The aviation medical examination serves not merely as a certification but as a vital instrument in the health management of aviation professionals. The pivotal role of aviation medical examiners is to ensure the health of airmen, focusing predominantly on conditions that directly impact aviation safety. However, there remains a discernible gap in the literature on the current dynamics of these examinations, especially in light of the recent COVID-19 pandemic.

The aims of the study is to provide a comprehensive retrospective review of the trends and status of aviation medical examinations over the past 24 years, emphasizing the potential impact of the COVID-19 pandemic on them. A longitudinal assessment of the distribution and trends in aviation medical examinations based on sex, age, and qualification was conducted. A dedicated section aimed to shed light on the influence of the COVID-19 pandemic on aviation medical examinations. An evaluation of the correlation between pilot age and disqualification rate was performed.

I utilized the Airmen Medical Certificate Management System operated by the Ministry of Land, Infrastructure, and Transport, which electronically store and process data such as airman applicants, aviation medical examinations, and airman medical certificates. The age and sex, current license type, affiliation, diagnosis name, final screening decision of the advisory committee, and reasons for the decision were used in the analysis of this study for those who underwent aviation medical examinations from January 2000 to June 2023.

This study was approved by the Seoul National University Hospital Institutional Review Board (IRB number: E-2308-082-1458). I conducted our statistical analysis using STATA 18.0 (StataCorp.) to ensure the accuracy of our findings.

1. Demographics and categorization of applicants

There were 124,751 (95.5%) males and 5,861 (4.5%) females. By age, 94,228 (53.2%) were under 40, 46,718 (26.4%) were in their 40s, 28,577 (16.1%) were in their 50s, and 7,437 (4.2%) were over 60. By species, 167,524 (94.7%) had class 1 licenses, 3,176 (1.8%) had class 2 licenses, and 6,259 (3.5%) had class 3 licenses. 154,632 (87.4%) were fit to fly, 21,130 (11.9%) conditionally fit to fly, 853 (0.5%) failed, and 359 (0.2%) were inconclusive. There were 41,834 (23.6%) first-time applicants and 135,140 (76.4%) licenses renewal applicants. There were statistical differences in sex, age group, license classes, and proportions of results between initial and renewal applicants (P-values <0.001) (Table 1).

2. Trend analysis over the years

From 2000 to 2023, a consistent growth in aviation medical exams was observed. Initial counts were 2,529 in 2000, escalating to a peak of 15,149 by 2019. This upward trend corresponded to a Compound Annual Growth Rate of 10%. The pandemic years, namely 2021 and 2022, saw a decline in the number of aviation medical exams, aligning with 2017 levels (around 12,000). However, projections for 2023 indicate a revival, approximating 15,000 examinations (Fig. 1).

3. Sex-based trends

While the male-to-female ratio for aviation medical examination skewed, there’s been a steady incline in female representation. The proportion of females among initial applicants for airmen certification saw a rise from 4.4% in 2010 to 12.8% by 2023. However, the proportion of females who secured and maintained certification through subsequent aviation medical exams increased modestly from 0.4% in 2010 to 3.5% in 2023 (Fig. 2).

4. Specific trends among airline pilots

Consistent with overall trends, airline pilots exhibited yearly growth in medical exams: from 2,071 in 2000 to 9,220 by 2019. COVID-19 induced a slight reduction to 8,401 in 2020 and 8,199 in 2021. Yet, 2022’s projection stands at 8,713, with expectations of surpassing 12,000 in 2023 (Fig. 3).

5. Age-related trends in pilot medical disqualifications

Over the 24-year span, 196 pilots out of 12,639 in South Korea were deemed medically unfit, translating to a 0.15% disqualification rate. Delving deeper, this disqualification rate escalated with age. The disqualification rate for those under 40 was 0.06%. Those in their 40s had a 0.12%, with an odds ratio of 2.0 (1.3–3.1). Those in their 50s had a 0.30% with an odds ratio of 4.8 (3.2–7.4). The 60+ age group had the highest disqualification rate at 0.37%, with an odds ratio of 5.9 (3.5–9.9) (Table 2).

6. Data consistency

Sex data presented some inconsistencies. Specifically, 26.2% (46,362) of records were missing sex labels, a flaw that was rectified entirely post-2014.

The comprehensive analysis of aviation medical examinations spanning 24 years provides insightful revelations into the demographics, outcomes, and temporal trends associated with the aviation medical fitness of examinees, particularly airline pilots in South Korea. With an overarching goal of aviation safety, these examinations are paramount, and understanding these trends helps inform and fine-tune the examination framework. In the previous study, the overall denial rate of airmen included pilots and air traffic controllers in South Korea from 2016–2020 was 0.08% [1]. In this study, the rate of pilot incapacitation in South Korea from 2010–2023 was 0.15%. There was a study of pilot incapacitation in the United Arab Emirates from 2018-2021, which found that the permanent suspension rate was 0.25%. The longest incapacitation periods in this study were associated with psychiatric illness [2]. In another South Korean airmen study, the cardiovascular disease was the most common reason for disqualification, followed by tumors and psychiatric disorders [3].

The majority of the examinees successfully pass the medical tests, indicative of the rigorous pre-selection and training protocols in place. A study of 595 pilots in New Zealand found that pilots in New Zealand are healthier than the general population for most medical conditions [4]. Although the study found that New Zealand pilots had a higher prevalence of kidney disease and melanoma skin cancer. However, the age-wise escalation in the disqualification rate underscores the importance of age-specific medical scrutiny, given that aging may present with medical challenges potentially impeding aviation safety. According to this study’s analysis, those in their 40s had a 2.2 times higher disqualification rate than those before them, those in their 50s had a 4.8 times higher rate, and those in their 60s had a 5.9 times higher rate. Previous similar studies have also shown that disqualification rates increase with age [5]. When categorized by various diagnoses, cardiovascular disease was the most common, followed by ophthalmology, malignancy, neurology, and psychiatry.

Unsurprisingly, the COVID-19 pandemic has posed disruptions, reflecting in the decreased counts of medical examinations during 2020 and 2021. These interruptions might have long-term ramifications on the industry’s medical fitness, especially if annual examinations play a role in early detection of conditions that could impair performance. However, the steady increase in medical examinations among pilots over the years is due to the rapidly growing demand for aviation globally and the requirement to ensure good health in the industry. The comprehensive nature and rigor of these examinations is worthwhile, as pilot health is the most important factor in aviation safety. We should be prepared not only for the increasing number of aviation medical examinations, but also for the growing healthcare needs of aviation workers.

While males predominantly constitute the aviation sector, a gradual and positive shift towards increased female representation is evident. The progressive increase, especially in the newer generation of aviation professionals, is a testament to diversifying industry norms. Nevertheless, more encouragement and support systems for female participation are needed, and the health care of female workers in particular requires additional attention.

The findings reaffirm the medical community’s commitment to aviation safety through careful medical evaluation and highlight areas for improvement and potential challenges. The dynamic nature of the aviation industry, constantly evolving medical standards, and challenges such as a global pandemic require constant adaptation, research, and improvement of screening protocols. Further research could help to establish more targeted screening criteria if it specifically identifies correlations between medical disqualifiers and age. Additionally, given the unprecedented impact of the pandemic, post-pandemic data should be closely monitored to determine the long-term impact on the medical fitness of airmen.

No potential conflict of interest relevant to this article was reported. Juwon Lim has been the editor-in-chief since 2022 and had no role in the decision to publish this article.

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