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TRANSCRIPT
Vitreous Fluid and/or Urine Glucose Concentrations in 1,335 Civil Aviation Accident Pilot Fatalities
Sabra R. BotchArvind K. ChaturvediDennis V. CanfieldEstrella M. ForsterCivil Aerospace Medical InstituteOklahoma City, OK 73125
May 2008
Final Report
DOT/FAA/AM-08/11Office of Aerospace MedicineWashington, DC 20591
OK-08-1997
NOTICE
This document is disseminated under the sponsorship of the U.S. Department of Transportation in the interest
of information exchange. The United States Government assumes no liability for the contents thereof.
___________
This publication and all Office of Aerospace Medicine technical reports are available in full-text from the Civil Aerospace Medical Institute’s publications Web site:
www.faa.gov/library/reports/medical/oamtechreports/index.cfm
�
Technical Report Documentation Page 1. Report No. 2. Government Accession No. 3. Recipient's Catalog No.
DOT/FAA/AM-08/11 4. Title and Subtitle 5. Report Date
May 2008 Vitreous Fluid and/or Urine Glucose Concentrations in 1,335 Civil Aviation Accident Pilot Fatalities 6. Performing Organization Code
7. Author(s) 8. Performing Organization Report No. Botch SR, Chaturvedi AK, Canfield DV, Forster EM
9. Performing Organization Name and Address 10. Work Unit No. (TRAIS)
11. Contract or Grant No. FAA Civil Aerospace Medical Institute P.O. Box 25082 Oklahoma City, OK 73125 12. Sponsoring Agency name and Address 13. Type of Report and Period Covered
Office of Aerospace Medicine Federal Aviation Administration 800 Independence Ave., S.W. Washington, DC 20591 14. Sponsoring Agency Code 15. Supplemental Notes Work was accomplished under approved task AM-B-08-TOX-202. 16. Abstract For aviation accident investigations at the Civil Aerospace Medical Institute (CAMI), vitreous fluid and urine samples from pilot fatalities are analyzed for glucose, and in those cases wherein glucose levels are elevated, blood hemoglobin A1c (HbA1c) is measured. These analyses are conducted to monitor diabetic pilots to ensure that their disease was in control at the time of accidents and to discover other pilots with undiagnosed and unreported diabetes. In this study, the prevalence of elevated glucose concentrations in fatally injured civilian pilots is evaluated. Glucose and HbA1c are measured by hexokinase and latex immunoagglutination inhibition methodologies, respectively. The former was adopted at the beginning of 1998, while the latter in the middle of 2001. The analytical results are electronically stored in the CAMI Toxicology Database. This database was searched for pilots from whom samples were received during 1998–2005 and whose vitreous fluid and/or urine glucose concentrations were measured. HbA1c levels and information on diabetic pilots were also retrieved. The probable cause and contributing factors of the associated accidents were obtained from the National Transportation Safety Board's (NTSB's) Aviation Accident Database. Out of 1,335 pilots involving 363 vitreous fluid, 365 urine, and 607 vitreous fluid and urine analyses, 43 pilots had elevated glucose in vitreous fluid (> 125 mg/dL) and/or in urine (> 100 mg/dL). Of the 20 pilots whose blood samples were analyzed, 9 had > 6% HbA1c—4 were known diabetics (HbA1c: 7.1; 8.3; 10.8; and 12.4%), and 5 were not known diabetics (HbA1c:6.2; 8.2; 8.3; 8.6; and 13.0%). Urinary glucose levels were elevated in all 13 known hyperglycemic pilots. One pilot had a history of renal glycosuria (low renal threshold). The disease of the 13 diabetic pilots was not in control at the time of accidents. Additionally, there were a considerable number of pilots with elevated glucose (30 of 43) and HbA1c (5 of 20), suggesting undiagnosed and unreported diabetic conditions. However, health, medical condition(s), and use of medications (authorized or unauthorized) by pilots were determined by the NTSB to be the cause or a factor in 5 accidents: elevated glucose level of the pilot was a factor in 1 and incapacitation/impairment of the pilot was a cause and/or factor in 4. Greater attention is necessary in controlling diabetes by aviators in coordination with Aviation Medical Examiners.
17. Key Words 18. Distribution Statement
Forensic Science, Toxicology, Glucose, Hemoglobin A1c,Fatalities, Civil Aviation Accident Investigation
Document is available to the public through the Defense Technical Information Center, Ft. Belvior, VA 22060; and the National Technical Information Service, Springfield, VA 22161
19. Security Classif. (of this report) 20. Security Classif. (of this page) 21. No. of Pages 22. Price Unclassified Unclassified 11
Form DOT F 1700.7 (8-72) Reproduction of completed page authorized
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CONTENTs
IntroductIon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
MaterIals.and.Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Postmortem.B�olog�cal.spec�mens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
B�olog�cal.spec�men.analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
database.search. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
elevated.Glucose.and.hba1c
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Fl�ght.categor�es. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
a�rman.Med�cal.and.Fly�ng.cert�ficates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
P�lot.Med�cal.h�story.and.acc�dent.cause/Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
dIscussIon.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
reFerences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1
Vitreous Fluid and/or urine Glucose concentrations in 1,335 ciVil aViation accident Pilot Fatalities
INTrOduCTION
dur�ng.av�at�on.acc�dent.�nvest�gat�ons.at.the.Federal.av�at�on.adm�n�strat�on.(Faa’s).c�v�l.aerospace.Med�-cal.Inst�tute.(caMI),.v�treous.flu�d.and.ur�ne.samples.from.p�lot. fatal�t�es.are.analyzed. for.glucose. (1–3) .. In.those.fatal�t�es.(cases).where�n.glucose.levels.are.elevated,.blood.hemoglob�n.a
1c.(hba
1c). �s.also.measured.(3,4) ..
concentrat�ons. of. glucose. >. 125. mg/dl. �n. v�treous.flu�d.and.>.100.mg/dl.�n.ur�ne.are.cons�dered.elevated.(2) ..these.glucose.and.hba
1c.analyses.are.conducted.to.
mon�tor.d�abet�c.p�lots.to.ensure.that.the�r.d�sease.was.�n.control.at.the.t�me.of.acc�dents.and.to.d�scover.other.p�lots.w�th.unreported.d�abetes ..such.analyses.of.post-mortem.samples.from.av�at�on.acc�dent.p�lot.fatal�t�es.are.useful. �n.determ�n�ng.whether.hyperglycem�a-�nduced.performance. �mpa�rment.was. the.probable. cause. or. a.contr�butory.factor.�n.a.part�cular.acc�dent ..
at.caMI,.v�treous.flu�d.and.ur�ne.glucose.analys�s.was.�mplemented.�n.the.beg�nn�ng.of.1998.and.blood.hba
1c.�n.the.m�ddle.of.2001 ..however,.�nformat�on.on.
the.prevalence.and.causal.effects.of.elevated.glucose.and.hba
1c.�n.fatal.c�v�l.av�at�on.acc�dents.�s.not.documented ..
In.th�s.study,.elevated.glucose.and.hba1c
.�n.fatally.�njured.c�v�l.av�ators.from.whom.b�olog�cal.samples.were.rece�ved.at.caMI.dur�ng.1998–2005.were.evaluated.by.retr�ev�ng.and.analyz�ng.necessary.�nformat�on.from.relevant.data-bases ..the.poss�ble.causal.effects.of.the.elevated.glucose.and.hba
1c.�n.the.assoc�ated.acc�dents.were.also.retr�eved.
dur�ng.the.database.searches ..the.find�ngs.thus.obta�ned.are.presented.here�n .
MaTErIals aNd METhOds
Postmortem Biological specimensautops�ed.b�olog�cal.samples.(blood,.ur�ne,.l�ver,.k�d-
ney,.v�treous.flu�d,.and.other.body.spec�mens).collected.from.fatally.�njured.p�lots.of.u .s ..c�v�l.av�at�on.acc�dents.are.subm�tted.to.caMI.for.tox�colog�cal.analyses.for.the.�nvest�gat�on.of.a�rcraft.acc�dents.occurr�ng.w�th�n.the.jur�sd�ct�on.of. the.un�ted.states. (1,3) ..these.av�at�on.acc�dents. enta�l. acc�dents. �nvolv�ng. reg�stered,. as. well.as.unreg�stered.a�rcraft ..not.all.of.the.av�ators.�nvolved.�n. these. acc�dents. held. a�rman. med�cal. and/or. fly�ng.cert�ficates.requ�red.to.legally.p�lot.an.a�rcraft ..collected.postmortem.samples.are.subm�tted.to.caMI.�n.the.Faa’s.toX-BoX.ev�dence.conta�ners.(3) ..subm�ss�ons.of.the.
postmortem.samples.are.coord�nated.through.the.Faa’s.office.of.acc�dent.Invest�gat�on.by.the.nat�onal.trans-portat�on.safety.Board.(ntsB) ..the.ntsB.�s.respons�ble.for.�nvest�gat�ng.all.u .s ..c�v�l�an.a�rcraft.acc�dents ..
Biological specimen analysesIn. add�t�on. to. rout�ne. tox�colog�cal. analyses.of. the.
subm�tted.spec�mens.follow�ng.standard.procedures.of.the.caMI.tox�cology.laboratory,.v�treous.flu�d.and.ur�ne.samples.are.analyzed.for.glucose.and.blood.for.hba
1c.
(3–5) .. Glucose. analys�s. �s. performed. by. a. hexok�nase.method.us�ng.a.du.Pont.analyst.Benchtop.chem�stry.stat�on.(du.Pont.company.Med�cal.Products,.W�lm-�ngton,.dl) ..Blood.hba
1c.�s.measured.by.a.latex.�mmu-
noagglut�nat�on.�nh�b�t�on.us�ng.a.dca.2000+.analyzer.and.dca.2000.hba
1c.reagent.K�t.(Bayer.corporat�on,.
elkhart,.In) ..the.glucose.analys�s.�n.the.laboratory.was.�mplemented.�n.the.beg�nn�ng.of.1998.and.the.hba
1c.�n.
the.m�ddle.of.2001 ..the.hba1c
.analys�s.was.performed.�n.those.cases.where�n.v�treous.flu�d.and/or.ur�ne.glucose.concentrat�ons.were.elevated.(2,4).and.where�n.su�table.blood.samples.were.ava�lable ..
database searchInclud�ng. glucose. and. hba
1c. analyt�cal. values,. all.
tox�colog�cal.results.of.c�v�l.a�rcraft.acc�dent.p�lot.fatal�-t�es.are.electron�cally.stored.�n.a.database.ma�nta�ned.at.caMI.�n.oklahoma.c�ty,.oK ..the.caMI.tox�cology.database.was.searched.for.an.8-year.per�od.(1998–2005).for.p�lot.fatal�t�es.from.whom.postmortem.samples.were.subm�tted.and.the�r.v�treous.flu�d.and.ur�ne.samples.were.analyzed.for.glucose ..Blood.hba
1c.and.tox�colog�cal.find-
�ngs.were.also.retr�eved.from.th�s.database ..add�t�onally,.the.caMI.tox�cology.database.search.
enta�led.the.numbers.of.all.u .s ..c�v�l.av�at�on.acc�dents.and.p�lot.fatal�t�es,.�nclud�ng.the.a�rman.fly�ng.and.med�-cal.cert�ficates.of.those.p�lots.and.the.fl�ght.categor�es.of.the.assoc�ated.acc�dents ..some.add�t�onal. �nformat�on.related.to.a�rman.fly�ng.cert�ficates.and.fl�ght.categor�es,.along.w�th.the.probable.cause.and.contr�but�ng.factors.�n.the.acc�dents,.was.obta�ned.from.the.ntsB’s.av�a-t�on.acc�dent.database.(Wash�ngton,.dc) ..the.cause.and.factors-related.�nformat�on.�ncluded.�n.the.study.�s.based.on.the.find�ngs.reported.�n.the.ntsB.database.through. december. 2006 .. av�ators. that. d�d. not. have.a�rman.med�cal.and/or.fly�ng.cert�ficates.were.also.part.of.the.study ..
2
rEsulTs
Pilot Fatalities and accidentsdur�ng. 1998–2005,. postmortem. samples. from.
2,487.p�lot. fatal�t�es.were.subm�tted.to.caMI ..th�s.number. of. fatal�t�es. corresponded. to. the. equ�valent.number.of.av�at�on.acc�dents.�n.wh�ch.p�lot.fatal�t�es.had.occurred.and.the�r.postmortem.samples.were.tox�-colog�cally. evaluated ..of. the.2,487.acc�dents,.2,210.were.of.general.av�at�on,.107.a�r.tax�.and.commuter,.20.ultral�ght.veh�cle,.and.32.publ�c.use.categor�es.(6) ..the.rema�n�ng.118.acc�dents.were.assoc�ated.w�th.a�r.carr�er,.agr�cultural,.and.other.categor�es ..
Elevated Glucose and hba1c
V�treous. flu�d. and/or. ur�ne. spec�mens. from. 1,335.(54%).of.the.2,487.p�lot.fatal�t�es.(cases).were.analyzed.for.glucose.�n.1998−2005 ..In.the.rema�n�ng.1,152.(46%).cases,.v�treous.flu�d.and.ur�ne.samples.were.e�ther.not.subm�tted,.not.ava�lable.�n.suffic�ent.amounts,.or.not.of.analyt�cal.qual�ty.to.perform.glucose.analyses ..analyses.of.the.1,335.cases.cons�sted.of.363.v�treous.flu�d,.365.ur�ne,.and.607.v�treous.flu�d.and.ur�ne.spec�mens.(F�g ..1) ..although.the.major�ty.of.the.glucose.concentrat�ons.found.�n.v�treous.flu�d.and.ur�ne.ranged.from.0.to.99.mg/dl. (F�g .. 2),. there. were. 26. v�treous. flu�d. and. 39.ur�ne.samples.where�n.the.glucose.concentrat�ons.were.determ�ned.to.be.>100.mg/dl ..
as. g�ven. �n.table. I,. 43.p�lots.had. elevated. glucose.�n.v�treous.flu�d.(>.125.mg/dl).and/or.�n.ur�ne.(>.100.mg/dl) ..In.29.of.the.43.cases,.both.v�treous.flu�d.and.ur�ne.samples.were.analyzed—3.had.elevated.glucose.�n.v�treous.flu�d.only,.19.�n.ur�ne.only,.and.7.�n.v�treous.flu�d,.as.well.as.�n.ur�ne ..In.3.cases,.only.v�treous.flu�d.was.rece�ved.and.analyzed ..In.11.cases,.only.ur�ne.was.rece�ved.and.analyzed ..Glucose.was.found.to.be.elevated.�n.these.14.samples ..
of.the.20.p�lots.whose.blood.samples.were.analyzed.for.hba
1c,.9.had.>.6%.hba
1c—4.were.known.d�abet-
�cs.(hba1c
:.7 .1;.8 .3;.10 .8;.and.12 .4%),.and.5.were.not.known.d�abet�cs.(hba
1c:.6 .2;.8 .2;.8 .3;.8 .6;.and.13 .0%) ..
ur�nary.glucose.concentrat�ons.were.elevated.�n.all.13.known.hyperglycem�c.p�lots ..
analyt�cal. tox�cology. fa�led. to. d�sclose. the. pres-ence.of.drugs.and/or.ethanol.�n.26.of.the.43.p�lots ..however,.drugs.were.detected. �n. the. rema�n�ng.17.p�lots ..drugs.found.were.am�tr�ptyl�ne,.amphetam�nes,.atrop�ne,.β-adrenerg�c.blockers,.calc�um.channel.block-ers,. h
1-. and. h
2-antagon�sts,. l�doca�ne,. m�dazolam,.
narcot�c.and.non-narcot�c.analges�cs,.pentobarb�tal,.and.s�ldenafil .
Flight Categoriesof.the.43.acc�dents,.a.h�ghest.number.of.37.acc�dents.
were. assoc�ated.w�th. general. av�at�on.fl�ghts,. followed.by.3.a�r.tax�.and.commuter,.2.ultral�ght.veh�cle,.and.1.publ�c.use.fl�ghts ..under.the.general.av�at�on.category,.v�treous. flu�d. glucose. was. elevated. �n. 4. p�lots,. ur�ne.glucose.�n.28,.and.v�treous.flu�d.and.ur�ne.glucose.�n.5.(table.II) ..of.the.9.p�lots.w�th.elevated.hba
1c.(>.6%),.
7.were.�nvolved.w�th.general.av�at�on.fl�ghts.and.1.each.�n.ultral�ght.veh�cle.and.publ�c.use.fl�ghts .
airman Medical and Flying Certificatesof.the.43.p�lots,.1.held.F�rst-class,.21.second-class,.
and.18.th�rd-class.a�rman.med�cal.cert�ficates ..the.other.3.p�lots.were.w�thout.val�d.med�cal.cert�ficates ..the.p�lot.w�th.the.F�rst-class.med�cal.cert�ficate.was.�nvolved.�n.a.general.av�at�on.acc�dent ..of.the.21.second-class.med�cal.cert�ficate.holders,.17.were.�nvolved.�n.general.av�at�on.acc�dents,.followed.by.3.�n.a�r.tax�.and.commuter,.and.1.�n.publ�c.use.acc�dents ..out.of.the.18.p�lots.w�th.th�rd-class.med�cal.cert�ficates,.17.were. �nvolved. �n.general.av�at�on.and.1.�n.ultral�ght.veh�cle.acc�dents ..of.the.3.non-cert�ficated.p�lots,.2.were.�nvolved.�n.general.av�at�on.acc�dents.and.1.�n.an.ultral�ght.veh�cle.acc�dent ..except.the.F�rst-class.p�lot,.all.p�lots.w�th.elevated.glucose.�n.v�treous.flu�d.and/or.ur�ne.and.w�th.elevated.hba
1c.were.
holders.of.second-.and.th�rd-class.med�cal.cert�ficates.(table.III) ..the.major�ty.of.these.second-.and.th�rd-class.p�lots.had.commerc�al.and.pr�vate.fly�ng.rat�ngs,.respect�vely.(table.IV) ..
W�th.respect.to.fly�ng.rat�ngs,.19.p�lots.held.pr�vate,.16.commerc�al,.and.7.a�rl�ne.transport.cert�ficates ..one.p�lot.was.non-cert�ficated ..of.the.19.pr�vate.p�lots,.18.were.�nvolved.�n.general.av�at�on.acc�dents,.wh�le.1.�n.an.ultral�ght.veh�cle.acc�dent ..In.the.16.commerc�al.p�lots,.12.were.�nvolved.�n.general.av�at�on,.3.�n.a�r.tax�.and.commuter,. and.1. �n.publ�c.use.acc�dents ..all.7.p�lots.w�th.a�rl�ne.transport.p�lot.cert�ficates.were.�nvolved.�n.general.av�at�on.acc�dents ..
Pilot Medical history and accident Cause/Factorout.of.the.43.p�lots,.14.had.an.aeromed�cal.h�story.
of. hyperglycem�a—1. had. renal. glycosur�a. (low. renal.threshold). and. 13. known. h�story. of. d�abetes. (table.I) ..accord�ng.to.the.h�story,.d�abetes.should.have.been.controlled.by.d�et.�n.5.p�lots,.by.hypoglycem�c.drugs.�n.5,.by.d�et.and.hypoglycem�c.drugs.�n.1,.and.by.�nsul�n.w�th.oral.hypoglycem�c.drugs.�n.2 ..the.rema�n�ng.29.p�lots.d�d.not.have.h�story.of.hyperglycem�a ..
of. the. 43. acc�dents,. health,. med�cal. cond�t�on(s),.and/or. use. of. med�at�on(s)—author�zed. or. unauthor-�zed—of.av�ators.have.been.establ�shed.by.the.ntsB.to.be.the.cause.or.a.factor.�n.5.acc�dents ..
3
470
34 4028
15 11
348
231
91
37
5 2 1
392634
191
76
45
15
194
8
0
50
100
150
200
250
300
350
400
450
500
0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90–99 100Glucose (mg/dL)
Freq
uenc
y
Vitreous Fluid Urine
Figure 2. Frequency of glucose concentrations in vitreous fluid and urine specimens from the 1,335 pilot fatalities.
Urine 365 (27.3%)
Vitreous Fluid363 (27.2%)
Vitreous Fluid and Urine
607 (45.5%)
Figure 1. Proportion of vitreous fluid, urine, and vitreous fluid and urine samples in the 1,335 cases analyzed for glucose.
4
Tabl
e I.
Glu
cose
and
HbA
1c C
once
ntra
tions
and
Hyp
ergl
ycem
ic M
edic
al H
isto
ry o
f 43
Fata
lly In
jure
d P
ilots
and
The
ir H
ealth
and
/or
Med
ical
Con
ditio
ns a
s C
ause
/Fac
tors
in T
hose
Civ
il A
viat
ion
Acc
iden
ts (1
998–
2005
)
Pilo
ts
Vitr
eous
Fl
uid
Glu
cose
(m
g/dL
)
Urin
ary
Glu
cose
(m
g/dL
)
Blo
od
HbA
1c (%
)*H
yper
glyc
emic
Med
ical
His
tory
Pi
lot's
Hea
lth a
nd/o
r Med
ical
Con
ditio
ns a
s the
C
ause
/Fac
tors
in th
e A
ccid
ents
as D
eter
min
ed
by th
e N
TSB
1998
1 45
18
9 –†
Dia
bete
s con
trolle
d by
hy
pogl
ycem
ic d
rugs
--
-
2 12
30
55
– G
lyco
suria
(low
rena
l thr
esho
ld)
---
3 14
7 65
–
---
---
4 25
6 88
15
– D
iabe
tes c
ontro
lled
by d
iet
---
5 11
9 76
0 –
Dia
bete
s con
trolle
d by
hy
pogl
ycem
ic d
rugs
--
-
1999
6‡,§
194
– –
---
---
7 16
3 15
6 –
---
Fact
or: P
ilot's
inca
paci
tatio
n du
e to
ille
gal
subs
tanc
es8
0 10
5 –
---
---
2000
9 18
0 71
82
– D
iabe
tes c
ontro
lled
by
hypo
glyc
emic
dru
gs
---
10
42
165
– --
- --
- 11
–
1438
–
Dia
bete
s con
trolle
d by
die
t --
- 12
¶47
52
5 –
---
Cau
se: P
ilot's
impa
irmen
t due
to th
e us
e of
un
appr
oved
med
icat
ion
13
228
24
– --
- --
- 14
13
2 –
– --
- --
- 15
0
1175
–
Dia
bete
s con
trolle
d by
die
t Fa
ctor
: Pilo
t's e
leva
ted
gluc
ose
leve
l 16
76
26
5 –
---
---
2001
17
43
365
– --
- --
- 18
33
3 31
4.
7 --
- C
ause
: Pilo
t's in
capa
cita
tion
(car
diov
ascu
lar)
20
0219
23
0 18
70
8.6
---
---
20
301
6050
12
.4
Dia
bete
s con
trolle
d by
insu
lin
and
by o
ral h
ypog
lyce
mic
dru
gs
---
21
265
4487
8.
2 --
- Fa
ctor
: Hyp
oxia
22
71
30
2 5.
4 --
- --
-
5
Tabl
e I (
cont
inue
d). G
luco
se a
nd H
bA1c
Con
cent
ratio
ns a
nd H
yper
glyc
emic
Med
ical
His
tory
of 4
3 Fa
tally
Inju
red
Pilo
ts a
nd T
heir
Hea
lth
and/
or M
edic
al C
ondi
tions
as
Cau
se/F
acto
rs in
Tho
se C
ivil
Avi
atio
n A
ccid
ents
(199
8–20
05)
Pilo
ts
Vitr
eous
Fl
uid
Glu
cose
(m
g/dL
)
Urin
ary
Glu
cose
(m
g/dL
)
Blo
od
HbA
1c (%
)*H
yper
glyc
emic
Med
ical
His
tory
Pi
lot's
Hea
lth a
nd/o
r Med
ical
Con
ditio
ns a
s the
C
ause
/Fac
tors
in th
e A
ccid
ents
as D
eter
min
ed
by th
e N
TSB
23
98
4700
10
.8
Dia
bete
s con
trolle
d by
die
t and
by
hyp
ogly
cem
ic d
rugs
--
-
24
11
162
8.3
---
---
25
– 15
48
– D
iabe
tes r
equi
ring
insu
lin a
nd
oral
hyp
ogly
cem
ic m
edia
tion
Cau
se: P
ilot's
inca
paci
tatio
n Fa
ctor
: The
pilo
t and
med
ical
exa
min
er
prov
idin
g fa
lse
info
rmat
ion
on th
e pi
lot's
m
edic
al a
pplic
atio
ns
2003
26
97
435
5.0
---
---
27
100
139
5.2
---
---
28
16
264
5.3
---
---
29
122
162
– --
- --
- 30
–
369
5.8
Dia
bete
s con
trolle
d by
hy
pogl
ycem
ic d
rugs
--
-
31
– 53
0 5.
1 --
- --
- 32
‡ 12
6 47
00
13.0
--
- --
- 20
0433
0
1750
–
Dia
bete
s con
trolle
d by
die
t --
- 34
–
5700
–
---
---
35
174
– 6.
2 --
- --
- 36
–
5450
–
---
---
37
0 78
6 6.
0 --
- --
- 38
–
377
5.9
---
---
2005
39
– 33
50
7.1
Dia
bete
s con
trolle
d by
die
t --
- 40
–
2585
8.
3 D
iabe
tes c
ontro
lled
by
hypo
glyc
emic
dru
gs
---
41
– 12
0 4.
4 --
- --
- 42
–
630
– --
- --
- 43
10
1 47
3 5.
1 --
- --
- * H
bA1c
ana
lysi
s was
impl
emen
ted
in 2
001.
† N
o an
alys
is.
‡ Unr
egis
tere
d ai
rcra
ft.
§ With
out m
edic
al a
nd fl
ying
cer
tific
ates
. ¶ W
ithou
t med
ical
cer
tific
ate.
6
Table III. Airman Medical Certificate Categories With Elevated Glucose and HbA1c Levels in Aviation Accident Pilot Fatalities, 1998–2005
Pilot Fatalities†Medical Certificate Categories* Vitreous Fluid Glucose
(> 125 mg/dL)Urine Glucose (> 100 mg/dL)
Blood HbA1c(> 6%)‡
First-Class 0 1 –§
Second-Class 8 19 4 Third-Class 3 16 5 *See reference (7). †Three pilots without medical certificates are not included. There were 7 pilots (6 Second-Class and 1 Third-Class pilots) wherein glucose was elevated in vitreous fluid as well as in urine. ‡Blood HbA1c analysis was implemented in 2001. §No analysis.
Table IV. Airman Flying Ratings With Elevated Glucose and HbA1c Concentrations in Aviation Accident Pilot Fatalities, 1998–2005
Pilot Fatalities†
Airman Flying Ratings*
Vitreous Fluid Glucose (> 125 mg/dL)
Urine Glucose (> 100 mg/dL)
Blood HbA1c(> 6%)‡
First-Class Medical Certificate-Holding PilotsAirline Transport --- 1 –§
Commercial --- --- – Private --- --- –
Second-Class Medical Certificate-Holding PilotsAirline Transport¶ 3 4 2 Commercial** 5 12 2 Private 0 3 0
Third-Class Medical Certificate-Holding PilotsAirline Transport --- 1 – Commercial 0 2 1 Private†† 3 13 4 *See reference (7). †Two pilots without medical and flying certificates and 1 pilot without medical certificate are not included. ‡Blood HbA1C analysis was implemented in 2001. §No analysis. ¶Two pilots had elevated glucose in vitreous fluid and in urine. **Four pilots had elevated glucose in vitreous fluid and in urine. ††One pilot had elevated glucose in vitreous fluid and in urine.
Table II. Aviation Accident Flight Categories With Elevated Glucose and HbA1c Concentrations in Pilot Fatalities (1998–2005)
Pilot Fatalities†Flight Categories
Vitreous Fluid Glucose
(> 125 mg/dL)
Urine Glucose (> 100 mg/dL)
Blood HbA1c(> 6%)‡
General Aviation (Part 91)§ 9 33 7 Air Taxi and Commuter (Part 135) 0 3 0 Ultralight Vehicle (Part 103)¶ 2 1 1 Public Use** 1 1 1 *See reference (6). †In 7 fatalities (cases), glucose was elevated in vitreous fluid as well as in urine. ‡Blood HbA1c analysis was implemented in 2001. §Five pilots had elevated glucose in both vitreous fluid and urine. ¶Pilots flying unregistered aircraft were also included. One pilot had elevated glucose in both specimen types (vitreous fluid and urine). **Used for the federal, state, and local government agencies. One pilot had elevated glucose in both specimen types.
7
1 .. In.1. acc�dent,. the. elevated.glucose. level. of. the.p�lot.was.a.factor ..th�s.p�lot.had.a.h�story.of.d�abetes.that.should.have.been.controlled.by.d�et ..the.p�lot’s.ur�nary.glucose.concentrat�on.was.1,175.mg/dl . ..no.drugs.and.ethanol.were.found.�n.th�s.case2 .. In.3.acc�dents,.�ncapac�tat�on.of.the.p�lot.was.the.probable.cause.or.a.contr�but�ng.factor ..
a .. the.p�lot.of.the.1st.acc�dent.had.elevated.ur�ne.(156.mg/dl).and.v�treous.(163.mg/dl).glucose.levels.w�th.no.reported.h�story.of.d�abetes ..the.ntsB.de-term�ned.that.a.factor.�n.the.acc�dent.was.the.p�lot’s.�ncapac�tat�on.due.to.�llegal.substances ..tox�colog�-cal.analys�s.reveled.amphetam�ne.and.methamphet-am�ne.�n.the.p�lot’s.blood,.ur�ne,.and.bra�n ..b .. the. ntsB. determ�ned. the. cause. of. the.2nd. acc�dent. to. be. “Incapac�tat�on. of. the. p�lot.(card�ovascular). result�ng. �n. h�s. �nab�l�ty. to. fly.the. a�rplane .”. In. add�t�on. to. autopsy. find�ngs.of. “Fresh. posteroseptal. myocard�al. �nfarct�on;.stenot�c. coronary. atherosclero�s�s,”. the. tox�co-log�cal.exam�nat�on.revealed.that.hydrocodone,.d�hydrocode�ne,.and.hydromorphone.were.present.�n.the.ur�ne ..the.p�lot’s.glucose.levels.were.333.mg/dl.�n.the.v�treous.and.31.mg/dl.�n.the.ur�ne.w�th.no.reported.h�story.of.d�abetes ..c .. the.ntsB.establ�shed.the.cause.of.the.3rd.ac-c�dent.to.be.the.�ncapac�tat�on.of.the.p�lot.w�th.a.contr�but�ng.factor.be�ng.the.p�lot.and.the.av�at�on.Med�cal.exam�ner.(aMe).prov�d�ng.false.�nforma-t�on.on.the.p�lot’s.med�cal.appl�cat�ons ..the.ntsB.stated.that.the.p�lot.had.mult�ple.ser�ous.med�cal.cond�t�ons,. �nclud�ng. congest�ve. heart. fa�lure;.coronary.heart.d�sease,.requ�r�ng.ang�oplasty.and.bypass.surgery;.and.d�abetes,.requ�r�ng.�nsul�n.and.oral.hypoglycem�c.med�cat�on ..however,.ne�ther.the.p�lot.nor.h�s.aMe.reported.h�s.med�cal.con-d�t�ons. to. the.Faa,.wh�ch.was.known. to.both.�nd�v�duals.at.the.t�me.of.appl�cat�on ..the.p�lot’s.ur�nary.glucose.level.was.1,548.mg/dl ..
3 .. In. the. last. acc�dent,. the. ntsB. attr�buted. the.p�lot’s.�mpa�rment.to.the.use.of.unapproved.med�ca-t�on.as.the.cause.of.the.acc�dent ..the.p�lot’s.glucose.levels.were.525.mg/dl.�n.the.ur�ne.and.47.mg/dl.�n.the.v�treous ..the.p�lot.had.no.reported.h�story.of.d�abetes ..tox�colog�cal.analys�s.revealed.the.presence.of.propoxyphene,.am�tr�ptyl�ne,.and.d�phenhydram�ne.�n.the.blood ..
In.36.acc�dents,.health,.med�cal.cond�t�on(s),.or.use.of.med�cat�ons.by.av�ators.was.not.determ�ned.by.the.ntsB.to.be.the.cause.or.a.factor ..two.acc�dents.were.not.�nvest�gated.by.the.ntsB .
dIsCussION
Postmortem.v�treous.flu�d.and.ur�ne.can.be.used.for.glucose.analys�s.to.establ�sh.d�abetes.(2,8) ..concentra-t�ons. of. glucose. >. 125. mg/dl. �n. v�treous. flu�d. and..>.100.mg/dl.�n.ur�ne.are.cons�dered.as.elevated.glucose.levels. (2,4).and.are.thus. �nd�cat�ve.of.hyperglycem�a ..s�nce.�n�t�al.rap�d.decrease.�n.v�treous.humor.glucose.levels.has.been.reported.after.death.(8–11),.a.v�treous.glucose.concentrat�on.of.<.125.mg/dl.would.not.neces-sar�ly.suggest.a.normal.glucose.level.at.the.t�me.of.death ..however,.glucose.values.>.125.mg/dl.�n.v�treous.flu�d.and/or.>.100.mg/dl.�n.ur�ne.would.certa�nly.be.�nd�ca-t�ve.of.hyperglycem�a ..In.add�t�on.to.renal.glycosur�a.and.d�abetes,.elevat�on.of.glucose.could.be.related.to.trans�t.hyperglycem�a. assoc�ated. w�th. trauma,. stress,. and/or.med�cal.�ntervent�on ..For.d�abet�cs,.the.elevated.glucose.does.not.prov�de.�nformat�on.on.how.well.the.d�sease.had.been.controlled,.but.long-term.d�abet�c.controls.can.eas�ly.be.establ�shed.by.measur�ng.hba
1c.�n.postmortem.
blood.samples.(4) ..hba1c
.values.>.6 .0%.correlated.well.w�th.a.known.h�story.of.d�abetes.and.w�th.the.elevated.v�treous.flu�d.and/or.ur�ne.levels.�n.p�lots.(4) ..therefore,.such.elevated.hba
1c.values.would.suggest.that.d�abetes.
was.not.properly.controlled.by.the.pat�ents ..only.3 .2%.of.the.1,335.p�lots.found.to.be.hyperglyce-
m�c.suggested.a.very.small.number.of.assoc�ated.av�at�on.acc�dents ..the.ur�nary.glucose.find�ngs.�n.13.(30%).of.the.43.p�lots.were.cons�stent.w�th.the�r.aeromed�cal.h�s-tory.of.d�abetes—th�s.number.d�d.not.�nclude.the.p�lot.who.had.renal.glycosur�a.(low.renal.threshold) ..Blood.hba
1c. analyses.of.4.of. the.13.known.d�abet�c.p�lots.
revealed.that.the�r.d�sease.was.not.well.controlled,.as.the�r.hba
1c.values.were.>.6 .0% ..Furthermore,.a.cons�d-
erable.number.of.p�lots.(30.of.43).had.elevated.v�treous.flu�d.and/or.ur�ne.glucose.concentrat�ons.and.were.not.known.to.be.hyperglycem�c.(or.d�abet�c) ..Blood.hba
1c.
analys�s.of.15.of.the.30.non-d�abet�c.p�lots.�nd�cated.that.d�abetes.�n.5.av�ators.was.not.�n.control,.as.the.hba
1c.
levels.were.>.6 .0% ..the.h�ghest.number.of.p�lots.w�th.elevated.glucose.
held.second-class.med�cal.cert�ficates,.followed.by.p�lots.w�th.th�rd-class.med�cal.cert�ficates ..these.2.groups.of.p�lots.were.correspond�ngly.rated.as.commerc�al.and.pr�vate.p�lots ..the.observat�on.of.the.major�ty.(86%).of.the.43.glucose-assoc�ated.acc�dents.found.to.be.of.the.general.av�at�on.category.was.cons�stent.w�th.the.observat�ons.reported.�n.prev�ous.stud�es.(5,.12–15) ..
of.the.2.p�lots.w�th.known.d�abet�c.cond�t�ons,.the.p�lot’s.elevated.glucose.was.a.factor.�n.1.acc�dent ..the.�n-capac�tat�on.of.the.p�lot.as.the.cause.of.the.second.acc�dent.may.not.necessar�ly.be.attr�buted.to.only.hyperglycem�a ..
8
the.�ncapac�tat�on.m�ght.have.been.the.resultant.of.the.med�cal. cond�t�ons,.hyperglycem�a,.hypertens�on,. and.ulcer,.as.postmortem.tox�cology.also.d�sclosed.the.pres-ence.of.metoprolol.and.ran�t�d�ne.�n.the.p�lot ..
overall,.the.find�ngs.from.th�s.study.revealed.that.the.d�sease.of.the.d�abet�c.p�lots.was.not.�n.control.at.the.t�me.of.acc�dents ..add�t�onally,.there.were.a.cons�der-able.number.of.p�lots.w�th.elevated.glucose.and.hba
1c.
concentrat�ons,.suggest�ng.und�agnosed.and.unreported.d�abet�c.cond�t�ons ..therefore,.greater.attent�on.�s.neces-sary.�n.controll�ng.d�abetes.by.av�ators.�n.coord�nat�on.w�th.av�at�on.Med�cal.exam�ners .
rEFErENCEs
1 .. av�at�on.safety.research.act.of.1988,.Publ�c.law.100–591. [h .r .. 4686] .. 100th. u .s .. cong .,. 2nd.sess ..102.stat ..3011.(nov.3,.1988) ..
2 .. canf�eld. dV,. chaturved�. aK,. Boren. hK,.Veronneau. sJh,. Wh�te. Vl .. abnormal. glucose.levels.found.�n.transportat�on.acc�dents . Aviat Space Environ Med.2001;.72:813–5 .
3 .. chaturved�.aK,.sm�th.dr,.soper. JW,.canf�eld.dV,.Wh�nnery.Je ..character�st�cs.and.tox�colog�-cal.process�ng.of.postmortem.p�lot.spec�mens.from.fatal.c�v�l.av�at�on.acc�dents ..Aviat Space Environ Med.2003;.74:252–9 .
4 .. Wh�te.Vl,.chaturved�.aK,.canf�eld.dV,.Garber.M ..assoc�at�on.of.postmortem.blood.hemoglob�n.a
1c.
levels.w�th.d�abet�c.cond�t�ons.�n.av�at�on.acc�dents.p�lot.fatal�t�es ..Wash�ngton.(dc):.Federal.av�at�on.adm�n�strat�on,. off�ce. of. aerospace. Med�c�ne;.2001.Jul ..report.no ..dot/Faa/aM-01/12 .
5 .. chaturved�.aK,.craft.KJ,.canf�eld.dV,.Wh�nnery.Je ..tox�colog�cal.f�nd�ngs.from.1587.c�v�l.av�at�on.acc�dent. p�lot. fatal�t�es,. 1999–2003 ..Aviat Space Environ Med.2005;.76:1145–50 .
6 .. code.of.Federal.regulat�ons ..t�tle.14—aeronaut�cs.and. space,. chapter. I. (1-1-06. ed�t�on)—Federal.av�at�on. adm�n�strat�on,. department. of. trans-portat�on,.subchapter.F—a�r.traff�c.and.general.operat�ng.rules.and.subchapter.G—a�r.carr�ers.and.operators. for. compensat�on.or.h�re:. cert�f�cat�on.and.operat�ons,.Parts.91–139 ..Wash�ngton,.dc:.u .s ..Government.Pr�nt�ng.off�ce,.2006 .
7 .. code.of.Federal.regulat�ons ..t�tle.14—aeronaut�cs.and. space,. chapter. I. (1-1-06. ed�t�on)—Federal.av�at�on. adm�n�strat�on,. department. of. trans-portat�on,.subchapter.d—a�rmen,.Parts.60–67 ..Wash�ngton,.dc:.u .s ..Government.Pr�nt�ng.of-f�ce,.2006 .
8 .. coe.Je ..Postmortem.chem�str�es.on.human.v�treous.humor ..Am J Clin Path 1969;.51:741–50 .
9 .. Bray.M,.luke.Jl,.Blackbourne.Bd ..V�treous.humor.chem�stry.�n.deaths.assoc�ated.w�th.rap�d.ch�ll�ng.and.prolonged.freshwater.�mmers�on ..J Forensic Sci.1983;.28:588–93 .
10 .. Pex. Jo,. Meneely. Kd,. andrews. Fc .. t�me. of.death.est�mat�on.�n.blackta�l.deer.by.temperature.and.aqueous.humor.glucose ..J Forensic Sci.1983;.28:594–600 .
11 .. ham�lton-Paterson.Jl,.Johnson.eWM ..Postmor-tem.glycolys�s ..J Path Bact.1940;.50:473–82 .
12 .. ak�n.a,.chaturved�.aK ..select�ve.seroton�n.reup-take. �nh�b�tors. �n.p�lot. fatal�t�es.of. c�v�l. av�at�on.acc�dents,. 1990–2001 ..Aviat Space Environ Med.2003;.74:1169–76 .
13 .. soper.JW,.chaturved�.aK,.canf�eld.dV ..Prevalence.of.chlorphen�ram�ne.�n.av�at�on.acc�dent.p�lot.fatal�-t�es,.1991–1996 ..Aviat Space Environ Med.2000;.71:1206–9 .
14 .. sen.a,.ak�n.a,.craft.KJ,.canf�eld.dV,.chaturved�.aK ..F�rst-generat�on.h
1.ant�h�stam�nes.found.�n.p�-
lot.fatal�t�es.of.c�v�l.av�at�on.acc�dents,.1990–2005 ..Wash�ngton,.dc:.Federal.av�at�on.adm�n�strat�on,.off�ce.of.aerospace.Med�c�ne;.2007.May ..report.no ..dot/Faa/aM-07/12 .
15 .. sen.a,.ak�n.a,.craft.KJ,.canf�eld.dV,.chaturved�.aK ..F�rst-generat�on.h
1.ant�h�stam�nes.found.�n.p�-
lot.fatal�t�es.of.c�v�l.av�at�on.acc�dents,.1990–2005 ..Aviat Space Environ Med.2007;.78:514.–22 .