Interventions to support the management of work-related stress (WRS) and wellbeing/mental health issues for commercial pilots

Abstract

Research indicates that sources of work-related stress (WRS) impact on the physical, social, and psychological health of pilots. Furthermore, specific features of the job can increase a pilot’s risk in relation to developing a mental health (MH) issue. It is impossible to remove all stress from the work life of pilots. A high stress situation may not necessarily be detrimental to the person, once they have learned to cope with it in a healthy manner. Nonetheless, risk pertaining to WRS need to be effectively managed by a pilot’s employer. Therefore, it is important to identify solutions at an airline and pilot self-management level. This paper reports on the findings of human factors research undertaken with commercial pilots pertaining to work-related stress (WRS) and its impact on wellbeing, performance, and safety. The findings of a series of co-design workshops and a follow-up anonymous survey were analysed to identify potential solutions at (1) an airline and (2) pilot self-management level. Potential solutions are framed in relation to six impact scenarios. Furthermore, they are located within the existing regulatory framework, including the latest implementation rules (IR), acceptable means of compliance (ACM), and guidance material (GM) as outlined by the European Union Aviation Safety Agency (EASA 2019). Proposed interventions should promote wellbeing and positive mental health while also addressing suffering and mental ill health. Airline interventions might focus on enhancing existing Safety Management System (SMS) approaches to better manage risks pertaining to WRS, advancing new tools to enable wellbeing briefing, risk assessment, and reporting, and training pilots in relation to MH awareness, risk identifying behaviour, and coping strategies. Furthermore, new role/functions might be introduced to support the implementation and management of WRS/wellbeing/MH safety/risk processes at an airline level. Requirements for new digital tools to support pilot awareness of WRS/wellbeing/MH, self-management of WRS/wellbeing/MH and risk identification both inside and outside the cockpit are also proposed. Some of recommendations arising in this research require changes to the existing rule-making and/or modification to existing AMC and GM.

Full text

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Cognition, Technology & Work
ISSN 1435-5558
Cogn Tech Work
DOI 10.1007/s10111-019-00586-z
Interventions to support the management
of work-related stress (WRS) and
wellbeing/mental health issues for
commercial pilots
Joan Cahill, Paul Cullen & Keith Gaynor

1 23
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Vol.:(0123456789)
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Cognition, Technology & Work
https://doi.org/10.1007/s10111-019-00586-z
ORIGINAL ARTICLE
Interventions tosupport themanagement ofwork‑related stress
(WRS) andwellbeing/mental health issues forcommercial pilots
JoanCahill1 · PaulCullen1· KeithGaynor2
Received: 1 May 2019 / Accepted: 24 July 2019
© Springer-Verlag London Ltd., part of Springer Nature 2019
Abstract
Research indicates that sources of work-related stress (WRS) impact on the physical, social, and psychological health of
pilots. Furthermore, specific features of the job can increase a pilot’s risk in relation to developing a mental health (MH)
issue. It is impossible to remove all stress from the work life of pilots. A high stress situation may not necessarily be det-
rimental to the person, once they have learned to cope with it in a healthy manner. Nonetheless, risk pertaining to WRS
need to be effectively managed by a pilot’s employer. Therefore, it is important to identify solutions at an airline and pilot
self-management level. This paper reports on the findings of human factors research undertaken with commercial pilots
pertaining to work-related stress (WRS) and its impact on wellbeing, performance, and safety. The findings of a series of
co-design workshops and a follow-up anonymous survey were analysed to identify potential solutions at (1) an airline and (2)
pilot self-management level. Potential solutions are framed in relation to six impact scenarios. Furthermore, they are located
within the existing regulatory framework, including the latest implementation rules (IR), acceptable means of compliance
(ACM), and guidance material (GM) as outlined by the European Union Aviation Safety Agency (EASA 2019). Proposed
interventions should promote wellbeing and positive mental health while also addressing suffering and mental ill health.
Airline interventions might focus on enhancing existing Safety Management System (SMS) approaches to better manage
risks pertaining to WRS, advancing new tools to enable wellbeing briefing, risk assessment, and reporting, and training pilots
in relation to MH awareness, risk identifying behaviour, and coping strategies. Furthermore, new role/functions might be
introduced to support the implementation and management of WRS/wellbeing/MH safety/risk processes at an airline level.
Requirements for new digital tools to support pilot awareness of WRS/wellbeing/MH, self-management of WRS/wellbeing/
MH and risk identification both inside and outside the cockpit are also proposed. Some of recommendations arising in this
research require changes to the existing rule-making and/or modification to existing AMC and GM.
Keywords Safety· Airline safety management systems· Pilot mental health· Work-related stress (WRS)· Stress
management· Wellbeing· Risk assessment· Self-management and performance
Abbreviations
AMC Acceptable means of compliance
BALPA British Airline Pilots Association
CAA Civil aviation authority
CMD Common mental disorders
CRM Crew resource management
CBT Cognitive behavioural therapy
EAAP European Association of aviation
psychologists
EASA European Union aviation safety agency
ECA European Cockpit Association
ECT Electroconvulsive therapy
ESAM European Society of Aerospace Medicine
EU-OSHA European Agency for Safety and Health in
Work
ESARRs Eurocontrol Safety Regulatory Requirements
(ESARRs)
EU European Union
FRMS Fatigue risk management system
GM Guidance material
IFALPA International federation of airline pilots
associations
* Joan Cahill
cahilljo@tcd.ie
1 Centre forInnovative Human Systems, School
ofPsychology, Trinity College Dublin (TCD), Dublin,
Ireland
2 School ofPsychology, University College Dublin (UCD),
Dublin, Ireland
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IATA International air transport association
ICAO International Civil Aviation Organisation
IR Implementing rules
MH Mental health
NICE National Institute for Health and Clinical
Excellence
RM Risk management
SM-ICG Safety Management International Collabora-
tion Group ()
SMS Safety management system
SPI Safety performance indicators
SRM Safety risk management
SARPs Standards and recommended practices
PHQ Patient health questionnaire
TEM Threat and error management
UAS Undesired aircraft states
WCQ Ways of coping questionnaire
WHO World Health Organisation
WRS Work-related stress
1 Introduction
1.1 Introduction totheresearch problem
Commercial aviation is a 24/7 business. The travelling pub-
lic expects low-cost tickets and flexible flight schedules. This
puts pressure on the operation (including flight scheduling
and crew rostering) and has an impact for pilots. Pilots work
anti-social hours and their working schedules are continu-
ously changing. This can make it difficult to maintain regular
‘healthy lifestyle’ routines and access support and treatment.
Research indicates that sources of work-related stress
(WRS) affect the physical, social, and psychological health
of pilots. Recent studies demonstrate that pilots are suffer-
ing with the same wellbeing issues as the general population
(particularly those relating to mental health), and possibly
to a larger extent (Pasha and Stokes 2018; Wu etal. 2016).
Overall, these studies have attempted to measure the preva-
lence of wellbeing issues (including mental health issues)
and to understand the factors that contribute to this. How-
ever, these studies fall short in terms of providing a rich
picture of the lived experience of pilots, and the complex
relationship between individual wellbeing factors as con-
ceptualized in the biopsychosocial approach (Engel 1977).
In addition, there has been little emphasis on understanding/
identifying the following: (1) the relationship between WRS,
pilot wellbeing, and safety, (2) how pilots adapt to WRS
and associated coping/self-management techniques, (3) the
role of other stakeholders (including airlines and the avia-
tion authorities) in terms of supporting pilots and managing
this problem, and (4) potential solutions at different levels.
Employers (i.e., airlines) have a duty to their employees
(i.e., pilots). It is expected that they exercise due care by put-
ting in place the necessary protective and preventive meas-
ures, to manage risks to health and safety in work. Research
pertaining to airline engagement and attitudes to wellbeing
indicates that airlines are not adequately addressing wellbe-
ing risks. In a recent European study investigating safety
culture with > 7000 pilots, only 17% of participants reported
that their organisation cared about their wellbeing, and 21%
felt that fatigue was taken seriously within their organisation
(Reader etal. 2016).
Self-management of health is a new strategy to managing
health conditions including chronic conditions. Individuals
actively identify challenges associated with their condition/
illness and actively manage these. Overall, the emphasis
is on the responsibility of the person, in conjunction with
working with health providers. A high level of self-efficacy
can help employees to cope more effectively cope with work-
related stress. Past research with nurses has demonstrated
that higher levels of self-efficacy coupled with social support
facilitate healthier lifestyles and healthier coping behaviours
for nurses (Jordan etal. 2016). Furthermore, recent research
indicates that organisational wellness programmes created to
promote healthy living habits have led to improvements in
workers’ health and job satisfaction and a decrease in worker
absenteeism (Goetzel etal. 2014).
Evidently, interventions/solutions are required for pilots
and airlines to tackle issues pertaining to WRS and its
impact on pilot wellbeing, performance, and safety. Argu-
ably, the issue of understanding and managing Pilot health
and wellbeing and identifying solutions/interventions to
managing sources of WRS and allied outcomes (i.e., well-
being, performance, and safety outcomes), can be treated
as a wicked problem (Conklin 2005). As with other wicked
problems, the conceptualisation of the problem (i.e., sources
of WRS and the associated impacts on wellbeing, perfor-
mance, and safety) influences (1) how the problem is framed
and (2) the generation of solutions.
Potential interventions are likely to be multi-component,
spanning different socio-technical dimensions (i.e., training,
culture, technology, and process design). Such interventions
must adapt to local contexts (Conklin 2005). Furthermore,
organisational change takes time and is often piece-meal
(Morris etal. 2011). In the aviation context, change often
follows from the requirement to demonstrate compliance to
new rules defined by the aviation authority.
1.2 Paper overview
This paper reports on the findings of two studies address-
ing WRS and the impact of the job (i.e., lived experience
of being a commercial pilot) on pilot wellbeing, and the
ensuing impact on pilot performance and flight safety. As
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this research addresses sources of WRS and their impact
on pilot wellbeing, performance, and flight safety, the nega-
tive impact of the job is considered. Furthermore, the paper
presents some preliminary requirements for interventions to
support the management of WRS and associated risks at an
airline level and pilot self-management level. The require-
ments are predicated on an analysis of the literature and
field research with pilots. Specifically, the requirements
are framed in relation to the existing regulatory framework
(European Agency for Safety and Health in Work 2019),
and the six impact scenarios which emerged in this research.
First, a background to this research is provided. Both
workshop and online survey methodologies are presented.
The findings of both the workshops and the online survey are
outlined, including findings pertaining to WRS, the impact
of WRS on pilot wellbeing, the ensuing impact on pilot
performance and flight safety, and pilot coping strategies.
Potential solutions at an airline and pilot self-management
level are then proposed. The research findings are discussed
and some preliminary conclusions drawn.
2 Background toproblem
2.1 Wellbeing andmental health
The term “wellbeing” includes various aspects of the way
people feel about their lives, including their jobs and their
relationships with the people around them. Medical, psy-
chological factors, and family and social factors (including
working conditions) are some of the determinants affecting
a person’s health and wellbeing (Engel 1977). None of these
factors in isolation will definitively lead to wellness or ill-
ness. Rather, the interrelationships between all three pillars
lead to a given outcome.
The World Health Organisation (WHO) defines mental
health as ‘a state of wellbeing in which every individual
realizes his or her own potential, can cope with the normal
stresses of life, can work productively and fruitfully, and is
able to make a contribution to her or his community’(2018).
A mental health illness generally means the presence a diag-
nosed psychiatric condition using an accepted diagnostic
manual (WHO 2005). Mental ill health includes a spectrum
of disorders, some of which can be debilitating and impact
on a person’s daily functioning (including their ability to
work). The experience of distress and disability is closely
associated with the definition of a mental disorder (Telles-
Correia etal. 2018).
The concept of mental wellbeing is linked to that of men-
tal health. Mental wellbeing is defined ‘as a dynamic state in
which the individual is able to develop their potential, work
productively and creatively, build strong and positive rela-
tionships with others, and contribute to their community. It
is enhanced when an individual is able to fulfil their personal
and social goals and achieve a sense of purpose in society’
(Foresight Programme 2008). Critically, certain MH illness
such as anxiety and depression can have a negative impact
on mental wellbeing.
‘Mental wellbeing at work’ is determined by the inter-
action between the working environment, the nature of
the work, and the individual (NICE 2009). Work can have
negative effects on mental health, particularly in the form
of stress.
In relation to the management of mental wellbeing and
common mental health problems, the National Institute for
Health and Clinical Excellence (NICE) recommends a range
of psychological therapies (referred to as the Stepped Care
Model) to treat people with depression and anxiety disorders
(NICE 2011). As depicted in Fig.1, Stepped Care is a five-
step system of delivering and monitoring treatments. The
Fig. 1 Stepped care model (Source: https ://wellb eingi nfo.org/self-help/menta l-healt h/stepp ed-care/)
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patient is first provided with the most effective and least
resource intensive treatment. Treatments are ‘stepped up’
or ‘stepped down’ as clinically required. Interventions can
include one or a mix of the following: assessment, psycho-
social education and guided self-help, social support, medi-
cation, Cognitive Behavioural Therapy (CBT), and Electro-
convulsive Therapy (ECT).
2.2 Stress andwork‑related stress
Stress is any experience or sensation that creates physi-
ological, psychological, and behavioural imbalances within
a person (Flinchbaugh etal. 2015; Houtman and Jetting-
hoff 2007; Lazarus 1990). Stress is not a medical condition.
However, research shows that prolonged stress is linked to
psychological conditions such as anxiety and depression,
as well as physical conditions such as heart disease, back
pain, and headache (NICE 2019). Self-assessment scales are
used to promote awareness in relation to stress, to determine
the degree and type of stress that is being experienced, and
to assess how well stress coping skills are working. These
include the Perceived Stress Scale (Cohen etal. 1983) and
the Ardell Wellness Stress Test (Ardell 1977).
Work-Related Stress (WRS) is defined as the response
people may have when presented with work demands and
pressures that are not matched to their knowledge and abili-
ties, and which challenge their ability to cope (Leka etal.
2003). Things outside the workplace, like family problems,
or debt can be responsible for stress (personal stressors). A
person experiencing stressful life events may find that he/she
is less able to cope with the demands of work, even though
work is not the cause and/or may not have been a problem
before.
Workplace stress is becoming more prevalent across dif-
ferent occupations, including those working in ‘high stress
occupations’ such as nurses, paramedics, teachers, and fire-
fighters. Around half of European workers consider stress
to be common in their workplace, and it contributes to
around half of all lost working days (European Agency for
Safety and Health in Work 2019). Like many other issues
surrounding mental health, stress is often misunderstood
or stigmatised (European Agency for Safety and Health in
Work 2019).
Critically, individuals vary in relation to their ability to
cope successfully with stress, including WRS. Stress cop-
ing is an important psychological construct which moder-
ates/mediates the relationship between stressors and behav-
ioural outcomes such as flying performance (Joseph 2016).
Humans use either adaptive or maladaptive strategies to
cope with stress. The substitution of maladaptive coping
with more adaptive coping is an important component of
therapeutic interventions and prognoses.
Monat and Lazarus (1991) define stress management as a
general treatment approach, such as good nutrition and exer-
cise, to a wide variety of adaptations and health problems.
Common stress coping strategies include exercise, the prac-
tice or relaxation techniques (i.e., deep breathing, yoga, and
meditation), and seeking social support and/or social par-
ticipation/engagement. The practice of healthy behaviours
strengthens the person’s resistance to stress (Morimoto and
Shimada 2015). As such, stress management and the prac-
tice of healthy behaviours underpins wellness and a healthy
lifestyle. Several instruments are used to assessing coping
ability. These include the Ways of Coping Questionnaire
(WCQ) (Folkman and Lazarus 1988), the COPE Inventory
(Carver etal. 1989) and the Stress Coping Resources Inven-
tory (Matheny etal. 1993).
2.3 Pilot job, types ofoperations, andlived
experience
Pilots are both “shift-workers” and “remote-workers”. How-
ever, in many ways, pilots represent a unique occupational
group. Pilots are not subjected to the provisions of the Euro-
pean Time Working Directive (EU 2003). Working hours in
a typical week can vary greatly from week to week and are
regulated in accordance with several parameters, such as
Duty Time and Block Time, as defined by the EASA (2019)
and others (for example, Civil Aviation Authority (CAA)
in the United Kingdom 2014). The overall intensity of the
operation can also vary greatly, typically with busier sum-
mers and quieter periods during the winter.
The working routines of pilots vary according to the type
of operations which they fly. Three types of operations can
be distinguished—namely short, medium, and long ranges.
These different types of options pose diverse wellbeing chal-
lenges. For example, pilots working long range are more
likely to spend periods of time away from home—affecting
the home/work interface and their ability to maintain social
routines. Pilots operating short range tend to experience
intense working days—potentially, involving three to four
take-offs and landings. This type of operation, despite accru-
ing relatively low Block Hours, involves high workload. In
medium and long range, the Block Hours may be higher,
with longer periods of rest/down time while on duty (i.e.,
cruise periods), and typically longer duty periods.
Pilots experience much disruption to their sleeping and
eating patterns. Specific patterns may also vary according
to the operations flown. For example, if flying short range,
duty might involve a week of ‘earlies’ (i.e. starting at 5am),
followed by a week of ‘lates’ (finishing at 2am), resulting
in disruption of the circadian rhythm associated with sleep-
ing and eating patterns. As reported by Wright etal. (2005),
mental fatigue and sleepiness may rise to unacceptably high
levels given relatively long duty periods that may coincide
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with disruption of the circadian rhythm due to time zone
shifts.
2.4 Pilot WRS
Pilots experience many physiological, psychological, and
environmental stressors. Explorative interviews with pilots
(n = 103) investigated the lived experience of pilots (Cahill
etal. 2016). This research indicates that different sources of
WRS affect the physical, social, and psychological health
of pilots (Cahill etal. 2016). These include fatigue, work-
ing irregular hours, low levels of autonomy at work, and
working in a confined space (Cahill etal. 2016). As reported
by Hansen (2015), the top three sources of WRS for pilots
include fatigue, working hours, and jet lag. Certain sleep/
fatigue factors can be associated with specific dimensions of
the job, including irregular sleep schedules, long duty days,
night flying, and multiple time zone changes.
2.5 Pilot mental health
In a survey commissioned by the British Airline Pilots Asso-
ciation (BALPA), Steptoe and Bostock (2011) found an
increased incidence of, and a positive correlation between,
reported symptoms of anxiety and depression and fatigue,
and work patterns amongst a sample of commercial pilots.
Similarly, an anonymous study of commercial airline pilots
in Brazil found the prevalence of pilots with common mental
disorders (CMD), such as mixed anxiety and depression, to
be 6.7% (Feijó etal. 2012).
A systematic review of aircraft related suicide in the
United States indicates that pilot suicides account for less
than 1% of aircraft fatalities (Lewis etal. 2014). Follow-
ing the Germanwings 9525 accident (2015), the issue of
pilot suicide and detecting/managing mental health issues
amongst pilots has been gaining increased attention.
Research undertaken by Bor etal. (2017) suggests that com-
mon psychological problems in pilots include adjustment
disorder, mood disorder, anxiety and occupational stress,
relationship problems, sexual dysfunction, and alcohol
problems.
In a recent large-scale survey of airline pilots, 12.6% of
respondents met the threshold for experiencing depression
in the last fortnight (Wu etal. 2016). Similarly, a system-
atic review of 20 studies examining depression in airline
pilots found that the prevalence of major depressive disorder
experienced by commercial airline pilots ranged from 1.9 to
12.6% (Pasha and Stokes 2018). As reported by Pasha and
Stokes (2018), pilots experience several occupational stress-
ors such as disrupted circadian rhythms and fatigue, which
are recognised as being associated with the development of
mood disorders.
2.6 Safety performance/measurement andlagging
andleading safety indicators
The International Civil Aviation Organisation (ICAO)
defines safety performance as ‘a service provider’s safety
achievement as defined by its safety performance targets and
safety performance indicators’ (2013). A safety performance
indicator is ‘a data-based safety parameter used for monitor-
ing and assessing performance’ (ICAO 2013a, b). A safety
performance target is ‘the planned or intended objective for
safety performance indicator(s) over a given period’ (ICAO
2013a, b).
To measure safety, airlines need to measure (1) the results
of their safety interventions as well as (2) whether they are
being effective in terms of preventing incidents and acci-
dents. Two common classifications for safety performance
indicators (SPIs) are commonly used (Safety Management
International Collaboration Group—SM-IMG 2013). These
are lagging and leading indicators. Lagging indicators are
measures of safety occurrences, in particular the negative
outcomes that the organisation is aiming to prevent (Skybary
2019a). They measure the results of safety interventions (i.e.,
number of incident and accidents). A leading indicator is a
measure preceding or indicating a future event used to drive
and measure activities carried out to prevent and control
injury—such as safety training and safety audits (Skybary
2019b). As such, leading indicators assess risk factors pre-
sent in the workplace that will contribute to future incidents
or accidents. This includes things that have the potential to
become or contribute to a negative outcome in the future
(‘negative’ indicators), and things that contribute to safety
(‘positive’ indicators) (Skybary 2019c; SM-ICG 2013)).
2.7 Risk management andsafety‑II
Three risk management (RM) approaches are defined. Reac-
tive RM approaches address the risks identified in an acci-
dent or incident after it has occurred. Proactive RM involves
taking action before an accident happens. This typically
requires the utilization of data to identify risks from past
accidents or incidents. Predictive RM approaches take action
based on potential risk as determined from normal opera-
tional data (i.e., not accident data) to reduce the risk of an
accident that has not yet happened.
Safety (Safety-I) has traditionally focussed on the avoid-
ance of bad events. That is, a reactive approach responding
to what is going wrong and/or identified risks. Safety-II is a
novel and complementary approach to Safety-I, highlight-
ing the importance of utilizing both proactive and predic-
tive approaches (Hollnagel 2014; Hollnagel etal. 2015). In
addition, Safety-II emphasizes the importance of learning
from normal operations, including when things go well. As
stated by Hollnagel ‘focusing on what goes right, rather than
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on what goes wrong, changes the definition of safety from
‘avoiding that something goes wrong’ to ‘ensuring that eve-
rything goes right’ (2014). Importantly, ‘Safety-II’ is under-
pinned by open communication (briefings and debriefing),
routine reporting and a just culture (Hollnagel 2014; Holl-
nagel etal. 2015).
2.8 European directives: workplace stress andrisk
assessment
The European Commission (EU) has introduced measures to
ensure the safety and health of workers. The 1989 Council
Directive (89/391) makes employers responsible for mak-
ing sure that employees are not harmed by work, including
through the effects of WRS (European Agency for Safety
and Health in Work 2019). The Safety, Health and Welfare at
Work Act (2005) requires employers to put in place systems
of work which protect employees from hazards which could
lead to mental or physical ill health. Risk assessment for
stress involves the same basic principles and processes as
for other workplace hazards. Risk pertaining to WRS must
be addressed and managed using a risk assessment process,
involving participation and consultation, and the application
of the principles of prevention (European Agency for Safety
and Health in Work 2019). The hazards must be identified,
the risks assessed, and control measures identified, imple-
mented, and evaluated. Furthermore, the European Pact
for Mental Health and Well-being recognises the chang-
ing demands and increasing pressures in the workplace and
encourages employers to implement additional, voluntary
measures to promote mental wellbeing (European Pact for
Mental Health and Well-being 2008).
3 Current interventions andpilot coping
strategies
3.1 Aviation authorities andmanagement ofhealth
andwellbeing
As recommended by ICAO in ‘Annex 19; Safety Manage-
ment’ (2013), and mandated by the EASA (2019), airline
Safety Management Systems (SMS) are designed to meas-
ure and manage safety risks. The objective of an SMS is to
provide a structured management approach to control safety
risks in operations (Skybrary 2019a, b, c, d).
In principle, an SMS addresses all risks. According to
ICAO Doc 9859 (2013), an SMS may include both proactive
and reactive methods and techniques (for example, occur-
rence reporting and investigation). As stated by European
Agency for Safety and Health in Work (2019), their SMS
rules ‘are designed to embed the ICAO Annex 19 in a way as
to ensure SMS compatibility with the existing management
systems and to encourage an integrated management sys-
tem’. The term ‘Safety-II’ is not used in ICAO’s recommen-
dations (2013). However, ICAO’s ‘Global Aviation Safety
Plan’ (2019a, b) refers to the future implementation of pre-
dictive risk management practices by 2027.
As defined by ICAO, an SMS includes four parts: (1)
safety policy, (2) safety risk management, (3) safety promo-
tion, and (4) quality assurance (2013). A safety risk manage-
ment (SRM) is a formal process within the SMS composed
of describing the system, identifying the hazards, assessing
the risk, analysing the risk, and controlling the risk (ICAO
2013a, b). As indicated in Fig.2, specific risks associated
with hazards to flight conditions are systematically and for-
mally defined, along with corresponding safety performance
indicators and acceptable thresholds. Counter-measures/pro-
tections are identified, monitored, and assessed to ensure that
that risks are adequately managed (and safety maintained).
Crew Resource Management (CRM) training is consid-
ered a key component of an airline’s SMS (i.e., safety pro-
motion). The aviation authorities mandate CRM/human fac-
tors training for pilots, which includes information about the
practice of ‘safety behaviours’ and associated CRM theories
(European Agency for Safety and Health in Work 2019).
EASA have provided extensive guidance for CRM training.
For example, EASA’s document ‘Crew Resource Manage-
ment in Practice’ (2017b). In addition, EASA have defined
the Air Ops requirements for CRM Trainers (EASA 2012).
CRM training is informed by both CRM theory and
‘Threat and error management’ (TEM) theory. CRM theory
‘focuses on the effective utilization of all resources includ-
ing crew members, aircraft systems, supporting facilities,
Fig. 2 Risk management process (ICAO Doc 9859—safety manage-
ment manual)
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and persons to achieve safe and efficient operations’ (EASA
2017c). TEM theory is a subset of CRM theory which
addressees the practice of thinking ahead to prevent and
mitigate errors and operational threats, and manage Unde-
sired Aircraft States (UAS), which can result from these
(Helmreich etal. 1999; Cahill 2010). A cornerstone of TEM
‘is the acceptance that threats and errors will occur and that
they have to be identified and managed’ (EASA 2017a).
CRM training largely relates to certain bio-medical aspects
of health (for example, the management of fatigue), the use
of substances (for example, avoidance of alcohol and drugs),
and certain socio-cognitive dimensions of performance (for
example, crew teamwork and communication and compli-
ance with procedures). In many ways, safety behaviour is
conceived from an operational perspective (short term—
while on duty) and not in relation to maintaining a healthy
lifestyle (including work/life balance)—which has implica-
tions in relation to performance and safety. CRM training is
discussed and evaluated in more detail below.
Pilot health and fitness (including mental health) is
assessed annually in accordance with mandatory rules
regarding aeromedical assessment (Bor etal. 2017). There
are very clear guidelines concerning the impact of a psy-
chiatric disorder on pilots (Dickens 2016). All regulatory
bodies distinguish between conditions that mean mandatory
exclusion from flying and those that allow a pilot to fly under
controlled conditions (Dickens 2016).
EASA has recently introduced new rules on pilot mental
fitness, following the Germanwings tragedy in 2015 (Euro-
pean Agency for Safety and Health in Work 2019). These
rules pertain to three key areas—psychological testing of
aircrew pre-employment in line flight, access to a psycho-
logical support/peer-support resource, and substance abuse
testing on a random basis. European airlines will be required
to demonstrate compliance with these rules by 2021.
In relation to psychological assessment, EASA’s cur-
rent focus is MH issues. Current AMC and GM does not
focus on the promotion of wellbeing more generally and
specifically, the promotion of positive MH. Furthermore,
the focus of assessment is at the recruitment and training
stage. Crucially, a pilot’s wellbeing and mental state may
change over time. Accordingly, such an assessment would
need to provide an insight into potential future wellbeing
and MH risk. EASA has also recommended that any pro-
posed assessment ‘should not be considered or conducted
as a clinical psychological evaluation’ (European Agency
for Safety and Health in Work 2019). This raises questions
about the potential for bias in the assessment processes (i.e.,
not using clinically validated and/or standardised assessment
instruments). Evidently, Pilots would need to understand
and trust the assessor and the assessment process. Further-
more, to be effective, the evaluation would need to be of
benefit to pilots (and not just their employers). Potentially,
a self-management assessment model, which includes the
assessment of wellbeing along with common mental health
disorders (i.e., anxiety and depression), might complement
such an approach.
3.2 Airline interventions (wellbeing andMH)
Airlines follow existing guidance pertaining to aeromedical
assessment of pilots, as mandated by the regulatory authori-
ties. The health of a commercial airline pilot is assessed
annually. Licences and flying privileges can be suspended if
serious health problems (including MH issues) are detected.
Given that their licence is at stake, pilots are likely to under
report MH issues. Furthermore, pilots are not likely to
approach aeromedical examiners for help.
Currently, sources of WRS and wellbeing factors (span-
ning the three pillars of wellbeing) are not properly defined
within existing airline safety management systems. As such,
it is difficult to assess whether a particular safety event (for
example, over-speed in landing) follows from an error linked
to a wellbeing problem (which, in turn, can be attributed to a
source of WRS), or a training deficit. Furthermore, there is
no risk assessment in relation to WRS and wellbeing issues.
Presently, the primary focus of airline wellbeing inter-
ventions is in relation to the management of crew fatigue
and alertness. The ‘Fatigue Management Guide for Airline
Operators’ specified by the International Air Transport
Association (IATA), the International Civil Aviation Organi-
sation (ICAO), and the International Federation of Airline
Pilots Associations (IFALPA) (2015) describe a science-
based and operationally oriented fatigue management pro-
cesses. Fatigue Risk Management Systems (FRMS) have
been advanced by a number of airlines including EasyJet
and Singapore Airlines (Skybrary 2019a, b, c, d). Typically,
airline FRMS provide outputs to crew pairing/rostering and
flight scheduling systems to ensure that risks pertaining to
fatigue are managed from an operational perspective.
Operational reporting is a key component of any SMS
(Cahill 2010). Currently, specific wellbeing/WRS reporting
systems are not used at an airline level. However, nothing
prevents pilots from reporting wellbeing/WRS issues using
the existing SMS reporting system (i.e., voluntary and man-
datory safety reporting tools). Anecdotally, it is known that
pilots do not report wellbeing issues (including MH), using
existing safety reporting systems. In terms of organisational
structure, pilots can report issues to their head of flight oper-
ations and/or chief pilot. However, this is rarely done.
Airline CRM training addresses the socio-cognitive
dimensions of task performance (for example, teamwork,
briefing, and decision-making) and crew management of
threats, to avoid errors and/or unacceptable aircraft states as
outlined in the TEM model (Helmreich al. 1999). Typically,
airlines classify threats in relation to high-level taxonomies
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such as crew, aircraft, and the environment (Cahill 2010;
Cahill etal. 2011). As highlighted by Cahill etal. (2011,
2013), the crew state is conceived in relation to fatigue, situ-
ation awareness, and crew competency (i.e., training level
and flight experience). Critically, the TEM model does not
comprehensively address the crew state as conceived from
a biopsychosocial perspective.
As part of CRM training, safety behaviours such as the
performance of crew briefings and checklists at differ-
ent flight phases (as mandated by EASA) are introduced.
The impact of fatigue on alertness is also addressed. Stress
management is also part of the CRM syllabus as defined
by EASA (2017a, 2019). As such, airlines must include
general stress management training as part of their CRM
syllabus. Specific stress management modules have been
successfully implemented and positive outcomes realized
(Moriarty 2015). However, the guidance material does not
explicitly mention WRS, techniques for managing WRS/
wellbeing issues, and stress coping behaviours while on
and off duty. This includes issues related to the biological
pillar (i.e., food and exercise), the psychological pillar (i.e.,
mood/emotional states and MH awareness), and the social
pillar (i.e., including both crew relations and the crew mem-
ber’s broader social relationships). As reported by Joseph
(2016), coping strategies relate to crew interaction styles and
are of relevance to CRM. Specifically, coping is linked to
how social and cognitive challenges in the aviation environ-
ment are handled and pertain to situational awareness and
decision-making (Fornette etal. 2012). It should be noted
that EASA’s document ‘Crew Resource Management in
Practice’ (2017c) refers to concepts of ‘resilience’ and the
recent ‘resilience training’ implemented by Luzair (EASA
2017a). However, there is no actual guidance pertaining
to the implementation of such resilience and stress coping
training. Evidently, there is nothing preventing airlines from
elaborating on EASA’s guidance material.
Following from CRM and TEM concepts, pilots follow
strict procedures in terms of crew briefing at the pre-flight
planning and briefing stage (Cahill 2010). However, existing
airline briefing processes (linking to TEM constructs) do not
address WRS/wellbeing issues. Moreover, specific pre-flight
checklists (i.e., standard operating procedures—SOP) do not
include human factors checks in relation to crew wellbe-
ing and the joint crew state (Cahill 2010). Such issues are
understood by pilots to have a bearing on safety and should
be raised in crew briefings (Cahil 2010; Cahill etal. 2011,
2013). It could be argued that WRS is already addressed
as part of pre-flight briefings. That is, it is formalised in
the duty/responsibility of pilots to refuse to fly when he or
she feels unfit to fly. Anecdotally, it is known that often fail
to ‘call in sick’ given operational pressures. Furthermore,
stigma in relation to MH can impact on a pilot’s willing-
ness to declare themselves as suffering. In this regard, new
electronic checklist/briefing solutions predicated on CRM/
TEM concepts have been advanced to enhance crew brief-
ings at the pre-flight stage (Cahill 2010; Cahill etal. 2011).
Potentially, these tools might be extended to include briefing
around WRS and wellbeing, and specifically risk assess-
ment pertaining to WRS and its impact on wellbeing, per-
formance, and safety.
Ideally, a good crew composition mitigates the effects of
individual crew state weaknesses (for example, fatigue and
experience, etc.). Specific airline crew pairing and rostering
systems vary in sophistication. Advanced systems consider
crew factors such as fatigue (i.e., taking data from airline
Fatigue Risk Management Systems), operational experience
(i.e., routes flown), training/competency, and reported crew
inter-personal problems.
Many airlines provide crews with their roster information
(for example, a PDF file of their duty schedule). This can be
used by pilots to support self-management of sleep/fatigue
(i.e., to anticipate busy times/fatigue and take rest). In an
attempt to enable pilots to better manage the home/work
interface, some airlines have developed bidding systems,
which allows pilots to select specific days off (i.e., leave for
family events and holidays).
In addition, some airlines provide psychological support
using a peer-support service (Atherton 2019). As reported by
Atherton (2019), peer-support services have been operated
by American Airlines, British Airways, Lufthansa, KLM,
and Qantas for many years. Peer-support programmes can
take many forms (Gibbs 2016). However, all require cer-
tain fundamental features such as confidentiality and mutual
respect (Dickens 2016). Specifically, the peer employee
assistance programme implemented by Delta (2015) has
been positively received by the Aerospace Medical Asso-
ciation Working Group on Pilot Mental Health (2016).
3.3 Pilot coping strategies andwellbeing/MH
interventions
Currently, pilots adopt their own coping mechanisms, relying
on themselves as opposed to their employers. As reported by
Sloan and Cooper (1986), overall mental ill health amongst
pilots has a very close association with lack of autonomy
at work, fatigue, the inability to relax, and insufficient
social support. Bennett (2006) highlights the importance of
social support obtained from fellow pilots, reporting that
team members’ mutual support, camaraderie, and cohesion
enhance their resilience to internal pressures (for example,
busy rosters), and external pressures (for example, adverse
weather, technical faults, delays, and unruly passengers).
Evidence also suggests that support from family/spouse is
of use (Karlins etal. 1989). A recent study by Avis etal.
(2019) indicates that partner support was key in managing
the demands of shift work. Pilots suffering marital distress
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are less able to concentrate effectively on their piloting
duties and responsibilities (Raschmann etal. 1991). On the
other hand, anti-social work practices have the potential to
undermine the positive social support provided by romantic/
spousal relationships.
In the military sphere, interventions include critical inci-
dent stress debriefing, stress inoculation training, and stress
management techniques Joseph (2016). Furthermore, cogni-
tive behaviour therapy has been applied in the management
of fear of flying (Dobie and May 1994).
3.4 Pilot advisory groups
Many pilot unions have Pilot advisory groups (PAG). These
provide a confidential service that pilots can use to talk
about problems and obtain support. However, there is no
published evidence as to the effectiveness of such groups.
4 Opportunities: new tools/technologies
4.1 Health apps
Smartphone ownership continues to increase and there
has been considerable growth in relation to the develop-
ment of mHealth Apps and Mhapps for the general popu-
lation. Currently, the app markets provide people with an
ever-increasing number of applications, about 40,000 of
which are related to healthcare, namely “health and fitness”
apps or mHealth Apps (Boulos etal. 2014). Furthermore,
smartphone apps for mental health (Mhapps) represent a
compelling new delivery mode for self-guided psychologi-
cal interventions in prevention and stepped care (Bakker
etal. 2016). Self-guided interventions are part of a stepped
care approach, which prioritises “high intensity” psycho-
logical interventions (e.g., psychotherapy and psychoactive
medications) for those with the greatest distress and clinical
need, and “low intensity interventions” for those who may
not require one-on-one clinician support (van Straten etal.
2015).
4.2 Self‑management forpilots
As part of a joint safety initiative, Boeing and Jeppesen have
advanced a new digital tool supporting pilot management of
alertness and fatigue (Jeppesen 2018). Built on the Boeing
Alertness Model (Ingre etal. 2014), ‘CrewAlert’ is the first
iOS application designed specifically to help airlines and
their crews manage alertness and fatigue (Jeppesen 2018).
The app provides risk assessment information to pilots in
relation to current and future fatigue and alertness levels.
As part of this, the pilot reports on their own sleep and
the app deduces expected alertness levels over time. This
information can be used by the pilot in relation to their own
coping strategies/self-management of fatigue/sleep, so that
predicted fatigue/alertness risks are appropriately managed.
Pilots can use the tool (1) as part of an integrated approach
(i.e., sharing of data between pilot and airline) and/or (2)
independent of their airline. If the airline has procured the
tool, the pilot’s roster is automatically prepopulated. If not,
the pilot can manually add this information (i.e., synch from
a PDF file). The pilot can select to share anonymous infor-
mation about their sleep and fatigue/alertness levels—so
that the airline can have a real picture of crew fatigue and
potential operational/safety impact. In principle, this infor-
mation informs flight planning and crew rostering activi-
ties. However, there is little information available about the
airline process for this and the associated wellbeing and
operational/safety impacts. Furthermore, the main focus
of ‘CrewAlert’ is on the management of pilot fatigue and
alertness (i.e., factors associated with the biological pillar of
wellbeing). Pilot wellbeing spans the three pillars of wellbe-
ing—that is, their physical, psychological, and social health.
Critically, there is a relationship both (1) between different
factors within each of these pillars and (2) across these pil-
lars. Potentially, this tool might be extended to include data
collection, monitoring, and risk assessment in relation to
the three pillars of wellbeing and the complex relationship
between different wellbeing factors. Such developments
might link to broader health and wellness interventions
(including pilot mental wellbeing) at both a (1) pilot self-
management level and (2) an airline level.
4.3 Machine learning andarticial intelligence
Airlines are now making use of statistical modelling tech-
niques and new machine learning and artificial intelligence
technologies to make predictions about flight safety. Spe-
cifically, machine learning techniques have been used to
inform risk assessment and prediction in relation to unstable
approaches (Baranzini 2018; Baranzini and Zanin 2015).
This follows the integration and analysis of operational data
(Baranzini 2018; Baranzini and Zanin 2015). Potentially,
equivalent approaches might inform risk assessment around
crew state/wellbeing and the allied impact on performance/
flight safety.
4.4 Organisational tools toenable assessment
ofmental health andstress coping
Tools such as MindQ™ and MindFull online enable mental
wellbeing assessment for organisations wanting to monitor
and support their staff’s mental health at work (Symbiotics
2019). These tools provide organisations and employees with
insights relating to the employees existing mental health
and their risk for developing a mental health condition.
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Critically, these tools are designed for use at the recruit-
ment and selection stage and to support ongoing monitoring
of employee mental health. These tools have been adapted to
the aviation context. However, little information is available
about specific implementation strategies and barriers at an
airline level. In principle, these tools might form part of a
confidential employee assistance programme (EAP). How-
ever, this requires much trust and commitment on behalf of
the employee. Given that a pilot’s licence depends on the
assessment of MH, pilots may not be willing to volunteer
this information. Potentially, such tools might be adapted
from a pilot self-management perspective.
5 Research methodology
5.1 Overview andresearch design
Two sequential phases of field research were undertaken
with commercial pilots. This research built on prior explora-
tory interviews with pilots (N = 103), investigating the lived
experience of pilots and associated sources of WRS (Cullen
etal. 2017).
Three workshops were undertaken with 33 commercial
pilots (workshop 1: N = 12, workshop 2: N = 10, workshop 3:
N = 11). The workshop methodology integrated participatory
evaluation (Bødker and Burr 2002) and stakeholder evalua-
tion approaches (Cousins etal. 2013). The workshops were
undertaken between March and May 2018.
This was followed by a cross-sectional descriptive study.
An anonymous web-based survey was completed by com-
mercial pilots between November 2018 and February 2019.
Participants were invited to participate in a web-based
online survey which examines the effects of work-related
stress (WRS) on pilot wellbeing, and the associated impact
on both pilot performance and flight safety. The survey also
investigated pilot coping methods, and pilot perception of
the airline role in relation to managing WRS and wellbeing
issues.
The survey incorporated several standardised instruments
to measure levels of common mental health issues which
have been widely validated and have good psychometric
properties. These are these Patient Health Questionnaire-9
(PHQ-9) (Kroenke etal. 2001), the Oldenburg Burnout
(OLBI 8) (Demerouti etal. 2003), and the Oldenburg Burn-
out (Modified Instrument) (Demerouti etal. 2018). Further-
more, the survey design draws upon prior research under-
taken by the authors pertaining to a biopsychosocial model
of wellbeing, the factors that can positively and negatively
influence a pilot’s physical, mental, and social health, and
the ensuing impact on pilot performance and flight safety
(Cullen etal. 2017, 2018a, b, c).
In relation to the workshops, the pilots were recruited
through network and word of mouth. In the case of the sur-
vey, pilots were recruited using social media platforms such
as LinkedIn and Twitter. In both cases, ethics approval was
granted by the School of Psychology, Trinity College Dublin
(TCD).
5.2 Pilot workshops
Specifically, the workshops had three objectives:
• To validate prior research relating to the impact of the
job/WRS on pilot wellbeing.
• To map the relationship between WRS, pilot wellbeing,
pilot performance, and flight safety.
• To validate preliminary workshop findings related to the
relationship between WRS, pilot wellbeing, pilot perfor-
mance, and flight safety.
Participants were provided with a short presentation per-
taining to the biopsychosocial model of pilot lived experi-
ence, the preliminary safety case, and associated worked
examples. In workshop 1, participants were invited to review
both the model, the safety case, and associated worked
examples. This was followed by a group discussion concern-
ing the relationship between WRS, pilot wellbeing, pilot per-
formance, and flight safety. In workshop 2 and 3, the findings
of workshop 1 were presented to participants. This included
six scenarios pertaining to the impact of WRS on wellbeing,
performance, and flight safety. Participants were invited to
review/validate the six scenarios. Following this, there was
a general discussion about the relationship between WRS,
pilot wellbeing, pilot performance, and flight safety. All par-
ticipants were invited to complete a homework exercise after
the workshop. All participants were debriefed, at the end of
each workshop. The debriefing included information about
follow-up supports and confidentiality.
5.3 Anonymous survey
Survey objectives include the following: to (1) measure rou-
tine suffering amongst pilots, (2) understand pilots experi-
ence of WRS/wellbeing issues, (3) understand pilot attitudes
to reporting wellbeing issues (including mental health), (4)
understand the relationship between work-related stress,
pilot wellbeing, pilot performance, and safety, (5) understand
how pilots adapt to WRS and wellbeing issues, (6) identify
pilot coping/self-management techniques, and (7) examine
pilots perceptions regarding the role of their employers/air-
lines in terms of managing WRS/wellbeing issues.
First, pilots received background information about the
study. They complete the electronic consent. Following this,
they complete questions for each of the nine sections (part 2
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to part 10), as indicated above. Following this, there was a
debriefing—includes contact information for relevant sup-
port groups and Pilot Support Groups.
6 Workshop andsurvey results
6.1 Summary
Overall, 33 commercial pilots (spanning three airlines)
attended the workshops. Workshop participants had on aver-
age 9178h of flying experience and included 20 Captains
and 13 First Officers. Of the 33 participants, 7 were female
and 26 were male. 8 participants had part time work con-
tracts, while 25 were working full time. In terms of flight
operations, this included 4 short range, 7 long range, and 22
mid-range pilots.
325 respondents completed the online survey (62% rate).
70% completed the PHQ. Overall, survey respondents can
be described as male (83.9%), full time (91%), married
(57.88%), and based in home country (82.33%). Table1
below provides a summary of respondent ages. Table2
provides a summary of respondent time working as a com-
mercial pilot.
The integrated findings of two strands of research are
outlined in relation to several topics as indicated in Table3.
6.2 Awareness ofwellbeing problems
Workshop participants reported a significant stigma in terms
of talking about wellbeing problems (including MH). Fur-
thermore, feedback indicates that pilots often normalise
the problems that they are experiencing, and many may not
even realize that they have problems (including MH prob-
lems). In terms of MH, participants stated that the prevailing
culture (i.e., machoism and stigma associated with mental
health issues) presents significant challenges. As reported by
participants, this contributes to a situation where there is a
lack of awareness/openness about MH issues. As such, MH
issues are not being identified and addressed.
These findings were validated in the survey. Over 80%
of participants agreed that there are low levels of speaking
out and/or reporting mental health among Pilots (46.46%
of participants strongly agreed, while 38.89% agreed). The
majority of participants indicated that they would talk to
a partner/spouse (78.89%) about an MH issue, closely fol-
lowed by a friend (56.28%). Only 24.6% indicated that they
would talk to a close-friend colleague. 14.07% indicated
that they would speak to a peer-support group. A very small
number (2.51%) indicated that they would speak with their
line manager.
6.3 Prevalence ofwellbeing andMH problems
All workshop participants reported wellbeing problems
spanning physical and social pillars. Participants disclosed
that they periodically experience stress and WRS. Workshop
participants did not report specific MH problems, but noted
that others were experiencing MH difficulties.
Table 1 Age brackets
<25 25–35 36–45 46–55 56–65
4.2% 33.5% 27.8% 23.0% 10.0%
Table 2 Time working as a pilot <2years 2–5years 6–10years 11–15years 16–20years 21–25years 26–30years 30years
8.5% 12.6% 17.1% 15.7% 14.7% 7.2% 12.0% 12.3%
Table 3 Research themes and
findings # Theme/topic Workshops Survey
1 Awareness of wellbeing problems (including MH) and talking
about wellbeing problems X-detail X-detail
2 Prevalence of wellbeing problems (including MH) X X-detail
3 Reporting MH problems in work X X-detail
4 Experience of WRS and ability to cope X X-detail
5 Sources of WRS X-detail X-detail
6 WRS and impact on wellbeing, performance, and safety X-detail X-detail
7 Pilot coping mechanisms x X-detail
8 Engagement x X-detail
9 Airline role in relation to management of wellbeing problems x X
10 Perception of current airline role/activity in relation to management
of wellbeing problems X-detail X-detail
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Just under half of the survey, respondents (48.7%)
reported that they had spoken to somebody about an MH
issue which they were experiencing or had experienced.
42.5% of respondents indicated that they have a close-friend
pilot colleagues who has experienced MH issues. 12.8% of
participants meet the threshold for Clinical Depression.
7.9%, had suicidal thoughts in the previous 2 weeks.
6.4 Reporting MH issues inwork
Overall, workshop participants indicated a considerable
level of stigma in relation to reporting mental health issues
at work. In terms of MH, it was agreed that pilots may be
reluctant to stand down or disclose mental health problems,
given real concerns over the potential impact of this on their
job (i.e., fears of losing their licence and/or possible impact
on future career progression).
Survey feedback is consistent with these findings. 77.6%
indicated that if they had a mental health issue, they would
not disclose it to their employer. Only 8.08% had reported
“unfit for flight” due to a mental health issue. 16.67% indi-
cated that they previously reported “unfit for flight” due
to a mental health issue, but provided a different reason.
56.92% reported that if they were “unfit for flight” due to a
mental health issue, they would provide a different reason.
When asked about their reasons for this, the vast majority of
respondents (71.69%) indicated ‘fear of loss of licence and
loss of long-term earnings’. Other reasons included ‘fear of
stigmatisation by employer’ (57.83%) and ‘potential nega-
tive impact on career progression’ (54.22%). On a more
positive note, over 75% agreed that they would look for help
(with 45.45% agreeing and 29.8% strongly agreeing). Nearly
97% of participants agreed with the statement ‘Promoting
mental health awareness (recognising problems in one’s self
or others) is important from a safety perspective’ (70.56%
strongly agreed and 26.9% agreed).
6.5 Experience ofWRS andability tocope
Workshop feedback indicates that individual differences
in relation to pilot coping ability must be considered. As
reported by participants, Pilots are coping all the time.
As stated by one participant, ‘pilots are managing stress,
adapting to the job and its challenges, and not having safety
events/accidents’. As stated by participants, ‘some pilots
cope better than others’. Specifically, ‘they have developed
strategies to cope with the challenges they face’. It was noted
that the general estimation amongst pilots is that ‘70% cope
well, while 30% find adapting more difficult’. However, par-
ticipants agreed that ‘pilots show up to work and tick all the
boxes’. Furthermore, ‘things don’t give until the very end’.
As observed by participants, the fact that pilots are coping,
presents its own risk. Critically, this masks the suffering that
is experienced by pilots, and gives the impression that safety
risks are being managed.
Nearly 50% of participants (48.9%) indicated that they
find the job stressful ‘now and again’, while 24.44% indi-
cated that the job is ‘frequently stressful’. Pilots were asked
to rate their ability to cope with WRS. The majority (over
83%) agreed that they tolerate the pressures of their work
very well (68.57% agreed, while 14.76 strongly agreed).
However, over 75% of participants agreed that they feel worn
out and weary after work (50.95% agreed, while 24.29%
strongly agreed). Survey data suggest that Pilots are adapting
and coping. Over half of respondents agreed to the statement
‘Pilots are suffering, but they are also adapting and coping’
(48.1% agreed, while 8.7% strongly agreed).
6.6 Sources ofWRS
It was agreed that both work and personal stressors either
(1) acting on their own and/or (2) acting together, put pilots
in a situation where they are at increased risk of developing
an MH issue, and/or worsening a pre-existing MH issue.
Participants highlighted the potential impact of personal
stressors which can be intensified/made worse by certain
features of the job (for example, time away from home and
inability to contact family while in work).
Participants provided feedback as to sources of WRS and
the potential impact on pilot wellbeing. Participants indi-
cated that the key sources of WRS include the following:
1. Fatigue, potentially leading to burnout.
2. Unnatural workspace (5 miles up in the sky).
3. Sleep disruption.
4. Lack of breaks.
5. Time away from home.
6. Close confines of cockpit.
7. Social isolation.
8. Having different goals and values to management.
9. Lack of management engagement with pilots.
10. Lack of support from flight operations and manage-
ment.
11. Imposed sedentary nature of job.
Survey data indicate a similar trend. Respondents
reported the top 3 most common sources of WRS (indicated
in order) as working irregular hours (72.07%), working ant
social hours (59.46%), and the divergence of values between
management and pilots (54.95%).
6.7 WRS andimpact onwellbeing, performance,
andsafety
Participants indicated that aspects of the job present a poten-
tial threat to flight safety, given the ensuring impairments
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to task performance In terms of specific impacts on per-
formance, workshop participants highlighted issues around
impact on cognition, workload management, teamwork,
and communication. Specifically, participants referred to
the following:
• Potential reduction insituation awareness.
• Impaired decision-making.
• Inability to focus on the current task.
• Difficulties managing multiple tasks/workload.
• Task omissions.
• Reduction in quality of error identification and manage-
ment behaviour.
• Poor quality communications with fellow pilot.
• Withdrawal of pilot (not communicating).
Overall, six impact scenarios were identified (see Table4
below). Of these, participants suggested that the primary
focus of wellbeing interventions might be on addressing
routine suffering (Scenarios 1 and 2), the prevention of
Scenario 3 (i.e., pilot not coping on the day—impacting on
flight safety), and Scenario 5 (i.e. pilot suffering which ends
in harm to the person).
Survey data substantiate this picture. Overall, the data
indicate that sources of WRS have a negative impact on pilot
wellbeing. As indicated in Fig.3, sleep difficulties (79.8%)
were reported as the most common wellbeing issue that
respondents either attributed to the job or believed to be
worsened by the job. This is followed closely by musculo-
skeletal symptoms (73.74%) and then digestive symptoms
(55.05%). Other impacts include social isolation (41.92%),
marital/family discord (36.87%), respiratory symptoms
(33.84%), and psychological distress (31.82%).
Just over 75% of participants agreed to the statement
‘My partner/spouse/friends think that my job has a nega-
tive impact on my social/family life’ (48.13% agreed, while
27.10% strongly agreed). Although psychological distress
was ranked the lowest in terms of wellbeing impact, the vast
majority of respondents indicated that the environment in
which Pilots work can contribute to the onset of or worsen an
existing a mental health issue (58.88% participants agreed,
while 28.5% strongly agreed).
Survey feedback also indicates that sources of WRS
impact on performance and flight safety. Over 78% of partic-
ipants agreed to the statement that ‘certain sources of Work-
Related Stress (WRS) have an impact on my performance
(58.50% agreed, while 20% strongly agreed). Furthermore,
just under 75% of respondents agreed to the statement ‘Cer-
tain sources of WRS have an impact on my performance
and by implication, have the potential to impact on flight
safety agree’ (52.02% of respondents agreed, while 22.73%
strongly agreed). Respondents were invited to identify spe-
cific performance impacts in relation to different sources of
WRS. 83.33% of respondents reported ‘working within the
close confines of the cockpit’ as the having the strongest
impact, specifically, in relation to distraction and inability
to focus on current task. Working irregular hours (76.8%)
and working long duties (76.53%) were rated as having most
impact on decision-making. Nearly 60% of respondents
agreed to the statement that they are ‘mostly coping well
and that periodically, they may make a mistake, but they
will identify their own mistake and correct their actions,
thus ensuring that a safety event does not occur’ (51.24%
agreed, with 8.46% strongly agreeing). Equally, nearly 70%
of respondents agreed to the statement ‘if something were
to give on the day, and I were to make a mistake, it is most
likely that my fellow pilot would detect this and take a cor-
rective action, thus ensuring that a safety event would not
occur’ (57.21% agreed, while 11.94 strongly agreed).
6.8 Coping mechanisms
Overall, workshop participants indicated that pilots attempt
to self-manage with some using sleep diaries and adopting
exercise routines. All participants alluded to the benefits of
talking with colleagues and/or friends and family.
In terms of survey data, pilots were asked to select from
list of common methods of coping with (1) non-WRS (stress
outside work) and (2) WRS (stress inside work). 61.64%
reported adopting coping strategies for non-WRS, while
55.30% reported using coping strategies for WRS. In rela-
tion to coping strategies for non-WRS, 30.48% reported
using positive diet each day. Only 1.23% used relaxation
devices/tools on a daily basis. At a weekly level, respondents
reported using sleep and fatigue (53.65%), exercise (52.88%)
positive diet (48.13%), and relaxation (14.11%). In rela-
tion to daily activities to manage WRS, the strongest focus
appears to be on sleep and rest (29.28%), diet (26.47%),
and exercise (13.61%). In terms of activities performed sev-
eral times a week, respondents reported exercise (49.74%),
positive diet (45.88%), and sleep/rest (45.30%). 22.56% of
respondents reported talking with colleagues, while 21.5%
reported talking with family and friends. The data analy-
sis indicates that pilots do not use relaxation methods as
frequently as others (2.84% every day, 11.35% a few times
a week, and 7.80% once a week). In addition, it indicates
that pilot use of professional supports is infrequent (1.54%
several times a week; 0.77% once a week).
6.9 Engagement
Overall, it seems that pilot engagement is quite low. All
workshop participants reported low level of engagement
with airline management.
In terms of survey data, just over 20% of participants
agreed with the statement ‘my employer and I share the
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Table 4 Impact scenarios
# High-level scenario Work-related stress (WRS) Wellbeing impact Impact on pilot performance Frequency Safety outcome
1 Pilots mostly coping well Any pillar—e.g., fatigue and
social isolation Minor impact Minor—sometimes degraded—
small errors and omissions Frequent None—pilot self corrects own
actions
2 Pilots mostly coping well, but
impacts on physical health
(e.g., gastrointestinal and
musculoskeletal issues)
Mostly biological pillar Minor impact—suffering in
daily life Minor—sometimes degraded—
small errors and omissions Frequent None—pilot self corrects own
actions
3 Pilots experiencing difficulties
but mostly coping—however,
something gives on the day—
potential for event but fellow
pilot acts as a barrier
Complex combination of
personal and work factors and
operational situation on the
day
Significant impact Loss of attention—Impact on
situational awareness, deci-
sion-making and teamwork
Infrequent Near-miss—Potential for incident/
accident, if not picked up by
other pilot
4 Pilots mostly coping, but long-
term impacts Any pillar—e.g., fatigue and
social isolation Long-term impact on health—
develop illness when on annual
leave on upon retirement
N/A N/A N/A
5 Pilots not coping—impact on
wellbeing Complex combination of per-
sonal and work factors Significant impact—suffering
in daily life—stop work-
ing—potential for serious MH
issues, including self-harm
and/or suicide
N/A N/A N/A
6 Extreme cases—murder–suicide Potentially pre-existing MH
issue Major impact Major impact Extremely rare N/A
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same set of values’, (19.14% agreed, while 1.91% strongly
agreed). Over 76% of participants rated the level of engage-
ment between themselves and their employer as poor
(38.10% rated it as very poor, while 38.57% rated it as poor).
6.10 Airline role andcurrent perception ofairline
management ofwellbeing/WRS issues
The workshops did not investigate existing airline
approaches in much detail. However, all participants indi-
cated that the airlines should have a role in relation to man-
aging issues pertaining to WRS and the ensuing impact on
pilot wellbeing, performance, and safety. Furthermore, all
participants noted that existing airline SMS systems do not
address issues pertaining to sources of WRS and impacts on
wellbeing, performance and safety. All participants indicated
that this needs to be addressed from a safety perspective.
Nearly 99% of survey respondents indicated that ensur-
ing and maintaining positive mental health for pilots should
be a key priority for all airlines (82.74% strongly agreed,
while 16.24 agreed). However, it appears that this is not
being taken seriously at an airline level. Just under 20%
of respondents agreed with the statement ‘Ensuring and
maintaining positive mental health for pilots is a key prior-
ity for my airline’ (10.15% agreed, while 8.12% strongly
agreed). 97% of participants agreed that the process for sup-
porting positive mental health and managing mental health
problems in Pilots should be clearly defined at an airline
level (63.27% strongly agreed, while 34.18% participants
agreed). However, survey data indicate that airline opera-
tional and safety processes fall short of this. A very small
number (11%) agreed that this process is clearly defined at
their airline (8.67% agreed, while 2.55% strongly agreed).
Furthermore, a small number of respondents (8%) agreed
with the statement ‘The Safety Management practices at my
airline adequately address issues concerning the support and
management of Pilot mental health and wellbeing’ (7.11%
agreed, and 0.51% strongly agreed).
7 Proposed interventions: airlines
andpilots
7.1 Introduction
Airlines and pilots need the right tools to safeguard the
wellbeing and mental fitness of pilots, and ensure flight
safety. Following the analysis of workshop and survey data,
a preliminary set of requirements for interventions at (1)
an airline and (2) pilot self-management level have been
identified. The interventions focus on (1) the promotion of
positive mental health, (2) the prevention of WRS/wellbe-
ing problems, and (3) the management of wellbeing/MH
problems. As such, prevention, predictive risk assessment,
and proactive risk assessment approaches underscore many
of the interventions. This links to Safety-II concepts, safety
performance evaluation processes pertaining to the evalua-
tion of ‘leading indicators’, and specific processes pertaining
to predictive risk assessment as defined in ICAO’s recent
‘Global Aviation Safety Plan’ (2019).
Overall, the proposed interventions go further than the IR
and GM provided by European Agency for Safety and Health
in Work (2019), in relation to the management of mental
health issues in pilots. This is discussed in more detail in a
later section.
In line with occupational health and safety approaches to
stress management, the interventions focus on three levels:
1. Primary: prevention (entire workforce)—promoting and
educating on WRS and wellbeing, preventing or mini-
mising the occurrence of stress and promoting stress
coping.
2. Secondary: protection/management (entire workforce—
including those who are suffering)—interventions tar-
geted at different stages in the lifecycle of being an
employee (i.e., recruitment, training, on the job mentor-
ing, on the job performance feedback, etc.) and manage-
ment of WRS & associated impacts on person.
Fig. 3 Wellbeing issues suffered
due to the job
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3. Tertiary: rehabilitation (pilots who are suffering—
including those who may need expert help)—managing
existing suffering, rehabilitating symptoms of existing
stress-related problems or diseases to minimise potential
harm. This also involves referring pilots to specialist
support services.
Furthermore, the proposed interventions map to the
Stepped Care model (NICE 2011), albeit they are adapted to
take into account the occupational context (i.e., pilot specific
adaptations) and the complex relationship between different
sources of WRS and the associated impact on the three pil-
lars of wellbeing (i.e., physical, social, and psychological).
In relation to mental wellbeing and mental health, the
interventions attempt to promote positive mental health and
mental wellbeing in the workplace, while also addressing
suffering and mental ill health.
Overall, the proposed interventions address the impact
scenarios as identified in the workshops and validated in
the anonymous survey. Accordingly, the proposed interven-
tions span all aspects of health and are not limited to MH.
The proposed interventions target routine suffering and its
impact on wellbeing (scenarios 1, 2, and 4), as well as well-
being issues that impact on performance/safety (scenario 3).
Evidently, there is a requirement for specific interventions
pertaining to mental health (scenario 5 and 6). In line with
workshop feedback, there is less of focus on extreme cases/
consequences (scenario 6).
The proposed interventions have their conceptual under-
pinnings in concepts of self-efficacy, awareness, acceptance,
and behaviour change. Our recommendations span the socio-
technical perspective (i.e., people, process, technology, cul-
ture, training, and environment). Smart technology is core
feature of many of these recommendations. However, the
interventions are not all technology-based. Finally, in some
cases, there is a link between certain interventions for (1)
airlines and (2) pilots—specifically, in relation to those
interventions that are technology-based and involve report-
ing and/or data sharing.
7.2 Airline approaches
Arguably, risks pertaining to crew WRS/wellbeing and
their impact on pilot performance and flight safety might be
more adequately managed at an airline level. Overall, field
research results indicate that airlines need to actively manage
these risks and adopt a systemic approach to assessing and
maintaining the health and wellbeing of pilots both ‘on the
line’ and at an earlier stage (i.e., recruitment and training).
In accordance with safety management system approaches,
specific wellbeing issues and associated performance/
safety risks need to be identified, prioritised, measured, and
managed.
Airlines need to address the occupational barriers to sup-
porting all the aspects of pilot wellbeing (i.e., stigma, long
hours, and working anti-social hours). As part of an organ-
ised approach, airlines might collaborate with health promo-
tion researchers, human factors psychologists, and clinical
psychologists, to see how existing approaches might be tai-
lored to the occupational context (this is specifically relevant
in relation to wellness support interventions and specific MH
interventions).
Table5 provides a summary of specific recommenda-
tions/interventions. Each intervention is associated with
an issue, and an impact scenario. Furthermore, a summary
indication (i.e. yes/no) of the potential implications of
these recommendations in relation to changes to existing
the implementing rules (IR), acceptable means of compli-
ance (AMC), and guidance material (GM) as documented
by European Agency for Safety and Health in Work (2019)
is also provided.
7.3 New digital tools forpilots
Table6 below provides a summary of the proposed require-
ments for new digital tools to enable pilot self-management
of WRS and wellbeing. The specific solutions are defined in
relation to existing problems and the six impact scenarios.
Overall, this includes functionality to support WRS and
wellness awareness, risk assessment in relation to WRS and
impact on wellbeing/performance/safety, personality profil-
ing and stress coping methods, reporting wellness issues,
coping skills, and resilience building and monitoring and
self-assessment of wellbeing. Specific functionality is tar-
geted at the management of specific sources of WRS such
as fatigue/sleep difficulties (Scenario 1) and operational risk
assessment at a pre-flight stage (Scenario 3). Furthermore,
a set of tools to support the promotion of positive mental
health for pilots, personality profiling and MH risk assess-
ment, the management of MH problems such as depression
and mood disorders (Scenario 5 and 6), and the manage-
ment of crisis situations (scenario 5 and 6) is also defined.
As indicated in Table2, some of the proposed functionality
links to potential airline interventions.
Primarily, we are focusing on tools for pilots—which
directly support safety behaviour. Other relevant stakehold-
ers (i.e., family member, PAG, clinician, and aeromedical
examiner) might have access to this information and/or anal-
ysis outputs, pending permission from the user/pilot. Fur-
thermore, additional reporting tools (i.e., observer reporting)
might be advanced for family members and others. Data
collected by ‘observer reports’ might be considered in terms
of wellness assessments/intelligence (i.e., facilitate inclusion
of observation reports/beyond self-report to mitigate report-
ing biases), and/or assessed by a clinician, if required (for
example, in relation to scenarios 5 and 6).
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Table 5 Proposed airline interventions: on the line
# Category Issue/problem Recommendation/potential airline intervention Impact scenario Recommendations
and regulatory
change
IR AMC GM
1 SMS design and risk assessment Airlines not gathering information about WRS/
wellbeing issues and associated impact on perfor-
mance and safety
Wellbeing/MH threats not identified in existing
Safety Management System
Define new safety performance indicators in rela-
tion to management of staff WRS and wellbeing/
MH
Gather data around WRS/wellbeing threats and
include in risk assessment process—see below
on reporting
All Yes Yes Yes
Existing SMS does not include specific processes
for risk assessment in relation to WRS and impact
on wellbeing, performance and safety
Advancement of new processes and tools to support
risk assessment in relation to WRS
Applying biopsychosocial framework
Integrated into SMS and reporting in relation to
WRS—see below
All Yes Yes Yes
2 SMS and reporting Reporting
No dedicated reporting process for wellbeing issues
Modification of existing anonymous reporting
systems to capture data about WRS/wellbeing
and impact on performance/safety
Reporting information might be linked to other
operational/safety information so that the impact
of sources of WRS in relation to (1) wellbe-
ing, (2) performance and (3) safety is better
understood. This should link to ongoing hazard/
risk identification and the identification of control
measures—and associated measurement of
outcomes at different levels
All Yes Yes Yes
Introduction of dedicated anonymous reporting
systems—which would feed into SMS (risk iden-
tification) and crew rostering systems.
All No No Yes
Airlines action their own wellbeing surveys—assess
prevalence of problem, identify sources of WRS
and impacts, elicit feedback on practical solutions
All No No Yes
3 SMS and fatigue risk management systems (FRMS) FRMS not linked to other biopsychosocial dimen-
sions of wellbeing
FRMS not standardised—variance in quality levels
Extension of fatigue risk management systems to
other biopsychosocial dimensions of wellbeing so
that fatigue understood in context of relationship
to other factors (i.e. diet, hydration, exercise)
All No No Yes
4 SMS and airline wellbeing/MH functions Lack of dedicated role/function within airline to
ensure the co-ordination and management of well-
being/MH support/training programmes, safety
promotion and interventions, management of risk
pertaining to WRS, wellbeing/MH etc.
Require new wellbeing role/function formalised
within SMS
All Yes Yes Yes
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Table 5 (continued)
# Category Issue/problem Recommendation/potential airline intervention Impact scenario Recommendations
and regulatory
change
IR AMC GM
5 WRS/wellbeing/MH: Stigma, awareness and culture Pilots have normalised wellbeing problems and
not aware that might be suffering—hence not
taking early action to mitigate potential adverse
consequences
Training—(1) general wellness awareness and (2)
promoting awareness of wellbeing/MH problems
amongst pilots and normalising this issue
Scenarios 1, 5 and 6 Ye s Yes Yes
Pilots not aware of WRS and associated impact on
wellbeing, performance and safety
Training—promoting awareness of WRS and
impact on wellbeing, performance and safety
Scenarios 1, 5 and 6 Ye s Yes Yes
Pilots not talking to line managers about wellbeing
problems—attributed to lack of trust and fear
about losing job or limited career progression
Pilot engagement low—this can be attributed to a
divergence in values between pilots and airline
management (third highest source of WRS)
Need to engage pilots—work with pilots on practi-
cal solutions that fit operation type and culture
Scenarios 3, 4, 5, and 6 No No Yes
Pilots denying, concealing or ignoring psychologi-
cal health issues (including both self-denial and
denial to others)
This can be attributed to
Pilot culture (machoism)
Stigma about MH
Airline culture—current perceived punitive culture
presents a clear threat to reporting wellness and
MH problems
Leadership and lack of understanding/awareness
In relation to both pilot culture and airline/organi-
sational culture, MH issues for pilots need to be
destigmatized. Pilots need to be encouraged to put
their hands up if they are experiencing difficulties.
Critically, pilots will not do this if they believe
the outcome will be punitive (i.e. loss of licence,
impact on career progression)
Development of a supportive and positive work
environment and culture in which the safety and
welfare of all employees is a priority
Scenarios 1, 5, and 6 No No Yes
Development of a Peer Assistance Network—see
below
No No No
Access to specialist confidential online supports via
Mhapps paid for by airline
No No Yes
Training airline leadership re MH and culture initia-
tives addressing stigma
No No Yes
6 Process design No formal process for briefing around wellbeing
issues
New pre-flight briefing process—incorporate
wellbeing briefing
Scenario 3 No No Yes
New checklists/tools to support briefing around
wellbeing/MH
Checklists/tools might be developed to support
pilots to identify MH risks. This might build on
prior research in relation to the application of
TEM concepts to the specification of an intel-
ligent flight plan, supporting pre-flight planning
and briefing (Cahill etal. 2011)
No No Yes
Processes for managing wellbeing/MH issues that
arise during flight operations (i.e. if co-pilot
suffering and expected or demonstrated impact on
performance/safety) not well defined
Airlines need to develop clear processes for pilots
in terms of managing wellbeing/MH issues that
arise during flight operations (i.e. if co-pilot
suffering and expected or demonstrated impact on
performance/safety)
No No Yes
Lack of flexibility in work/life interface Improved rostering/bidding processes and systems Scenarios 1, 2, 3, 4 and 5 No No Yes
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Table 5 (continued)
# Category Issue/problem Recommendation/potential airline intervention Impact scenario Recommendations
and regulatory
change
IR AMC GM
7 Training CRM training does not sufficiently address sources
of WRS and its impact
Training should focus on the less serious and more
common physical and mental health issues and
conditions that can arise as a result of WRS (i.e.
link to the job)
Scenarios 1 and 3 No No Yes
TEM Training does not provide suitable guidance
in terms of risk identifying behaviour—WRS
and impacts on wellbeing/MH, performance and
safety
Include training in risk identifying behaviour—as
part of TEM
All No No Yes
Insufficient emphasis on the pilot as an agent of
change and as having the ability to self-manage
their own health and positively contribute to
changes in quality of life and wellbeing
Encourage pilots to take responsibility for their own
health, giving them information on safety, health
and welfare and their own health and wellbeing—
see below on training and self-management tools
All No No Yes
Current training does not focus on the promotion of
resilience and the development of coping skills
(i.e. learning how to be resilient to challenges and
practice self-management techniques).
Current training does not focus on the promotion of
self-management techniques
Lack of support/training in terms of coping strate-
gies
Increase pilot’s ability to cope
Pilots need to be trained in terms of (a) self-man-
aging wellbeing issues and (b) risk identifying in
relation to their own wellbeing/MH (i.e. detecting
potential for problem/problem in self and manag-
ing this)
Require
Educational strategies to promote learning about
personal health and coping with stress (finding
coping strategies that suit person given occupa-
tional demands)
Specific wellness training—meditation, mindful-
ness
Maintaining work-family balance, and dealing
with complex professional practice situations that
eventually affect health and work performance
All No No Yes
Currently, no training/supports provided to pilots to
learn about their own personality style and ability
to cope with stress
Increased self-awareness and understanding of one-
self can be an effective preventive aid in curbing
the consequences of mental health decline
Use personality tests to promote awareness and edu-
cate pilots on personality type, ability to manage
stress and potential for MH problems
Also, educate on coping methods that make sense
for personality type
In relation to psychometrics/personality awareness
and assessment, the outcome should not be
disclosed to the employer, but process enabled by
employer to support employee awareness/coping
See what RAES recommending around Big 5 tests
All—but specifically 5 and 6 (MH) No No Yes
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Table 5 (continued)
# Category Issue/problem Recommendation/potential airline intervention Impact scenario Recommendations
and regulatory
change
IR AMC GM
8 Peer support and assistance Insufficient and inadequate support for pilots:
Experiencing general and less serious MH/wellbe-
ing issues
Experiencing decline in wellbeing/psychological
health
Experiencing wellbeing/MH problems—requir-
ing referral to specialist supports services where
appropriate
Require peer employee assistance programme
Require peer assistance network—provision of
confidential counselling and advice for all
All No No No
Confidential Peer Assistance Programmes not
standardised and/or widely implemented
Require peer employee assistance programme
Require peer assistance network—provision of
confidential counselling and advice for all
All No No No
Support networks help, but often there is a reluc-
tance to seek help/support within airline
Provide access to specialist confidential online
supports using online and/or Mhapps paid for
by airline
All—and specifically 5 and 6 No No Yes
Lack of support for crisis situations Require 24h/7day crisis support to deal with emer-
gency situations and ensure immediate referral to
clinical services and specialist help
Scenarios 5 and 6 No No Yes
9 Airline wellbeing/MH services/programmes Across the industry, there is limited evidence of
dedicated wellness programmes within airline—
focussing on preventing onset of problems
Such programmes are not the standard—but rather
the exception
Airline should implement a service focussing on
preventing the onset of wellbeing problems
This might include an array of employee wellness
activities to assist pilots with learning how to
recognize and cope with stress in a healthy way
Development of wellness management services—
yoga, meditations, groups to talk
The above would require adaptation given the work-
ing schedule of pilots and fact that often work
away from home
Scenarios 1, 2, 4 and 5 No No Yes
10 mHealth and MH apps Airlines not looking at external tools/resources (for
example, mHealth and MH apps)—in relation to
(1) safety promotion and (2) how they might inte-
grate to these, to promote better self-management
for pilots
Encourage use of mHealth and MH apps—to
support self-management and self-assessment in
relation to own wellbeing/MH
Scenarios 1 and 3 No No Yes
Advance own rostering functionality so can link
to apps
Advance tech, so that outputs of rostering can be
easily integrated into mHealth and MH apps—
specifically in relation to sleep and activity
Scenarios 1, 2, 3, 4 and 5 No No Yes
14 Assessment Currently, assessment is only carried out at the
recruitment stage—and not while flying the line
Pilots can develop MH problems at any stage in
their career
Define a new wellbeing/MH assessment process for
pilots while flying the line
All—but specifically 5 and 6 (MH) Yes Yes Yes
The aeromedical assessment of pilots should give
more attention to the less serious and more com-
mon mental health issues and conditions
Aeromedical examination should address routine
wellbeing/MH assessment –
Methods should be utilized to build rapport and
trust with the pilot in a nonthreatening environ-
ment
All—but specifically 5 and 6 (MH) No No Yes
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In relation to the proposed applications, this might involve
the use of mobile phones (i.e., phone apps) and other digital
devices. Furthermore, the proposed technology might be
integrated with other digital devices used by the pilot—for
example, Fitbit or other wearables, to enable the automatic
capturing of information (for example, in relation to sleep
and exercise).
8 Discussion
8.1 Mapping complex/wicked problems androle
ofaviation authority
Airlines and pilots need the right tools to safeguard the
wellbeing and mental fitness of pilots. Those seeking to
introduce solutions addressing wellbeing/MH problems (for
example, pilots, airlines, and aviation authority) are also part
of it. Stakeholders will have differing perspectives. These
perspectives influence how they think about the problem
and the solution. Thus, we need to engage all stakeholders
to find the best possible solution for all.
Pilots may argue that the airlines are not doing enough.
On the other hand, airlines can reasonably argue that they
are following the regulatory requirements (i.e. duties) as laid
out by the aviation authority. It is worth noting that airline
safety improvements follow from new regulatory guidance
and requirements. As such, the implementation of improved
safety practices pertaining to WRS and wellbeing (i.e., tool
recommendations emerging in this research) will largely
depend on the recommendations from the authorities and
potential modifications/changes to these. This is discussed
in more detail below.
8.2 Research recommendations andimpact
forrule‑making, acceptable means
ofcompliance, andguidance material
As stated previously, this research has led to evidence-based
recommendations for interventions to promote wellbeing
(including positive mental health and mental wellbeing) in
the workplace, both at an airline level and pilot self-man-
agement level. The interventions address awareness, pre-
vention, routine suffering, and mental ill health—following
from Safety-II concepts, safety evaluation metrics includ-
ing ‘leading indicators’, and proactive and risk assessment
approaches.
At an airline level, some recommendations from this
research (for example, in relation to training and culture)
can be addressed within the current regulatory framework
and associated rule-making (European Agency for Safety
and Health in Work 2019). As indicated in Table5 (see ear-
lier section), such recommendations might be considered in
Table 5 (continued)
# Category Issue/problem Recommendation/potential airline intervention Impact scenario Recommendations
and regulatory
change
IR AMC GM
15 Food and self-catering for pilots Research demonstrates that simple coping strategies
such as attention to diet and meals is useful—yet
existing regulations prohibit pilots to self cater
and bring own food
Work with Authorities/Regulator on other practical
solutions—pilots bringing own meals
All but specifically 1 and 4 Yes Yes Yes
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Table 6 Overall functions and features (pilot self-management tools)
# Issue/problem Proposed tool function/feature Scenario Airline link
1 Pilots have normalised wellbeing problems and not aware
that might be suffering—hence not taking early action to
mitigate potential adverse consequences
Pilots not aware of WRS/wellbeing risks
Pilots no clear benchmark to compare their own ‘WRS/well-
being level’ and associated risk
Wellness assessment and establishment of targets/goals
Pilot enter profile info and obtain preliminary wellness
assessment
Capture existing norms for person
Assessment against general norms
Assessment against pilot norms (at airline—pilots flying
similar range)
Directed towards goal setting and behaviour change—rec-
ommend areas/factors to focus attention on
Recommended approach/strategies
Goal setting and behaviour change targets
Link to other monitoring functionality (see below)
Scenarios 1, 2 and 4 If share sleep data can compare against other pilots at your
airline
2 Requirement to support self-management of wellbeing—
currently limited supports provided
Existing industry apps focus on subset of biopsychosocial
(i.e. fatigue/alertness)
Prompting ongoing self-monitoring of behaviour and
routine wellness assessment and managing any potential
decline in their psychological wellbeing (all and scenario
5 and 6)
Feedback on lifestyle/data entered—some automatically
generated (phone captures physical and sleep activity,
roster data etc.)?
Daily/weekly monitoring of key parameters
Sleep management
Activity and exercise
Social activity
Nutrition and diet
Mood
Potential inclusion of reporting feedback from others—to
avoid bias—require permission from pilot (for example,
spouse enters data on mood or other factor)
Rewards and feedback
Tools—screening/link to emergency help (Scenario 6)
Option to share with airline—use ‘anonymous’ data about
crew to inform assessment of risks (link to SMS) and
wellness programmes
Scenarios 1, 2, and 4
Scenario 6
Potential to share anonymised data with airline SMS
3 Lack of awareness/education in terms of how WRS impacts
on wellbeing and associated coping methods
Educates pilot on wellness—relationship between different
wellness factors—for example, mood, sleep and level of
socialisation
Education on WRS awareness
Educate on healthy lifestyle habits and coping strategies
Scenarios 1, 2 and 4 Corresponding programmes at airline—similar content
4 Pilots denying, concealing or ignoring psychological health
issues (including both self-denial and denial to others)
Requirement to support education in terms of MH aware-
ness and coping mechanisms
Education—MH awareness, how to manage MH problems,
supports available
Personality tests and risk factors for MH
Scenarios 5 and 6 Corresponding programmes at airline—similar content
5 Requirement to support pilots in terms of risk assessment
for WRS
Requirement to support pilots in terms of identifying
wellbeing risks that might impact on the operation and by
implication safety
Pre-flight risk assessment (self-assessment) in relation to
WRS and impacts on wellbeing/performance/safety
Scenario 3 Link to information from roster—assessment of fatigue
6 Requirement to support pilots in terms of sharing informa-
tion about potential wellbeing risks, as part of a pre-flight
briefing
Pre-flight briefing tool incorporated in pre-flight briefing
checklist
Scenario 3 Link to briefing checklist
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Table 6 (continued)
# Issue/problem Proposed tool function/feature Scenario Airline link
7 Requirement to obtain picture about operational real-
ity—gather information about current wellbeing status
of pilots—level of WRS, sources of WRS, wellbeing
impacts, performance/safety impacts
Lack of reporting about WRS and impact on wellbeing,
operational performance and safety
Reporting forms—send de-identified information to airline
so obtain picture of operational reality
Wellbeing report includes information about issue/source
of WRS, wellbeing impact, performance/safety impact
including near-misses and safety events)
Gathering of data (pending pilot consent) from any sleep/
duty logs—to inform operational picture
All scenarios Link to Airline SMS
8 Psychometric testing/assessment in recruitment and training
not meet on the line demands—need insights for pilot as
career progresses/wellbeing changes over time
Need to support self-management of wellbeing including
MH
Support personal insights re personality type, ability to man-
age stress and potential for MH problems
Requirement to educate on coping methods that make sense
for personality type
All scenarios Link to airline psychometric testing
9 Support networks help, but reluctance to seek help/support
within airline
Sharing of norms, info and tips across pilot groups/forums
Tools to support sharing info/tips with other pilots
Tools to enable a social support/network
Online groups
Calendar of events (sign-in and arrange online/offline
meet-ups)
Scenarios 1, 2, and 4
10 Personality tests—not linked to stress coping Get feedback about self/awareness (all scenarios)
Risk factors for stress (personality types)
Recommendations on coping methods/responses—linked to
personality type (all scenarios)
11 Sleep is a key source of WRS—require tools to support
sleep/fatigue management—in line with quantified self-
approach
Potentially pilots use many of the existing apps for sleep/
fatigue management—but not linked to biopsychosocial
Requirement to extend Jeppesen app to include diverse
sources of WRS—linking to biopsychosocial
Fatigue/Sleep component
Initial demonstration of tools—enhance sleep functional-
ity—to integrate airline rostering info with sleep diaries
Potential integrate with Jeppesen app
Extend Jeppesen to include biopsychosocial
Diet
Hydration
Physical exercise
Social activity
Relaxation
Mood
Scenario 1 Yes—link to roster information
12 No specific tools targeted at management of MH problems
for pilots—specifically in relation to mood disorders
Mood management (MH component)—customize existing
moodapps for pilots
Specific functionality linked to the Mental Health First Aid
model
Application of CBT and ACT therapies?
Scenario 5
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relation to a future elaboration process pertaining to safety
promotion material and guidelines. However, the current
OPS rules, AMCs, and GMs are insufficient to accommodate
all of the recommendations from this research. Certain rec-
ommendations require rule-making (amending rules, AMCs
or GMs) and/or modifications to the existing rules (European
Agency for Safety and Health in Work 2019). This pertains
to interventions to address.
• The promotion of wellbeing more generally.
• The promotion of positive mental health.
• Certain practical issues (such as diet and the ability of
pilot’s to bring their own food) that have an impact on
wellbeing and MH.
• Specific SMS safety/risk evaluation and safety promotion
processes and tools.
• New organisational roles for managing above and provid-
ing support above and beyond confidential peer support.
• ‘On the line’ assessment processes and supports.
Ideally, additional stakeholder evaluation research might
be actioned and/or undertaken by EASA. This might fol-
low the processes used in the initial stakeholder evalua-
tion/consultation process. Stakeholder engagement could
include IATA, the ERAA. and other industry organisations
[for example, the European Society of Aerospace Medi-
cine (ESAM), the European Association of Aviation Psy-
chologists (EAAP), and the European Cockpit Association
(ECA)], along with researchers gathering evidence pertain-
ing to these issues.
The existing IR does not address interventions at the pilot
self-management level (i.e., taking into account the work/life
interface). It is not likely that EASA can mandate/regulate
for the use of new self-management tools by pilots. How-
ever, these might be considered as ‘best practice’ and taken
into account in terms of EASA’s GM pertaining to safety
promotion and CRM training.
8.3 Safety evaluation andsafety performance
indicators
This research indicates that existing safety performance
indicators (SPI) require further elaboration in relation to
factors/measures pertaining to WRS and wellbeing. Exist-
ing SPI do not measure all aspects of wellbeing that con-
tribute to safe performance and flight safety. Given these
deficits, it could be argued that existing SPI result in a false/
incomplete picture in relation to (1) understanding routine
performance (i.e., pilots’ adapting/safety is maintained),
(2) understanding why accidents happen, and (3) making
flight safety estimates. To this end, we would argue that key
vulnerabilities exist in the current approach to risk/safety
management (i.e., proactive techniques are not considering
wellbeing dimensions linked to WRS). As indicated in this
research, if we use a different evaluation metric (for exam-
ple, consider metrics and SPI linked to wellbeing and WRS),
we might conclude that we are far from “Ultra-Safe” and that
a significant number of safety risks (i.e., wellbeing/MH) are
not being managed. Moreover, we are missing important
outcomes linked to pilot suffering and wellbeing (see sce-
narios 2, 4, and 5).
Crucially, this research indicates that pilots are coping
with significant challenges/sources of WRS (scenario 1). If
WRS leads to a potential error (scenario 3), this is typically
identified and managed by the co-pilot. The fact that pilots
are adapting/coping and working effectively as part of a team
is important. However, it should not be used to underesti-
mate or mask safety issues or wellbeing impact (scenarios
2, 4, and 5).
8.4 Data, risk management, anddecision‑making/
leadership
As stated in the EU report on The European Aviation Safety
Programme (EASP), ‘safety management needs to continu-
ously adapt to changes in the aviation market, technological
evolution, and the emergence of new safety hazards’ (2015).
The greatest hazards are those that we are not aware of, or
those that we naïvely believe do not apply to us. The collec-
tion of data enables us to not only look at past accidents and
incidents, but to also see what is happening in routine opera-
tions. This allows us to identify hazards and see what and
where the current risk trends are, and to identify potential or
new risks. Potentially, the above tools and specifically, (1)
crew reports: collecting data about sources of WRS which
have the potential to impact on pilot wellbeing and poten-
tially performance/safety, and (2) crew wellness informa-
tion: anonymous data about crew wellbeing levels via digital
self-management tools provide an opportunity for airlines to
advance a better understanding and assessment of wellbeing
risks. However, this is only one part of the process. Airline
management must be committed to acting on this informa-
tion and making real changes that yield benefits in relation
to staff wellbeing and operational safety. As defined, there
are two keys to being successful at being predictive in a reac-
tive world—(1) to have the data to verify the risk exists and
show that it is worth addressing, and (2) to have the support
of the decision-makers to address the risk without having an
accident to react to (Skybary 2019d).
8.5 Proposed interventions andlearning
fromcoping mechanisms
As indicated in this research, not all pilots are suffering.
This research presents a picture of pilots that are coping
and adopting strategies to enable them to cope with various
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work stressors. Fatigue and sleep management is a key strat-
egy, along with diet, exercise, and talking with others (col-
leagues and family). These strategies enable some pilots to
cope in a work environment that is detrimental for others.
If this relationship is better understood, then lessons might
be learned in terms of identifying strategies that enable
pilots to increase their resilience to WRS/wellbeing chal-
lenges (including MH). Furthermore, these coping strate-
gies might underscore interventions at different levels—and
specifically, in relation to new digital tools enabling self-
assessment and self-management of WRS for pilots.
8.6 Safety behaviours
This research calls for new definitions in relation to safety
behaviour for pilots. Arguably, we should conceptualize the
management of WRS and its impact on wellbeing, perfor-
mance and safety as a core safety behaviour. This concerns
managing WRS and wellbeing at different times—including
(1) recruitment, (2) training, (3) while flying the line, and
(4) while off duty. This follows from concept of behaviour-
based safety.
8.7 Research limitations
The results of this study should be interpreted/considered
with potential limitations in mind. In relation to both the
workshops and survey, the sample size is small. This limits
the statistical power of the study. Workshop participants may
have had difficulties self-reporting (i.e., issues pertaining
to trust and disclosing sensitive/personal information in a
group setting).
Survey participants were recruited using social media.
There may be issues pertaining to self-selection of candi-
dates (i.e., bias in relation to interest in wellbeing). Survey
data were self-reported. There is a potential bias in terms of
the respondent’s own perception. Furthermore, survey data
are cross section in nature. The results can only be used to
evaluate the sample for the time-period during which these
data were collected. Thus, no cause-and-effect relationship
can be drawn from the findings.
Additional research (for example, one-to-one interviews
with pilots) is required to unpack specific WRS issues and
wellbeing factors as emerged in both the workshop and sur-
vey feedback.
This research reflects the perspective of one stakeholder
group (namely pilots). This research needs to be validated
with other stakeholder groups. This might include clinicians,
occupational health and safety experts, airline management,
and the aviation authorities. Moreover, there is a specific
requirement to engage with both airlines and the aviation
authorities, in terms of advancing a road map for rule-mak-
ing and the implementation of solutions at an airline level.
Finally, the job of being a commercial pilot has some
positive effects. Furthermore, certain technical and non-
technical aspects of the ‘flying task’ have positive wellbeing
implications (Cahill 2010). Further research will address the
positive impacts of the job (in addition to sources of WRS
and its negative impacts).
8.8 Next steps
The next steps involve further analysis of the first wave of
this survey (November 2018–February 2019). A second
wave of survey data (spanning period from March to July
2019) will also be evaluated. In addition, we are planning a
second version of the survey to capture more detailed infor-
mation about the positive impacts of the job, specific sources
of WRS, and impact and coping strategies (specifically, in
relation to diet, sleep, physical activity, social activity, and
social support mechanisms).
We would also like to further validate our impact scenar-
ios with different stakeholders. Specifically, we would like
to obtain some measure of the frequency of these scenarios
and their impact.
Furthermore, interviews will be undertaken with pilots to
investigate specific sources of WRS, existing coping strate-
gies, and to evaluate the proposed tools both at an airline
and pilot self-management level. In relation to the proposed
self-management tools, we plan to prototype a subset of this
functionality. Following this, we will evaluate the prototypes
using co-design techniques.
In relation to specific airline solutions, we plan to under-
take broader stakeholder evaluation-based research to
validate the proposed solutions in terms of existing SMS
processes and tools, and to advance a road map for their
implementation at an airline level.
We also hope to undertake research with other opera-
tional personnel in the aviation system (i.e., cabin crew,
ATC, maintenance engineers, ground operations, airport
emergency services, and so forth).
Finally, we would like to use this research as an evidence
basis to engage with EASA and other interested parties/
working groups addressing the regulatory framework for
managing pilot mental health along with the promotion of
positive mental health and more broadly, pilot wellbeing.
9 Conclusions
If the wellbeing of pilots is being negatively affected by the
nature of their work (and specifically, stressors in the work
environment), this needs to be identified and measured, and
the associated risks managed accordingly.
In general, pilots try to normalise/adapt to the job and
manage wellbeing issues. However, there is much variation
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Cognition, Technology & Work
1 3
in relation to coping ability, with some pilots coping bet-
ter than others. As indicated in this research, this variation
needs to be considered in relation to (1) modelling perfor-
mance/safety impact, and (2) addressing wellbeing inter-
ventions at different levels (i.e., airline level and pilot self-
management level).
Addressing issues pertaining to pilot health and wellbeing
and sources of WRS is a problem whose solution requires a
great number of people to change their mindsets and behav-
iour and to collectively identify solutions of which they all
are a part. It is impossible to remove all stress from the work
life of pilots. The effectiveness of pilots coping techniques
affects their health and wellbeing. Therefore, it is important
for pilots (and their employers/airlines) to find healthy ways
for pilots to cope with work-related stress and wellbeing/MH
issues. As indicated in this research, there is much to learn
from existing coping mechanisms adopted by pilots.
The proposed interventions/recommendations attempt to
promote positive mental health and mental wellbeing in the
workplace, while also addressing suffering and mental ill
health. Critically, the proposed interventions are conceptual-
ized in relation to the six scenarios advanced in this research.
As such, they span all aspects of health and are not limited
to MH. The proposed interventions target routine suffer-
ing and its impact on wellbeing (scenarios 1, 2, and 4), as
well as wellbeing issues that impact on performance/safety
(scenario 3). Evidently, there is a requirement for specific
interventions pertaining to mental health (scenarios 5 and 6).
Recommendations are proposed both for airlines and at
a pilot self-management level. The proposed interventions
are designed to promote wellbeing and prevent or minimise
the occurrence of stress. Furthermore, they are designed to
help pilots manage or cope better with stress and the impact
on wellbeing, performance, and safety. It is hoped that in the
short term, some airlines may consider implementing some
of these solutions (voluntary measures) to promote mental
wellbeing. The specific solutions require further elaboration
using stakeholder evaluation methods (including feedback
from the authorities).
Airlines and pilots need the right tools to safeguard the
wellbeing and mental fitness of pilots, and ensure flight
safety. Some of recommendations arising in this research
relating to airline interventions can be addressed within
the current regulatory framework, while others will require
additional IR and/or modifications to existing IR, AMC, and
GM. The existing regulations do not address the pilot self-
management level.
Acknowledgements The authors would like to thank all those pilots
who participated in both workshop and survey research.
Appendix1: biopsychosocial model
ofwellbeing
See Fig.4.
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Fig. 4 Biopsychosocial model of wellbeing (workshop feedback)
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Appendix2: sources ofWRS
See Fig.5.
Fig. 5 Sources of WRS (work-
shop feedback)
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