Pilots With Diabetes Fight for Their Right to Fly
Commercial pilots with insulin-treated diabetes are being grounded. The American Diabetes Association is working to change that
As a pilot for the FBI, Bryan Stone flew a variety of surveillance missions out of the bureau’s Salt Lake City office. He investigated murders, covered security for the 2002 Winter Olympics, and, during a case Stone refers to as the “Stolen Dinosaur Caper,” gathered aerial photographs of a dig site where a rogue paleontologist had illegally excavated a Tyrannosaurus rex. “I was able to get quite a bit of unique flying experience,” Stone says of his time with the bureau.
By the time he left the FBI in 2009, at age 46, to pursue other opportunities, Stone had logged nearly 3,000 flight hours. He was confident his experience would allow him to fall back on a career as a commercial airline pilot. But the same week he left the FBI, Stone was diagnosed with type 1 diabetes. It was as if he’d been handed a pink slip.
“I never thought I’d fly again,” says Stone, now 56. A policy change years later would offer renewed hope, but also confusion.
Fit to Fly
Becoming a pilot is a complicated process. License requirements vary depending on the type of aircraft you plan to fly but, in general, pilots start by spending time and money going through flight school. They must pass a series of exams and record dozens of hours of flight time. Obtaining a commercial license—a necessary step for anyone hoping to get paid to fly, including as a pilot for a major airline—is even more stringent. All licenses are granted by the FAA.
Pilots also have to prove they’re physically fit to fly. Medical certificates come in three tiers with varying levels of health requirements. A third-class medical certificate allows an individual to fly recreationally or as a student. A second-class medical certificate allows pilots to take paying commercial jobs, such as transporting cargo and piloting helicopter tours. First-class certificates are required for airline transport pilots in command of scheduled airliners—those planes most people take when they fly out of town for vacation.
Diabetes isn’t a problem in and of itself. Pilots with the condition can receive what’s known as a special issuance medical certificate (licenses issued on a case-by-case basis by FAA-approved medical examiners for people with otherwise disqualifying medical conditions) as long as they have a proven ability to manage their blood glucose. But if that management plan involves insulin, the FAA’s approval process gets more complicated.
“For a long time, the FAA had a blanket policy saying we’re not going to certify any insulin-treated pilots for any type of certification,” says attorney Julius Chen, a partner in Akin Gump’s appellate litigation practice who works pro bono with the American Diabetes Association (ADA). That policy changed in 1996 when, thanks to a collaboration between the ADA and the FAA, the FAA began granting third-class medical certificates to pilots who use insulin.
While this was a major step forward, the FAA’s decision to allow pilots with insulin-treated diabetes to fly privately but not commercially raised more questions.
Contradictions at 20,000 Feet
By issuing medical certificates, the FAA wants to ensure that pilots don’t have any conditions that could incapacitate them midflight. Having a pacemaker, epilepsy, or a history of substance abuse are all disqualifying conditions that could endanger passengers, crew, and bystanders on the ground. Certain diabetes-related complications that can inhibit pilots—eye and heart problems, for instance—aren’t exclusive to diabetes and are tested independently by the FAA.
As for insulin-treated diabetes, the FAA’s concern is hypoglycemia (low blood glucose). Which is understandable. That’s why anyone with diabetes receiving a special issuance must have a record of successfully managing their blood glucose—that is, a report signed by a treating physician that shows avoidance of “clinically significant” hypoglycemic episodes in the past 60 days.
But the fact that this policy doesn’t extend to second- and first-class certificates makes little sense, says Daniel Lorber, MD, an endocrinologist who serves on the ADA’s advocacy committee. “How many people are in the cockpit of a private plane usually? One. If that person gets hypoglycemia, that plane crashes,” he says. “How many people are in the cockpit of a commercial plane? Never less than two. It’s counterintuitive. [The FAA] approves a situation where hypoglycemia would cause a crash but does not approve a situation where there’s a backup pilot.”
In other words, someone with insulin-treated diabetes can still fly over crowded metropolitan areas. They just can’t earn money while they’re doing it.
Adding to the confusion is the fact that the United States is behind the curve. The United Kingdom, Australia, New Zealand, and Canada all allow insulin-treated pilots to fly commercial airlines. These pilots can enter U.S. airspace.
“If you’re a Canadian pilot on insulin, you can fly from Montreal to LaGuardia and back with no problems,” Lorber says. “If you’re an American pilot on insulin, you cannot fly from LaGuardia to Montreal.”
To date, there have been zero reported accidents involving certified pilots with insulin-treated diabetes.
Pilots on Standby
In mid 2019, the ADA launched a new case to advocate for the rights of pilots. This is a continuation of an effort that began in 2014, when the ADA reached out to the FAA about expanding the special issuance medical certificates.
“The FAA asked us to convene an expert panel to make recommendations,” says Sarah Fech-Baughman, JD, director of litigation for the ADA’s government affairs and advocacy division. Despite these efforts, in 2015, the FAA ultimately rejected the recommendations.
But then the FAA did something curious.
That year, it suddenly updated its first- and second-class medical guidelines, saying they would consider pilots with insulin-treated diabetes on a case-by-case basis. How many have been approved thus far?
“We know that many pilots have applied under that guidance,” Fech-Baughman says. “All of their applications are pending with the agency. They’ve just been sitting in a virtual pile for, in some cases, four years.”
Enter Eric Friedman. As a commercial airline pilot with type 1 diabetes, Friedman had applied for a special issuance with the FAA in 2015 with no luck, so the ADA went to court on his behalf.
The FAA argued that it needed continuous glucose monitoring (CGM) data to guarantee Friedman’s fitness, but the costly device was not recommended for his treatment, and the FAA wouldn’t say what standards they would use to judge the CGM data. So he refused. “When Eric said he wasn’t going to submit the CGM data, it was a convenient way for the FAA to say, ‘Okay, we’re not going to do anything until you do,’ ” Chen says.
But while Friedman declined, several pilots have included CGM data with their applications. Despite having seemingly satisfied the FAA’s requirements, these pilots’ applications are still pending. One of these individuals is the subject of the ADA’s latest case, and Fech-Baughman is hopeful that it will lead to a formal FAA policy that clarifies how, exactly, the agency determines who they approve. “Pilots who are applying for a certificate should know what metrics they’ll be judged by so they have a chance to meet those metrics,” she says. “It’s only fair.”
The United States is currently in the midst of a pilot shortage. As many pilots with insulin-treated diabetes wait for FAA approval, some pilots are tempted to seek work abroad. “I can work for Canadian airlines,” says retired FBI agent Stone. He began updating his flight certifications after hearing about the FAA’s 2015 update. “I can do that for a year, two years, five years—however long it takes the FAA to approve my medical here.”
That sense of urgency is understandable. Each year he spends awaiting approval is another year of lost wages. The median annual wage for airline pilots is $150,000 according to the U.S. Department of Labor, and with his flight experience, Stone could make closer to $200,000 a year. “I’ve lost four years of high pay at this point,” he says.
Since commercial pilots have a mandatory retirement age of 65, Stone has less than 10 years left to fly for an American airline. But he’s also concerned for younger pilots who have invested time and money in a career they may never get to begin.
Pietro Marsala was in the middle of commercial training when he was diagnosed with type 2 diabetes at age 21. He was grounded for six months while stabilizing his blood glucose levels with insulin, but after switching to metformin, he was granted a special issuance first-class medical certificate.
There was a catch: The oral medication failed to keep his levels in check. Marsala’s doctor realized they had misdiagnosed him.
“My endocrinologist said, ‘It’s type 1. You need to stay on insulin,’ ” Marsala says. “It was heartbreaking for me, to know that my career and dream of becoming an airline pilot was potentially over.”
Marsala finished his flight training and currently works as a flight instructor and a check airman in Phoenix, where he’s responsible for evaluating other commercial airline pilots. He flies on a daily basis under his third-class medical certificate and has waited over two years for the FAA to approve his first-class certification. “I’m ready to take that next step in my career,” Marsala says.
These delays can affect more than just commercial airlines. Working in Northern California, 48-year-old Van Bogardus is the only certified helicopter pilot of the Placer County Sheriff’s Office. When he was diagnosed with type 1 in 2015, the FAA pulled his medical certificate. He was grounded, and the county was left without a rescue helicopter.
“There were calls for services we just couldn’t go handle, so it compromised public safety,” Bogardus says. His office relied on air support from surrounding counties and trained another officer to fly until Bogardus could receive his third-class medical. Even with this certificate, he’s still limited in the types of missions he can fly.
With plans to retire from the sheriff’s office at age 50, Bogardus is still waiting for approval of a second-class medical so he can pursue other career opportunities.“If I’m responsible and show a proven track record, why can’t I fly?” Bogardus says. “Why is the FAA grounding me and taking away my career opportunities?” That frustration, shared by many, is one the ADA is working to address.