested that the standard be modified to include the 
agency's concern for any clinically significant electrocardiographic 
abnormality rather than the current limited specification of myocardial 
infarction alone.
    In proposed Sec. 67.211(d), all applicants for second-class airman 
medical certification would be required to submit ECG's at the first 
examination after reaching age 35 and, biennially, after reaching age 
40. There is reciprocity between the first- and second-class 
cardiovascular standards in satisfying the ``after reaching the 35th 
birthday'' and the ``after reaching the 40th birthday'' ECG 
requirements. For example, an application with an ECG that satisfies 
the ``age 35'' ECG requirement for first-class medical certification 
also satisfies the ``age 35'' ECG requirement of an application for 
second-class medical certification and vice versa. In the case of the 
``after reaching the 40th birthday'' ECG requirement, however, the time 
provisions of Secs. 67.111(d)(3) and 67.211(d)(3), as discussed below, 
are also required for reciprocity.
    The proposed time provision for the ``after reaching the 40th 
birthday'' periodic ECG for first-class medical certification requires 
that an applicant submit an ECG with the application unless, within the 
preceding 9 months, an ECG was provided as part of an application for 
medical certification. That is, if an applicant has submitted an ECG as 
part of an application for airman medical certification within 9 months 
of the current application, the applicant does not have to submit 
another ECG for the current application. Thus, after reaching the 40th 
birthday, a person who maintains a first-class medical certificate 
would be required to have an ECG at alternate applications or 
approximately every year. In a few cases, it could be 1 year and 3 
months between first-class ECG's. The time provision for the ``after 
reaching the 40th birthday'' periodic ECG for second-class medical 
certification is the preceding 15 months. An applicant maintaining a 
second-class medical certificate would be required to have an ECG at 
alternate applications or approximately every 2 years. In a few cases, 
it could be 2 years and 3 months between ECG's. The proposed 
requirement for first-class medical certification allows more leeway 
than the current rule. An applicant with a first-class medical 
certificate could wait up to 9 months and the ECG of the previous 
application for a first-class medical certificate would meet the 
requirement for the succeeding application for a first-class medical 
certificate. An applicant with a second-class medical certificate could 
wait up to 15 months and the ECG of the second-class medical 
certificate would meet the requirement for the succeeding application 
for second-class medical certification. No ECG requirement is being 
proposed for third-class medical certification.
    To ensure the currency of an ECG, the FAA proposes in 
Secs. 67.111(e) and 67.211(e) that if a person is required to submit an 
ECG as part of an application for medical certification, it must be 
dated no earlier than 60 days before the date of the application it is 
to accompany and must be performed and transmitted according to 
acceptable standards and techniques. Of course, there is no requirement 
to submit an ECG with a current application for medical certification 
if a previous ECG submitted as a part of an application for medical 
certification can satisfy any current ECG requirement. Sixty days is a 
longer period than the 30 days recommended by the AMA Report but 
represents a reduction from the 90 days now permitted. The agency 
recognizes that many ECG's are provided by employers or through private 
physicians other than the AME, and a reasonable period, such as that 
proposed, is appropriate for the airman's convenience. Finally, the FAA 
did not propose a baseline ECG be performed for either first- or 
second-class medical certificate applicants because it had a negative 
cost analysis and the FAA considers the ECG after age 35 to serve as an 
adequate baseline ECG.
    The FAA also proposes to amend the wording of the standard to 
require that the affected person ``demonstrate an absence of myocardial 
infarction and other clinically significant abnormality on 
electrocardiographic examination.'' The FAA will continue to require 
electrocardiography or other appropriate evaluations for any airman 
whose medical history or findings suggest it.

Blood Pressure

    The current medical standard pertaining to blood pressure applies 
only for first-class medical certificates. Depending on the person's 
age and the scope of the examination accomplished, blood pressures from 
140 to 170 mm Hg pressure, systolic, and 88 to 100 mm Hg pressure, 
diastolic, are permitted. In practice, 170 mm Hg systolic and 100 mm Hg 
diastolic have been considered the maximum allowable pressures for all 
applicants for second- and third-class certificates. The ICAO standard 
provides only that the blood pressure of all airmen be ``within normal 
limits.''
    In addition, Sec. 67.13(e)(5) of the FAR provides that, ``if an 
applicant is at least 40 years of age, he must show a degree of 
circulatory efficiency that is compatible with the safe operation of 
aircraft at high altitudes.''
    It is rare for an applicant for certification to manifest 
hypertension (high blood pressure) at the level of the current standard 
or above. Current and accepted medical practice for several years has 
reflected knowledge of the adverse effects of even mild elevations of 
blood pressure and treatment is prescribed for most individuals at 
levels of blood pressure much lower than the FAA standard for medical 
certification. If any person is taking medication for hypertension, FAA 
practice is to consider the condition as coming under the provisions of 
present Sec. 67.13(f)(2), General medical condition, of the FAR. This 
section directs that the applicant have ``no other organic, functional, 
or structural disease, defect, or limitation that the Federal Air 
Surgeon finds makes the applicant unable to safely perform the duties 
or exercise the privileges of the airman certificate that he holds or 
for which he is applying; or may be reasonably expected, within 2 years 
after the finding, to make him unable to perform those duties or 
exercise those privileges; * * *'' Certification is conditioned on the 
findings of a more detailed medical evaluation, including an assessment 
of cardiovascular risk factors, the presence or absence of disease of 
``target'' organs, the degree of blood pressure control, and of the 
medication itself.
    The AMA Report recommends that the existing, outmoded standard for 
blood pressure be replaced. It suggests a sitting blood pressure 
standard of 150 mm Hg pressure, systolic, and 95 mm Hg pressure, 
diastolic, for all pilots. It further recommends that the systolic 
level never exceed 160 mm Hg, regardless of the diastolic blood 
pressure. The AMA Report notes that its recommendations represent a 
somewhat less rigid standard for younger airmen and a more rigid 
standard for older airmen. Less rigid standards for the younger airmen 
are appropriate in terms of safety. For older airmen the more rigid 
standards respond to data demonstrating the adverse medical 
significance of the high level of blood pressure permitted by the 
current standard.
    The FAA agrees that the existing standard relating to blood 
pressure is outmoded and does not reflect current medical knowledge or 
practice. It also finds that current Sec. 67.13(e)(5) is medically 
vague and does not serve a useful purpose. Accordingly, it proposes 
that the provisions of Sec. 67.13(e) (4) and (5) of the FAR, including 
the table, be deleted and replaced by new standards (proposed 
Secs. 67.111(b), 67.211(b), and 67.311(b)) applicable to all classes of 
medical certificates. It proposes that average blood pressure while 
seated not exceed 150 mm Hg, systolic, or 95 mm Hg, diastolic. For ease 
of application, the agency will not introduce into the standard the 
additional suggestion that the systolic pressure never exceed 160 mm 
Hg.
    The proposed standard would require more extensive assessment of 
airmen who require or use antihypertensive medication. To maintain 
first-class certification, the assessment will be required at least at 
annual intervals, usually with every other application. For second- and 
third-class certification, valid for 1 year and 2 years, respectively, 
the assessment will be required with each application. Unless otherwise 
determined by the FAA under the special issuance provisions of the FAR, 
certificates will be valid for the normal periods and, in most cases, 
issued by the designated AME if there are no adverse findings. These 
procedures are included in current FAA guidelines.
    This proposed amendment would clarify the FAA's concern for the 
cardiovascular risk represented by hypertension and the agency's 
position that persons who are undergoing therapy for hypertension 
should be evaluated to assess the degree of risk. Though these 
standards are being codified for the first time, this evaluation does 
not represent a new practice.

Cholesterol

    Currently no cholesterol standards exist in the regulations. In 
consideration of the responsibility for public safety held by airmen 
exercising pilot privileges in air transport operations, the FAA has 
partially accepted the recommendations of the AMA Report that the level 
of blood cholesterol be determined as part of the examination for 
medical certification. The Risk Factor Committee of the AMA that 
considered risk factors and qualifications for flying suggested that 
serum cholesterol and triglyceride levels be determined for all 
applicants initially and at 50 years of age. The Cardiovascular 
Committee of the AMA, however, recommended that a determination of 
serum cholesterol be made only for 50-year old applicants for first- 
and second-class medical certificates who exercise airman duties in 
single-pilot commercial operations. Both committees recommended further 
evaluation if a level greater than 300 milligrams per deciliter (mg/dl) 
of total cholesterol is found.
    The FAA proposes (proposed Sec. 67.111(f)) that total serum 
cholesterol be tested annually as part of the examination of all 
applicants for first-class medical certification who have reached their 
50th birthday. Unlike a single determination, an annual requirement 
will assist the FAA in the identification of adverse trends in 
cardiovascular risk factors as airmen age. Applicants whose cholesterol 
level is determined to exceed 300 mg/dl would be required to undergo an 
additional cardiovascular evaluation to determine if significant 
disease is present, but issuance of a medical certificate would not be 
withheld solely on the basis of the cholesterol level.
    The FAA agrees with the AMA Report and with the National Institutes 
of Health regarding the importance of this risk factor for disease and 
believes that the additional cost to the holders of first-class airman 
medical certificates is justified by the more effective identification 
of disease. By limiting this requirement to first-class certificate 
holders 50 years of age and older, public benefits are enhanced with 
minimum costs by targeting the population having the greatest risk and 
greatest public responsibility.
    The FAA does not consider feasible the AMA Report recommendation 
that the serum cholesterol level requirement be limited to persons who 
exercise airman duties in single-pilot commercial operations. 
Individual airmen frequently perform in a variety of commercial 
operations or change from one type of operation to another. There are 
no regulatory controls for limiting applicability of such a requirement 
to single-pilot commercial operations.

Hematocrit

    Currently no standard exists in the FAA regulations for blood 
hematocrit. The AMA Report recommends that all applicants at age 40, 
and periodically thereafter, demonstrate a hematocrit within the range 
of 32 to 55 percent. The requirement is recommended because the ability 
of blood to transport oxygen effectively to tissues is dependent on 
adequate hemoglobin concentration and on the ability of blood to 
perfuse organs. Abnormalities of this function can result in 
incapacitating organ infarcts. Also, a number of significant medical 
conditions are often reflected in abnormalities of the blood. Anemias 
of various etiology, organ malignancies, polycythemia, lung disease, 
hemoglobinopathies, coagulation and thrombotic disorders, hematologic 
neoplasia, lymphomas, immunodeficiency syndromes, and other disorders 
are included in the conditions that may be discovered through 
examination of the blood.
    The FAA is not proposing to add new standards for blood hematocrit 
testing at this time. Hematocrit testing would impose incremental costs 
on applicants for a first-class airman medical certificate and 
additional administrative costs on the FAA. While the recommendations 
of the AMA Report suggest that hematocrit testing would result in 
detection of certain adverse or potentially incapacitating medical 
conditions, the risk to flight safety appears minimal in comparison to 
the cost of testing. The list of specific conditions that would 
disqualify a person is not proposed for inclusion in the FAR because 
the conditions are already covered in the general medical standards.

Anticoagulation

    Current regulations do not contain specific standards for 
anticoagulation. Under the general rules of current paragraphs (f)(2) 
(i) and (ii) of Secs. 67.13, 67.15, and 67.17, the FAA has denied 
routine certification of persons who require medication for 
anticoagulation. The FAA does, however, grant special issuance to a 
limited number of airmen who use this type of medication after 
extensive evaluations of the conditions requiring anticoagulation, the 
stability of the airmen's treatment regimens, and the presence or 
absence of adverse side-effects. Periodic reevaluation always is 
required for subsequent certification.
    The AMA Report recommends denial of routine medical certification 
for any person who uses an anticoagulant medication. This 
recommendation is consistent with earlier medical reports such as the 
report of the Eighth Bethesda Conference of the American College of 
Cardiology in 1975, the Report of a Working Party of the Cardiology 
Committee of the Royal College of Physicians of London in 1978, The 
First United Kingdom Workshop in Aviation Cardiology in 1982, and The 
Second United Kingdom Workshop in Aviation Cardiology in 1987, and with 
recommendations of some FAA medical consultants. Based on its 
experience with airmen who are taking anticoagulant medication, the FAA 
believes that some individuals who receive anticoagulant medications 
may be granted airman medical certification after careful evaluation of 
their specific condition. Such certification represents an exception, 
however, and must be accomplished under the special issuance provisions 
of the FAR, subject to appropriate, periodic medical reevaluation and 
possible restrictions. To clarify this position and to meet the FAA's 
statutory responsibility to ensure public safety, the FAA proposes 
(proposed Sec. 67.111(c)) to add the use of anticoagulant medication to 
those conditions specified in the FAR as disqualifying an individual 
for certification. (Discussion of how a proposed disqualifying 
condition may affect a current medical certificate appears under 
``Additional Standards for Disqualification.'')

Respiratory System

    Current regulations do not contain specific standards pertaining to 
the respiratory system. The Respiratory System Committee, in its 
section of the AMA Report, recommended that all airmen older than 40 
years periodically demonstrate the absence of severe lung disease 
through spirometry, a simple, non-invasive test available in the 
physician's office. The committee stated its concerns for the danger to 
public safety represented by airmen with serious pulmonary disease such 
as chronic obstructive pulmonary disease (COPD), asthma, pulmonary 
fibrosis, infectious diseases of the lung, hypoventilation syndromes, 
chronic interstitial lung disease, and disorders of the respiratory 
muscles and bony thorax. Both judgment and the ability to perform 
complex tasks may be affected adversely by a reduction of oxygen 
available to the brain (hypoxia) because of poor pulmonary function, 
and acute lung disease can cause hypoxia without warning. Altitude 
itself affects pulmonary function, so careful assessment of pulmonary 
status is required to prevent incapacitation during flight, according 
to the committee's report.
    Tests that measure the actual levels of oxygen and carbon dioxide 
in the arterial blood are costly and not generally available in the 
aviation medical examiner's office. Careful clinical assessment of 
respiratory function, including medical history and physical 
examination ordinarily are used to separate those applicants requiring 
further evaluation of their pulmonary status from those who do not.
    The FAA is not proposing to add a new requirement for routine 
spirometric testing at this time. Spirometric testing would impose 
incremental costs on applicants for all classes of airman medical 
certificate and additional administrative costs on the FAA. AME's would 
be required to purchase the equipment necessary to perform the 
examination. Under current practice, individuals with potentially 
serious pulmonary disease are identified through existing procedures 
and referred for further evaluation, including spirometric testing, of 
their pulmonary status to determine their eligibility for medical 
certification.
    The AMA Report also recommends specifically disqualifying diseases 
and conditions of the respiratory system. These would include severe 
lung disease, poorly controlled asthma, sleep disorders, pulmonary 
hypertension, pneumothorax, pulmonary emboli, and carcinoma of the 
lung. The list of specific conditions that would disqualify a person is 
not proposed for inclusion in the FAR because the conditions are 
already covered in the general medical standards.

Diabetes

    In its discussion of diabetes in the preamble to Amendment 67-11, 
the FAA stated that the Federal Air Surgeon would continue to deny 
certification to individuals who have an established medical history or 
clinical diagnosis of diabetes that is controlled by the use of insulin 
or another hypoglycemic drug (47 FR 16298, April 15, 1982). The 
preamble further stated, ``If, in the future, information demonstrating 
that medical technology has advanced to the point that diabetes can be 
controlled without significant risk of incapacitation from hypoglycemia 
or other complications becomes available to the FAA, consideration for 
special issuance of a medical certificate under Sec. 67.19 will be 
possible.''
    As part of the review of part 67, the AMA Report made 
recommendations concerning individuals seeking medical certification 
who have an established history or clinical diagnosis of diabetes that 
is controlled by insulin or another hypoglycemic drug. The AMA Report 
recommended that persons whose diabetes is adequately controlled with 
oral hypoglycemic drugs and who show evidence of stability and freedom 
from adverse effects be considered for medical certification with 
proper medical monitoring. The Endocrine Committee assembled by the AMA 
believes that the likelihood of incapacitation from the effects of 
diabetes or its treatment with current oral hypoglycemic drugs, in 
those persons medically selected and monitored, is very remote. The AMA 
Endocrine Committee recommends that absolute prohibitions of 
certification of individuals requiring insulin for control of diabetes 
be continued. Informal surveys of agency medical consultants, comments 
by interested medical practitioners, and review by the FAA medical 
staff indicate general agreement with these findings and 
recommendations of the AMA Report. The more widespread use of 
technically advanced equipment and procedures has made it possible for 
physicians to better select those persons who should be allowed to use, 
or continue to use, oral drugs to control their disease. The increased 
use of simple equipment and tests for self-monitoring gives the 
diabetic and the physician a more accurate and timely picture of a 
person's immediate condition as well as his or her ability to control 
blood sugar over time.
    In view of the current consensus of the medical community, the FAA 
has determined that many individuals whose diabetes is without 
complications and acceptably controlled by diet and oral drugs, with 
appropriate monitoring and other conditions, can perform the duties 
authorized by their class of medical certificate without endangering 
public safety. Accordingly, though no substantive rule change is 
proposed to current requirements in paragraph (f)(1) of Secs. 67.13, 
67.15, and 67.17, the Federal Air Surgeon has determined that those 
persons who do not meet the medical standard of the FAR because their 
diabetes requires oral hypoglycemic drugs will no longer be 
categorically denied special issuance of airman medical certification.
    In determining eligibility for medical certification under the 
special issuance provisions of the FAR, the Federal Air Surgeon 
considers the natural history and severity of the problem, the period 
of satisfactory recovery since manifestation of the problem, and any 
treatment, as well as any continuing requirements for treatment, and 
the nature of treatment. For diabetics whose disease is controlled with 
oral hypoglycemic agents, additional factors that may be considered 
include: the age of onset of diabetes; the documented degree and means 
of past and present diabetes control; the presence or absence of 
adverse effects, including hypoglycemic episodes; the presence or 
absence of other known risk factors; and the individual's willingness 
and ability to maintain strict control of his or her condition and 
treatment and to cooperate with any monitoring plan required by the 
FAA.
    Four physicians who served on the AMA Report's Endocrinology 
Committee subsequently submitted a letter stating that they 
reconsidered their Committee's recommendation on diabetes. The 
recommendation of the Endocrine Committee was to continue to disqualify 
diabetics who use insulin to control their disease. In their letter, 
the four physicians stated that persons on insulin therapy should be 
allowed consideration for special issuance certification. Several other 
physicians who commented on the AMA Report also supported certification 
of persons on insulin therapy.
    The issues raised by these commenters pertain to current FAA policy 
of not permitting special issuance consideration for persons on insulin 
therapy. As recommended by the full AMA Committee, the FAA proposes to 
retain this policy but remains open to a change in its policy should 
there be any new medical developments. The issue was thoroughly covered 
by the full AMA Committee and its recommendation was made after 
deliberation and thorough discussion. The contra recommendation of the 
four physicians who submitted a letter to the FAA was not subjected to 
the same process, nor did their recommendation contain any acceptable 
procedure for identifying persons on insulin therapy who could be 
safely, reliably, and practically certified through the special 
issuance process.
    In a related matter, a summary of an American Diabetes Association 
(ADA) petition for rulemaking to review FAA rules and policies 
regarding individuals with diabetes was recently published in the 
Federal Register (56 FR 10383, March 12, 1991). Specifically, the ADA 
petitioned the FAA to amend FAR Secs. 67.13, 67.15, 67.17, and 67.19 to 
allow individuals with insulin-treated diabetes mellitus to be issued 
medical certificates on a case-by-case basis. The ADA further requested 
the creation of an FAA-appointed medical task force to develop a 
medical protocol capable of permitting meaningful case-by-case review.
    Docket No. 26493 was established to receive comments on the ADA 
petition. Since the comment period on the ADA petition has closed but 
the subject of that petition is directly related to the part 67 review, 
additional comments on the diabetes-related issues raised in the ADA 
petition may be submitted to the docket of this rulemaking. The FAA may 
dispose of the issues raised in the ADA petition through this action at 
the final rule stage, or through the issuance of a separate disposition 
of the ADA petition.

Musculoskeletal

    The Musculoskeletal System Committee of the AMA recommends 
standards that would disqualify an applicant for medical certification 
because of conditions such as quadriplegia, hemiplegia, hemiparesis, 
collagen disease, and vascular disease. The FAA does not propose 
specifying these conditions as disqualifying since they are already 
covered by current general medical standards (proposed Secs. 67.115, 
67.215, and 67.315).

Special Issuance of Medical Certificates

    The FAA has used special issuance (waiver) provisions of Sec. 67.19 
(proposed Sec. 67.401) for many years to grant airman medical 
certification to acceptable applicants who do not meet the published 
standards. Prior to 1982, except for applicants for air traffic control 
tower operator certificates, this authority was not available for 
airmen with histories of certain psychiatric, neurological, cardiac, or 
endocrine conditions, and exemptions from the regulations were 
required. Beginning in May 1982, however, airmen with a history or 
clinical diagnosis of any medical condition could be granted 
discretionary medical certification through the special issuance 
provisions if it could be determined that, notwithstanding the person's 
failure to meet the applicable medical standard, airman duties could be 
performed, with appropriate limitations or conditions, without 
endangering public safety. Through special issuance provisions, many 
airmen have returned to productive aviation careers and others to 
private flying after recovery and rehabilitation from serious medical 
conditions without adverse impact on public safety.
    Consideration for the granting of a special issuance can be 
initiated in different ways. Currently, the FAA will often consider an 
individual for a special issuance who does not meet the medical 
standards under part 67 without a formal request to the agency from the 
individual. In some cases an individual who does not meet the medical 
standards under part 67 will make a written request to the Federal Air 
Surgeon or to his or her authorized representative to be considered for 
a grant of a special issuance.
    Under current practice, a special issuance letter is issued 
advising an airman of the FAA's decision to grant the special issuance 
of a medical certificate. The letter describes the provisions and 
conditions of a special issuance of medical certification. Based on the 
letter and on the individual being otherwise eligible, the agency or 
examiner issues a medical certificate to the individual. These 
procedures apply for a new application and for an application for 
recertification.
    Current Sec. 67.19 provides that the Federal Air Surgeon may limit 
the duration of a medical certificate issued under that section, 
condition the continued effect of a medical certificate on the results 
of subsequent medical tests, examinations, or evaluations, impose any 
operational limitation needed for safety, or condition the continued 
effect of a second- or third-class medical certificate on compliance 
with a statement of functional limitations issued to the person in 
coordination with the Director of Flight Standards or the Director's 
designee. It is implicit in this section that in the interests of 
public safety a finding of adverse change in the medical condition of 
the holder would result in termination of the validity of the medical 
certificate.
    The validity of the special issuance letter, however, does not 
lapse until the FAA takes some affirmative action to modify or 
terminate it. Similarly, once a medical certificate is issued pursuant 
to the special issuance provisions, even if the FAA terminates the 
special issuance letter, it may be considered that the medical 
certificate itself does not lapse until the original date of 
expiration, unless it is sooner suspended or revoked under the 
provisions of section 609 of the Federal Aviation Act. Long-standing 
agency practice in the case of adverse medical change has been to send 
the holder a letter terminating the validity of the special issuance of 
medical certification and requesting the return of any medical 
certificates held.
    To ensure that the medical justification for the special issuance 
remains valid and the holder of the special issuance undergoes the same 
type of periodic reevaluation as the holder of any medical certificate 
does, it is proposed that the duration of an Authorization for Special 
Issuance of a Medical Certificate (Authorization) will be limited, and 
a new request for that Authorization will be required upon expiration. 
In addition, when the FAA determines that an Authorization should be 
withdrawn, the medical certificate issued pursuant to that 
Authorization will also expire, in accordance with proposed 
Sec. 67.401(a).
    An Authorization is one of two types of special issuances and 
covers those medical conditions, such as coronary heart disease, where 
the disease is progressive in nature. A Statement of Demonstrated 
Ability (SODA) is the second type of special issuance. If a medical 
condition, such as the accidental loss of a limb or deficient color 
vision is static and nonprogressive, the FAA issues a SODA to those 
applicants found able to perform airman duties without endangering 
public safety. This document remains valid indefinitely and permits a 
designated AME to issue a medical certificate of the specified class if 
the holder remains otherwise eligible. In the event of adverse change, 
certification is withheld and the person referred to the FAA for a new 
determination of eligibility.
    Current Sec. 67.19 (proposed Sec. 67.401) refers only to the 
special issuance of medical certificates. The FAA proposes to add 
specific reference to the two types of special issuance documents: An 
Authorization and a SODA. The first document codifies the special 
issuance letter currently used to grant and describe the provisions of 
a special issuance of medical certification, and the second codifies a 
document that has been in use for many years. The proposed change 
explicitly connects the duration of any medical certificate issued to 
the validity of the document upon which it is based and requires 
periodic requests for reissuance.
    The FAA also proposes to add language (proposed Sec. 67.401(f)) 
that explicitly provides that the Federal Air Surgeon may withdraw an 
Authorization or SODA when: There is adverse change in the holder's 
medical condition; the holder fails to comply with a statement of 
functional limitations or operational limitations issued as a condition 
of medical certification; the public safety would be endangered by the 
holder's exercise of airman privileges; the holder fails to provide 
medical information reasonably needed by the Federal Air Surgeon to 
determine continued eligibility for certification under the special 
issuance provisions; or the holder makes or causes to be made a 
fraudulent or false statement or an incorrect statement in support of 
his or her request or in any entry in any logbook, record, or report 
that is kept, made, or used, to show compliance with any requirement 
for an Authorization or SODA.
    Proposed Sec. 67.401(i) would allow a person to request a review of 
a decision to withdraw an Authorization or SODA. The holder of an 
Authorization or SODA that is withdrawn may request, within 60 days 
after the service or mailing of a letter of withdrawal, that the 
Federal Air Surgeon provide for a review of the decision to withdraw. 
The review procedures would provide the holder an opportunity to submit 
supporting evidence in his or her behalf, and to otherwise respond to 
the decision to withdraw. The proposed procedures and timeframes in 
Sec. 67.401(i) are intended to provide an expeditious administrative 
review for the benefit of those persons affected by a decision to 
withdraw an Authorization or SODA. The public is invited to comment on 
the proposed procedures for withdrawal of an Authorization or SODA.
    Proposed Sec. 67.401(j) implements the procedure by which the FAA 
will convert current special issuances to either Authorizations or 
SODA's. All Authorizations will have an expiration date. The date will 
coincide with the expiration date of the airman's medical certificate 
or a date as stipulated by the Federal Air Surgeon or his or her 
authorized representative that relates to any medical test, report, or 
examination required as a condition of the special issuance.

Applications, Certificates, Logbooks, Reports, and Records: 
Falsification, Reproduction, or Alteration

    Section 67.20(a) (proposed Sec. 67.403(a)) of the FAR provides the 
regulatory basis for enforcement action when an applicant or airman 
falsifies a medical certification document. In current Sec. 67.20(b), 
consequences for violating paragraph (a) include suspension or 
revocation of all airman, ground instructor, and medical certificates 
and ratings held by that person.
    Although present paragraph (a)(1) provides explicitly only for 
suspension or revocation for fraudulent or intentionally false 
statements on any application for a medical certificate, the FAA has 
denied the medical certificate applied for in such cases. If the FAA 
interpreted the current regulation narrowly, it would have to issue a 
medical certificate and then revoke it in cases where the person has 
falsified the application. The proposed revision of these requirements 
(proposed Sec. 67.403) provides explicitly for denial of an application 
for medical certification, as well as for suspension or revocation of 
all airman, ground instructor, and medical certificates and ratings 
held by that person, if the person makes a fraudulent or intentionally 
false statement or entry on the application or other document required 
to be kept, made, or used to show compliance with any requirement for 
any medical certificate under part 67.
    A new paragraph (c) has been added to proposed Sec. 67.403 to allow 
the FAA the option of denying, suspending, or revoking an airman 
medical certificate if any incorrect statement or entry has been made, 
even if the person did not knowingly make the incorrect statement or 
entry. Medical certification based on incorrect medical data may be 
inappropriate in the light of the true data.
    Proposed Sec. 67.403 also prohibits fraudulent or intentionally 
false statements or incorrect statements or entries in connection with 
any Authorization or SODA. In addition, proposed Sec. 67.401, which 
sets out the procedures for Authorizations and SODA's, specifically 
lists the making of a fraudulent or intentionally false statement or an 
incorrect statement as grounds for withdrawal of an Authorization or 
SODA.

Certification Procedures, Applicability, and Medical Examinations

    No substantive changes are proposed for present Sec. 67.23 of the 
FAR (proposed Sec. 67.405). Current Sec. 67.21 is deleted because it is 
unnecessary under the new reorganization.

Delegation of Authority

    This section (current Sec. 67.25; proposed Sec. 67.407) would be 
amended to substitute the current term ``Manager'' for ``Chief'' in the 
delegation of authority to the Manager, Aeromedical Certification 
Division, Civil Aeromedical Institute. It also would be amended to add 
issuance, renewal, denial, and withdrawal of Authorizations and SODA's 
to the authority delegated by the Administrator to the Federal Air 
Surgeon.

Denial of Medical Certificate

    Current Sec. 67.27 of the FAR (proposed Sec. 67.409), Denial of 
Medical Certificate, is proposed for amendment only to substitute 
current terminology and the address for the Manager, Aeromedical 
Certification Division, and to remove gender-specific pronouns.

Medical Records

    The FAA proposes to amend Sec. 67.31 of the FAR (proposed 
Sec. 67.413(a)) to change the word ``refuses'' to ``fails'' to make it 
clear that there need not be an actual refusal by an applicant or 
holder of a medical certificate to furnish requested information to 
trigger a suspension, modification, or revocation of a medical 
certificate. Failure to provide the requested information is sufficient 
cause for the Administrator to act. A new sentence would be added to 
this section (Sec. 67.413(b)) to make it clear that submission of 
requested information does not automatically lead to issuance of a 
medical certificate. A determination by the Federal Air Surgeon that 
the person meets applicable medical standards is needed before a 
certificate will be issued. The FAA also proposes to remove gender-
specific pronouns and to substitute the more appropriate word, 
``physician'' for the word ``doctor.''

Return of Medical Certificates After Suspension or Revocation

    Current Sec. 67.27(g) of the FAR provides that the holder of a 
medical certificate shall surrender it, upon request of the FAA, if its 
issuance is wholly or partly reversed upon reconsideration. Part 61 
(Sec. 61.19(f)) provides that the holder of any certificate issued 
under that part that is suspended or revoked shall, upon the 
Administrator's request, return it to the Administrator. Except for 
Sec. 67.27(g), part 67 is silent regarding return of medical 
certificates that have been suspended or revoked under the FAR or under 
Section 609 of the Federal Aviation Act of 1958 (49 U.S.C. 1422). 
Because the retention by an airman of an invalid medical certificate is 
not consistent with proper and efficient enforcement of safety 
regulations, new Sec. 67.415 is proposed. This amendment would codify 
existing practice, and clarify that any airman medical certificate 
revoked or suspended under existing authority must be returned on 
request of the Administrator.

Related Petition

    On July 7, 1981, the Civil Pilots for Regulatory Reform (CPRR) 
filed a petition with the FAA Administrator (Docket No. 22054; AVS-81-
520-P). The petition took issue with two aspects of the airman medical 
certification process. First, that the cardiovascular standards for 
first-, second-, and third-class medical certificates (paragraph (e)(1) 
in Secs. 67.13, 67.15, and 67.17; 1981), automatically disqualify an 
airman who has an established history or clinical diagnosis of a 
myocardial infarction regardless of degree or recency. Second, that the 
only means to regain medical certification is dependent on the sole 
discretion of the Federal Air Surgeon via an exemption under part 11 of 
the FAR.
    The CPRR petition proposes to modify a subparagraph of the 1981 
cardiovascular standard which reads, ``No established medical history 
or clinical diagnosis of myocardial infarction . . .,'' to read, ``No 
coronary artery disease that makes the applicant unable to safely 
perform the duties or exercise the privileges of the airman certificate 
that he holds or for which he is applying; or may reasonably be 
expected, within 2 years after the finding, to make him unable to 
perform those duties or exercise those privileges; and the findings are 
based on the case history and appropriate, qualified, medical judgment 
relating to the condition involved.'' The effect of the proposed change 
is that a history of coronary artery disease would not, per se, 
disqualify an airman.
    The CPRR petition also proposes that the standards and tests used 
by the Federal Air Surgeon to recertificate pilots who have sustained 
infarcts be published in regulatory form in an appendix to part 67, and 
that a pilot be granted appeal rights to the NTSB in the event that an 
exemption is denied. Furthermore, the CPRR petition proposes that the 
medical exemption procedures under part 11 be revised to provide a 
``due process'' format for the exemption deliberation under part 11. 
The format would include: (a) if the airman petitioner requests 
exemption under part 11 because of disqualification under the 
cardiovascular standard, the airman is given a complete file, prior to 
the exemption panel meeting, of all records, reports and other 
documents which the agency plans to consider in the ruling; (b) the 
airman may attend and present evidence at the exemption panel meeting; 
(c) panel members must record their individual position in the official 
record of the meeting; and (d) the agency must construct a record 
sufficient to form a basis for review by the courts of appeal under the 
arbitrary and capricious standard of review.
    FAA Response: The medical standards were revised in 1982 (47 FR 
16298; April 15, 1982). The revision eliminated the need for the time 
consuming and cumbersome exemption pathway under part 11 for part 67 
medical disqualification cases and opened up part 67 medical 
disqualification cases (including cardiovascular cases) to special 
issuance procedures under Sec. 67.19. Additionally, the 1982 rule 
change stated, in the preamble, general and specific criteria that 
would be considered in the determination of a cardiovascular special 
issuance. The 1982 change considerably reduces the administrative costs 
and processing time for special issuance cases.
    In regard to the CPRR proposals to change the disqualifying 
statement on myocardial infarction and to allow for ``due process'' and 
appeal, FAA review of part 67 has not led to such proposals. The 
disqualification for myocardial infarction remains in the proposed 
rules. However, it is, and would continue to be, possible for an 
applicant with a history or diagnosis of myocardial infarction to 
receive a medical certificate through the special issuance procedures 
if further medical evaluation of the applicant shows that he or she is 
able to perform the privileges of an airman certificate without 
endangering public safety. Any applicant who has been denied 
certification because he or she is unqualified under the cardiovascular 
standards is notified of the procedures, standards, and tests required 
for special issuance determination. Test results are reviewed and 
evaluated by medical specialists. Generally, in difficult cases or 
those involving commercial pilots, a panel of cardiovascular 
specialists reviews the medical reports and other required 
documentation, assesses the risks involved in accordance with its best 
medical judgment and advises if it believes a special issuance is 
warranted. The procedures provide for a reasoned, objective 
determination based on medical facts and judgment. The determination is 
not based on a hearing-type procedure in which subjective facts are 
weighed. In any case, the proposed rule would allow for the same ``due 
process'' as under the present rule.

Discussion of Public Comments

    The FAA requested public comments on the review of part 67 in two 
separate notices. On July 15, 1982, the FAA announced the review of the 
regulations and invited public comment (47 FR 30795). On May 23, 1986, 
the FAA announced the availability of the AMA Report and invited public 
comment on recommendations in the report (51 FR 19040). A total of 211 
comments were received. Comments were submitted by pilots, pilot 
organizations, and physicians, including several AME's. Most of the 
comments refer to the AMA Report recommendations, only some of which 
are proposed in this document for adoption.
    The following discussion of comments addresses only the main 
medical issues raised by commenters that are relevant to this 
rulemaking document. It does not address comments on AMA 
recommendations that the FAA did not choose to adopt. Some commenters 
recommended changes similar to those recommended in the CPRR petition 
and, since the FAA's position on these issues has already been stated, 
it is not repeated below. While the following discussion addresses the 
main medical issues raised by commenters, it is not intended to be an 
exhaustive discussion of all of the comments received and considered by 
the FAA.

Comments Received on the Review of Part 67

    In response to the first notice, the FAA received 52 comments 
providing suggestions for the FAA to consider during its review of part 
67.
    Twenty commenters, including four physicians, comment on persons 
with diabetes. In general, the commenters argue that diabetes is a 
disease that is well understood and easily monitored by a personal 
physician. Advances in treating diabetes, such as home glucose 
monitoring and other tests, provide full control to a pilot of his/her 
illness. Several pilots suggest that diabetes is readily containable 
with the appropriate medical care, and no significant physical strain 
is placed on a diabetic pilot in providing continuous treatment of the 
illness.
    Four commenters discuss the possible benefits of an 
electrocardiogram (ECG) in evaluating a person's medical situation. One 
doctor who is also an AME recommends a chest X-ray as a preventive 
test.
    Another physician explains that there are currently no standards 
for risk factors such as cholesterol, cigarette smoking, and blood 
pressure. These all have links to heart disease and, as a result, 
should be closely examined. Three people, including two physicians, 
support closer testing of pilots for signs and effects of alcoholism. 
They point out that alcohol abuse is a major cause of aviation 
accidents and should, therefore, be tested.
    Nineteen people objected to the stringent medical standards for 
persons obtaining a third-class medical certificate under Sec. 67.17. 
They argue that these strict standards are too rigid for this class of 
flyers, who are generally leisure and sports pilots and can not easily 
obtain a medical examination.
    The Aircraft Owners and Pilots Association (AOPA) submitted a 
detailed section by section recommendation for revising part 67 that 
was based on recommendations of a medical advisory panel of 
distinguished physicians that was convened by AOPA.
    FAA Response: The FAA considered all of these comments, including 
AOPA's section by section recommendations, during its review of part 
67. The FAA's proposed standards and policy on diabetes are discussed 
under the proposed rule portions of this preamble. New ECG requirements 
are proposed in this notice. Assessment of risk factors such as 
cholesterol and blood pressure is included and standards pertaining to 
alcoholism have been updated in the proposal.
    The proposed rule amends the standards for third-class medical 
certificates in light of recent technology and medical knowledge. As 
noted in the discussion of the proposed rule, the standards for third-
class medical certificates are less stringent than those for first- and 
second-class certificates in recognition of the lower level of 
responsibility inherent in noncommercial flight operations.

Comments Received on AMA Report Recommendations

    Most commenters were generally opposed to any AMA recommendations 
that involved a perceived strengthening of the standards for airman 
medical certification. Only eight commenters generally favored the AMA 
recommendations, some with suggestions for improving them.
    Many of the opposing comments from pilots were based on their 
reading of an editorial about the AMA Report which appeared in Flying 
magazine (Volume 113, November 1986, page 24) entitled ``What's Up, 
Doc?'' While the editorial was factually accurate, it briefly 
summarized some of the recommendations and was primarily a subjective 
editorial opinion opposing certain recommendations in the AMA Report.

Cost and Safety

    The most frequent comment from those who objected to the AMA Report 
recommendations is that the recommended changes will result in a 
substantial increase in the cost of obtaining a medical certificate and 
that there are no accident data to indicate a need for increasing 
medical standards and thereby medical certification costs.
    FAA Response: The review of part 67 was necessary to ensure that 
the standards reflect current medical technology and evolving knowledge 
about conditions that could affect a pilot's ability to perform safely. 
For the most part, the proposed revisions to part 67 are not a 
strengthening of the standards over current regulations and policy. 
They represent clarification, codification of policy, and an updating 
of the current standards and practices. The proposed rule would make 
some standards less stringent, such as the deletion of uncorrected 
distant visual acuity requirements and the revised wording of those 
requirements pertaining to the eye, ear, nose, pharynx, and larynx. In 
other instances, additions to the medical examination requirements such 
as the proposed new standards for blood pressure for second- and third-
class medical certification are clearly warranted. The FAA would be 
remiss in its responsibility for safety if it ignored medical findings 
and advances that can better identify those individuals subject to 
incapacitation or deterioration of performance. The estimated costs and 
benefits of this proposal are addressed in a Regulatory Evaluation 
Summary later in this preamble and more fully in a full regulatory 
evaluation which is in the public docket.

Prevention vs. Safety

    Several commenters object to statements in the AMA Report that 
certain recommendations are based on concepts of preventive medicine. 
These commenters say that the FAA's responsibility is to safety rather 
than to a system of healthier pilots. According to these commenters, 
the purpose of the agency's medical examination is to determine if a 
pilot is able to perform safely the privileges of the airman 
certificate, not whether the pilot is generally healthy.
    FAA Response: The FAA is not proposing to change the primary safety 
objective of the medical certification examination. Rather, the 
proposed revisions to the standards embody what has been learned in the 
last 25 years about medical risk factors. FAA's interest in risk 
assessment is directly related to its need to determine at the time of 
a medical examination as much objective information as possible on the 
medical condition of the person being examined. This information is 
directly relevant to FAA's need to determine the likelihood that the 
person being examined will remain medically fit for the next 6 months, 
or 1 or 2 years, as applicable.
    The AMA report is fully consistent with helping the FAA meet its 
statutory safety responsibilities. The AMA Report notes that some of 
its recommendations include ``risk factor identification items.'' It 
further notes:

    These items add to the safety factor for which the examination 
is designed; they also increase the likelihood that pilots who pay 
attention to these risk factors will be able to enjoy flying 
aircraft for more years.

    The fact that the AMA Report mentions potential long term 
preventive health benefits that may accrue to the person being examined 
in no way diminishes the importance of the short term health evaluation 
benefits that are of primary concern to the FAA.

AMA Contract

    Several commenters object to the AMA Report because they believe 
the recommendations are in the AMA's self interest. According to these 
commenters, any proposed increase in requirements would serve to 
increase the cost of the medical examination and thereby the income of 
doctors.
    FAA Response: In its consideration of the AMA Report, the FAA found 
no indication of self-serving motives. The AMA committees which worked 
on developing the recommendations were made up of experienced and 
respected specialists in each area of medical interest. Each committee 
did an in-depth and thorough analysis of the current standards in 
relation to advances in medical knowledge and examination techniques 
and recommended, as appropriate, optimum standards for safety. The FAA 
reviewed and considered these recommendations along with public 
comments (many from professionals in the field) and advice from its own 
staff. Factors such as pilot performance, aircraft technology, and 
cost, in addition to general safety were considered by the FAA in 
assessing each AMA recommendation. (A cost benefit analysis appears in 
the Regulatory Evaluation portion of this preamble.) The FAA believes 
the proposed standards will benefit all airmen as well as the general 
public.

FAA Workload

    Several commenters express concern that the AMA Report 
recommendations, if adopted, would lead to an increase of denials and, 
therefore, an increase in requests for certification under the special 
issuance provisions of the FAR. This in turn would lead to 
certification processing delays.
    FAA Response: The FAA does not anticipate that the proposed 
standards will significantly increase the internal FAA workload. The 
potential for such an increase and the FAA's plans to meet the increase 
are discussed more fully in the regulatory evaluation.

Industry Disincentive

    Several commenters state that general aviation is presently in 
economic trouble and that more stringent medical standards would 
discourage more people from becoming general aviation pilots.
    FAA Response: The FAA does not agree. The safer the system, the 
greater the number of participants and the lower the cost. The FAA 
believes that these proposals encourage and support aviation.

Alleged Discrimination Against Older Pilots

    Several commenters allege that the AMA recommendations discriminate 
against older pilots in favor of younger ones, since many of the tests 
recommended become critical for pilots after the age of 40 or 50. Air 
transport pilots who commented argue that, if adopted, the 
recommendations might prohibit some older and more experienced pilots 
from flying. According to these commenters, older pilots represent a 
high percentage of the highly competent and seasoned professional 
pilots.
    FAA Response: Any medical standards necessarily have a greater 
effect on older persons since many disorders occur more frequently with 
advancing age, especially after age 40. The FAA contracted with Johns 
Hopkins University to prepare a detailed statistical analysis of 
computerized medical information collected by the FAA from examination 
of approximately 31,000 air traffic controllers over a 15-year period. 
The study sample was demographically comparable to the private pilot 
population and the examinations were similar to airman medical 
examinations. The analysis shows that the incidence of pathology 
recorded at periodic examinations increases with age; the prevalence of 
pathology in individuals over the age of 50 was greater than in those 
under the age of 40. The AMA recommendations and the FAA proposed rule 
focus on those disorders most likely to result in reduced performance 
or to incapacitate a pilot. They provide for more relevant, more 
thorough, and more predictive evaluations after age 40 or 50, 
particularly for those persons seeking first-class medical 
certification. Proposed changes in this category relate to vision; 
electrocardiograms; and blood cholesterol determinations. The proposed 
standards will permit the identification of risk factors and encourage 
pilots to maintain better control over those conditions which 
eventually could lead to disqualification. Those AMA recommendations 
included in the FAA proposal should serve, in the long term, to 
increase the pool of experienced, professional, and medically eligible 
pilots.

AME's or Private Physicians

    Several commenters raise issues about the role of AME's and the 
role of private physicians in the maintenance of a pilot's health. Two 
flight instructor pilots state that mistrust exists between pilots and 
medical examiners caused by pilots' fear of losing their medical 
certification and their careers as pilots. More stringent rules, as 
recommended by the AMA, will increase pilots' concerns and mistrust. 
Commenters also believe that some of the recommendations concerning 
family history, for example, should be the domain of a pilot's personal 
physician and that in some instances personal physicians could supply 
the information required by the recommended standards.
    FAA Response: Both current and proposed standards permit the use of 
test results provided by personal physicians, such as ECG's and X-rays. 
However, the historical and legal role of the AME as a designee of the 
FAA is to conduct a medical examination to determine the fitness of the 
pilot to exercise the privileges of his or her certificate without 
endangering public safety. The proposed standards in no way are 
intended to interfere with or replace a pilot's use of a personal 
physician. Experience, however, indicates that the FAA's statutory 
responsibility to ensure that an airman is medically fit to perform his 
or her duties cannot be delegated to any personal physician. The 
proposed changes, however, should not affect the relationship between 
pilots and AME's.

Specific Standards

    Several commenters object to one or more specific recommendations 
in the AMA Report. Objections to cardiovascular and vision standards 
are the most frequent. Some of these commenters express concern that 
the recommended standards will serve to discourage good health 
practices through fear of denial. For example, commenters who objected 
to the AMA recommendation for a blood pressure standard particularly 
object to the AMA recommendation that an applicant shall have no 
established medical history of use of antihypertensive medication 
within the last year. Commenters who use antihypertensive medication 
said they would either stop taking the medication (which they need) or 
be denied.
    FAA Response: The proposed standards do not specify that 
individuals using antihypertensive medication shall be denied 
certification. If antihypertensive medication is used or is needed to 
meet the blood pressure requirement, a person may be issued a 
certificate only after a current, satisfactory medical assessment, 
prescribed by the Federal Air Surgeon. In this case as in some others, 
the FAA has not followed the AMA recommendation. However, the comments 
indicate a misunderstanding. A medical history of a disqualifying 
condition, whatever that condition is, does not necessarily mean that a 
person will be denied certification absolutely. It may mean that 
additional evaluation may be required before the FAA can determine if 
certification is appropriate. This may require additional time and some 
expense for additional tests, but, for most of the proposed standards, 
the added inconvenience is minimal compared to the improvement in 
safety.

Regulatory Evaluation Summary

Introduction

    Three requirements pertain to economic impacts of regulatory 
changes to the FAR. First, Executive Order 12291 directs Federal 
agencies to promulgate new regulations or modify existing regulations 
only if the potential benefits to society outweigh the potential costs. 
Second, the Regulatory Flexibility Act of 1980 requires agencies to 
analyze the economic impact of regulatory changes on small entities. 
Finally, the Office of Management and Budget (OMB) directs agencies to 
assess the effects of regulatory changes on international trade. In 
conducting these analyses, the FAA has determined that this rule:
    (1) would generate benefits exceeding costs, and, thus, is not a 
major rule as defined by the Executive Order; (2) is significant as 
defined in DOT's Policies and Procedures; and (3) would not have a 
significant impact on a substantial number of small entities; and (4) 
would not have an impact on international trade. These analyses, 
available in the docket, are summarized below.

Regulatory Evaluation Summary

    The majority of the proposed amendments would have insignificant 
attributable costs with respect to the benefits received. This 
evaluation does not address the minor proposed amendments such as 
changes in syntax, technical corrections, reorganization, updating 
medical terminology, or adjustments to cross-references for conformance 
purposes.
    Furthermore, the evaluation attributes no significant costs or 
benefits to several other proposed amendments that would add a specific 
disease or medical condition to the list of medical standards. Such 
additions do not necessarily constitute a change in the standards. 
Current regulations include two open-ended (general) medical standards 
that cover:
    (1) any other personality disorder, neurosis, or mental condition * 
* *, or (2) any other organic, functional, or structural disease, 
defect, or limitation * * * that the Federal Air Surgeon finds would 
make, or may reasonably be expected to make, the applicant unable to 
perform the duties associated with the certificate. Thus, the 
applicable medical standards are not limited to those actually listed 
in the regulation. As medical knowledge and experience progress, the 
Federal Air Surgeon may find a previously unlisted disease or condition 
to be grounds for withholding or restricting a medical certificate, so 
long as that finding is based on qualified medical judgment.
    Under the proposed standards, a small number of airmen who 
currently hold certificates as a result of an order of the NTSB would 
become disqualified from further medical certification because of the 
addition of specifically disqualifying medical conditions. These airmen 
were denied medical certification by the FAA under the current general 
medical standards. For example, the FAA has denied certification to 
airmen who have had cardiac valve replacement and the NTSB has ordered 
certification in some of these cases. Under the proposed standards, a 
medical history of cardiac valve replacement would be specifically 
disqualifying and those airmen would no longer be entitled to 
certification. It is expected, however, that certification of the 
affected individuals would continue under the Federal Air Surgeon's 
special issuance authority once the FAA evaluates the case and is 
satisfied that the airman's condition has not worsened since the NTSB 
ordered certification. As such, the expected economic impact of the 
specifically disqualifying medical conditions would be minor.

Costs and Benefits That Are Not Quantified

    Prior to summarizing the evaluation of the substantive proposals, 
it is important to note one category of costs and one category of 
benefits that have not been quantified in this analysis. The evaluation 
does not explicitly quantify the economic consequences to those 
individuals who would lose their pilot certificate privileges as a 
result of the proposed additional medical tests or standards. Where 
such consequences are expected, the evaluation estimates the numbers of 
persons who would be denied but does not attribute a cost to those 
actions.
    It is recognized that the denial of pilot privileges would mean the 
loss of a highly valued avocation for some individuals. For others, it 
would actually result in the loss of primary livelihood. An accurate 
assessment of the economic valuation of the denials that are projected 
under this proposed rule is beyond the scope of the evaluation.
    At the same time, the evaluation also does not quantify the 
overwhelming personal health benefits, external to flight safety, that 
would be afforded to those individuals whose medical conditions would 
be detected and whose treatment would be enabled by the proposed tests 
and standards. On average, third-class medical certificate holders 
spend only 0.7 percent of their time flying. The evaluation only 
quantifies the direct benefits of the proposed rule to reduced aviation 
accidents.
    Under existing regulations, the Federal Air Surgeon is charged to 
deny a certificate in those cases where a disease or other physical or 
mental condition would make, or may be reasonably be expected to make, 
the applicant unable to perform the duties associated with the 
certificate. Such findings are not capricious, but instead, are based 
on the case history of the individual and on appropriate, qualified 
medical judgment.

Summary of Quantified Costs and Benefits

Vision Proposals, All Classes

    The proposed rule would institute additional vision tests and 
standards for all three classes. For first- and second-class applicants 
age 50 and older, it would add a new standard (20/40 Snellen) and a new 
test for intermediate vision (32 inches). Applicants for third-class 
medical certificates would be subject to a new standard (20/40 Snellen) 
and a new test for near vision (16 inches).
    The projected 10-year (1994-2003) costs of the intermediate vision 
proposal for first-class applicants are $1.1 million in primary testing 
costs, $1.7 million in follow-up compliance costs (examinations and 
glasses) for those persons not meeting the standard, $5,641 in direct 
processing costs for the expected 14 additional persons who would be 
denied under the provision, totalling $2.8 million, with a 1993 present 
value of $2.0 million.
    The projected 10-year costs of the intermediate vision proposal for 
second-class applicants are $462,887 in primary testing costs, $2.2 
million in follow-up compliance costs (examinations and glasses) for 
those persons not meeting the standard, and $6,529 in direct processing 
costs for the expected 17 additional persons who would be denied under 
the provision, totalling $2.7 million, with a 1993 present value of 
$1.8 million.
    The projected 10-year costs of the near vision proposal for third-
class applicants are $2.8 million in primary testing costs, $1.3 
million in follow-up compliance costs (examinations and glasses) for 
those persons not meeting the standard, and $131,340 in direct 
processing costs for the expected 339 additional persons who would be 
denied under the provision, totalling $4.2 million, with a 1993 present 
value of $2.9 million. It is emphasized that the denials and costs 
associated with the near vision proposal are not wholly attributable to 
the proposed amendment. Although this requirement does not exist in 
current regulations, it has been in place administratively for some 
time. Thus, the associated costs are being, and would continue to be, 
incurred without this proposed amendment.
    NTSB accident records were investigated for the periods from 1962 
through 1989 for commercial flights and from 1982 through 1989 for 
general aviation (GA). For these periods, no accident was found where 
intermediate or near vision deficiency was specifically determined to 
be the cause. As such, the FAA is not able to quantitatively ascribe 
the benefits of the three proposed vision amendments based on 
historical accident analysis.
    Notwithstanding the absence of documented accidents related to 
these three proposals, the FAA maintains that such accidents may well 
have occurred and could continue to occur in the absence of the 
proposed amendments. The NTSB accident analysis system may not document 
those cases where a near or intermediate vision problem caused or 
contributed to accidents. Examples would include deviations from course 
or altitude, inaccurate monitoring of gauges and other avionic 
displays, and incorrect setting of aeronautical parameters such as 
headings or radio frequencies.
    While the extent to which intermediate or near vision problems have 
caused such accidents is unknown, it is the FAA's position that: (1) 
general aviation pilots require adequate near vision to read charts and 
checklists, and (2) commercial pilots require adequate intermediate 
vision to properly monitor aircraft instruments. Although this 
evaluation is not able to quantify the benefits of the proposed vision 
amendments, the FAA holds that the benefits would be significant and 
would exceed the expected costs.

Electrocardiogram (ECG), Second-Class

    The proposal would add a new requirement whereby applicants for 
second-class medical certificates would be required to have a routine 
resting ECG at the first application after reaching age 35 and every 2 
years after reaching age 40. The projected ten-year costs of the 
provision are $25.5 million in primary testing costs, and $1.7 million 
of additional testing and processing costs for those persons who would 
not meet the standard, including 178 persons who would be denied, 
totalling $27.2 million, with a 1993 present value of $19.2 million.
    The projected benefits of this provision were based on a review of 
the related NTSB accident records. In the absence of this proposal, 
commercial pilot, heart-related accidents over the 1994-2003 period are 
projected to consist of: 2.64 deaths per year valued at $6.60 million, 
.14 serious injuries per year valued at $89,600, .14 minor injuries per 
year valued at $322, and 2.06 damaged or destroyed (GA and commercial) 
airplanes per year valued at $169,360, totalling $6,859,282 per year. 
The projected benefits of this provision over the ten-year study period 
are $68.6 million, with a present value of $48.2 million. The FAA holds 
that the proposed amendment would meet or exceed the 40 percent 
effectiveness level ($19.2 million cost / $48.2 million potential 
benefit) necessary to be cost beneficial.

Blood Pressure, Second-Class

    The proposal would add a new requirement that the sitting blood 
pressure second-class medical certificate applicants not exceed 150/95 
millimeters of mercury. The projected ten-year costs of the provision 
are $1.8 million in primary testing costs and $0.7 million of 
additional testing and processing costs for those persons who would not 
meet the standard, including 32 persons who would be denied, totalling 
$2.5 million, with a 1993 present value of $1.7 million.
    The projected benefits of this provision were based on the review 
of the related NTSB accident records. For second-class (commercial 
pilots), only one general aviation accident was found where 
hypertension or stroke was specifically listed as the cause. That 
accident caused one death and destroyed one aircraft. Based on that 
accident, commercial pilot accidents related to hypertension or stroke 
are projected over the forecast period to equal: (1) .14 deaths per 
year valued at $350,000 and (2) .14 destroyed airplanes per year valued 
at $10,920, totalling $360,920 annually.
    In addition to the directly attributable pathologies, high blood 
pressure is also an associated risk factor for other pathologies 
including cardiovascular disease and kidney failure. The exact impact 
of the proposed rule on preventing accidents from these related 
diseases is not known but the FAA estimates that the magnitude of 
associated-disease accident costs that would be averted by the proposed 
amendment is at least equal to 5 percent of the projected costs 
attributable to second-class cardiovascular accidents. Such potential 
benefits would total $342,964 per year. The combined (direct and 
associated risk disease) potential benefits of the proposed second-
class blood pressure amendment over the ten-year study period are 
expected to total $7.0 million, with a 1993 present value of $4.9 
million. The FAA holds that the proposed amendment would meet or exceed 
the 35 percent effectiveness level ($1.7 million cost / $4.9 million 
potential benefit) necessary to be cost beneficial.

Blood Pressure, Third-Class

    The proposal would add a new requirement that the sitting blood 
pressure of all applicants for third-class medical certificates not 
exceed 150/95 millimeters of mercury. The projected ten-year costs of 
the provision are $2.8 million in primary testing costs and $1.0 
million of additional testing and processing costs for those persons 
who would not meet the standard, including 48 persons who would be 
denied, totalling $3.8 million, with 1993 present value of $2.7 
million.
    The projected benefits of this provision were based on a review of 
the related NTSB accident records for the period 1982 through 1989. For 
third-class certificate holders, 6 general aviation accidents were 
found where hypertension or stroke was specifically listed as the 
cause. In the absence of this proposal, third-class accidents related 
to hypertension or stroke are projected to equal .75 deaths per year 
valued at $1,875,000, .5 serious injuries per year valued at $320,000, 
.13 minor injuries per year valued at $299, and .75 destroyed airplanes 
per year valued at $58,500, totalling $2.3 million per year. Over the 
ten-year study period, the potential benefits would equal $22.5 
million, with a 1993 present value of $15.8 million.
    Similar to the proposal for second-class, the proposed third-class 
blood pressure standard would also reduce those accidents caused by the 
secondary pathologies where high blood pressure is an associated risk 
factor. However, the magnitude of accidents directly caused by 
hypertension and stroke in third-class pilots is so large that an 
estimate of these secondary benefits is unnecessary. The FAA holds that 
the proposed amendment would meet or exceed the 17 percent 
effectiveness level ($2.7 million cost / $15.8 million potential 
benefit) necessary to be cost beneficial.

Cholesterol, First-Class

    The proposal would add a new requirement whereby applicants for 
first-class medical certificates age 50 and over would be tested and 
would be subject to a standard of 300 milligrams per deciliter. The 
projected ten-year costs of the provision are $3.4 million in primary 
testing costs and $2.0 million of additional testing and processing 
costs for those persons who would not meet the standard, including 81 
persons who would be denied, totalling $5.4 million, with a 1993 
present value of $3.7 million.
    A review of general aviation accidents from 1982 through 1989 found 
six accidents caused by heart attacks in air transport pilots. These 
accidents resulted in seven deaths, one serious injury, and six 
destroyed airplanes. Parallel statistics for commercial accidents (from 
1962 through 1989) revealed 4 accidents with 95 deaths, 15 major 
injuries, 2 destroyed commuter airplanes and 2 destroyed air transport 
planes.
    These statistics project an annual, cardiovascular-related accident 
cost of $2.0 million in damaged airplanes, and $27.2 million in lost 
life and injury costs. Multiplying the total $29.2 million projected 
cost by 5 percent, to estimate the likely proportion of these costs 
that would be averted by the proposed cholesterol test and standard, 
results in a potential annual benefit estimate of $1.46 million. 
Accordingly, the ten-year benefits are projected to be $14.6 million, 
with a 1993 present value of $10.3 million. The FAA projects that the 
expected minimum potential benefits of the proposal ($10.3 million) 
would exceed the estimated cost ($3.7 million).

Part 61, Certificate Validity Period, Third-Class

    Under the proposal, persons under age 40 would generally only be 
required to undergo a physical examination every 3 years. Medical 
certificates for persons age 40 through 69 would continue to be valid 
for 2 years. Persons age 70 and older would be required to undergo a 
physical examination every year.
    The amendment would reduce: (1) the projected years of pilot 
pathology exposure by an estimated 0.2 percent, (2) the projected 
flight hours of pilot pathology exposure by some 4.1 percent, and (3) 
the projected number of third-class medical examinations by 14.5 
percent. Accordingly, it is expected that the proposed amendment would 
not induce any costs to third-class applicants considered as a whole.
    The evaluation does not specifically quantify the potential 
benefits from the expected minor reductions in pathology exposure. The 
expected ten-year savings that would derive from the 14.5 percent 
reduction in examinations is projected to total $23.7 million in direct 
testing and time costs (a 1993 present value of $16.5 million). With a 
projected benefit of $16.5 million and no expected net costs, the FAA 
finds that this provision would be cost beneficial.
    It is noted that the provision would transfer costs and benefits 
across age groups. Third-class applicants younger than 40 would take 
fewer examinations and would be expected to manifest a higher incident 
of undetected pathologies. Conversely, the group of applicants age 70 
and older would take more examinations and would exhibit fewer 
undetected pathologies. However, the net effect would be a reduction in 
both examinations and pathologies, consistent with Executive Order 
12291 which requires that regulatory objectives be chosen to maximize 
the net benefits to society.

Regulatory Flexibility Determination

    The Regulatory Flexibility Act of 1980 (RFA) was enacted by 
Congress to ensure that small entities are not unnecessarily or 
disproportionately burdened by Government regulations. The RFA requires 
a Regulatory Flexibility Analysis if a rule would have a significant 
economic impact, either detrimental or beneficial, on a substantial 
number of small entities. FAA Order 2100.14A, Regulatory Flexibility 
Criteria and Guidance, provides threshold cost and small entity size 
standards for complying with RFA review requirements in FAA rulemaking 
actions. After reviewing the projected effects of the proposed rule in 
light of these standards, the FAA finds that the proposal would not 
have significant economic impact on a substantial number of small 
entities.

International Trade Impact Statement

    The proposed rule would have little or no impact on trade for both 
U.S. firms doing business in foreign countries and foreign firms doing 
business in the United States.

Paperwork Reduction Act

    The paperwork burden associated with part 67 is currently approved 
under OMB number 2120-0034. Any increase or decreases associated with 
this NPRM will be submitted to OMB for approval.

Federalism Implications

    The regulations proposed herein would not have substantial direct 
effects on the states, on the relationship between the national 
government and the states, or on the distribution of power and 
responsibilities among the various levels of government. Therefore, in 
accordance with Executive Order 12866, it is determined that this 
proposal would not have sufficient federalism implications to warrant 
the preparation of a Federalism Assessment.

Conclusion

    For the reasons discussed in the preamble, and based on the 
findings in the Regulatory Evaluation and the International Trade 
Impact Analysis, the FAA has determined that this proposed regulation 
is not major under Executive Order 12866. In addition, the FAA 
certifies that this proposal, if adopted, will not have a significant 
economic impact, positive or negative, on a substantial number of small 
entities under the criteria of the Regulatory Flexibility Act. This 
proposal is considered significant under DOT Regulatory Policies and 
Procedures (44 FR 11034; February 26, 1979). An initial regulatory 
evaluation of the proposal, including a Regulatory Flexibility 
Determination and Trade Impact Analysis, has been placed in the docket. 
A copy may be obtained by contacting the person identified under FOR 
FURTHER INFORMATION CONTACT.

Derivation and Distribution Tables

    The Derivation Table below shows the source in current part 67 on 
which each paragraph of each section of proposed revised part 67 is 
based. The Distribution Table below shows where each current part 67 
section and paragraph can be found in the proposed revised part 67. 

                            Derivation Table                            
------------------------------------------------------------------------
 Proposed section                         Based on                      
------------------------------------------------------------------------
                                                                        
     Subpart A                                                          
                                                                        
Section:                                                                
  67.01...........  Current Secs. 67.1 and 67.21.                       
  67.03...........  Current Sec. 67.11.                                 
  67.05...........  Current Sec. 67.12.                                 
  67.07...........  Current Sec. 67.3.                                  
                                                                        
     Subpart B                                                          
                                                                        
Section:                                                                
  67.101..........  Current Sec. 67.13(a) and new language.             
  67.103(a).......  Current Sec. 67.13(b)(1).                           
  67.103(b).......  Current Sec. 67.13(b)(2) and new language.          
  67.103(c).......  Current Sec. 67.13(b)(3) and new language.          
  67.103(d).......  Current Sec. 67.13(b)(4).                           
  67.103(e).......  Current Sec. 67.13(b)(5).                           
  67.103(f).......  Current Sec. 67.13(b)(6) and flush paragraph.       
  67.105(a).......  Current Sec. 67.13(c)(1) and new language.          
  67.105(b).......  Current Sec. 67.13(c)(2), (c)(3), (c)(4), (c)(5),   
                     and new language.                                  
  67.105(c).......  Current Sec. 67.13(c)(6) and new language.          
  67.107(a).......  Current Sec. 67.13(d)(1)(i) and new language.       
  67.107(b).......  New language.                                       
  67.107(c).......  Current Sec. 67.13(d)(1)(ii) reordered.             
  67.109(a).......  Current Sec. 67.13(d)(2)(i) and new language.       
  67.109(b).......  Current Sec. 67.13(d)(2)(ii).                       
  67.111(a).......  Current Sec. 67.13(e)(1) and new language.          
  67.111(b).......  New language.                                       
  67.111(c).......  New language.                                       
  67.111(d).......  Current Sec. 67.13(e) (2) and (3) and new language. 
  67.111(e).......  Flush paragraph after current Sec. 67.13(e)(5) as   
                     modified.                                          
  67.111(f).......  New language.                                       
  67.113(a).......  Current Sec. 67.13(f)(1).                           
  67.113(b).......  Current Sec. 67.13(f)(2).                           
  67.115..........  Current Sec. 67.13(g).                              
                                                                        
     Subpart C                                                          
                                                                        
Section:                                                                
  67.201..........  Current Sec. 67.15(a) and new language.             
  67.203(a).......  Current Sec. 67.15(b)(1).                           
  67.203(b).......  Current Sec. 67.15(b)(2) and new language.          
  67.203(c).......  Current Sec. 67.15(b)(5) and new language.          
  67.203(d).......  Current Sec. 67.15(b)(3).                           
  67.203(e).......  Current Sec. 67.15(b)(4) and new language.          
  67.203(f).......  Current Sec. 67.15(b)(6) and flush paragraph.       
  67.205(a).......  Current Sec. 67.15(c)(1) and new language.          
  67.205(b).......  Current Sec. 67.15(c)(2), (c)(3), (c)(4), (c)(5),   
                     and new language.                                  
  67.205(c).......  Current Sec. 67.15(c)(6) and new language.          
  67.207(a).......  Current Sec. 67.15(d)(1)(i) and new language.       
  67.207(b).......  New language.                                       
  67.207(c).......  Current Sec. 67.15(d)(1)(ii) reordered.             
  67.209(a).......  Current Sec. 67.15(d)(2)(i) and new language.       
  67.209(b).......  Current Sec. 67.15(d)(2)(ii) and new language.      
  67.211(a).......  Current Sec. 67.15(e)(1) and new language.          
  67.211(b).......  New language.                                       
  67.311(c).......  New language.                                       
  67.211(d).......  New language.                                       
  67.211(e).......  New language.                                       
  67.213(a).......  Current Sec. 67.15(f)(1).                           
  67.215(b).......  Current Sec. 67.15(f)(2).                           
  67.217..........  Current Sec. 67.15(g).                              
                                                                        
     Subpart D                                                          
                                                                        
Section:                                                                
  67.301..........  Current Sec. 67.17(a) and new language.             
  67.303(a).......  Current Sec. 67.17(b)(1) and new language.          
  67.303(b).......  New language.                                       
  67.303(c).......  Current Sec. 67.17(b)(3) and new language.          
  67.303(d).......  Current Sec. 67.17(b)(2) and new language.          
  67.305(a).......  Current Sec. 67.17(c)(1) and new language.          
  67.305(b).......  Current Sec. 67.17(c) (2) and (3), and new language.
  67.305(c).......  Current Sec. 67.17(c)(4) and new language.          
  67.307(a).......  Current Sec. 67.17(d)(1)(i) and new language.       
  67.307(b).......  New language.                                       
  67.307(c).......  Current Sec. 67.17(d)(1)(ii) reordered.             
  67.309(a).......  Current Sec. 67.17(d)(2)(i) and new language.       
  67.309(b).......  Current Sec. 67.17(d)(2)(ii) and new language.      
  67.311(a).......  Current Sec. 67.17(e)(1) and new language.          
  67.311(b).......  New language.                                       
  67.311(c).......  New language.                                       
  67.313(a).......  Current Sec. 67.17(f)(1).                           
  67.313(b).......  Current Sec. 67.17(f)(2).                           
  67.315..........  Current Sec. 67.17(g).                              
                                                                        
     Subpart E                                                          
                                                                        
Section:                                                                
  67.401(a).......  Current Sec. 67.19(a) and new language.             
  67.401(b).......  New language.                                       
  67.401(c).......  Current Sec. 67.19(b).                              
  67.401(d).......  Current Sec. 67.19(d) and new language.             
  67.401(e).......  Current Sec. 67.19(c)                               
  67.401(f).......  New language.                                       
  67.401(g).......  Current Sec. 67.19(e) and new language.             
  67.401(h).......  Current Sec. 67.19(f) and new language.             
  67.401(i).......  New language.                                       
  67.401(j).......  New language.                                       
  67.403(a).......  Current Sec. 67.20(a) and new language.             
  67.403(b).......  Current Sec. 67.20(b) and new language.             
  67.403(c).......  New language.                                       
  67.405(a).......  Current Sec. 67.23(a).                              
  67.405(b).......  Current Sec. 67.23(b).                              
  67.407(a).......  Current Sec. 67.25(a) and new language.             
  67.407(b).......  Current Sec. 67.25(a) flush paragraph and new       
                     language.                                          
  67.407(c).......  Current Sec. 67.25(b) and new language.             
  67.407(d).......  Current Sec. 67.25(c).                              
  67.409(a).......  Current Sec. 67.27(a).                              
  67.409(b).......  Current Sec. 67.27(b).                              
  67.409(c).......  Current Sec. 67.27(c).                              
  67.409(d).......  Current Sec. 67.27(d).                              
  67.411(a).......  Current Sec. 67.29(a).                              
  67.411(b).......  Current Sec. 67.29(b).                              
  67.411(c).......  Current Sec. 67.29(c).                              
  67.413(a).......  Current Sec. 67.31.                                 
  67.413(b).......  New language.                                       
  67.415..........  New language.                                       
------------------------------------------------------------------------


                           Distribution Table                           
------------------------------------------------------------------------
Current section                      Proposed section                   
------------------------------------------------------------------------
                                                                        
    Subpart A                                                           
Section:                                                                
  67.1..........  Sec. 67.01.                                           
  67.3..........  Sec. 67.07.                                           
  67.11.........  Sec. 67.03.                                           
  67.12.........  Sec. 67.05.                                           
  67.13(a)......  Sec. 67.101.                                          
  67.13(b)......  Sec. 67.103.                                          
  67.13(c)......  Sec. 67.105.                                          
  67.13(d)......  Sec. 67.107 and Sec. 67.109.                          
  67.13(e)......  Sec. 67.111.                                          
  67.13(f)......  Sec. 67.113.                                          
  67.13(g)......  Sec. 67.115.                                          
  67.15(a)......  Sec. 67.201.                                          
  67.15(b)......  Sec. 67.203.                                          
  67.15(c)......  Sec. 67.205.                                          
  67.15(d)......  Sec. 67.207 and Sec. 67.209.                          
  67.15(e)......  Sec. 67.211.                                          
  67.15(f)......  Sec. 67.213.                                          
  67.15(g)......  Sec. 67.215.                                          
  67.17(a)......  Sec. 67.301.                                          
  67.17(b)......  Sec. 67.303.                                          
  67.17(c)......  Sec. 67.305.                                          
  67.17(d)......  Sec. 67.307 and Sec. 67.209.                          
  67.17(e)......  Sec. 67.311.                                          
  67.17(f)......  Sec. 67.313.                                          
  67.17(g)......  Sec. 67.315.                                          
  67.19.........  Sec. 67.401.                                          
  67.20.........  Sec. 67.403.                                          
                                                                        
    Subpart B                                                           
                                                                        
Section:                                                                
  67.21.........  Sec. 67.401.                                          
  67.23.........  Sec. 67.405.                                          
  67.25.........  Sec. 67.407.                                          
  67.27.........  Sec. 67.409.                                          
  67.29.........  Sec. 67.411.                                          
  67.31.........  Sec. 67.413.                                          
------------------------------------------------------------------------

List of Subjects

14 CFR Part 67

    Airman medical certification, Airman medical standards, Air safety, 
Air transportation, Aviation safety, Falsification, Special issuance 
procedures.

14 CFR Part 61

    Airline transport pilots, Air safety, Aircraft ratings, Air 
transportation, Aviation safety, Commercial pilots, Flight instructors, 
Private pilots, Special certificates, Student and recreational pilots.
    1. The authority citation for part 61 is revised to read as 
follows:

    Authority: 49 U.S.C. 106(g), 1354(a), and 1422.

    2. Section 61.23 is amended by revising paragraphs (a)(3), (b)(2), 
and (c) to read as follows:


Sec. 61.23  Duration of medical certificate.

    (a) * * *
    (3) The period specified in paragraph (c) of this section for 
operations requiring only a private, recreational, or student pilot 
certificate.
    (b) * * *
    (2) The period specified in paragraph (c) of this section for 
operations requiring only a private, recreational, or student pilot 
certificate.
    (c) A third-class medical certificate for operations requiring a 
private, recreational, or student pilot certificate issued on or after 
[effective date of the final rule] expires at the end of the last day 
of the:
    (1) 36th month after the month of the date of the examination shown 
on the certificate if the person has not reached his or her 40th 
birthday on or before the date of the examination;
    (2) 24th month after the month of the date of the examination shown 
on the certificate if the person has reached his or her 40th birthday 
but has not reached his or her 70th birthday on or before the date of 
the examination; or
    (3) 12th month after the month of the date of the examination shown 
on the certificate if the person has reached his or her 70th birthday 
on or before the date of the examination.
    3. Section 61.39 is amended by revising paragraph (a)(3) to read as 
follows:


Sec. 61.39  Prerequisites for flight tests.

    (a) * * *
* * * * *
    (3) Hold a current medical certificate appropriate to the 
certificate the applicant seeks or, in the case of a rating to be added 
to the applicant's pilot certificate, at least a valid third-class 
medical certificate issued under Sec. 61.23;
* * * * *
    4. Part 67 is revised to read as follows:

PART 67--MEDICAL STANDARDS AND CERTIFICATION

Subpart A--General

Sec.
67.01  Applicability.
67.03  Issue.
67.05  Certification of foreign airmen.
67.07  Access to the National Driver Register.

Subpart B--First-Class Airman Medical Certificate

67.101  Eligibility.
67.103  Eye.
67.105  Ear, nose, throat, and equilibrium.
67.107  Mental.
67.109  Neurologic.
67.111  Cardiovascular.
67.113  General medical condition.
67.115  Discretionary issuance.

Subpart C--Second-Class Airman Medical Certificate

67.201  Eligibility.
67.203  Eye.
67.205  Ear, nose, throat, and equilibrium.
67.207  Mental.
67.209  Neurologic.
67.211  Cardiovascular.
67.213  General medical condition.
67.215  Discretionary issuance.

Subpart D--Third-Class Airman Medical Certificate

67.301  Eligibility.
67.303  Eye.
67.305  Ear, nose, throat, and equilibrium.
67.307  Mental.
67.309  Neurologic.
67.311  Cardiovascular.
67.313  General medical condition.
67.315  Discretionary issuance.

Subpart E--Certification Procedures

67.401  Special issuance of medical certificates.
67.403  Applications, certificates, logbooks, reports, and records: 
falsification, reproduction, or alteration.
67.405  Medical examinations: Who may give.
67.407  Delegation of authority.
67.409  Denial of medical certificate.
67.411  Medical certificates by flight surgeons of Armed Forces.
67.413  Medical records.
67.415  Return of medical certificate after suspension or 
revocation.

    Authority: 49 U.S.C. App. 1354, 1355, 1421, 1422, and 1427; 49 
U.S.C. 106(g).

Subpart A--General


Sec. 67.01  Applicability.

    This part prescribes the medical standards and certification 
procedures for issuing medical certificates for airmen and for 
remaining eligible for a medical certificate.


Sec. 67.03  Issue.

    Except as provided in Sec. 67.05, an applicant who meets the 
medical standards prescribed in this part, based on medical examination 
and evaluation of the applicant's history and condition, is entitled to 
an appropriate medical certificate.


Sec. 67.05  Certification of foreign airmen.

    A person who is neither a United States citizen nor a resident 
alien is issued a certificate under this part, outside the United 
States, only when the Administrator finds that the certificate is 
needed for operation of a U.S.-registered aircraft.


Sec. 67.07  Access to the National Driver Register.

    At the time of application for a certificate issued under this 
part, each person who applies for a medical certificate shall execute 
an express consent form authorizing the Administrator to request the 
chief driver licensing official of any state designated by the 
Administrator to transmit information contained in the National Driver 
Register about the person to the Administrator. The Administrator shall 
make information received from the National Driver Register, if any, 
available on request to the person for review and written comment.

Subpart B--First-Class Airman Medical Certificate


Sec.  67.101  Eligibility.

    To be eligible for a first-class airman medical certificate, and to 
remain eligible for a first-class airman medical certificate, a person 
must meet the requirements of this subpart.


Sec. 67.103  Eye.

    Eye standards for a first-class airman medical certificate include, 
but are not limited to:
    (a) Distant visual acuity of 20/20 or better in each eye separately 
with or without corrective lenses. If corrective lenses (spectacles or 
contact lenses) are necessary for 20/20 vision, the person may be 
eligible only on the condition that corrective lenses are worn while 
exercising the privileges of an airman certificate.
    (b) Near vision of 20/40, Snellen equivalent, at 16 inches in each 
eye separately, with or without corrective lenses. If age 50 or older, 
near vision of 20/40, Snellen equivalent, at both 16 inches and 32 
inches in each eye separately, with or without corrective lenses.
    (c) Ability to perceive those colors necessary for the safe 
performance of airman duties.
    (d) Normal fields of vision.
    (e) No acute or chronic pathological condition of either eye or 
adnexa that interferes with the proper function of an eye, that may 
reasonably be expected to progress to that degree, or that may 
reasonably be expected to be aggravated by flying.
    (f) Bifoveal fixation and vergence-phoria relationship sufficient 
to prevent a break in fusion under conditions that may reasonably be 
expected to occur in performing airman duties. Tests for the factors 
named in this paragraph are not required except for persons found to 
have more than 1 prism diopter of hyperphoria, 6 prism diopters of 
esophoria, or 6 prism diopters of exophoria. If any of these values are 
exceeded, the Federal Air Surgeon may require the person to be examined 
by a qualified eye specialist to determine if there is bifoveal 
fixation and an adequate vergence-phoria relationship. However, if 
otherwise eligible, the person is issued a medical certificate pending 
the results of the examination.


Sec. 67.105  Ear, nose, throat, and equilibrium.

    Ear, nose, throat, and equilibrium standards for a first-class 
airman medical certificate include, but are not limited to:
    (a) The person shall--
    (1) Demonstrate an ability to hear an average conversational voice 
in a quiet room, using both ears, at a distance of 6 feet from the 
examiner, with the back turned to the examiner;
    (2) Demonstrate an acceptable understanding of speech as determined 
by audiometric speech discrimination testing to a score of at least 70 
percent obtained in one ear or in a sound field environment; or
    (3) Provide acceptable results of pure tone audiometric testing of 
unaided hearing acuity according to the following table of worst 
acceptable thresholds, using the calibration standards of the American 
National Standards Institute, 1969: 

----------------------------------------------------------------------------------------------------------------
                       Frequency (Hz)                           500 Hz       1000 Hz      2000 Hz      3000 Hz  
----------------------------------------------------------------------------------------------------------------
Better ear (Db).............................................           35           30           30           40
Poorer ear (Db).............................................           35           50           50           60
----------------------------------------------------------------------------------------------------------------

    (b) No disease or condition of the middle or internal ear, nose, 
oral cavity, pharynx, or larynx that--
    (1) Interferes with, or is aggravated by, flying or may reasonably 
be expected to do so or
    (2) Interferes with, or may reasonably be expected to interfere 
with, clear and effective speech communication.
    (c) No disease or condition manifested by, or may reasonably be 
expected to be manifested by, vertigo or a disturbance of equilibrium.


Sec.  67.107  Mental.

    Mental standards for a first-class airman medical certificate 
include, but are not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) A personality disorder that is severe enough to have repeatedly 
manifested itself by overt acts;
    (2) A psychosis. As used in this section, ``psychosis'' refers to a 
mental disorder in which the individual has manifested psychotic 
symptoms or to a mental disorder in which an individual may reasonably 
be expected to manifest psychotic symptoms;
    (3) A bipolar disorder; or
    (4) Substance dependence, except where there is established 
clinical evidence, satisfactory to the Federal Air Surgeon, of 
recovery, including sustained total abstinence from alcohol for not 
less than the preceding 2 years in the case of alcohol dependence. In 
the case of other substance dependence, recovery must include sustained 
total abstinence from that substance for not less than the preceding 5 
years. As used in this section--
    (i) ``Substance'' includes: alcohol; other sedatives and hypnotics; 
muscle relaxants; anxiolytics; opioids; central nervous system 
stimulants such as cocaine, amphetamines, and similarly acting 
sympathomimetics; hallucinogens; phencyclidine or similarly acting 
arylcyclohexylamines; cannabis; volatile solvents and gases; and other 
psychoactive drugs and chemicals and
    (ii) ``Substance dependence'' means a condition in which a person 
is dependent on a substance, other than tobacco or ordinary xanthine-
containing (e.g., caffeine) beverages, as evidenced by--
    (A) Increased tolerance;
    (B) Manifestation of withdrawal symptoms;
    (C) Impaired control of use; or
    (D) Continued use despite damage to physical health or impairment 
of social, personal, or occupational functioning.
    (b) No substance abuse defined as:
    (1) Use of alcohol within the preceding 2 years in a situation in 
which that use is physically hazardous, if there has been at any other 
time an instance of the use of alcohol or another substance also in a 
situation in which that use was physically hazardous;
    (2) Use of a substance other than alcohol within the preceding 5 
years in a situation in which that use is physically hazardous, if 
there has been at any other time an instance of the use of that 
substance, alcohol, or another substance also in a situation in which 
that use was physically hazardous;
    (3) Use of a prohibited drug defined in appendix I of part 121 of 
this chapter within the preceding 5 years; or
    (4) Misuse of a substance, within the preceding 2 years if alcohol 
or within the preceding 5 years if another substance, that the Federal 
Air Surgeon, based on case history and appropriate, qualified medical 
judgment, finds--
    (i) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (ii) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.
    (c) No other personality disorder, neurosis, or other mental 
condition that the Federal Air Surgeon, based on the case history and 
appropriate, qualified medical judgment relating to the condition 
involved, finds--
    (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.109  Neurologic.

    Neurologic standards for a first-class airman medical certificate 
include, but are not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) Epilepsy;
    (2) A single seizure;
    (3) A disturbance of consciousness without satisfactory medical 
explanation of the cause; or
    (4) A transient loss of control of nervous system function(s) 
without satisfactory medical explanation of the cause.
    (b) No other seizure disorder, disturbance of consciousness, or 
neurologic condition that the Federal Air Surgeon, based on the case 
history and appropriate, qualified medical judgment relating to the 
condition involved, finds--
    (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.111  Cardiovascular.

    Cardiovascular standards for a first-class airman medical 
certificate include, but are not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) Myocardial infarction;
    (2) Angina pectoris;
    (3) Coronary heart disease that has required treatment or, if 
untreated, that has been symptomatic or clinically significant;
    (4) Cardiac valve replacement;
    (5) Permanent cardiac pacemaker implantation; or
    (6) Heart replacement;
    (b) The person's average systolic blood pressure while sitting must 
not exceed 150 millimeters of mercury, and the person's average 
diastolic blood pressure while sitting must not exceed 95 millimeters 
of mercury. If antihypertensive medication is used or is needed to meet 
the requirement of this section, a person may be issued a certificate 
only after a current (within the preceding 6 months) satisfactory 
medical assessment, prescribed by the Federal Air Surgeon. This medical 
assessment may include, but is not limited to, blood pressure control; 
the medication used; the presence or absence of cardiovascular risk 
factors other than hypertension; other vascular disease; and the 
presence or absence of disease of ``target'' organs (e.g., heart, 
brain, kidneys, eyes).
    (c) The person must not use anticoagulant medication.
    (d) A person applying for first-class medical certification must 
demonstrate an absence of myocardial infarction and other clinically 
significant abnormality on electrocardiographic examination:
    (1) At the first application after reaching the 35th birthday, 
unless the person has satisfied Sec. 67.211(d)(1) and
    (2) On an annual basis after reaching the 40th birthday, unless 
within the preceding 9 months an electrocardiogram (ECG) has been 
provided as part of an application for medical certification.
    (e) An ECG will satisfy a requirement of paragraph (d) of this 
section if it is dated no earlier than 60 days before the date of the 
application it is to accompany, and was performed and transmitted 
according to acceptable standards and techniques.
    (f) At the first examination after reaching the 50th birthday and 
annually thereafter, the level of total blood cholesterol must be 
determined. If the person's total blood cholesterol is determined to be 
300 milligrams per deciliter or more, the Federal Air Surgeon may 
require the person to submit reports of additional examinations to 
determine if disease exists. However, if otherwise eligible, the person 
is issued a medical certificate pending the results of those additional 
examinations.


Sec.  67.113  General medical condition.

    The general medical standards for a first-class airman medical 
certificate are:
    (a) No established medical history or clinical diagnosis of 
diabetes mellitus that requires insulin or any other hypoglycemic drug 
for control.
    (b) No other organic, functional, or structural disease, defect, or 
limitation that the Federal Air Surgeon, based on the case history and 
appropriate, qualified medical judgment relating to the condition 
involved, finds--
    (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.115  Discretionary issuance.

    A person who does not meet the provisions of Secs. 67.103 through 
67.113 of this subpart may apply for the discretionary issuance of a 
certificate under Sec. 67.401.

Subpart C--Second-Class Airman Medical Certificate


Sec. 67.201  Eligibility.

    To be eligible for a second-class airman medical certificate, and 
to remain eligible for a second-class airman medical certificate, a 
person must meet the requirements of this subpart.


Sec. 67.203  Eye.

    Eye standards for a second-class airman medical certificate 
include, but are not limited to:
    (a) Distant visual acuity of 20/20 or better in each eye separately 
with or without corrective lenses. If corrective lenses (spectacles or 
contact lenses) are necessary for 20/20 vision, the person may be 
eligible only on the condition that corrective lenses are worn while 
exercising the privileges of an airman certificate.
    (b) Near vision of 20/40, Snellen equivalent, at 16 inches in each 
eye separately, with or without corrective lenses. If age 50 or older, 
near vision of 20/40, Snellen equivalent, at both 16 inches and 32 
inches in each eye separately, with or without corrective lenses.
    (c) Ability to perceive those colors necessary for the safe 
performance of airman duties.
    (d) Normal fields of vision.
    (e) No acute or chronic pathological condition of either eye or 
adnexa that interferes with the proper function of an eye, that may 
reasonably be expected to progress to that degree, or that may 
reasonably be expected to be aggravated by flying.
    (f) Bifoveal fixation and vergence-phoria relationship sufficient 
to prevent a break in fusion under conditions that may reasonably be 
expected to occur in performing airman duties. Tests for the factors 
named in this paragraph are not required except for persons found to 
have more than 1 prism diopter of hyperphoria, 6 prism diopters of 
esophoria, or 6 prism diopters of exophoria. If any of these values are 
exceeded, the Federal Air Surgeon may require the person to be examined 
by a qualified eye specialist to determine if there is bifoveal 
fixation and an adequate vergence-phoria relationship. However, if 
otherwise eligible, the person is issued a medical certificate pending 
the results of the examination.


Sec. 67.205  Ear, nose, throat, and equilibrium.

    Ear, nose, throat, and equilibrium standards for a second-class 
airman medical certificate include, but are not limited to:
    (a) The person shall--
    (1) Demonstrate an ability to hear an average conversational voice 
in a quiet room, using both ears, at a distance of 6 feet from the 
examiner, with the back turned to the examiner;
    (2) Demonstrate an acceptable understanding of speech as determined 
by audiometric speech discrimination testing to a score of at least 70 
percent obtained in one ear or in a sound field environment; or
    (3) Provide acceptable results of pure tone audiometric testing of 
unaided hearing acuity according to the following table of worst 
acceptable thresholds, using the calibration standards of the American 
National Standards Institute, 1969: 

----------------------------------------------------------------------------------------------------------------
                       Frequency (Hz)                            500 Hz      1000 Hz      2000 Hz      3000 Hz  
----------------------------------------------------------------------------------------------------------------
Better ear (Db).............................................           35           30           30           40
Poorer ear (Db).............................................           35           50           30          60 
----------------------------------------------------------------------------------------------------------------

    (b) No disease or condition of the middle or internal ear, nose, 
oral cavity, pharynx, or larynx that--
    (1) Interferes with, or is aggravated by, flying or may reasonably 
be expected to do so or
    (2) Interferes with, or may reasonably be expected to interfere 
with, clear and effective speech communication.
    (c) No disease or condition manifested by, or may reasonably be 
expected to be manifested by, vertigo or a disturbance of equilibrium.


Sec.  67.207  Mental.

    Mental standards for a second-class airman medical certificate 
include, but are not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) A personality disorder that is severe enough to have repeatedly 
manifested itself by overt acts;
    (2) A psychosis. As used in this section, ``psychosis'' refers to a 
mental disorder in which the individual has manifested psychotic 
symptoms or to a mental disorder in which an individual may reasonably 
be expected to manifest psychotic symptoms;
    (3) A bipolar disorder; or
    (4) Substance dependence, except where there is established 
clinical evidence, satisfactory to the Federal Air Surgeon, of 
recovery, including sustained total abstinence from alcohol for not 
less than the preceding 2 years in the case of alcohol dependence. In 
the case of other substance dependence, recovery must include sustained 
total abstinence from that substance for not less than the preceding 5 
years. As used in this section--
    (i) ``Substance'' includes: alcohol; other sedatives and hypnotics; 
muscle relaxants; anxiolytics; opioids; central nervous system 
stimulants such as cocaine, amphetamines, and similarly acting 
sympathomimetics; hallucinogens; phencyclidine or similarly acting 
arylcyclohexylamines; cannabis; volatile solvents and gases; and other 
psychoactive drugs and chemicals; and
    (ii) ``Substance dependence'' means a condition in which a person 
is dependent on a substance, other than tobacco or ordinary xanthine-
containing (e.g., caffeine) beverages, as evidenced by--
    (A) Increased tolerance;
    (B) Manifestation of withdrawal symptoms;
    (C) Impaired control of use; or
    (D) Continued use despite damage to physical health or impairment 
of social, personal, or occupational functioning.
    (b) No substance abuse defined as:
    (1) Use of alcohol within the preceding 2 years in a situation in 
which that use is physically hazardous, if there has been at any other 
time an instance of the use of alcohol or another substance also in a 
situation in which that use was physically hazardous;
    (2) Use of a substance other than alcohol within the preceding 5 
years in a situation in which that use is physically hazardous, if 
there has been at any other time an instance of the use of that 
substance, alcohol, or another substance also in a situation in which 
that use was physically hazardous;
    (3) Use of a prohibited drug defined in Appendix I of part 121 of 
this chapter within the preceding 5 years; and
    (4) Misuse of a substance, within the preceding 2 years if alcohol 
or within the preceding 5 years if another substance, that the Federal 
Air Surgeon, based on case history and appropriate, qualified medical 
judgment, finds--
    (i) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (ii) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.
    (c) No other personality disorder, neurosis, or other mental 
condition that the Federal Air Surgeon, based on the case history and 
appropriate, qualified medical judgment relating to the condition 
involved, finds--
    (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.209  Neurologic.

    Neurologic standards for a second-class airman medical certificate 
include, but is not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) Epilepsy;
    (2) A single seizure;
    (3) A disturbance of consciousness without satisfactory medical 
explanation of the cause; or
    (4) A transient loss of control of nervous system function(s) 
without satisfactory medical explanation of the cause;
    (b) No other seizure disorder, disturbance of consciousness, or 
neurologic condition that the Federal Air Surgeon, based on the case 
history and appropriate, qualified medical judgment relating to the 
condition involved, finds--
    (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.211  Cardiovascular.

    Cardiovascular standards for a second-class medical certificate 
include, but are not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) Myocardial infarction;
    (2) Angina pectoris;
    (3) Coronary heart disease that has required treatment or, if 
untreated, that has been symptomatic or clinically significant;
    (4) Cardiac valve replacement;
    (5) Permanent cardiac pacemaker implantation; or
    (6) Heart replacement;
    (b) The person's average systolic blood pressure while sitting must 
not exceed 150 millimeters of mercury, and the person's average 
diastolic blood pressure while sitting must not exceed 95 millimeters 
of mercury. If antihypertensive medication is used or is needed to meet 
the requirement of this section, a person may be issued a certificate 
only after a current (within the preceding 6 months) satisfactory 
medical assessment, prescribed by the Federal Air Surgeon, of blood 
pressure control; of the medication used; of the presence or absence of 
cardiovascular risk factors other than hypertension; of other vascular 
disease; and of the presence or absence of disease of ``target'' organs 
(e.g., heart, brain, kidneys, or eyes).
    (c) The person must not use anticoagulant medication.
    (d) A person applying for second-class medical certification must 
demonstrate an absence of myocardial infarction and other clinically 
significant abnormality on electrocardiographic examination:
    (1) At the first application after reaching the 35th birthday, 
unless the person has satisfied Sec. 67.111(d)(1) and
    (2) On a biennial basis after reaching the 40th birthday, unless 
within the preceding 15 months an electrocardiogram (ECG) has been 
provided as part of an application for medical certification.
    (e) An ECG will satisfy a requirement of paragraph (d) of this 
section if it is dated no earlier than 60 days before the date of the 
application it is to accompany, and was performed and transmitted 
according to acceptable standards and techniques.


Sec. 67.213  General medical condition.

    The general medical standards for a second-class airman medical 
certificate are:
    (a) No established medical history or clinical diagnosis of 
diabetes mellitus that requires insulin or any other hypoglycemic drug 
for control.
    (b) No other organic, functional, or structural disease, defect, or 
limitation that the Federal Air Surgeon, based on the case history and 
appropriate, qualified medical judgment relating to the condition 
involved, finds--
    (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.215  Discretionary issuance.

    A person who does not meet the provisions of Secs. 67.203 through 
67.213 of this subpart may apply for the discretionary issuance of a 
certificate under Sec. 67.401.

Subpart D--Third-Class Airman Medical Certificate


Sec. 67.301  Eligibility.

    To be eligible for a third-class airman medical certificate, or to 
remain eligible for a third-class airman medical certificate, a person 
must meet the requirements of this subpart.


Sec. 67.303  Eye.

    Eye standards for a third-class airman medical certificate include, 
but are not limited to:
    (a) Distant visual acuity of 20/40 or better in each eye separately 
with or without corrective lenses. If corrective lenses (spectacles or 
contact lenses) are necessary for 20/40 vision, the person may be 
eligible only on the condition that corrective lenses are worn while 
exercising the privileges of an airman certificate.
    (b) Near vision of 20/40, Snellen equivalent, at 16 inches in each 
eye separately, with or without corrective lenses.
    (c) Ability to perceive those colors necessary for the safe 
performance of airman duties.
    (d) No acute or chronic pathological condition of either eye or 
adnexa that interferes with the proper function of an eye, that may 
reasonably be expected to progress to that degree, or that may 
reasonably be expected to be aggravated by flying.


Sec. 67.305  Ear, nose, throat, and equilibrium.

    Ear, nose, throat, and equilibrium standards for a third-class 
airman medical certificate include, but are not limited to:
    (a) The person shall--
    (1) Demonstrate an ability to hear an average conversational voice 
in a quiet room, using both ears, at a distance of 6 feet from the 
examiner, with the back turned to the examiner;
    (2) Demonstrate an acceptable understanding of speech as determined 
by audiometric speech discrimination testing to a score of at least 70 
percent obtained in one ear or in a sound field environment; or
    (3) Provide acceptable results of pure tone audiometric testing of 
unaided hearing acuity according to the following table of worst 
acceptable thresholds, using the calibration standards of the American 
National Standards Institute, 1969: 

----------------------------------------------------------------------------------------------------------------
                       Frequency (Hz)                           500 Hz       1000 Hz      2000 Hz      3000 Hz  
----------------------------------------------------------------------------------------------------------------
Better ear (Db).............................................           35           30           30           40
Poorer ear (Db).............................................           35           50           50           60
----------------------------------------------------------------------------------------------------------------

    (b) No disease or condition of the middle or internal ear, nose, 
oral cavity, pharynx, or larynx that--
    (1) Interferes with, or is aggravated by, flying or may reasonably 
be expected to do so or
    (2) Interferes with clear and effective speech communication.
    (c) No disease or condition manifested by, or may reasonably be 
expected to be manifested by, vertigo or a disturbance of equilibrium.


Sec.  67.307  Mental.

    Mental standards for a third-class airman medical certificate 
include, but are not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) A personality disorder that is severe enough to have repeatedly 
manifested itself by overt acts;
    (2) A psychosis. As used in this section, ``psychosis'' refers to a 
mental disorder in which the individual has manifested psychotic 
symptoms or to a mental disorder in which an individual may reasonably 
be expected to manifest psychotic symptoms;
    (3) A bipolar disorder; or
    (4) Substance dependence, except where there is established 
clinical evidence, satisfactory to the Federal Air Surgeon, of 
recovery, including sustained total abstinence from alcohol for not 
less than the preceding 2 years in the case of alcohol dependence. In 
the case of other substance dependence, recovery must include sustained 
total abstinence from that substance for not less than the preceding 5 
years. As used in this section--
    (i) ``Substance'' includes: alcohol; other sedatives and hypnotics; 
muscle relaxants; anxiolytics; opioids; central nervous system 
stimulants such as cocaine, amphetamines, and similarly acting 
sympathomimetics; hallucinogens; phencyclidine or similarly acting 
arylcyclohexylamines; cannabis; volatile solvents and gases; and other 
psychoactive drugs and chemicals and
    (ii) ``Substance dependence'' means a condition in which a person 
is dependent on a substance, other than tobacco or ordinary xanthine-
containing (e.g., caffeine) beverages, as evidenced by--
    (A) Increased tolerance;
    (B) Manifestation of withdrawal symptoms;
    (C) Impaired control of use; or
    (D) Continued use despite damage to physical health or impairment 
of social, personal, or occupational functioning.
    (b) No substance abuse defined as:
    (1) Use of alcohol within the preceding 2 years in a situation in 
which that use is physically hazardous, if there has been at any other 
time an instance of the use of alcohol or another substance also in a 
situation in which that use was physically hazardous;
    (2) Use of a substance other than alcohol within the preceding 5 
years in a situation in which that use is physically hazardous, if 
there has been at any other time an instance of the use of that 
substance, alcohol, or another substance also in a situation in which 
that use was physically hazardous;
    (3) Use of a prohibited drug defined in Appendix I of part 121 of 
this chapter within the preceding 5 years; and
    (4) Misuse of a substance, within the preceding 2 years if alcohol 
or within the preceding 5 years if another substance, that the Federal 
Air Surgeon, based on case history and appropriate, qualified medical 
judgment, finds--
    (i) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (ii) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.
    (c) No other personality disorder, neurosis, or other mental 
condition that the Federal Air Surgeon, based on the case history and 
appropriate, qualified medical judgment relating to the condition 
involved, finds--
    (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.309  Neurologic.

    Neurologic standards for a third-class airman medical certificate 
include, but are not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) Epilepsy;
    (2) A single seizure;
    (3) A disturbance of consciousness without satisfactory medical 
explanation of the cause; or
    (4) A transient loss of control of nervous system function(s) 
without satisfactory medical explanation of the cause; or
    (b) No other seizure disorder, disturbance of consciousness, or 
neurologic condition that the Federal Air Surgeon, based on the case 
history and appropriate, qualified medical judgment relating to the 
condition involved, finds--
    (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.311  Cardiovascular.

    Cardiovascular standards for a third-class airman medical 
certificate include, but are not limited to:
    (a) No established medical history or clinical diagnosis of any of 
the following:
    (1) Myocardial infarction;
    (2) Angina pectoris;
    (3) Coronary heart disease that has required treatment or, if 
untreated, that has been symptomatic or clinically significant;
    (4) Cardiac valve replacement;
    (5) Permanent cardiac pacemaker implantation; or
    (6) Heart replacement.
    (b) The person's average systolic blood pressure while sitting must 
not exceed 150 millimeters of mercury, and the person's average 
diastolic blood pressure while sitting must not exceed 95 millimeters 
of mercury. If antihypertensive medication is used or is needed to meet 
the requirement of this section, a person may be issued a certificate 
only after a current (within the preceding 6 months) satisfactory 
medical assessment, prescribed by the Federal Air Surgeon, of blood 
pressure control; of the medication used; of the presence or absence of 
cardiovascular risk factors other than hypertension; of other vascular 
disease; and of the presence or absence of disease of ``target'' organs 
(e.g., heart, brain, kidneys, or eyes).
    (c) The person must not use anticoagulant medication.


Sec. 67.313  General medical condition.

    The general medical standards for a third-class airman medical 
certificate are:
    (a) No established medical history or clinical diagnosis of 
diabetes mellitus that requires insulin or any other hypoglycemic drug 
for control.
    (b) No other organic, functional, or structural disease, defect, or 
limitation that the Federal Air Surgeon, based on the case history and 
appropriate, qualified medical judgment relating to the condition 
involved, find--
     (1) Makes the person unable to safely perform the duties or 
exercise the privileges of the airman certificate applied for or held 
or
    (2) May reasonably be expected, for the maximum duration of the 
airman medical certificate applied for or held, to make the person 
unable to perform those duties or exercise those privileges.


Sec. 67.315  Discretionary issuance.

    A person who does not meet the provisions of Secs. 67.303 through 
67.313 of this subpart may apply for the discretionary issuance of a 
certificate under Sec. 67.401.

Subpart E--Certification Procedures


Sec. 67.401  Special issuance of medical certificates.

    (a) At the discretion of the Federal Air Surgeon, an Authorization 
for Special Issuance of a Medical Certificate (Authorization), valid 
for a specified period, may be granted to a person who does not meet 
the provisions of subparts B, C, or D of this part if the person shows 
to the satisfaction of the Federal Air Surgeon that the duties 
authorized by the class of medical certificate applied for can be 
performed without endangering public safety during the period in which 
the Authorization would be in force. The Federal Air Surgeon may 
authorize a special medical flight test, practical test, or medical 
evaluation for this purpose. A medical certificate of the appropriate 
class may be issued to a person who does not meet the provisions of 
subparts B, C, or D of this part if that person possesses a valid 
Authorization and is otherwise eligible. An airman medical certificate 
issued in accordance with this section shall expire no later than the 
end of the validity period or upon the withdrawal of the Authorization 
upon which it is based. At the end of its specified validity period, 
for grant of a new Authorization, the person must again show to the 
satisfaction of the Federal Air Surgeon that the duties authorized by 
the class of medical certificate applied for can be performed without 
endangering public safety during the period in which the Authorization 
would be in force.
    (b) At the discretion of the Federal Air Surgeon, a Statement of 
Demonstrated Ability (SODA) may be granted, instead of an 
Authorization, to a person whose disqualifying condition is static or 
nonprogressive and who has been found capable of performing airman 
duties without endangering public safety. A SODA does not expire and 
authorizes a designated Aviation Medical Examiner to issue a medical 
certificate of a specified class if the examiner finds that the 
condition described on its face has not adversely changed.
    (c) In granting an Authorization or a SODA, the Federal Air Surgeon 
may consider the person's operational experience and any medical facts 
that may affect the ability of the person to perform airman duties 
including--
    (1) The combined effect on the person of failure to meet more than 
one requirement of this part and
    (2) The prognosis derived from professional consideration of all 
available information regarding the person.
    (d) In granting an Authorization under this section, the Federal 
Air Surgeon specifies the class of medical certificate authorized to be 
issued and may do any or all of the following:
    (1) Limit the duration of the Authorization;
    (2) Condition the granting of a new Authorization on the results of 
subsequent medical tests, examinations, or evaluations;
    (3) State on the Authorization, and any certificate based upon it, 
any operational limitation needed for safety; or
    (4) Condition the continued effect of an Authorization, and any 
second- or third-class medical certificate based upon it, on compliance 
with a statement of functional limitations issued to the person in 
coordination with the Director of Flight Standards or the Director's 
designee.
    (e) In determining whether an Authorization or SODA should be 
granted to an applicant for a third-class medical certificate, the 
Federal Air Surgeon considers the freedom of an airman, exercising the 
privileges of a private pilot certificate, to accept reasonable risks 
to his or her person and property that are not acceptable in the 
exercise of commercial or airline transport privileges, and, at the 
same time, considers the need to protect the safety of persons and 
property in other aircraft and on the ground.
    (f) An Authorization or SODA granted under the provisions of this 
section to a person who does not meet the applicable provisions of 
subparts B, C, or D of this part may be withdrawn, at the discretion of 
the Federal Air Surgeon, at any time if--
    (1) There is adverse change in the holder's medical condition;
    (2) The holder fails to comply with a statement of functional 
limitations or operational limitations issued as a condition of 
certification under this section;
    (3) Public safety would be endangered by the holder's exercise of 
airman privileges;
    (4) The holder fails to provide medical information reasonably 
needed by the Federal Air Surgeon for certification under this section; 
or
    (5) The holder makes or causes to be made a fraudulent or 
intentionally false statement or an incorrect statement--
    (i) In support of his or her request for an Authorization or SODA 
or
    (ii) In any entry in any logbook, record, or report that is kept, 
made, or used, to show compliance with any requirement for an 
Authorization or SODA.
    (g) A person who has been granted an Authorization or SODA under 
this section based on a special medical flight or practical test need 
not take the test again during later physical examinations unless the 
Federal Air Surgeon determines or has reason to believe that the 
physical deficiency has or may have degraded to a degree to require 
another special medical flight or practical test.
    (h) The authority of the Federal Air Surgeon under this section is 
also exercised by the Manager, Aeromedical Certification Division and 
each Regional Flight Surgeon.
    (i) If an Authorization or SODA is withdrawn under paragraph (f) of 
this section the following procedures apply:
    (1) The holder of the Authorization or SODA will be personally 
served or mailed a letter of withdrawal, stating the reason for the 
action;
    (2) By not later than 60 days after the service or mailing of the 
letter of withdrawal, the holder of the Authorization or SODA may 
request, in writing, that the Federal Air Surgeon provide for review of 
the decision to withdraw. The request for review may be accompanied by 
supporting medical evidence;
    (3) Within 60 days of receipt of a request for review, a written 
final decision either affirming or reversing the decision to withdraw 
will be issued; and
    (4) A medical certificate rendered invalid pursuant to a 
withdrawal, in accordance with paragraph (a) of this section, shall be 
surrendered to the Administrator upon request.
    (j) No grant of a special issuance made prior to (the effective 
date of this rule) may be used to obtain a medical certificate after 
the earlier of the following dates:
    (1) (One year after the effective date of this rule) or
    (2) The date on which the holder of such special issuance is 
required to provide additional information to the FAA as a condition 
for continued medical certification.


Sec. 67.403  Applications, certificates, logbooks, reports, and 
records: falsification, reproduction, or alteration.

    (a) No person may make or cause to be made--
    (1) A fraudulent or intentionally false statement on any 
application for a medical certificate or on a request for any 
Authorization for Special Issuance of a Medical Certificate 
(Authorization) or Statement of Demonstrated Ability (SODA) under this 
part;
    (2) A fraudulent or intentionally false entry in any logbook, 
record, or report that is kept, made, or used, to show compliance with 
any requirement for any medical certificate or for any Authorization or 
SODA under this part;
    (3) A reproduction, for fraudulent purposes, of any medical 
certificate under this part; or
    (4) An alteration of any medical certificate under this part.
    (b) The commission by any person of an act prohibited under 
paragraph (a) of this section is a basis for--
    (1) Suspending or revoking all airman, ground instructor, and 
medical certificates and ratings held by that person;
    (2) Withdrawing all Authorizations or SODA's held by that person; 
and
    (3) Denying all applications for medical certification and requests 
for Authorizations or SODA's.
    (c) The making of an incorrect statement in support of any 
application for a medical certificate or request for any Authorization 
or SODA or the making of an incorrect entry in any logbook, record, or 
report that is kept, made, or used, to show compliance with any 
requirement for any medical certificate or any Authorization or SODA is 
a basis for suspending or revoking the medical certificate or 
withdrawing the Authorization or SODA or for denying an application for 
medical certification or a request for an Authorization or SODA.


Sec. 67.405  Medical examinations: Who may give.

    (a) First-class. Any aviation medical examiner who is specifically 
designated for the purpose may give the examination for the first-class 
certificate. Any interested person may obtain a list of these aviation 
medical examiners, in any area, from the FAA Regional Flight Surgeon of 
the region in which the area is located.
    (b) Second- and third-class. Any aviation medical examiner may give 
the examination for the second- or third-class certificate. Any 
interested person may obtain a list of aviation medical examiners, in 
any area, from the FAA Regional Flight Surgeon of the region in which 
the area is located.


Sec. 67.407  Delegation of authority.

    (a) The authority of the Administrator, under section 602 of the 
Federal Aviation Act of 1958 (49 U.S.C. App. 1422), to issue or deny 
medical certificates is delegated to the Federal Air Surgeon to the 
extent necessary to--
    (1) Examine applicants for and holders of medical certificates to 
determine whether they meet applicable medical standards and
    (2) Issue, renew, and deny medical certificates, and issue, renew, 
deny, and withdraw Authorizations for Special Issuance of a Medical 
Certificate and Statements of Demonstrated Ability to a person based 
upon meeting or failing to meet applicable medical standards.
    (b) Subject to limitations in this chapter, the delegated functions 
of the Federal Air Surgeon to examine applicants for and holders of 
medical certificates for compliance with applicable medical standards 
and to issue, renew, and deny medical certificates are also delegated 
to aviation medical examiners and to authorized representatives of the 
Federal Air Surgeon within the FAA.
    (c) The authority of the Administrator, under subsection 314(b) of 
the Federal Aviation Act of 1958 (49 U.S.C. App. 1355(b)), to 
reconsider the action of an aviation medical examiner is delegated to 
the Federal Air Surgeon; the Manager, Aeromedical Certification 
Division; and each Regional Flight Surgeon. Where the person does not 
meet the standards of Secs. 67.107(c), 67.109(b), 67.113(b), 67.207(c), 
67.209(b), 67.213(b), 67.307(c), 67.309(b), or 67.313(b), any action 
taken under this paragraph other than by the Federal Air Surgeon is 
subject to reconsideration by the Federal Air Surgeon. A certificate 
issued by an aviation medical examiner is considered to be affirmed as 
issued unless an FAA official named in this paragraph (authorized 
official) reverses that issuance within 60 days after the date of 
issuance. However, if within 60 days after the date of issuance an 
authorized official requests the certificate holder to submit 
additional medical information, an authorized official may reverse the 
issuance within 60 days after receipt of the requested information.
    (d) The authority of the Administrator, under section 609 of the 
Federal Aviation Act of 1958 (49 U.S.C. App. 1429), to re-examine any 
civil airman to the extent necessary to determine an airman's 
qualification to continue to hold an airman medical certificate, is 
delegated to the Federal Air Surgeon and his or her authorized 
representatives within the FAA.


Sec. 67.409  Denial of medical certificate.

    (a) Any person who is denied a medical certificate by an aviation 
medical examiner may, within 30 days after the date of the denial, 
apply in writing and in duplicate to the Federal Air Surgeon, 
Attention: Manager, Aeromedical Certification Division, AAM-300, 
Federal Aviation Administration, P.O. Box 26080, Oklahoma City, 
Oklahoma 73126, for reconsideration of that denial. If the person does 
not ask for reconsideration during the 30-day period after the date of 
the denial, he or she is considered to have withdrawn the application 
for a medical certificate.
    (b) The denial of a medical certificate--
    (1) By an aviation medical examiner is not a denial by the 
Administrator under section 602 of the Federal Aviation Act of 1958 (49 
U.S.C. App. 1422);
    (2) By the Federal Air Surgeon is considered to be a denial by the 
Administrator under section 602 of the Act; and
    (3) By the Manager, Aeromedical Certification Division, or a 
Regional Flight Surgeon is considered to be a denial by the 
Administrator under section 602 of the Act except where the applicant 
does not meet the standards of Secs. 67.107(c), 67.109(b), or 
67.113(b); 67.207(c), 67.209(b), or 67.213(b); or 67.307(c), 67.309(b), 
or 67.313(b).
    (c) Any action taken under Sec. 67.407(c) that wholly or partly 
reverses the issue of a medical certificate by an aviation medical 
examiner is the denial of a medical certificate under paragraph (b) of 
this section.
    (d) If the issue of a medical certificate is wholly or partly 
reversed by the Federal Air Surgeon; the Manager, Aeromedical 
Certification Division; or a Regional Flight Surgeon, the person 
holding that certificate shall surrender it, upon request of the FAA.


Sec. 67.411  Medical certificates by flight surgeons of Armed Forces.

    (a) The FAA has designated flight surgeons of the Armed Forces on 
specified military posts, stations, and facilities, as aviation medical 
examiners.
    (b) An aviation medical examiner described in paragraph (a) of this 
section may give physical examinations for the FAA medical certificates 
to applicants who are on active duty or who are, under Department of 
Defense medical programs, eligible for FAA medical certifications as 
civil airmen. In addition, such an examiner may issue or deny an 
appropriate FAA medical certificate in accordance with the regulations 
of this chapter and the policies of the FAA.
    (c) Any interested person may obtain a list of the military posts, 
stations, and facilities at which a flight surgeon has been designated 
as an aviation medical examiner from the Surgeon General of the Armed 
Force concerned or from the Manager, Aeromedical Education Division, 
AAM-400, Federal Aviation Administration, P.O. Box 26082, Oklahoma 
City, Oklahoma 73125.


Sec. 67.413  Medical records.

    (a) Whenever the Administrator finds that additional medical 
information or history is necessary to determine whether an applicant 
for or the holder of a medical certificate meets the medical standards 
for it, the Administrator requests that person to furnish that 
information or to authorize any clinic, hospital, physician, or other 
person to release to the Administrator all available information or 
records concerning that history. If the applicant or holder fails to 
provide the requested medical information or history or to authorize 
the release so requested, the Administrator may suspend, modify, or 
revoke all medical certificates the airman holds or may, in the case of 
an applicant, deny the application for an airman medical certificate.
    (b) If an airman medical certificate is suspended, modified, or 
revoked under paragraph (a) of this section, that suspension, 
modification, or revocation remains in effect until the requested 
information, history, or authorization is provided to the FAA and until 
the Federal Air Surgeon determines whether the person meets the medical 
standards under this part.


Sec. 67.415  Return of medical certificate after suspension or 
revocation.

    The holder of any medical certificate issued under this part that 
is suspended or revoked shall, upon the Administrator's request, return 
it to the Administrator.

    Issued in Washington, D.C. on October 17, 1994.
Jon L. Jordon,
Federal Air Surgeon, Federal Aviation Administration.
[FR Doc. 94-26047 Filed 10-18-94; 8:45 am]
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