MED.C.020 General

Regulation (EU) No 1178/2011

Cabin crew members shall be free from any:

(a) abnormality, congenital or acquired;

(b) active, latent, acute or chronic disease or disability;

(c) wound, injury or sequelae from operation; and

(d) effect or side effect of any prescribed or non-prescribed therapeutic, diagnostic or preventive medication taken that would entail a degree of functional incapacity which might lead to incapacitation or an inability to discharge their safety duties and responsibilities.

MED.C.025 Content of aero-medical assessments

Regulation (EU) No 1178/2011

(a) An initial aero-medical assessment shall include at least:

(1) an assessment of the applicant cabin crew member’s medical history; and

(2) a clinical examination of the following:

(i) cardiovascular system;

(ii) respiratory system;

(iii) musculoskeletal system;

(iv) otorhino-laryngology;

(v) visual system; and

(vi) colour vision.

(b) Each subsequent aero-medical re-assessment shall include:

(1) an assessment of the cabin crew member’s medical history; and

(2) a clinical examination if deemed necessary in accordance with aero-medical best practice.

(c) For the purpose of (a) and (b), in case of any doubt or if clinically indicated, a cabin crew member’s aero-medical assessment shall also include any additional medical examination, test or investigation that are considered necessary by the AME, AeMC or OHMP.

AMC1 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

Aero-medical examinations and assessments of cabin crew members should be conducted in accordance with AMC2 to AMC18 MED.C.025.

AMC2 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

CARDIOVASCULAR SYSTEM

(a) Examination

(1) A standard 12-lead resting electrocardiogram (ECG) and report should be completed on clinical indication, at the first examination after the age of 40 and then at least every five years after the age of 50. If cardiovascular risk factors such as smoking, abnormal cholesterol levels or obesity are present, the intervals of resting ECGs should be reduced to two years.

(2) Extended cardiovascular assessment should be required when clinically indicated.

(b) Cardiovascular system - general

(1) Cabin crew members with any of the following conditions:

(i) aneurysm of the thoracic or supra-renal abdominal aorta, before surgery;

(ii) significant functional abnormality of any of the heart valves; or

(iii) heart or heart/lung transplantation

should be assessed as unfit.

(2) Cabin crew members with an established diagnosis of one of the following conditions:

(i) peripheral arterial disease before or after surgery;

(ii) aneurysm of the abdominal aorta, before or after surgery;

(iii) minor cardiac valvular abnormalities;

(iv) after cardiac valve surgery;

(v) abnormality of the pericardium, myocardium or endocardium;

(vi) congenital abnormality of the heart, before or after corrective surgery;

(vii) a cardiovascular condition requiring systemic anticoagulation;

(viii) vasovagal syncope of uncertain cause;

(ix) arterial or venous thrombosis; or

(x) pulmonary embolism

should be evaluated by a cardiologist before a fit assessment may be considered.

(c) Thromboembolic disorders

Whilst anticoagulation therapy is initiated, cabin crew members should be assessed as unfit. After a period of stable anticoagulation, a fit assessment may be considered with limitation(s), as appropriate. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range and the haemorrhagic risk is acceptable. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment may be considered after a stabilisation period of 3 months. Cabin crew members with pulmonary embolism should also be evaluated by a cardiologist. Following cessation of anticoagulant therapy, for any indication, cabin crew members should undergo a re-assessment.

(d) Syncope

(1) In the case of a single episode of vasovagal syncope which can be satisfactorily explained, a fit assessment may be considered.

(2) Cabin crew members with a history of recurrent vasovagal syncope should be assessed as unfit. A fit assessment may be considered after a 6-month period without recurrence, provided cardiological evaluation is satisfactory. Neurological review may be indicated.

(e) Blood pressure

Blood pressure should be recorded at each examination.

(1) The blood pressure should be within normal limits and should not consistently exceed 160 mmHg systolic and/or 95 mmHg diastolic, with or without treatment, taking into account other risk factors.

(2) Cabin crew members initiating medication for the control of blood pressure should be assessed as unfit until the absence of any significant side effects has been established and verification that the treatment is compatible with the safe exercise of cabin crew duties has been achieved.

(f) Coronary artery disease

(1) Cabin crew members with:

(i) cardiac ischaemia;

(ii) symptomatic coronary artery disease; or

(iii) symptoms of coronary artery disease controlled by medication

should be assessed as unfit.

(2) Cabin crew members who are asymptomatic after myocardial infarction or surgery for coronary artery disease should have fully recovered before a fit assessment may be considered. The affected cabin crew members should be on appropriate secondary prevention treatment.

(g) Rhythm/conduction disturbances

(1) Cabin crew members with any significant disturbance of cardiac conduction or rhythm should undergo cardiological evaluation before a fit assessment may be considered.

(2) Cabin crew members with a history of:

(i) ablation therapy; or

(ii) pacemaker implantation

should undergo satisfactory cardiovascular evaluation before a fit assessment may be made.

(3) Cabin crew members with:

(i) symptomatic sinoatrial disease;

(ii) symptomatic hypertrophic cardiomyopathy

(iii) complete atrioventricular block;

(iv) symptomatic QT prolongation;

(v) an automatic implantable defibrillating system; or

(vi) a ventricular anti-tachycardia pacemaker

should be assessed as unfit.

AMC3 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

RESPIRATORY SYSTEM

(a) Cabin crew members with significant impairment of pulmonary function should be assessed as unfit. A fit assessment may be considered once pulmonary function has recovered and is satisfactory.

(b) Cabin crew members should undergo pulmonary morphological or functional tests on when clinically indicated.

(c) Cabin crew members with a history or established diagnosis of:

(1) asthma;

(2) active inflammatory disease of the respiratory system;

(3) active sarcoidosis;

(4) pneumothorax;

(5) sleep apnoea syndrome/sleep disorder; or

(6) major thoracic surgery

should undergo respiratory evaluation with a satisfactory result before a fit assessment may be considered.

(d) Cabin crew members who have undergone a pneumonectomy should be assessed as unfit.

AMC4 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

DIGESTIVE SYSTEM

(a) Cabin crew members with any disease or sequelae of surgical intervention in any part of the digestive tract or its adnexa likely to cause incapacitation in flight, in particular any obstruction due to stricture or compression, should be assessed as unfit.

(b) Cabin crew members should be free from herniae that might give rise to incapacitating symptoms.

(c) Cabin crew members with disorders of the gastro-intestinal system, including:

(1) recurrent severe dyspeptic disorder requiring medication;

(2) peptic ulceration;

(3) pancreatitis;

(4) symptomatic gallstones;

(5) an established diagnosis or history of chronic inflammatory bowel disease;

(6) after surgical operation on the digestive tract or its adnexa, including surgery involving total or partial excision or a diversion of any of these organs;

(7) morphological or functional liver disease; or

(8) after surgery, including liver transplantation

may be assessed as fit subject to satisfactory gastroenterological evaluation.

AMC5 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

METABOLIC AND ENDOCRINE SYSTEMS

(a) Cabin crew members should not possess any functional or structural metabolic, nutritional or endocrine disorder which is likely to interfere with the safe exercise of their duties and responsibilities.

(b) Cabin crew members with metabolic, nutritional or endocrine dysfunction may be assessed as fit, subject to demonstrated stability of the condition and satisfactory aero-medical evaluation.

(c) Diabetes mellitus

(1) Cabin crew members with diabetes mellitus requiring insulin may be assessed as fit:

(i) if it can be demonstrated that adequate blood sugar control has been achieved and hypoglycaemia awareness is established and maintained; and

(ii) in the absence, within the preceding 12 months, of any;

(A) hospitalisation related to diabetes; or

(B) hypoglycaemia that resulted in a seizure, loss of consciousness, impaired cognitive function or that required the intervention by another party; or

(C) episode of hypoglycaemia unawareness.

(2) Limitations should be imposed as appropriate. A limitation to undergo specific medical examinations (SIC) and a restriction to operate only in multi-cabin crew operations (MCL) should be placed as a minimum.

(3) Cabin crew members with diabetes mellitus not requiring insulin may be assessed as fit if it can be demonstrated that adequate blood sugar control has been achieved and hypoglycaemia awareness, if applicable considering the medication, is achieved.

AMC6 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

HAEMATOLOGY

Cabin crew members with a haematological condition, such as:

(a) abnormal haemoglobin including, but not limited to, anaemia, erythrocytosis or haemoglobinopathy;

(b) coagulation, haemorrhagic or thrombotic disorder;

(c) significant lymphatic enlargement;

(d) acute or chronic leukaemia; or

(e) splenomegaly

may be assessed as fit subject to satisfactory aero-medical evaluation. If anticoagulation is being used as treatment, refer to AMC2 MED.C.025(c).

AMC7 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

GENITOURINARY SYSTEM

(a) Urine analysis should form part of every aero-medical examination and assessment. The urine should not contain any abnormal element(s) considered to be of pathological significance.

(b) Cabin crew members with any disease or sequelae of surgical procedures on the kidneys or the urinary tract, in particular any obstruction due to stricture or compression likely to cause incapacitation should be assessed as unfit.

(c) Cabin crew members with a genitourinary disorder, such as:

(1) renal disease; or

(2) a history of renal colic due to one or more urinary calculi

may be assessed as fit subject to satisfactory renal/urological evaluation.

(d) Cabin crew members who have undergone a major surgical operation in the genitourinary apparatus involving a total or partial excision or a diversion of its organs should be assessed as unfit and be re-assessed after recovery before a fit assessment may be made.

(e) Cabin crew members who have undergone renal transplantation may be considered for a fit assessment if it is fully compensated and tolerated with only minimal immuno-suppressive therapy after at least 12 months. A requirement to undergo specific medical examinations (SIC) and a restriction to operate only in multi-cabin crew operations (MCL) should be considered.

(f) Cabin crew members requiring dialysis should be assessed as unfit.

AMC8 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

INFECTIOUS DISEASE

Cabin crew members who are HIV positive may be assessed as fit if investigation provides no evidence of clinical disease and subject to satisfactory aero-medical evaluation.

AMC9 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

OBSTETRICS AND GYNAECOLOGY

(a) Cabin crew members who have undergone a major gynaecological operation should be assessed as unfit until after recovery.

(b) Pregnancy

(1) A pregnant cabin crew member may be assessed as fit only during the first 16 weeks of gestation following review of the obstetric evaluation by the AME or OHMP.

(2) A limitation not to perform duties as single cabin crew member should be considered.

(3) The AME or OHMP should provide written advice to the cabin crew member and supervising physician regarding potentially significant complications of pregnancy resulting from flying duties.

AMC10 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

MUSCULOSKELETAL SYSTEM

(a) Cabin crew members should have sufficient standing height, arm and leg length and muscular strength for the safe exercise of their duties and responsibilities.

(b) Cabin crew members should have satisfactory functional use of the musculoskeletal system. Particular attention should be paid to emergency procedures and evacuation, and related training.

(c) Cabin crew members with any significant sequelae from disease, injury or congenital abnormality affecting the bones, joints, muscles or tendons with or without surgery require full evaluation prior to a fit assessment.

(d) Cabin crew members with inflammatory, infiltrative, traumatic or degenerative disease of the musculoskeletal system may be assessed as fit provided the condition is in remission or is stable and the affected cabin crew member is not taking any medication that may lead to unfitness.

AMC11 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

MENTAL HEALTH

(a) Cabin crew members with a mental or behavioural disorder due to use or misuse of alcohol or other psychoactive substances should be assessed as unfit pending recovery and freedom from psychoactive substance use or misuse and subject to satisfactory psychiatric evaluation after successful treatment.

(b) Cabin crew members with an established history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder should be assessed as unfit.

(c) Cabin crew members with a psychiatric condition such as:

(1) mood disorder;

(2) neurotic disorder;

(3) personality disorder; or

(4) mental or behavioural disorder

should undergo satisfactory psychiatric evaluation before a fit assessment may be considered.

(d) Cabin crew members with a history of a single or repeated acts of deliberate self-harm should be assessed as unfit. Cabin crew members should undergo satisfactory psychiatric evaluation before a fit assessment may be considered.

(e) Where there is established evidence that a cabin crew member has a psychological disorder, he/she should be referred for psychological opinion and advice.

(f) The psychological evaluation may include a collection of biographical data, the review of aptitudes, and personality tests and psychological interview.

(g) The psychologist should submit a report to the AME or OHMP, detailing the results and recommendation.

AMC12 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

NEUROLOGY

(a) Cabin crew members with an established history or clinical diagnosis of:

(1) epilepsy; or

(2) recurring episodes of disturbance of consciousness of uncertain cause

should be assessed as unfit.

(b) Cabin crew members with an established history or clinical diagnosis of:

(1) epilepsy without recurrence after 5 years of age and without treatment for more than 10 years;

(2) epileptiform EEG abnormalities and focal slow waves;

(3) progressive or non-progressive disease of the nervous system;

(4) inflammatory disease of the central or peripheral nervous system;

(5) migraine;

(6) a single episode of disturbance of consciousness of uncertain cause;

(7) loss of consciousness after head injury;

(8) penetrating brain injury; or

(9) spinal or peripheral nerve injury

should undergo further evaluation before a fit assessment may be considered.

(c) Cabin crew members with a disorder of the nervous system due to vascular deficiencies including haemorrhagic and ischaemic events should be assessed as unfit. A fit assessment may be considered if neurological review and musculoskeletal assessments are satisfactory.

AMC13 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

VISUAL SYSTEM

(a) Examination

(1) a routine eye examination should form part of the initial and all further examinations and assessments; and

(2) an extended eye examination should be undertaken by an eye specialist when clinically indicated.(Refer to GM2 MED.B.070)

(b) Distant visual acuity, with or without correction, should be with both eyes 6/9 (0,7) or better.

(c) Cabin crew members should be able to read an N5 chart (or equivalent) at 30–50 cm, with correction if prescribed (Refer to GM1 MED.B.070).

(d) The binocular visual field or, in the case of monocularity, the monocular visual field should be acceptable.

(e) Cabin crew members who have undergone refractive surgery may be assessed as fit subject to satisfactory ophthalmic evaluation.

(f) Cabin crew members with diplopia should be assessed as unfit.

(g) Spectacles and contact lenses:

If satisfactory visual function is achieved only with the use of correction:

(1) in the case of myopia or hyperopia or both, spectacles or contact lenses should be worn whilst on duty;

(2) in the case of presbyopia, spectacles should be readily available for immediate use;

(3) the correction should provide optimal visual function and be well-tolerated;

(4) a spare set of similarly correcting spectacles should be readily available for immediate use whilst on duty;

(5) orthokeratologic lenses should not be used.

AMC14 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

COLOUR VISION

Cabin crew members should be able to correctly identify 9 of the first 15 plates of the 24-plate edition of Ishihara pseudoisochromatic plates. Alternatively, cabin crew members should demonstrate the ability to readily perceive those colours of which the perception is required for the safe performance of their duties.

AMC15 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

OTORHINOLARYNGOLOGY (ENT)

(a) Hearing should be satisfactory for the safe exercise of cabin crew duties and responsibilities. Cabin crew with hypoacusis should demonstrate satisfactory functional hearing abilities.

(b) Examination

(1) An ear, nose and throat (ENT) examination should form part of all examinations and assessments. A tympanometry or equivalent should be performed at the initial examination and when clinically indicated.

(2) Hearing should be tested at all examinations and assessments:

(i) the cabin crew member should understand correctly conversational speech when tested with each ear at a distance of 2 metres from and with the cabin crew member’s back turned towards the examiner;

(ii) notwithstanding (b)(2)(i), hearing should be tested with pure tone audiometry at the initial examination and when clinically indicated;

(iii) at initial examination the cabin crew member should not have a hearing loss of more than 35 dB at any of the frequencies 500 Hz, 1 000 Hz or 2 000 Hz, or more than 50 dB at 3 000 Hz, in either ear separately.

(3) If the hearing requirements can be met only with the use of hearing aid(s), the hearing aid(s) should provide optimal hearing function, be well-tolerated, and suitable for aviation purposes.

(c) Cabin crew members with:

(1) an active pathological process of the internal or middle ear;

(2) unhealed perforation or dysfunction of the tympanic membrane(s);

(3) disturbance of vestibular function;

(4) significant restriction of the nasal passages;

(5) sinus dysfunction;

(6) significant malformation or significant infection of the oral cavity or upper respiratory tract;

(7) significant disorder of speech or voice

should undergo further examination to establish that the condition does not interfere with the safe exercise of their duties and responsibilities.

AMC16 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

DERMATOLOGY

In cases where a dermatological condition is associated with a systemic illness, full consideration should be given to the underlying illness before a fit assessment may be made.

AMC17 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

ONCOLOGY

(a) After treatment for malignant disease, cabin crew members should undergo satisfactory oncological and aero-medical evaluation before a fit assessment may be considered.

(b) Cabin crew members with an established history or clinical diagnosis of intracerebral malignant tumour should be assessed as unfit. Considering the histology of the tumour, a fit assessment may be considered after successful treatment and recovery.

GM1 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

(a) When conducting aero-medical examinations and assessments, typical cabin crew duties as listed in (b) and (c), particularly those to be performed during abnormal operations and emergency situations, and cabin crew responsibilities to the travelling public should be considered in order to identify:

(1) any physical and/or mental conditions that could be detrimental to the performance of the duties required from cabin crew; and

(2) which examination(s), test(s) or investigation(s) should be undergone to complete an appropriate aero-medical assessment.

(b) Main cabin crew duties and responsibilities during day-to-day normal operations

(1) During pre/post-flight ground operations with/without passengers on board:

(i) monitoring of situation inside the aircraft cabin and awareness of conditions outside the aircraft including observation of visible aircraft surfaces and information to flight crew of any surface contamination such as ice or snow;

(ii) assistance to special categories of passengers (SCPs) such as infants and children (accompanied or unaccompanied), persons with disabilities or reduced mobility, medical cases with or without medical escort, and inadmissible persons, deportees and passengers in custody;

(iii) observation of passengers (any suspicious behaviour, passengers under the influence of alcohol and/or drugs, mentally disturbed), observation of potential able-bodied persons, crowd control during boarding and disembarkation;

(iv) safe stowage of cabin luggage, safety demonstrations and cabin secured checks, management of passengers and ground services during re-fuelling, observation of use of portable electronic devices;

(v) preparedness to carry out safety and emergency duties at any time, and security alertness.

(2) During flight:

(i) operation and monitoring of aircraft systems, surveillance of the cabin, lavatories, galleys, crew areas and flight crew compartment;

(ii) coordination with flight crew on situation in the cabin and turbulence events/effects;

(iii) management and observation of passengers (consumption of alcohol, behaviour, potential medical issues), observation of use of portable electronic devices;

(iv) safety and security awareness and preparedness to carry out safety and emergency duties at any time, and cabin secured checks prior to landing.

(c) Main cabin crew duties and responsibilities during abnormal and emergency operations

(1) In case of planned or unplanned emergency evacuation: briefing and/or commands to passengers including SCPs and selection and briefing to able-bodied persons; crowd control monitoring and evacuation conduct including in the absence of command from the flight crew; post-evacuation duties including assistance, first aid and management of survivors and survival in particular environments; activation of applicable communication means towards search and rescue services.

(2) In case of decompression: checking of crew members, passengers, cabin, lavatories, galleys, crew rest areas and flight crew compartment, and administering oxygen to crew members and passengers as necessary.

(3) In case of pilot incapacitation: secure pilot in his/her seat or remove from flight crew compartment; administer first aid and assist operating pilot as required.

(4) In case of fire or smoke: identify source/cause/type of fire/smoke to perform the necessary required actions; coordinate with other cabin crew members and flight crew; select appropriate extinguisher/agent and fight the fire using portable breathing equipment (PBE), gloves, and protective clothing as required; management of necessary passengers’ movement if possible; instructions to passengers to prevent smoke inhalation/suffocation; give first aid as necessary; monitor the affected area until landing; preparation for possible emergency landing.

(5) In case of first aid and medical emergencies: assistance to crew members and/or passengers; correct assessment and correct use of therapeutic oxygen, defibrillator, first-aid kits/emergency medical kit contents as required; management of events, of incapacitated person(s) and of other passengers; coordination and effective communication with other crew members, in particular when medical advice is transmitted by frequency to flight crew or by a telecommunication connection.

(6) In case of disruptive passenger behaviour: passenger management as appropriate including use of restraint technique as considered required.

(7) In case of security threats (bomb threat on ground or in-flight and/or hijack): control of cabin areas and passengers’ management as required by the type of threat, management of suspicious device, protection of flight crew compartment door.

(8) In case of handling of dangerous goods: observing safety procedures when handling the affected device, in particular when handling chemical substances that are leaking; protection and management of self and passengers and effective coordination and communication with other crew members.

DIABETES MELLITUS TREATED WITH INSULIN

When considering a fit assessment for cabin crew with diabetes mellitus requiring insulin, account should be taken of the IATA Guidelines on Insulin-Treated Diabetes (Cabin Crew), as last amended.

GM3 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

COLOUR VISION – GENERAL

Examples of colours of which the perception is required for the safe performance of cabin crew members’ duties are: cabin crew indication panels, pressure gauges of emergency equipment (e.g. fire extinguishers) and cabin door status.

GM4 MED.C.025 Content of aero-medical assessments

ED Decision 2019/002/R

OTORHINOLARYNGOLOGY (ENT) – PURE TONE AUDIOGRAM

The pure tone audiogram may also cover the 4 000 Hz frequency for early detection of decrease in hearing.