Health and Physiological Factors Affecting Pilot Performance (Part 1)

A number of health factors and physiological effects can be linked to flying. Some are minor, while others are important enough to require special attention to ensure safety of flight. In some cases, physiological factors can lead to inflight emergencies. Some important medical factors that a pilot should be aware of include hypoxia, hyperventilation, middle ear and sinus problems, spatial disorientation, motion sickness, carbon monoxide (CO) poisoning, stress and fatigue, dehydration, and heatstroke. Other subjects include the effects of alcohol and drugs, anxiety, and excess nitrogen in the blood after scuba diving.

Hypoxia

Hypoxia means “reduced oxygen” or “not enough oxygen.” Although any tissue will die if deprived of oxygen long enough, the greatest concern regarding hypoxia during flight is lack of oxygen to the brain, since it is particularly vulnerable to oxygen deprivation. Any reduction in mental function while flying can result in life-threatening errors. Hypoxia can be caused by several factors, including an insufficient supply of oxygen, inadequate transportation of oxygen, or the inability of the body tissues to use oxygen. The forms of hypoxia are based on their causes:
  • Hypoxic hypoxia
  • Hypemic hypoxia
  • Stagnant hypoxia
  • Histotoxic hypoxia

Hypoxic Hypoxia

Hypoxic hypoxia is a result of insufficient oxygen available to the body as a whole. A blocked airway and drowning are obvious examples of how the lungs can be deprived of oxygen, but the reduction in partial pressure of oxygen at high altitude is an appropriate example for pilots. Although the percentage of oxygen in the atmosphere is constant, its partial pressure decreases proportionately as atmospheric pressure decreases. As an aircraft ascends during flight, the percentage of each gas in the atmosphere remains the same, but there are fewer molecules available at the pressure required for them to pass between the membranes in the respiratory system. This decrease in number of oxygen molecules at sufficient pressure can lead to hypoxic hypoxia.

Dangers of Transporting Dry Ice

Sublimation is a process in which a substance transitions from a solid to a gaseous state without passing through an intermediate liquid state. Dry ice sublimates into large quantities of CO2 gas, which can rapidly displace oxygen-containing air and potentially cause hypoxia via carbon dioxide intoxication. Case studies have shown that both illness and death can be caused by occupational and/or unintentional exposure when transporting dry ice in small, confined spaces such as a flightdeck or airplane. Exposure to high concentration of CO2 gas may lead to increased respiration, tachycardia, cardiac arrhythmia, and unconsciousness. Exposure to concentration of CO2 gas in excess of 10 percent may cause convulsions, coma, and/or death.

The tendency of dry ice to rapidly sublimate also means that without proper ventilation, it can rapidly pressurize. For this reason, dry ice should never be placed inside a sealed transport container (i.e., leak-proof secondary container) and must be placed within an outer shipping container or storage container that allows adequate ventilation to release the CO2 gas and avoid pressurization. Sealing dry ice within a leak-proof container may result in explosion of the container potentially leading to serious physical injury or death.

Hypemic Hypoxia

Hypemic hypoxia occurs when the blood is not able to take up and transport a sufficient amount of oxygen to the cells in the body. Hypemic means “not enough blood.” This type of hypoxia is a result of oxygen deficiency in the blood, rather than a lack of inhaled oxygen, and can be caused by a variety of factors. It may be due to reduced blood volume (from severe bleeding), or it may result from certain blood diseases, such as anemia. More often, hypemic hypoxia occurs because hemoglobin, the actual blood molecule that transports oxygen, is chemically unable to bind oxygen molecules. The most common form of hypemic hypoxia is CO poisoning. This is explained in greater detail later in this site. Hypemic hypoxia can also be caused by the loss of blood due to blood donation. Blood volume can require several weeks to return to normal following a donation. Although the effects of the blood loss are slight at ground level, there are risks when flying during this time.

Stagnant Hypoxia

Stagnant means “not flowing,” and stagnant hypoxia or ischemia results when the oxygen-rich blood in the lungs is not moving, for one reason or another, to the tissues that need it. An arm or leg “going to sleep” because the blood flow has accidentally been shut off is one form of stagnant hypoxia. This kind of hypoxia can also result from shock, the heart failing to pump blood effectively, or a constricted artery. During flight, stagnant hypoxia can occur with excessive acceleration of gravity (Gs). Cold temperatures can also reduce circulation and decrease the blood supplied to extremities.

Histotoxic Hypoxia

The inability of the cells to effectively use oxygen is defined as histotoxic hypoxia. “Histo” refers to tissues or cells, and “toxic” means poisonous. In this case, enough oxygen is being transported to the cells that need it, but they are unable to make use of it. This impairment of cellular respiration can be caused by alcohol and other drugs, such as narcotics and poisons. Research has shown that drinking one ounce of alcohol can equate to an additional 2,000 feet of physiological altitude.

Symptoms of Hypoxia

High-altitude flying can place a pilot in danger of becoming hypoxic. Oxygen starvation causes the brain and other vital organs to become impaired. The first symptoms of hypoxia can include euphoria and a carefree feeling. With increased oxygen starvation, the extremities become less responsive and flying becomes less coordinated. The symptoms of hypoxia vary with the individual, but common symptoms include:
  • Cyanosis (blue fingernails and lips)
  • Headache
  • Decreased response to stimuli and increased reaction time
  • Impaired judgment
  • Euphoria
  • Visual impairment
  • Drowsiness
  • Lightheaded or dizzy sensation
  • Tingling in fingers and toes
  • Numbness

As hypoxia worsens, the field of vision begins to narrow and instrument interpretation can become difficult. Even with all these symptoms, the effects of hypoxia can cause a pilot to have a false sense of security and be deceived into believing everything is normal.

Treatment of Hypoxia

Treatment for hypoxia includes flying at lower altitudes and/ or using supplemental oxygen. All pilots are susceptible to the effects of oxygen starvation, regardless of physical endurance or acclimatization. When flying at high altitudes, it is paramount that oxygen be used to avoid the effects of hypoxia. The term “time of useful consciousness” describes the maximum time the pilot has to make rational, life-saving decisions and carry them out at a given altitude without supplemental oxygen. As altitude increases above 10,000 feet, the symptoms of hypoxia increase in severity, and the time of useful consciousness rapidly decreases. [Figure 1]

Health and Physiological Factors Affecting Pilot Performance
Figure 1. Time of useful consciousness

Since symptoms of hypoxia can be different for each individual, the ability to recognize hypoxia can be greatly improved by experiencing and witnessing the effects of it during an altitude chamber “flight.” The Federal Aviation Administration (FAA) provides this opportunity through aviation physiology training, which is conducted at the FAA CAMI in Oklahoma City, Oklahoma, and at many military facilities across the United States. For information about the FAA’s one-day physiological training course with altitude chamber and vertigo demonstrations, visit the FAA website at www.faa.gov.

Hyperventilation

Hyperventilation is the excessive rate and depth of respiration leading to abnormal loss of carbon dioxide from the blood. This condition occurs more often among pilots than is generally recognized. It seldom incapacitates completely, but it causes disturbing symptoms that can alarm the uninformed pilot. In such cases, increased breathing rate and anxiety further aggravate the problem. Hyperventilation can lead to unconsciousness due to the respiratory system’s overriding mechanism to regain control of breathing.

Pilots encountering an unexpected stressful situation may subconsciously increase their breathing rate. If flying at higher altitudes, either with or without oxygen, a pilot may have a tendency to breathe more rapidly than normal, which often leads to hyperventilation.

Since many of the symptoms of hyperventilation are similar to those of hypoxia, it is important to correctly diagnose and treat the proper condition. If using supplemental oxygen, check the equipment and flow rate to ensure the symptoms are not hypoxia related. Common symptoms of hyperventilation include:
  • Visual impairment
  • Unconsciousness
  • Lightheaded or dizzy sensation
  • Tingling sensations
  • Hot and cold sensations
  • Muscle spasms

The treatment for hyperventilation involves restoring the proper carbon dioxide level in the body. Breathing normally is both the best prevention and the best cure for hyperventilation. In addition to slowing the breathing rate, breathing into a paper bag or talking aloud helps to overcome hyperventilation. Recovery is usually rapid once the breathing rate is returned to normal.

Middle Ear and Sinus Problems

During climbs and descents, the free gas formerly present in various body cavities expands due to a difference between the pressure of the air outside the body and that of the air inside the body. If the escape of the expanded gas is impeded, pressure builds up within the cavity and pain is experienced. Trapped gas expansion accounts for ear pain and sinus pain, as well as a temporary reduction in the ability to hear.

The middle ear is a small cavity located in the bone of the skull. It is closed off from the external ear canal by the eardrum. Normally, pressure differences between the middle ear and the outside world are equalized by a tube leading from inside each ear to the back of the throat on each side called the Eustachian tube. These tubes are usually closed but open during chewing, yawning, or swallowing to equalize pressure. Even a slight difference between external pressure and middle ear pressure can cause discomfort. [Figure 2]

Health and Physiological Factors Affecting Pilot Performance
Figure 2. The Eustachian tube allows air pressure to equalize in the middle ear

During a climb, middle ear air pressure may exceed the pressure of the air in the external ear canal causing the eardrum to bulge outward. Pilots become aware of this pressure change when they experience alternate sensations of “fullness” and “clearing.” During descent, the reverse happens. While the pressure of the air in the external ear canal increases, the middle ear cavity, which equalized with the lower pressure at altitude, is at lower pressure than the external ear canal. This results in the higher outside pressure causing the eardrum to bulge inward.

This condition can be more difficult to relieve due to the fact that the partial vacuum tends to constrict the walls of the Eustachian tube. To remedy this often painful condition, which also causes a temporary reduction in hearing sensitivity, pinch the nostrils shut, close the mouth and lips, and blow slowly and gently into the mouth and nose.

This procedure forces air through the Eustachian tube into the middle ear. It may not be possible to equalize the pressure in the ears if a pilot has a cold, an ear infection, or sore throat. A flight in this condition can be extremely painful, as well as damaging to the eardrums. If experiencing minor congestion, nose drops or nasal sprays may reduce the risk of a painful ear blockage. Before using any medication, check with an AME to ensure that it will not affect the ability to fly.

In a similar way, air pressure in the sinuses equalizes with the pressure in the flight deck through small openings that connect the sinuses to the nasal passages. An upper respiratory infection, such as a cold or sinusitis, or a nasal allergic condition can produce enough congestion around an opening to slow equalization. As the difference in pressure between the sinuses and the flight deck increases, congestion may plug the opening. This “sinus block” occurs most frequently during descent. Slow descent rates can reduce the associated pain. A sinus block can occur in the frontal sinuses, located above each eyebrow, or in the maxillary sinuses, located in each upper cheek. It usually produces excruciating pain over the sinus area. A maxillary sinus block can also make the upper teeth ache. Bloody mucus may discharge from the nasal passages.

Sinus block can be avoided by not flying with an upper respiratory infection or nasal allergic condition. Adequate protection is usually not provided by decongestant sprays or drops to reduce congestion around the sinus openings. Oral decongestants have side effects that can impair pilot performance. If a sinus block does not clear shortly after landing, a physician should be consulted.

Spatial Disorientation and Illusions

Spatial disorientation specifically refers to the lack of orientation with regard to the position, attitude, or movement of the airplane in space. The body uses three integrated systems that work together to ascertain orientation and movement in space.
  • Vestibular system—organs found in the inner ear that sense position by the way we are balanced
  • Somatosensory system—nerves in the skin, muscles, and joints that, along with hearing, sense position based on gravity, feeling, and sound
  • Visual system—eyes, which sense position based on what is seen

All this information comes together in the brain and, most of the time, the three streams of information agree, giving a clear idea of where and how the body is moving. Flying can sometimes cause these systems to supply conflicting information to the brain, which can lead to disorientation. During flight in visual meteorological conditions (VMC), the eyes are the major orientation source and usually prevail over false sensations from other sensory systems. When these visual cues are removed, as they are in instrument meteorological conditions (IMC), false sensations can cause a pilot to quickly become disoriented.

The vestibular system in the inner ear allows the pilot to sense movement and determine orientation in the surrounding environment. In both the left and right inner ear, three semicircular canals are positioned at approximate right angles to each other. [Figure 3] Each canal is filled with fluid and has a section full of fine hairs. Acceleration of the inner ear in any direction causes the tiny hairs to deflect, which in turn stimulates nerve impulses, sending messages to the brain. The vestibular nerve transmits the impulses from the utricle, saccule, and semicircular canals to the brain to interpret motion.

Health and Physiological Factors Affecting Pilot Performance
Figure 3. The semicircular canals lie in three planes and sense motions of roll, pitch, and yaw

The somatosensory system sends signals from the skin, joints, and muscles to the brain that are interpreted in relation to the Earth’s gravitational pull. These signals determine posture. Inputs from each movement update the body’s position to the brain on a constant basis. “Seat of the pants” flying is largely dependent upon these signals. Used in conjunction with visual and vestibular clues, these sensations can be fairly reliable. However, the body cannot distinguish between acceleration forces due to gravity and those resulting from maneuvering the aircraft, which can lead to sensory illusions and false impressions of an aircraft’s orientation and movement.

Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which combinations of normal motions and forces create convincing illusions that are difficult to overcome.

Prevention is usually the best remedy for spatial disorientation. Unless a pilot has many hours of training in instrument flight, flight should be avoided in reduced visibility or at night when the horizon is not visible. A pilot can reduce susceptibility to disorienting illusions through training and awareness and learning to rely totally on flight instruments.

Vestibular Illusions

The Leans

A condition called the leans, is the most common illusion during flight and is caused by a sudden return to level flight following a gradual and prolonged turn that went unnoticed by the pilot. The reason a pilot can be unaware of such a gradual turn is that human exposure to a rotational acceleration of 2 degrees per second or lower is below the detection threshold of the semicircular canals. [Figure 4] Leveling the wings after such a turn may cause an illusion that the aircraft is banking in the opposite direction. In response to such an illusion, a pilot may lean in the direction of the original turn in a corrective attempt to regain the perception of a correct vertical posture.

Health and Physiological Factors Affecting Pilot Performance
Figure 4. Human sensation of angular acceleration

Coriolis Illusion

The “coriolis illusion” occurs when a pilot has been in a turn long enough for the fluid in the ear canal to move at the same speed as the canal. A movement of the head in a different plane, such as looking at something in a different part of the flight deck, may set the fluid moving, creating the illusion of turning or accelerating on an entirely different axis. This action causes the pilot to think the aircraft is performing a maneuver it is not. The disoriented pilot may maneuver the aircraft into a dangerous attitude in an attempt to correct the aircraft’s perceived attitude.

For this reason, it is important that pilots develop an instrument cross-check or scan that involves minimal head movement. Take care when retrieving charts and other objects in the flight deck—if something is dropped, retrieve it with minimal head movement and be alert for the coriolis illusion.

Graveyard Spiral

As in other illusions, a pilot in a prolonged coordinated, constant-rate turn may experience the illusion of not turning. During the recovery to level flight, the pilot will then experience the sensation of turning in the opposite direction causing the disoriented pilot to return the aircraft to its original turn. Because an aircraft tends to lose altitude in turns unless the pilot compensates for the loss in lift, the pilot may notice a loss of altitude. The absence of any sensation of turning creates the illusion of being in a level descent. The pilot may pull back on the controls in an attempt to climb or stop the descent. This action tightens the spiral and increases the loss of altitude; this illusion is referred to as a “graveyard spiral.” [Figure 5] This may lead to a loss of aircraft control.

Health and Physiological Factors Affecting Pilot Performance
Figure 5. Graveyard spiral

Somatogravic Illusion

A rapid acceleration, such as experienced during takeoff, stimulates the otolith organs in the same way as tilting the head backwards. This action may create what is known as the “somatogravic illusion” of being in a nose-up attitude, especially in conditions with poor visual references. The disoriented pilot may push the aircraft into a nose-low or dive attitude. A rapid deceleration by quick reduction of the throttle(s) can have the opposite effect, with the disoriented pilot pulling the aircraft into a nose-up or stall attitude.

Inversion Illusion

An abrupt change from climb to straight-and-level flight can stimulate the otolith organs enough to create the illusion of tumbling backwards, known as “inversion illusion.” The disoriented pilot may push the aircraft abruptly into a nose-low attitude, which may intensify this illusion.

Elevator Illusion

An abrupt upward vertical acceleration, as can occur in an updraft, can stimulate the otolith organs to create the illusion of being in a climb. This is known as “elevator illusion.” The disoriented pilot may push the aircraft into a nose-low attitude. An abrupt downward vertical acceleration, usually in a downdraft, has the opposite effect with the disoriented pilot pulling the aircraft into a nose-up attitude.

Visual Illusions

Visual illusions are especially hazardous because pilots rely on their eyes for correct information. Two illusions that lead to spatial disorientation, false horizon and autokinesis, affect the visual system only.

False Horizon

A sloping cloud formation, an obscured horizon, an aurora borealis, a dark scene spread with ground lights and stars, and certain geometric patterns of ground lights can provide inaccurate visual information, or “false horizon,” when attempting to align the aircraft with the actual horizon. The disoriented pilots as a result may place the aircraft in a dangerous attitude.

Autokinesis

When flying in the dark, a stationary light may appear to move if it is stared at for a prolonged period of time. As a result, a pilot may attempt to align the aircraft with the perceived moving light potentially causing him/her to lose control of the aircraft. This illusion is known as “autokinesis.”

Postural Considerations

The postural system sends signals from the skin, joints, and muscles to the brain that are interpreted in relation to the Earth’s gravitational pull. These signals determine posture. Inputs from each movement update the body’s position to the brain on a constant basis. “Seat of the pants” flying is largely dependent upon these signals. Used in conjunction with visual and vestibular clues, these sensations can be fairly reliable. However, because of the forces acting upon the body in certain flight situations, many false sensations can occur due to acceleration forces overpowering gravity. [Figure 6] These situations include uncoordinated turns, climbing turns, and turbulence.

Health and Physiological Factors Affecting Pilot Performance
Figure 6. Sensations from centrifugal force

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