Summary
The medical risks to pilots, whether to their physical or mental health, are clearly
theoretically raised during the COVID-19 pandemic for the reasons outlined in this
paper, and access to medical and psychological support should be improved in order
to address pilot stress, distress and the potential for increased pilot suicides as
a direct result of economic effects of the pandemic.
The links between pilot suicides and social change, such unemployed threats and financial
recession, have not been studied. Significant and sudden changes in society may increase
suicide risk and serious mental health problems may affect pilots equally. After the
9/11 terrorist attacks, for example, the risk of suicide by aircraft in the year following
the attack was almost four times the average risk in the 5 years prior to the terrorist
attack. This paper discusses the potential causes of mental health problems to pilots
resulting from COVID-19.
Pilot aircraft-assisted suicide in commercial aviation is a rare phenomenon. In general
aviation in the United States, pilot aircraft-assisted suicide rates in a 20-year
period was positively determined in 0.33% (24/7,244) of fatal aircraft accident cases
(1). Pilot murder-suicides, where it has been concluded through post-accident analysis
and investigation that the pilot deliberately crashed a commercial aircraft killing
the pilot and all others on board have occurred in six instances over the past 30
years (2). The most recent of these was the Germanwings pilot murder-suicide crash
in 2015 on a commercial flight between Barcelona and Dusseldorf (3), an incident which
brought this phenomenon to public attention and led to the regulator, the European
Aviation Safety Authority, to require that airline pilots in the EU be psychologically
assessed prior to joining an airline and for crew to have access to pilot peer support
programmes. The regulator also required aviation medical examiners to focus greater
attention on pilot mental health and well-being in their annual pilot assessments
(4). It is noteworthy that the pilot of the Germanwings aircraft suffered with financial
problems in addition to other significant mental health problems.
The links between pilot suicides and social change, such unemployed threats and financial
recession, have not been studied, given the low numbers of pilot suicide cases as
well as the unpredictability and infrequency of recession, coupled with methodological
challenges such as suitable comparison groups and the absence of baseline measures.
However, it has been found that significant sudden changes in society may increase
the number of pilot suicides. For example, after the 9/11 terrorist attacks in New
York, the risk of suicide by aircraft in the year following the attack was almost
four times the average risk in the 5 years prior to the terrorist attack (5). Although
we are unable to precisely determine a causal link between societal changes on pilot
suicide, it is arguably feasible that significant, sudden and adverse changes in society
can have an impact on pilot mental health. Due to the deleterious effects of COVID-19
on society generally, and on aviation specifically, we are living through the most
significant and enduring aviation crisis in the history of modern commercial aviation.
Thousands of air crew worldwide including pilots and cabin crew, are threatened with
redundancy, unwelcome changes to their employment contracts such as increased duty
times and lower pay, and the prospect that some may never fly for a living again.
Currently a large proportion of pilots are furloughed or out of work. As they find
employment, it is very likely that their job demand and workload will increase. Additionally,
some pilots are self-employed and continue to work on zero-hours contracts and are
without employment protection or health care support.
A study of 424 pilots over 35 years ago has shown that during an occupational dispute,
the stress experienced by pilots had a significant impact on their mental health (6).
This study also demonstrated that the combination of factors including career development,
autonomy at work, organizational climate and family support and cohesion are important
regarding job satisfaction, but also potentially increase the risk of accidents if
work and personal stress levels are left unchecked. It has been shown that economic
crises increase the mental burden on work and workload (7). In addition to this, it
is well established that an economic downturn is associated with an increase in suicides
in the general population (8, 9).
The social, economic, employment and personal challenges of COVID-19 in society threatens
several factors important for pilots' mental well-being. The current situation is
compounded by the additional social stress brought about by social and physical distancing
measures brought in to contain the spread of infection. A recent position paper by
the UK Academy of Medical Sciences offers a strategy for how to study and to take
account of the psychological, social and neuroscientific aspects of the pandemic (10).
It is recognized that the pandemic may increase suicide rates just as Acute Respiratory
Syndrome (SARS) did in 2003 (11–13). This risk is increased due to economic prolonged
downturn, which particularly affects aviation. The most significant and concerning
effects may only become apparent in the future. Another threat concerns pilots who
themselves have suffered with infection with COVID-19. Although infection may be asymptomatic
in many instances, it may lead to serious mental and neurological problems in those
who have been hospitalized due to the effects of the virus and also side-effects of
hospitalization and treatment (10, 14). It has been reported that those people who
suffered serious infection with SARS were at increased risk of post-traumatic stress
disorder and depression (11, 12). Post-traumatic stress disorder has been shown to
be associated with fatal aircraft accidents (15). COVID-19 data from a national sample
of over 10,000 U.S. adults gathered on March 2020 showed that about 15% of respondents
had high risk on the Suicide Behaviors Questionnaire-Revised survey (16).
One challenge in health care generally, and in aviation medicine specifically, is
how to best prevent or mitigate the risk of mental health problems and especially
suicide risk during the COVID-19 pandemic whilst airline employees suffer a threat
to their job and livelihoods due to economic effects. It is important to note that
each time a pilot visits their aeromedical examiner (AME) or aviation psychologist,
there may be a fear the loss of their medical certification (17). It has been shown
that pilots may be reluctant to report to their AME conditions that could affect crew
licensing due to their concerns that this could affect their livelihoods (18). Private
medical insurance and support and company-organized occupational healthcare is not
available to many pilots. It is not yet possible to determine how physical health,
routine medical checks and AME visits by pilots have been affected by the COVID-19
pandemic and it is possible some pilots will have avoided seeking health care during
this time for economic, infection risk and occupational threat reasons. Some regulators,
such as European Aviation Safety Agency (EASA) have allowed pilots to renew their
medical certificates by accessing AME's remotely and by extending the validity of
their licenses, reducing contact between airline crew and medical specialists.
The medical risks to pilots, whether to their physical or mental health, are clearly
theoretically raised during the COVID-19 pandemic for the reasons outlined in this
paper, and access to medical and psychological support should be improved in order
to address pilot stress, distress and the potential for increased pilot suicides as
a direct result of economic effects of the pandemic. As there are no standardized
clinical scales for assessing suicide risk, the focus of support should target all
pilots who are distressed, have experienced severe life-events in their own life,
have depressive symptoms or express hopelessness (19). Thus, all pilots with any risk
should receive psychoeducation, information on stress management and needs-based care.
This requires also informing and educating health care staff working with the pilots.
Author Contributions
All authors listed have made a substantial, direct and intellectual contribution to
the work, and approved it for publication.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.