MONTORING
Monitoring is an essential element of the HIMS Program.
Monitoring is an essential element of the HIMS program that not only routinely assesses the quality of a pilot’s recovery but also is critical to assure the safety of the National Air Space and the validity of a pilot’s medical certification. Although there is much subjectivity in the monitoring of pilots in recovery, unannounced abstinence testing provides a critical objective component.
As noted in the Continuing Care section, the disease of chemical dependency is primary, chronic and progressive. It is prone to relapse, similar to other diseases such as cancer, diabetes and heart disease. Just as with these diseases, careful monitoring and periodic testing allows for the reassurance that current treatment is effective in negating the potential consequences of disease progression.
The quality of the monitoring program depends on active, open and frequent communications between all persons involved in the monitoring process. A team approach is essential The HIMS AME/Independent Medical Sponsor (former AME with current HIMS training who no longer performs FAA medical examinations, but works in conjunction with another AME) is the “quarterback” of the HIMS Monitoring Team and receives the inputs from all other participants as well as the pilot. Sharing observations and concerns among all involved in the pilot’s monitoring rather than having information in individual silos greatly enhances the monitoring. Each member has a different perspective regarding the pilot’s actions and words reflecting on recovery. Concerns can be shared and a consensus developed among the monitoring group. Ultimately, the HIMS AME / IMS is the FAA’s “eyes on the target” and determines the recommendations for initial and ongoing medical certification.
In some airline HIMS programs, the monitoring team is active as the pilot exits treatment and well before the intial special issuance medical certificate. This establishes a familiarity with the pilot’s recovery efforts. It also helps the pilot become familiar with the process expected to hold a medical certificate. A few airlines have members of the HIMS Team, usually the peer pilot, meet with the pilot prior to and during the intial treatment phase.
History
Since the inception of the HIMS program, the components and duration of monitoring of pilots in recovery who have regained their medical certification have evolved. This is due to several factors and has resulted in the highest long-term abstinence rates in addiction treatment. The rates of long-term abstinence are similar to those of Physician Health Programs (PHP), exceeding 80% abstinence over the duration of medical certification. PHP’s grew out of the HIMS programs and both look to the other to adopt better strategies for maintaining long-term sobriety.
Factors that influence monitoring include the gathering of data regarding the history of pilots who have relapsed and those who have not, the evolution of new chemicals of abuse and tests to detect them, philosophical changes and feedback within the HIMS community (FAA, pilot unions and airlines) and safety recommendations from the National Transportation Safety Board (NTSB).
Monitoring Duration
Monitoring periods, as required by the FAA, have been extended over time. From the early days of the HIMS program which featured very limited or short monitoring periods, monitoring in some cases today extends to the pilot’s retirement age.
For the first three decades of the HIMS program, monitoring periods under the requirements of a Special Issuance generally stopped after two years. Some pilots with a history of drug use, as opposed to alcohol or those with a history of relapse, may have extended monitoring periods of 3 – 5 years. For pilots with multiple relapses, the FAA required monitoring with the standard Special Issuance requirements for the duration of their career.
Shortly after 2000, the standard monitoring periods increased in duration with three years being the minimum for alcohol dependence and five years for drug dependence. After another decade, the FAA’s monitoring periods lengthened to five years for nearly all professional pilots and all substances.
In 2007, the NTSB made 2 safety recommendations to the FAA A-07-42 and A-07-43 related to alcohol. The first one led the FAA to require reports of any drug or alcohol-related arrests, convictions or administrative actions be reported on the FAA medical application. This resulted in a large increase in the number of requests for substance use disorders by the FAA and identification of pilots required to enter the HIMS program to regain medical certification. The recommendation was “Closed – Acceptable” by the NTSB in 2012.
The second recommendation, A-07-043, required monitoring “all airmen clinically diagnosed with substance dependence (including dependence on alcohol),” who hold a Special issuance for this diagnosis for the duration they hold a medical certificate. This recommendation was considered “Open – Unacceptable Response” by the NTSB until March 2020 when the FAA indicated they would comply with this safety recommendation. Many pilots involved in the HIMS program felt that the requirement to maintain all monitoring requirements including continuing care and abstinence testing would discourage pilots from entering the HIMS program and reduce participation to only those that were identified through positive DOT tests or the alcohol / drug evaluations triggered by the reporting requirements generated by A-07-42. This also coincided with the COVID-19 pandemic when travel, face to face monitoring meetings and testing were severely restricted due to public health orders and pilot furloughs.
In response, the FAA held a summit for the Chairs of each airline’s HIMS program in July 2020 for feedback on effective components of monitoring, those that inhibited encouragement to enter HIMS and duration of monitoring components. The following month, the FAA announced a “HIMS Step Down Plan” that was finalized on September 8, 2020. It outlined a progressive reduction in monitoring requirements over a minimum of seven years after initial certification. For pilots whose recovery was not as strong as desired, monitoring requirements would be extended. The final phase of monitoring, for the duration a pilot holds a medical certificate, requires that eh pilot take each medical exam with a HIMS AME trained by the FAA in addiction issues in aviation. The plan was widely supported by HIMS Chairs and medical professionals as a sound way to recognize the progression of most recoveries with the need to assure aviation safety.
Monitoring Components
HIMS AME/IMS
The HIMS AME/IMS leads the monitoring process and receives inputs and reports from each member. The AME/IMS also meets with the pilot, reviews medical records, FAA medical files and any court or legal documents related to the pilot’s substance use. The initial submission to the FAA petitioning for a Special Issuance medical certificate comes from the HIIMS AME/IMS. See FAA Certification.
Because of the AME/IMS’ unique position as manager of all the reports, the IMS may be aware of disparate pieces of information that indicate potential problems with a pilot’s recovery. However, the AME/IMS will also probably have the least personal contact with the pilot of all the caregivers and monitors. So, the IMS may be both more, and less likely to become aware of problem behavior depending on the source of the information. In general, it is very important to provide comprehensive and accurate information to the AME/IMS, and equally important that the AME/IMS’ experience confirm the information that is reported.
Many IMS’ choose to meet with the pilot frequently early in recovery. These frequent meetings, often monthly, help establish familiarity with the pilot, provide a “base line” to evaluate future behavior and extend support to the pilot while they are early in sobriety. Six months after treatment discharge, the meeting frequency is usually reduced to quarterly until the pilot completes a year of sobriety. Of course, this reduction in frequency is dependent on the quality and stability of the pilot’s recovery program and can be influenced by input from other members of the HIMS Team.
The FAA requires reports and affidavits from the HIMS AME/IMS every six months if the pilot is doing well. If there are concerns about the pilot’s abstinence from substances or compliance with the requirements of the Special issuance, the HIMS AME/IMS must notify the FAA immediately. This may result in a withdrawal of the pilot’s Special issuance medical certificate.
The pilot must stay with the same AME/IMS for at least the first seven years after initial certification with rare exceptions. This provides continuity and familiarity with the individual situation and prevents the pilot from “doctor shopping” for an AME/IMS that may have less rigorous monitoring requirements. In some cases, with the concurrence of the pilot, the losing AME/IMS and the gaining AME/IMS, the FAA may allow a transfer of the assigned AME/IMS. Examples include an AME stopping practice, a pilot being assigned to a new base or employed with a new airline or the airline HIMS team requiring monitoring by a particular AME/IMS for their program.
As a condition of the HIMS Step Down Plan, the HIMS AME/IMS must meet with the pilot every three months for the first five years after certification. Virtual video visits are permitted on alternating meetings with in-person visits to assess the pilot’s recovery. After five years, the AME/IMS must meet with the pilot in person every six months although the more frequent visits may be extended at the AME’s recommendation. After a minimum of seven years, the pilot is not required to meet with the HIMS AME/IMS.
Peer Pilot
Peer pilots are frequently the most critical component of the subjective monitoring process. They are required to submit reports on their assessment of the pilot’s recovery on a monthly basis to the HIMS AME/IMS. In most situations, peer pilots are fellow pilots who are in recovery themselves and are familiar with the HIMS program as participants. They know recovery and they best at seeing through flaws in a pilot’s recovery activities. Meetings are usually face-to-face basis on a monthly basis, although many peer pilots speak with those they are monitoring weekly or more frequently.
When conducting a meeting, the peer pilot should remember they are not acting as the HIMS pilot’s union representative, company supervisor, or AA sponsor. The peer pilot’s role is to evaluate the quality of a pilot’s recovery and thereby contribute information to help determine the pilot’s likelihood of maintaining his/her sobriety. The peer pilot has a responsibility to communicate with other people involved in the pilot’s recovery including the pilot’s supervisor and the HIMS AME/IMS. The peer’s report is not expected to meet clinical standards, but rather it is a layman’s report on the behavior of the HIMS pilot.
Due to this responsibility, the peer pilot cannot provide privacy, privilege, or anonymity to the HIMS pilot. However, the peer pilot is expected to act with the upmost discretion and not talk about the pilot with those who do not have a “need to know.” The peer pilot is also not in the position to “punish” the pilot or enforce any sanction in the event of undesired behavior. The peer pilot is limited to communicating their observations to the HIMS AME/IMS and company supervisor. The peer pilot is also not responsible for the HIMS pilot’s recovery. If the peer pilot cares more about the pilot’s recovery than the pilot, then there is a problem.
Peer pilots are specifically not the pilot’s 12 Step sponsor as they are completely different roles. The AA sponsor is privy to all information and holds it in confidence whereas the peer pilot has a primary responsibility of monitoring the quality of the pilot’s recovery and reporting any concerns to the HIMS AME/IMS. This is not to say the peer pilot can be an additional resource of help to the monitored pilot, particularly when aviation specific issues arise.
Reports from peer pilots to the HIMS AME/IMS take many forms. At least one written report is required monthly. Usually, an email is sent. Some HIMS AME/IMS’s have template forms to use to insure a broad range of specific items are addressed as well as subjective overall impressions.
A peer who has concerns may relay those to the HIMS AME/IMS’ verbally prior to a written report. This may prompt a closer evaluation of the pilot, additional abstinence compliance testing or contact with the HIMS Team. The peer’s input is most valuable in early detection of potential relapse behavior.
Some airlines require that a pilot be released from the Initial, Early and Advanced stages of monitoring before serving as a peer monitor, while others do not have any restrictions. This is particularly true when the need for a trained, experienced monitor is urgent. Although a sustained recovery is ideal to serve as a peer, this is not an FAA requirement. In some cases, airlines have pilots who are not in recovery themselves but have been trained in the HIMS program to serve as peer monitors.
As certification for chemical dependency in the general aviation community has become more common, many GA pilots may not have a peer sponsor. The HIMS AME/IMS and the FAA will make alternate accommodations for oversight.
Company Supervisor
Similar to the peer monitor, the company supervisor monitor meets with the pilot face to face at least monthly and provides a written report to the HIMs AME/IMS. The company supervisor, usually a Chief Pilot, is familiar with the pilot’s on-duty performance and layover behavior. The Chief Pilot would have information on training performance, interactions with fellow crew members and personnel.
Although pilots with substance dependence usually manifest any weaknesses in their recovery in non-work situations, concerns arising from this area to be taken very seriously. Ideally, company supervisors monitoring pilots will have completed HIMS training, although most are not in recovery and may not recognize pre-relapse behavior as early as a peer, all know the typical and atypical actions of their pilots. If no feedback is coming from the field and the pilot is otherwise “invisible” to the supervisor other than at meetings, this is usually a good situation. Those pilots that highlight themselves to management may have weaknesses or failure in their recovery program.
For those monitors not in recovery, both management and peer pilots, the monthly interview with the recovering pilot can be difficult. Being direct and inquiring about problems can be most helpful and discussed in the Relapse section of this site. The Resources section has a Monitor’s Guide to the Recovery Interview for assistance.
Aftercare Counselor
The aftercare counselor is the one addiction professional who sees the pilot in a group setting. Although the group is generally very diverse, some counselors focus on professionals’ continuing care programs and very few have exclusively pilot aftercare groups. The counselor will assess the pilot’s recovery by evaluating positive behaviors and reporting on challenges the pilot is facing.
A written report by the aftercare counselor to the HIMS AME /IMS is required every three months. The challenge faced by many HIMS AME’s / IMS’s is that aftercare counselors are not accustomed to writing reports on individual attendees and are trained to protect the confidentiality of the pilot’s information. This frequently results in a very generic, brief report of little value. Direct discussions with the aftercare counselor about the goals of the reports and the FAA requirements are helpful in improving the quality and timeliness of the reports. This area is consistently the most consistently the biggest challenge in following the special issuance requirements.
When pilots are required to be in aftercare for extended periods of time, the quality usually deteriorates. Most aftercare programs are limited to 3-6 months prior to discharge. Pilots staying longer are frequently looked at as “junior counselors” because of their profession, the duration of their sobriety and the quality of their recovery. Frequently, they have been in the group longer than the counselor. This reduces the accountability gained from a professionally supervised recovery group. Fortunately, the HIMS Step Down Plan addressed this area very effectively in allowing aftercare to be discontinued after a minimum of one year after initial certification so that the pilot frequently has nearly two years of aftercare group meetings following discharge from treatment.
Abstinence Testing
Abstinence testing is the only objective piece of information required in the HIMS monitoring process. It is not an indication of the quality of recovery. Rather it is only a report of the presence or absence in the pilot’s specimen / matrix (urine, breath, blood, hair, nails, saliva) of the chemical tested for at the testing threshold selected during the pharmacokinetic window of detection.
Depending on the type of testing matrix used, the substance tested for the frequency of testing and the limits of detection used, abstinence testing can fail to detect a pilot that is using a prohibited substance. Similarly, a positive test may be a result of cross reactivity with a similar chemical, skin absorption rather than ingestions or laboratory / administrative errors in a pilot that remains abstinent from all prohibited substances.
Because of biochemical and structural function in the brain of a person with chemical dependency, triggers for relapse can be provoked by other substances that are not the pilot’s chemical of choice. Therefore abstinence testing should include not only the pilot’s primary drug(s) of choice but other psychoactive substances on a periodic basis. For example, a pilot with alcohol dependence may remain abstinent from alcohol, but be using sedative hypnotics such as benzodiazepines so feel a similar effect.
Because persons who have relapsed who are trying to avoid detection use substances that may not be commonly tested for, abstinence testing should periodically incorporate chemicals not included in standard drug panels. Examples include testing for synthetic cannabinoids in marijuana users, synthetic opiates such as fentanyl in opioid users and “Z drugs” in benzodiazepine users. A HIMS AME / IMS must be familiar with the various testing panels and windows of detections.
Abstinence testing is not random, but it is unannounced. The pilot is specifically targeted for testing and usually the testing is done in an off-duty status. Pilots are subject to random DOT testing when one duty just as all safety sensitive aviation employees are. However, the abstinence testing mandated by the FAA is NOT DOT testing and does not count toward the employer’s random testing program requirements. It is very important for the testing facility to understand that abstinence testing for the HIMS program is NOT DO testing as is reported to the HIMS AME / IMS rather than the company’s Designated Employer Representative. For more information see the DOT Office of Drug and Alcohol Testing Policy and 49 CFR Part 40.
The minimum frequency of testing and type of testing is specified in the pilot’s Special issuance by the FAA. For the first four years after medical certification, the minimum frequency is usually 14 urine ethyl glucuronide (EtG) tests annually or periodic breath testing for those who are dependent on alcohol. Breath testing is usually done several times a day on a daily basis. After at least four years of medical certification, testing frequency can be reduced to four times annually using blood phosphatidyl ethanol (PEth). Alter at least seven years of monitoring, abstinence testing may be discontinued. For pilots with other chemical as their drug of choice, testing for those substances is required and should include related substances at similar minimum frequencies.
Some testing may be done by MAE with contracts with testing laboratories and facilities in their offices. However most testing is contracted to a Third Party Administrator (TPA) who is familiar with the HIMS program and pilots’ travel requirements so that a worldwide network of collection sites are available. The TPA wills end reports directly to the AME / IMS and frequently will give feedback if the pilot’s behavior during testing or testing availability is unusual.
HIMS AME’s / IMS’s who are experienced in testing frequently test more than the FAA prescribed minimum and use broader testing strategies. For example, in addition to urine testing for EtG, the request may also include a broad panel of substances. Following surgery with narcotics prescribed, the testing may include the prescribed narcotic (expected positive) and other narcotics (should be negative). After a significant celebratory event such as a wedding, college reunion, holiday weekend or out of country vacation, testing immediately upon return is frequently scheduled in addition to the routine testing.
Although the primary purpose of testing is to detect prohibited use of a substance, many pilots also view testing as a documentation of their sobriety, Should there be any reports of suspicious activity, a recent test result may address some concerns and tests with a long detection window may provide additional information for consideration. False positives a laboratory using GC-MS and similar technologies are extremely rare, but not impossible. If testing is done at an aftercare facility, it is usually done by ELISA testing without and confirmatory testing. ELISA testing leads to a number of false positives due to cross reactivity. Additional testing using laboratories may refute an initial non-negative suspicious ELISA test.
Increasing the frequency of testing is one of two methods of reducing the possibility of an undetected relapse. Because the windows of detection vary for different tests and substances, it is possible to fail to detect a physical relapse. Using tests with longer detection windows also mitigates this possibility.
A key to remember is the relapse happens in the mind before the drink or drug enters the body. That is why the comprehensive spectrum of monitoring by various individuals is so important with abstinence testing used as a backup, but objective, piece of information to assess a pilot’s recovery.
Psychiatrist
A HIMS trained psychiatrist, often with a specialty in addiction medicine evaluates a pilot prior the intial certification and submits a forensic type report to the HIMS AME/IMS that ultimately is sent to the FAA. The psychiatrist reviews all treatment records, aftercare reports, the FAA medical file and test results in forming an opinion. There is no therapeutic relationship with the pilot, but rather, the psychiatrist has a relationship with the HIMS AME/IMS assessing the pilot’s recovery and risk of relapse which is submitted in a report.
After one year following certification, the HIMS psychiatrist evaluates the pilot again. Prior to the Step Down plan, this was an annual requirement for the duration of the Special Issuance. Currently, if the psychiatrist and the AME/IMS conclude the pilot has a good recovery after one year following intial certification, future psychiatric evaluations may not be required unless the pilot has a dual diagnosis and is taking antidepressant medications.
Individual Counselor
Individual counseling is generally not a requirement of a special Issuance for chemical dependence. However, because of collateral issues resulting from substance use or pre-existing mental health conditions, a pilot may be involved in individual, marital or family counseling. This counseling is encouraged if potentially beneficial. The HIMS AME/IMS will review a summary report from the therapist prior to each submission to the FAA
12 Step Sponsor
A recovering pilot’s most important relationship in recovery is with his/her AA (12 Step) sponsor. This relationship is sacred and confidentiality is the keystone. Therefore, reports to the HIMS AME/IMS or to the FAA are NOT requested or required. Persons in recovery should feel completely comfortable in discussing any subject with their sponsors without concern that that information will be revealed elsewhere. Similar to a doctor-patient or attorney- client relationship, the AA sponsor must never feel pressured to release any information to any person, organization or authority. Occasionally, a pilot in monitoring will request a brief statement from the sponsor be provided to the HIMS AME / IMS, but this is only at the initiation of the pilot and with the agreement of the sponsor. NO ONE in the HIMS process should ever require a statement from a pilot’s 12 Step Sponsor.
Monitoring Meetings
As noted above, the FAA requires monthly meetings with the peer pilot monitor and company supervisor meeting with reports generated for the HIMS AME/IMS. Often, the airline HIMS union Chairman will also meet with the pilot. There are two basic strategies for accomplishing these meetings.
HIMS Team Group Meeting
In this strategy, the pilot meets on a monthly basis in person with the peer monitor and company supervisor. Frequently, these are larger meetings including all pilots at that base or airline in monitoring, all of the peer pilots and all of the company supervisors. The meeting usually starts with just the peers and supervisors discussing each pilot’s monthly progress prior to the pilots entering the room. This meeting is approximately 30-60 minutes depending on the number of pilots being monitored and the developments over the last month including new entrants to the program and concerns about particular pilots.
The second part of the meeting brings in all pilots in monitoring with each one giving a monthly update. Then the pilot gets feedback from peer, supervisors and other pilots in monitoring. This portion is similar to an AA meeting with cross talk. It can be very helpful in helping pilots improve their recovery and addressing upcoming challenges such as a pending divorce hearing, a child’s wedding, surgery or other possible challenges t sobriety.
The final part of the meeting, if done, will excuse the pilots in monitoring and conclude with a brief summarization of each pilot’s status with reports being generated. A particularly effective addition is the attendance of these monthly meetings by the HIMS AME/IMS assigned to each pilot and /or company EAP personnel involved in the HIMS program to add their observations and receive inputs form as well as observing the pilots in person. Often, sidebar conversations during breaks give much insight. The entire HIMS Team is involved in the evaluation of each pilot and can speak directly to each other at the time information is most fresh in everyone’s mine.
The advantages to this approach include being very time efficient for the chief pilots and the peer monitors who may be monitoring more than one pilot on a Special issuance. If an AME/IMS is monitoring multiple pilots in the airline, it is also very time efficient to see multiple pilots while observing each for an extended period of time and seeing interactions with other pilots during the cross talk portion.
Likewise, the airline union HIMS Chairs who are often the most experienced in recovery can participate. It is often very difficult for a pilot with a weak recovery to fool and entire room of people familiar with addiction and recovery, both first hand and with training and experience. For those airlines that bring pilots who are recently out of treatment and do not yet have a Special Issuance, participation in a group meeting leads to a sense of comfort that they are not alone in this process and that they have many resources to turn to for their questions and problems.
Disadvantages of these group settings are that they only provide one “snapshot” of the pilot. All the monitors see the pilot at the same time. Additionally, because a number of pilots must be addressed, each individual pilot is likely to receive less time and attention than they’d receive in an individual meeting. And, the “multi-eyeball” advantage may be lost if one or more of the monitors is prone to defer to another. For example, a supervisor or peer might defer to a healthcare professional whose view may or may not be more accurate than his/her own
These meetings can occur at airline hubs in the secure portion of the airport or may occur outside of the airport property to give the pilots more privacy than in the airport. Another advantage is the reports required for the AME/IMS are usually completed at the meeting and submitted on a timely basis.
Individual Meetings
Individual meeting strategies have the pilot meeting separately with the peer monitor, company supervisor and when required, the HIMS AME/IMS. The meeting usually occur on different days.
The advantages of this include more time for one on one discussion and the privacy that that affords. Coordination of schedules does not require multiple people, but rather two. These meetings tend to be more convenient for airlines with smaller numbers of people involved in the HIMS program, unusual schedules or multiple international flights.
An individual meeting with a HIMS pilot may overcome some of the disadvantages of a group setting, but individual meetings can have their own set of problems. While an individual meeting allows more time for an in-depth discussion, this is only true if adequate time is scheduled for the meeting. Meetings should generally be for 30 minutes to an hour, and additional time should be set aside for writing the report. Also, the “multi-eyeball” advantage is lost in a one-on-one meeting, along with the ease of communication present in a group setting. It is essential if the individual model is used that any concern that arises with one monitor be immediately communicated to the other monitors. Finally, multiple individual meetings are harder to schedule and more time consuming for the HIMS pilot and the monitors.
Some airlines have a preference of one type of monitor meeting over another. Generally, airlines with dozens of pilots in their HIMS program tend to use the group model, while airlines and domiciles with smaller numbers use the individual approach. In practice, both work equally well if the limitations are recognized and properly addressed.
Scheduling and Pay
Scheduling and payment for attendance at the meetings varies. Some airlines have pilots attend the meeting on a duty status, perhaps between flights to and from a hub or on a layover. Other airlines may bring in monitors for meetings on a paid status and have the pilots being monitored in an off-duty status requiring them to bid around the scheduled meeting. Peers from the same domicile can also make individual arrangements to meet. Some HIMS programs use a cost sharing strategy for the meetings with the company, union and pilot sharing the expenses.