Mental Health is being discussed in the aviation industry due to recent events. Yet the Mental Fitness of humans has been a focal point for governments and welfare organisations for years.

ATCOs work in organisations where safety is the most important output. It is likely that psychological examination will be introduced before and during their career. But can everything be tested for?

This paper emphasizes the importance of awareness, education and discrete reporting and reintegration policies that are safe for the ATCO and the aviation system.

2.1 Mental Health / Mental Fitness

2.1.1 Mental Health includes emotional, psychological, and social well-being. It affects how people think, feel and act as they cope with life. It also helps determine how they handle stress, relate to others, and make choices.

2.1.1.1 Stress has been addressed in the TPM with Critical Incident Stress Management (CISM).

2.2.1 The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders . It provides a common language for clinicians and researchers, while also justifying insurance reimbursement. Because our understanding of mental health is evolving, the DSM is periodically updated. The latest version, DSM-5, was published in May 2013.

2.2.2  DSM-5 is a manual for assessment and diagnosis of mental disorders and is compatible with the International Classification of Diseases (ICD-10). The WHO maintains this international list. ICD codes are reported to insurance companies for the purpose of providing reimbursement for clinical services.

2.2.3  There are many gaps in our understanding of mental health. While the attempt of DSM-5 to make a definitive list of all recognized mental health conditions is considered by some to be controversial , the manual does have a major influence on how mental health is thought about and treated. It is believed the latest version of the DSM will have major influence on the ICD, which is currently under revision. The newest version, ICD-11, is expected in 2018.

2.3 Global initiatives

2.3.1 To reduce the health, social and economic burdens of mental disorders, WHO emphasizes it is essential that countries and regions pay great(er) attention to prevention and promotion in mental health. Consequently, positive mental health is an integral part of health and well-being policies of most countries.

2.3.1.1  In the United States, for instance, Social Work Public Policy contains many educational and development programs that reduce the biological and psychosocial risk factors that can cause mental disorders. Examples are Parent-Child Interaction Therapy, Big Brothers/Big Sisters programme and Life Skills Training.

2.3.1.2  The World Health Organisation (WHO) hosted a European Ministerial Conference on Mental Health in 2005, where a Declaration and Action plan for Europe was made. Also the European Union has a Public Health Programme that seeks to give support to EU member states in developing mental health. As a starting point for states, the IMHPA Network for Mental Health Promotion and Mental Disorder Prevention was founded.

2.4.1  For personnel working operationally in High Reliability Organisations (HROs), severe mental fitness problems could ultimately lead to a threat to public safety. For these organisations, a proper mental health program is of great importance.

2.4.2  More specifically, ATCOs operate in a social environment based on mutual trust. They are team workers with Safety as main outcome. In this very in-group social atmosphere (small circle), for an individual it can be very hard to come forward and seek help for (mental) problems. At the same time, the group might be very cautious in accepting and trusting colleagues reintegrating after having coped with mental issues.

2.4.3  ANSP’s should be pro-active in creating a working environment in which professionals are stimulated to seek help and report to their superiors without having to be afraid for job security.

2.4.4  ATCOs should be aware of life occurrences that could lead to mental health problems and know what to do when they think they might experience symptoms that could evolve in mental issues.

2.5 Mental Fitness initiatives for pilots

2.5.1 Within the aviation community, airlines and industry are studying pilot fitness.

2.5.1.1  The Federal Aviation Administration (FAA) is working with commercial aviation and medical communities to study the emotional and mental health of U.S. commercial pilots. This industry group is known as the Commercial Aviation Safety Team (CAST). The group will include U.S. and international government and industry aviation experts, including a working group of medical professionals who specialise in aerospace medicine. Issues to be examined are:

• awareness and reporting of emotional and mental health;
• barriers to reporting emotional and mental health issues.

2.5.1.2  In July 2015 a European Aviation Safety Agency (EASA) led task force, which included senior representatives from airlines, flight crew associations, medical advisors and authorities, noted that its greatest task was related to medical aspects such as aeromedical checks for pilots.

2.5.1.3  Some of the recommendations concerning mental fitness to come from the EASA led task force include:

• That all airline pilots should undergo psychological evaluation as part of training or before entering service. The airline shall verify that a satisfactory evaluation has been carried out. The psychological part of the initial and recurrent aeromedical assessment and the related training for aero-medical examiners should be strengthened. EASA will prepare guidance material for this purpose. Additionally, he following additional recommendations might be considered to reinforce the system: Psychological evaluation shall be done with aviation psychological expertise. A formal recognition of aviation psychologist could be explored separately with the relevant professional bodies. EASA should develop guidance material to describe what is expected to be undertaken by the Aeromedical Examiner at the initial and revalidation medicals, including guidance on how to conduct a general mental health assessment. Enhanced psychiatric or psychological assessment does not need to be introduced into the initial Class 1 medical assessment, unless clinically indicated. The current rules allow for additional assessment if indicated. Periodic psychiatric review should be considered after a period of mental illness.
• The establishment of robust oversight programme over the performance of aero- medical examiners including the practical application of their knowledge. In addition, national authorities should strengthen the psychological and communication aspects of aero-medical examiners training and practice. Networks of aero-medical examiners should be created to foster peer support.
• That national regulations ensure that an appropriate balance is found between patient confidentiality and the protection of public safety.
• The creation of a European aeromedical data repository as a first step to facilitate the sharing of aeromedical information and tackle the issue of pilot non- declaration.
• The implementation of pilot support and reporting systems, linked to the employer Safety Management System within the framework of a non-punitive work environment and without compromising Just Culture principles. Requirements should be adapted to different organisation sizes and maturity levels, and provide provisions that take into account the range of work arrangements and contract types.

2.6 Medical fitness initiatives for ATCOs

2.6.1  On March 25th 2015, IFATCA published a press release on the accident, in which Mr. Patrik Peters, President and CEO of IFATCA, encouraged everybody not to engage in speculation surround the Germanwings accident. Yet, under political and media pressure, EASA brought recommendations on the subject of Mental Fitness, which are by itself interesting to investigate. And, while no accidents have been reported concerning Air Traffic Controllers (ATCOs) with known mental health issues, it is proactive to begin discussions about mental fitness. Generally action is only taken based on accidents, instead of continuously on the reporting of incidents.

2.6.2  In most countries, ab-initio ATCOs are psychologically tested as part of the selection process. This assessment typically consists of a personality assessment (e.g. a test with personality questions) and/or a conversation with a selection psychologist. The purpose of these tests, however, is mostly to examine the candidate’s personality ‘fit’, stress coping and motivation, rather than to test for mental disorders . After initial selection, an ATCO is only required to renew his medical license, for which only physical examinations are in order.

2.6.3  Taking this in mind, it is not surprising that the first recommendation of the EASA taskforce is for all airline pilots to undergo a thorough psychological examination by licenced aviation psychologists. It is likely that this will be recommended for ATCOs as well in the near future. Regular re-testing could be advised, together with incidental ones, for instance after an incident or accident when Critical Incident Stress Management (CISM) was in place to support the ATCOs.

2.6.4  Dealing with mental health issues outside the workplace is fairly straightforward, when speaking about dealing with medical professionals having discretion and Just Culture principles in mind. Dealing with mental health issues in the workplace -whether caused by work related or non-work related factors- could be significantly more complex. For instance an ATCO could be asked by the ANSP to undergo a mental health check after CISM was provided. Employer, regulator or accident investigation authorities could wrongly use this tool.

2.6.5 Despite the good intentions of the EASA recommendations, one must realise that Mental Fitness is very difficult to be determined by any person or test. As mentioned earlier in this paper, mental problems are often caused by a combination of factors. Tests results are just a snapshot and future events cannot be predicted. PLC is of the opinion that it is of greater importance for states to have measures in place to educate the workforce and help ATCOs experiencing mental problems in daily professional life. Possible measures are:

• Educate ATCOs about Mental Fitness. Give examples of symptoms and risks that could lead to mental problems, such as particular life occurrences, addictions and FRMS.
• Stimulate ATCOs to seek help and report when they are not mentally fit, without them having to be afraid for job security.
• Have psychological assistance available either in the facility, or arrange for psychological treatment and reimburse the costs if necessary.
• When dealing with reports, treatment and reintegration of ATCOs with mental health problems, absolute discretion shall be taken into account. Also, Just Culture principles apply when dealing with reports of mental issues.
• Have a clear policy for dealing with Mental Fitness, but also for reintegration.
  This should include rules on by which persons or agencies an ATCO can be declared ‘mentally fit’ again, and how this colleague re-joins the operational group in a safe manner. Mutual trust is a factor that should not be assessed as being simple.

3.1  According to the World Health Organisation, one person in four will develop one or more mental or behavioural disorders during their lifetime. Because ATCOs work in High Reliability Organisations where safety is the most important output, focus on Mental Fitness is of great importance. There are no specific numbers available on the percentage among ATCOs.

3.2  There are many global initiatives to promote mental health. In the aviation community it has also become a very current topic and recommendations for the flight deck have already been made, recommending psychological examinations for pilots as most important outcome.

3.3  It is likely that initial and recurrent psychological examinations for ATCOs will also be implemented in the near future. In addition, PLC thinks it is equally important to have a solid system in place to deal with Mental Fitness in the operational environment. This includes education for ATCOs to raise awareness, a discrete reporting system based on Just Culture principles, psychological assistance and a prudent reintegration policy that is safe for the ATCO as well as for the aviation system.

It is recommended that:

4.1 To advise the Executive Board to develop guidelines for MA’s on how to raise awareness and reporting of mental health issues, together with guidance for ATS management on implementing a safe mental health program.

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