Eight years on from the Germanwings tragedy, the need for aviation mental health programs has taken on global importance. Robert Moorman examines the issue.

The subject of mental health among aviation employees may have finally taken center stage. The International Civil Aviation Organization (ICAO) has formed a Mental Health Working Group to set standards and practices for employee mental health programs at airlines worldwide.

“Our ultimate goal is to standardize mental health practices in aviation across ICAO member states,” said Dr. Johanna Jordaan, Chief of Aviation Medicine, ICAO. “It’s really a combination of who plays what role. We try to communicate that the mental health issue is not different from any other disease."

The group finalized the aviation mental health terminology and is reviewing the guidance material on mental health in the Manual of Civil Aviation Medicine, as well as the use of substances in the workplace. The group also completed a circular of peer support.

Meetings for the group, said Jordaan, have been accelerated with subject matter experts, including psychiatrists and psychologists.

The group will next submit the completed guidance material, for comments by other sections within ICAO, revise the documents and submit them for approval to the Director of the Air Navigation Bureau, Stephen P. Creamer. The material will then go to the Secretary General, Juan Carlos Salazar, for final approval before publication and submission to the member states.

If, however, there is a need for new Standards and Recommended Practices (SARPs), or amending an existing SARP, the item will be discussed by the Air Navigation Commission (ANC). Once accepted by the ANC, the material goes to the ICAO Council for approval.

Jordaan expects the guidance materials and recommended practices to be finished by June 2023. The group intends to publish best practices in mental health so member states and stakeholders can learn from each other. 

The national and regional regulatory authorities are aware of ICAO’s work in mental health. Plus, ICAO has obtained a lot of information from pilot and other employee groups.


The Tragedy at Prads-Haute-Bléone

The mental health issue was thrust into the limelight following the 24 March 2015 tragedy of Germanwings Flight 9525. The Airbus A320-211 was en route from Barcelona-El Pratt Airport to Dusseldorf when First Officer Andreas Lubitz, who had been treated for depression, locked out the Captain from the flight deck. Lubitz then flew the aircraft into a mountain purposely, killing 144 passengers and six crew members. 

Following the crash, the European Union Aviation Safety Agency (EASA) mandated that two authorized personnel be in the cockpit at all times.

In addition, the Pilot Fitness Aviation Rulemaking Committee, a joint industry and regulatory group, was tasked by the US FAA to assess methods for evaluating and monitoring pilot mental health and possible barriers to reporting concerns.

ICAO is not just considering mental health programs for pilots and flight attendants. Care programs for aircraft mechanics, air traffic controllers, engineers, managers and other air transport personnel are being considered.

Previously, ICAO, in collaboration with the International Air Transport Association (IATA) and the International Federation of Air Line Pilots’ Associations (IFALPA), published Fitness to Fly, which included material on mental health.

During the height of the Covid pandemic, ICAO published an electronic bulletin on mental health “outlining various roles and responsibilities of aviation stakeholders, which also could be applied to other mental health problems,” said Jordaan. “For all aviation employees, as a minimum, we need to focus on better awareness and training, and then tailor interventions for different categories of employees.”


Need for a Global Standard?

One challenge to creating a global standard for mental health programs for various air transport sectors is cultural, according to several experts queried by CAT. Some countries don’t recognize the need for these programs. Pilots and flight attendants, and other airline employees, also fear losing their jobs. Pilots also have the added worry of losing their medical certificate, which authorizes them to fly. Then, there is the stigma attached to mental health which, while fading, is still present. 

According to some reports, younger pilots are more willing to admit they need help, but that contention has been challenged. Nevertheless, attitudes toward mental health counseling are changing.

“From a global perspective, there is considerable drum-beating to finally deal with this issue,” said Heather Healy, Director of Employee Assistance Program (EAP), Association of Flight Attendants (AFA). Healy, who has been involved in the EAP field since 1984, also serves as Program Manager for the Flight Attendant Drug and Alcohol Program (FADAP).

Also noteworthy: ”There is specific regulatory language directing European airlines to get a handle on this issue,” said Healy.

AFA, which represents 50,000 flight attendants at 19 airlines, offers one of the larger peer programs in the aviation industry, with 66 locations and numerous trained peers around the system.

AFA’s constitution and bylaws state that the union must offer support services for the mental health and well being of its members through its EAP program. Flight attendants in distress undergo an initial evaluation by a peer, who conducts the assessment. Nothing is off the table. Everything from financial and relationship problems to cocaine and alcohol addiction could be discussed. From the initial evaluation, an action to plan is developed to address the issue. 

Most times, the stressor is the working environment. Said Healy: “For a program to be effective, we believe that it should be thorough, well rounded and multi-layered. We require every flight attendant who receives substance abuse counseling to also be evaluated for mental health disorders. We cannot get access to treatment without getting the full complement of treatment they need for all presenting issues.”

Healy said she is providing training for Allegiant and Omni Air managers on how to recognize a flight attendant in distress and support them. Not long after our interview, Healy completed a full-day training for inflight supervisors and managers of those carriers, who are in a position to identify and refer flight attendants for help. 

As for instruction, AFA provides comprehensive, multi-stage training for peers, from basic to advanced in-person training. Continuing education is both in-person and virtual.

Training topics include: 

  • the value of peer support, 
  • best peer practices, 
  • stages of the peer help process, 
  • assessing and responding to threats of harm/suicide, 
  • understanding substance use and mental health disorders, 
  • conflict resolution interventions, 
  • case management requirements, 
  • responding to an aircraft incident/accident, 
  • and other subjects.


Airline Support Programs

The Air Line Pilots Association (ALPA), which represents 66,000 pilots at 40 US and Canadian airlines, has mental health-related programs worth noting. The association is long known for its structured HIMS (Human Intervention Motivation Study) program, which addresses alcohol and substance abuse in a frank and fair manner. 

In the 1970s, pilots diagnosed with alcohol dependence were often fired. But, thanks to the work of Dr. Richard L. Masters, an Aeromedical Advisor to ALPA’s governing bodies, and ALPA pilot volunteers, pilots got help and most returned to the cockpit. 

By 1984, HIMS programs had been established at most US  airlines. Since then, ALPA expanded its mental health-related efforts. The association developed several programs, including the Critical Incident Response Program (CIRP), Canadian Pilot Assistance, and the Pilot Peer Support Program (PPS). All are designed to help pilots in crisis.

ALPA’s PPS group and international groups help pilots in crisis. PPS provides a network of pilot volunteers, who are available to listen and advise a pilot in crisis. PPS is part of ALPA’s Air Safety Organization Pilot Assistance Group.

“Removing barriers that could prevent or discourage airline pilots from seeking help when they need it is an essential step in making in making Pilot Peer Support work,” said First Officer Travis Ludwig, ALPA Pilot Assistance Vice-Chair.

All ALPA peer support volunteers go through extensive initial training and recurrent training, said Ludwig. ALPA instructors, who have been certified by the International Critical Incident Stress Foundation (ICISF), teach the Critical Incident Response Program (CIRP). ALPA’s PPS program was developed in-house and certified by mental health experts and a former federal air surgeon.

The Southwest Airlines Pilots Association (SWAPA), which represents nearly 10,000 pilots, has an extensive pilot support program. Capt Chess Fulton is Chairman of the peer-run Project LIFT and Pilot Services. Project LIFT is separate, yet co-funded by Southwest and SWAPA.

SWAPA has a hotline by which a pilot can have a confidential conversation about a problem. The conversation and follow-up care ranges from depression, anxiety, substance abuse, relationship and financial issues. The team member is taught how to pick up on cues about a pilot’s current problem and stress levels. All Project LIFT team members are trained and hold a certificate on initially dealing with a pilot in distress. Recurrent training is encouraged. 

“We are not counselors or therapists, but have extensive training on mental health issues and FAA procedures regarding them,” said Fulton. “We can make referrals to mental health professionals that are pilot savvy.”

The flight operations department makes the final determination on whether the pilot is a threat to themselves and/or the flying public, said Fulton.

One major hurdle to these programs is for the pilot/aviation professional to admit that they need help. “I wouldn’t say it is a must, but you’re on the right track,” said Fulton. “You have to have a desire to get better.”

One outside expert is Denver-based LiftAffect, which provides mental health services for professional pilots. Training solutions provider CAE selected LiftAffect to provide mental health services for its pilots at CAE Phoenix Flight Academy as part of a pilot project. (See sidebar URL)

LiftAffect “fully understands the importance of treating mental health while also navigating the FAA reporting requirements,” said Richard Morris, Director of Global Safety, Quality Assurance and Compliance. CAE’s goal is to “provide its pilots with the tools to manage stress and anxiety and improve their overall performance to minimize the risk of more severe mental health issues and reduce the overall levels of risk to our organization and the flying public.”

More Than a Training Issue

CAT reached out to numerous major airlines for comment on their respective employee mental health programs. A few responded. 

United Airlines Flight Training Center in Denver, Colorado provides guidance and help for pilots in crisis that will not be fixed by additional training. “We have the ability to refer pilots initially through ALPA’s Soar program,” said Rob Strickland, Senior Manager of Human Factors and Pilot Development. The center also has access to various mental health specialists and doctors. “We can refer pilots to our corporate medical department, which has a variety of in-house and external resources available to pilots. Pilots can be referred to the EAP while in training or be referred by the Chief Pilot’s office,” said Strickland. 

The center’s resilience training program focuses primarily on the pilot’s ability to perform under pressure. It also allows the trainer to identify that the pilot has challenges unrelated to his/her piloting skills. 

Pilots might become more vulnerable during this phase of pilot training. “The resilience training allows the pilot’s guard to drop a bit and could reveal that the pilot needs deeper support,” said Strickland. “This is no longer a training issue. It could be related to depression or a cognitive issue. And that is not our area of expertise.”  

If counseling or other help is deemed necessary, mental health experts handle pilots’ exit training temporarily and the issue. “We wait for the medical professionals to say that the pilot is ready to resume training,” added Strickland. 

Southwest Airlines declined to be interviewed, but offered this statement regarding its Clear Skies Employee Assistance Program: “The EAP benefit begins on day one of employment and offers several options (regardless of the type of insurance and even if an employee declines coverage) and provides employees and their dependents eight EAP sessions per person, per issue, per calendar year at no cost.”

Business aviation similarly recognizes the need for mental health programs for pilots. During a September 2022 mental wellness panel, moderator and NBAA Director of Safety and Flight Operations, Mark Larsen, observed: “Many individuals in our industry are affected by underlying mental health issues, including struggles with depression, anxiety, adjustment disorders, performance challenges, substance dependence and others.”

NBAA works with other organizations and the FAA to better address mental health in aviation, he added.

Will ICAO’s involvement demonstrate the importance of mental health programs globally? 

Said AFA’s Healy: “ICAO’s involvement will help to ensure that the design of mental health services considers the industrial and also the cultural context in which services are delivered.”

The need for the mental health programs for airlines and other transport-related staff remains a top priority.

Concluded ICAO’s Jordaan: “The current global environment adds to mental stress at various levels of life, which means all of us need to do our share in trying to understand the underlying mechanisms and providing the necessary support to maintain aviation safety.”


System-Wide Peer Support

ALPA’s Pilot Peer Support (PPS) groups provides a network of pilot volunteers, who are available 24 hours a day, seven days a week to speak with pilots over the telephone about various issues affecting the pilot’s life. PPS pilot volunteers at various airlines listen and offer confidential, nonjudgmental support. 

For information or peer support contact:

  • ALPA National PPS: 309-PPS-ALPA (309-777-2572).
  • Canadian Pilot Assistance: 309-PPS-ALPA (309-777-2572).
  • Delta PAN: 800-673-7150.
  • FedEx Express PATH: 866-FDX-ALPA.
  • JetBlue PAN/PPS: 309-PPS-ALPA.
  • United SOAR: 866-653-SOAR.


Cohesive Coalition

The International Pilot Peer Assist Coalition (IPPAC) is comprised of representatives from various pilot support groups. The goal is to promote and facilitate psychological wellbeing throughout the US and international aviation sectors. 

The IPPAC is comprised of representatives from: 

  • Project Lift – Southwest Airlines and Southwest Airlines Pilot Association (SWAPA)
  • SOAR PSP – United Airlines and the Air Line Pilots Association (ALPA)
  • Project Wingman – American Airlines and the Allied Pilots Association (APA)
  • Pilot Assistance Network - British Airways and the British Air Line Pilots Association (BALPA)
  • New Zealand Airlines and the New Zealand Air Line Pilots Association (NZALPA)
  • Center for Aviation Mental Health (C4AMH)
  • Japan Airlines and the Air Line Pilots Association of Japan (ALPA-Japan)
  • Odilia Clark-Impairment Risk Management
  • Center for Aviation Psychology (CAP)