Protocol for pilots with type 1 diabetes

This page sets out the requirements for first certification of Class 2 Type 1 diabetics (on insulin).

Exclusion criteria

Hypoglycaemia

The applicant must have had:

• no recurrent (2 or more) episodes of hypoglycaemia (resulting in intervention by another party) in the past 5 years and
• no episodes of hypoglycaemia in the preceding 1 year.

Significant complications

The applicant must have no presence of significant complications such as:

• autonomic neuropathy
• significant cardiovascular disease
• retinopathy
• renal disease.

Information to provide

Medical records

The applicant must provide copies of all medical records as well as aviation accident and incident records pertinent to their history of diabetes.

Endocrinologist report

A report of a complete medical examination by an endocrinologist will be required. The report must include, as a minimum:

• 2 measurements of glycosylated haemoglobin (total A1 or A1c concentration and the laboratory reference range), the first at least 90 days prior to the current measurement
• specific reference to the applicant's insulin dosages and diet
• specific reference to the presence or absence of cerebrovascular, cardiovascular, peripheral vascular disease and neuropathy
• confirmation by an ophthalmologist of the absence of clinically significant diabetic eye disease
• verification that the applicant has been educated in diabetes and its control and understands the actions that should be taken if complications, especially hypoglycaemia, should arise
• examining physician verification that the applicant has the ability and willingness to satisfactorily monitor and manage their diabetes
• if the applicant is age 40 or older, a report, with ECG tracings, of a maximal graded exercise stress test.

The applicant must also submit a statement from their treating physician, aviation medical examiner, or other knowledgeable person. It must attest to the applicant’s dexterity and ability to determine blood glucose levels using a recording glucometer.

Medical factors considered in CASA’s decision making

Indicative criteria for blood sugar control

Indicative criteria for blood sugar control that may be considered reasonable for consideration of entry into the following protocol are:

• HbA1c between 6.5 and 8.0
• Blood glucose analysis (over a three month period immediately prior to the time of application) indicating:
  • No more than 5% of readings below 4.0 mmol/L
  • 80% of readings must be between 5 and 15 mmol/L

Other factors that can influence outcomes

Other factors that can influence outcomes could include but are not limited to:

• excessive frequency of hypoglycaemia or hyperglycaemia
• documented hypoglycaemic unawareness
• poor treatment compliance.

Implications of acceptance of meeting the criteria by CASA

If applicants meet the above criteria, CASA will consider them for entry into the protocol cohort on a case-by-case basis.

If accepted into the cohort, the applicant will initially be issued a Class 2 certificate valid for flight with safety pilot only.

To have the safety pilot requirement removed, the applicant must:

• carry out the in-flight requirements in a 2 pilot situation for a minimum of 15 flights
• provide the on-ground and in-flight data to CASA for assessment and consideration.

CASA will tailor details of types of flights and durations to meet individual requirements.

Monitoring and actions required during flight operations

To ensure safe flight, the insulin-using diabetic aviator must carry:

• 2 recording devices during flight, preferably a Continuous Glucose Monitoring System and a back up glucometer
• adequate supplies to obtain blood samples
• amount of rapidly absorbable glucose, in 15 gm portions, appropriate to the planned duration of the flight.

The aviator must discuss this protocol with his treating physician. They must obtain advice as to the best combination of food intake and medication that will optimise the glycaemic control, without adversely affecting safety.

Actions to take in connection with flight operations

Flight should not commence within 90 minutes of the administration of insulin (either short or long acting types), unless the aviator uses an insulin pump.

Measuring blood glucose

One-half hour prior to flight, the aviator must measure the blood glucose concentration.

• If the concentration is more than 15 mmols/l the aviator must cancel the flight.
• If it is less than 5 mmol/l they must ingest an appropriate (not less than 15 gm) glucose snack and measure the glucose concentration one-half hour later.
• If the concentration is within 5-15 mmol/l, they may conduct flight operations.
• If the blood glucose is less than 5 mmol/l, they must repeat the process, if over 15 mmol/l, they must cancel the flight.

30 minutes into the flight, at each successive hour of flight and within 30 minutes prior to landing, the aviator must measure their blood glucose concentration.

• If the concentration is less than 5 mmols/l, they must ingest a 30 gm glucose snack, and arrange land at the nearest suitable airport. They may not resume flight until the glucose concentration can be maintained in the 5- 15 mmols/l range.
• If the concentration is 5-15 mmol/l, no action is required.
• If the concentration is greater than 15 mmol/l, the aviator must land at the nearest suitable airport and may not resume flight until the glucose concentration can be maintained in the 5-15 mmols/l range (Note 1).

When determining blood glucose concentrations during flight, the aviator must use judgement to decide whether measuring concentrations or operational demands of the environment (such as adverse weather) should take priority.

In cases where they decide that operational demands take priority, the aviator must ingest a 15 gm glucose snack and measure their blood glucose level 1 hour later. If measurement is not practical at that time, the aviator must:

• ingest a 30 gm glucose snack
• land at the nearest suitable airport to determine their blood glucose concentration.

Ongoing requirements for any subsequent medical certification

Blood glucose measuring devices

For documentation of diabetes management, the aviator must carry and use 2 whole blood glucose measuring devices with memory function. They must immediately report to CASA any:

• hypoglycaemic incidents requiring external assistance
• involvement in accidents resulting in serious injury (whether or not related to hypoglycaemia)
• evidence of loss of control of diabetes, change in treatment regimen, or significant diabetic complications.

With any of these occurrences, the aviator must cease flying until CASA clears them.

Endocrinologist evaluations

Quarterly evaluations

At 3-month intervals, the aviator must be evaluated by the treating endocrinologist. This evaluation must include a:

• general physical examination
• review of the interval medical history,
• the results of a test for glycosylated haemoglobin concentration.

The endocrinologist must review the record of the aviator’s daily blood glucose measurements and comment on the results. The blood glucose measurements must be done at least 4 times every day.

Annual evaluations

The results of quarterly evaluations must be accumulated and submitted annually, unless:

• there has been a change in the treatment regime
• the endocrinologist’s review is indicative of a deterioration of control.

The results must include a downloaded set of blood sugar readings to be analysed to identify 'high' and 'low' readings outside the physiological range. Also see the indicative criteria above.

If there has been a change the aviator must:

• report the change(s) to CASA
• wait for an eligibility letter before resuming flight duties.

On an annual basis, the reports from the examining endocrinologist must include confirmation by an eye specialist of the absence of significant eye disease.

Examinations after age 40

At the first examination after age 40 and at 5-year intervals, the report, with ECG tracings, of a maximal graded exercise stress test must be included in consideration of continued medical certification.

In-flight measurements and logbook entries

At the time of all subsequent medical certifications, for all flights undertaken since the last certificate the aviator must provide CASA with:

• records of all in-flight measurements
• logbook entries.