You’ve Checked the Aircraft—Now Check Yourself: The I’M SAFE Checklist for Pilot Readiness for Flight

Pilots and other aviation professionals are very familiar with checklists—organized and systematic processes that minimize the chances of mishaps.

And while it can be argued that a checklist is only as good as its ease of use, the relevance of the information/task being ‘checked’, they still remain a vital component in supporting aviation safety.

Pilot readiness and fitness for flight are critical, rate-limiting elements in the flight safety dynamic, so it would make sense that there would be a checklist to help pilots self-assess prior to manning the controls of an aircraft.

In the mid-1980’s the FAA developed the IM SAFE Checklist as a tool to help pilots determine assess whether there might be any potential barriers to focused and safe aircraft operation.  Each letter in the IMSAFE acronym represents a potential hazard or barrier to safe flight.

I = ILLNESS
This category is the pilot’s reminder that any level of physical illness, dis-ease (un-wellness) can impact safe and focused aircraft operation and overall flight safety.  

Upper respiratory symptoms can sometimes cause excessive drowsiness (even when not treated with medication), equilibrium disturbance.  

Infectious diseases may cause distraction with uncontrolled bouts of coughing, shortness of breath, fever, chills or distracting headache and/or muscle/joint pain.  

A seemingly innocent ‘stomach flu’ might cause intermittent debilitating gastrointestinal pain or uncontrolled vomiting and/or diarrhea.  

The FAA guidance is that pilots should not fly if they are feeling any sort of illness, since this may affect a pilot’s ability to fly due to the distracting nature of the symptoms themselves or the impact of the symptoms on memory, judgement, alertness, concentration, task accuracy, cognitive function (calculation and problem solving) and mood.  

 
M = MEDICATION
All medications are chemical compounds that impact physiological processes within the body.  Additionally, all medications have the potential to produce both common/expected and uncommon or unexpected side effects.  Both normal medication effects and side effects can alter a pilot’s capacity to safely fly.  

Even if a pilot is medicated for an illness, it still may be unwise for them to fly, since medications can cause changes in performance, especially if they interfere with a pilot’s alertness, responsiveness, task accuracy and problem-solving ability.  

The relationship between medications and flying is more complex than many pilots realize. While pilots frequently seek definitive lists of approved medications, there is no universal lists.  It is important to understand that sometimes the medication may present the risk while in other circumstances it is the medical condition that the medication is treating that is the concern.  

The FAA has a list of ‘NO FLY’ medications which allude to that fact.  Some medications are on that list because of their chemical composition and the effects of those chemicals on organs and tissues while other medications are on the list because the condition being treated by the medication is disqualifying.
 
The intent of aviation safety professionals is to optimize safe flight conditions—not to ‘ground’ pilots.  With that said, however, the general principle still holds true with respect to acute illness—in most instances if a pilot requires medication for acute symptoms of illness, then they’re likely too ill to fly safely.

There are some medications that are ‘NO FLY – NEVER FLY’, meaning that the FAA will likely never medically qualify an airman who is taking that medication.
 
Other medications are ‘NO FLY’ without approval and surveillance, while others still, are ‘NO FLY- WHILE UNDER THE INFLUENCE’.  These are typically OVER-THE-COUNTER medications.   And even if these medications are approved, the FAA recommends the ‘RULE OF FIVE’S” which requires the pilot take the longest dosing interval for a medication and multiply that number by 5.

     RULE-OF-FIVE’S FOR BENADRYL
     Dosing Interval:  Every 4 to 6 hours
     Calculation:  6 hours x 5 = 30 hours between last dose and resuming flight duties

Additionally, if after 30-hours the pilot still believes that he/she is symptomatic, continue to self-ground.

There is other FAA guidance regarding specific medications and classes of medications where a ‘ground trial’ is required for 14 or more days before resuming flight duties.

Remember also that medication approvals may vary internationally, with drugs permitted by the FAA potentially being prohibited in Europe and vice versa.

The bottom line— pilots that require any medical treatment or medications should consult both their general practitioner and Aviation Medical Examiner before flying.


S = STRESS
The third element of the IMSAFE checklist refers to a pilot’s response to events or factors known as “stressors,” which can often lead to overwhelming feelings that can produce impaired problem-solving, task accuracy and other important elements of decision-making in flight.

Stressors can take on many forms, such as those that stem from work, finances, and health. Stress is unavoidable, however, all stressors have the potential to create distraction. 

It is important for pilots to be able to compartmentalize stress in moments during flight in order to remain singularly focused on safe aircraft operation.  Pre-flight delays, ground stops, disagreements with ATC personnel are examples of unexpected stressors just prior to flight that, if not managed, could impact aircraft safety.

The skills to manage stress are born from a variety of stress management practices and a strong emotional support structure beyond the flight deck.
 

A = ALCOHOL
Pilots should be wary when consuming alcohol and how long the effects will last.  There are a number of often overlooked factors that impact the effects of alcohol beyond the alcohol content:
   - pilot weight
   - pilot's general and acute health status (I= ILLNESS)
   - nutrition
   - hydration
   - volume of alcohol consumed and/or speed of consumption
   - alcohol use frequency
   - alcohol use with prescribe and over-the-counter medications

The FAA prohibits pilots from flying within eight hours of alcohol consumption, although they recommend that a pilot waits at least 12 to 24 hours after consumption to fly.
 

F = FATIGUE
Fatigue can be categorized as both acute and chronic, and many pilots report both.  Data consistently show that between 50% and 90% of professional pilots report ‘significant fatigue’.  

More alarming, 60% of professional aviators surveyed reported falling asleep involuntarily while in-flight.  

Over 40% of professional pilots self-report that their ability to operate and aircraft safely is compromised by fatigue/tiredness at least once a month.

Flying while fatigued and flying while sleep/rest-deprived produces impairment, no different than being under the influence of alcohol.  Tired pilots should not fly and it is up to each pilot to determine whether they are getting adequate rest and what they need to do to prevent prolonged periods of fatigue.  

You should have the type of relationship with your AME that allows for open discussion about fatigue and strategies to get adequate rest.


E = EMOTION, ‘ENOUGH’
Emotion is different than stress.  While stress and stressors are external ‘things’ emotion refers to a pilot’s feelings at any given moment in time that might influence their ability to make decisions in the areas of aircraft operation.  Stress and emotion can be related but some elements of emotion are linked to other chronic conditions and even to brain chemistry.  

For example, a stressor can make a pilot angry and the pilot’s anger response can impact safe flight operations.
 
However, a pilot may also have a previously disclosed behavioral health diagnosis for which he/she is being treated that has now suddenly worsened.

Pilots must be able to conduct regular-interval and ‘in-the-moment’ self-checks when he/she feels that they are becoming emotionally triggered in order to determine if overall flight safety might be better served by not flying.   Flying while impaired by feelings that cannot be managed is a risk to flight safety.

‘Enough’ refers to hydration and nutrition-- having enough water and calories for proper body/brain function.  

Perhaps the most common but often overlooked impactors of pilot fitness for flight are calories and hydration.  The brain is the largest consumer of both water and glucose.

Unlike other body organs, the brain cannot manufacture glucose.  Both water and glucose must be contantly supplied meaning that pilots should be adequately hydrated and fed before, during and after flight.


THE FINAL ANALYSIS
The IMSAFE checklist is a guide.  It is a quick, simple, user-friendly self-check mechanism that pilots can use to ‘screen’ themselves for flight fitness, readiness and safety.
You should always feel comfortable connecting with your AME about any questions that you might have as it relates to aviation health and your fitness for flight.  We are here to help.

At Steel City Direct Care, LLC, pilots are our business and we exist to keep you in the sky and at the controls.  We’d love to connect with you!


Christopher T. Conti, MD is the Founder and Owner of Steel City Direct Care, LLC., a Pittsburgh, PA-based medical practice specializing in the care of athletes and aviators.  He is an emergency medicine physician with additional training in sports and concussion health.  He is currently a Team Physician for the US Soccer Federation (USSF), U14-U17 Youth National Team player pools, Medical Advisor for the PA West Soccer Association, a local affiliate of the United States Youth Soccer Association and the Medical Advisor for the Woodland Hills School District in suburban Pittsburgh, PA.  Dr. Conti serves as Medical Advisory Board Member for  SportGait and is also a Credentialed ImPACT Consultant (CIC) for sports concussion care.  Dr. Conti is a designated Senior Aviation Medical Examiner (AME) for the Federal Aviation Administration (FAA)

Disclaimer
The information, opinions and content presented do not necessarily represent the policies or opinions of USSF, the FAA, PA West Soccer, USYS, FIFA, ImPACT, SportGait, the Woodland Hills School District or Steel City Direct Care, LLC.  
None of the information presented should be construed as formal medical advice, nor should it be considered an acceptable substitute for a formal virtual or in-person encounter with an appropriately trained and licensed healthcare professional.  None of the above-listed entities, including Steel City Direct Care, LCC, are responsible for any adverse outcome associated with this content.  

If you would like to schedule a virtual or in-person visit with Dr. Conti, please contact Steel City Direct Care

Steel City Direct Care is a Direct Patient Care (DPC) practice that provides targeted & specialized in-person and virtual care for aviators and athletes of every age and level of skill and participation.