Fat Necks—the Latest Safety Bogeyman!

November 20, 2013 by Bruce Landsberg

iStock_000004024837SmallOne more thing to be concerned about—but not to worry, a solution is at hand.

By now you may have heard that the federal air surgeon has decreed that someone who is overweight with a fat neck is a hazard in the cockpit. That’s not the diplomatic way of putting it, but there it is. I am more concerned about fat heads and the occasional lack of judgment, but that’s not what this is about. One could surmise all kinds of potential hazards, but the fear is that a large person with a 17-inch neck will (my emphasis) suffer from obstructive sleep apnea (OSA). This is a condition where someone does not sleep well at night and therefore is likely to fall asleep almost anywhere, anytime. Reminds me of many college students, but I digress.

This is not to make light of the condition or the individuals who suffer from OSA, but to point out that pilots—as a group—have exercised good judgment relative to medical hazards. There are exceptions, but regulation by anecdote is a bad idea and unfair to the vast majority who play by the rules.

Never mind that there is no general aviation accident or incident data that supports this level of intervention. The NTSB investigated a regional airline crew falling asleep and overflying the destination. Here is what the NTSB said, “Contributing to the incident were the captain’s undiagnosed obstructive sleep apnea (OSA) and the flight crew’s recent work schedules, which included several consecutive days of early-morning start times.” There are some air carrier ASRS reports on file regarding OSA but these are few and far between.

So this and some other anecdotal evidence is the basis for such a sweeping change? The airline industry has been under the gun for sometime about work schedules, but instead of addressing Part 121 operations, the blunt tool is used and we take in all pilots.

A friend, Dr. Brent Blue, who is a senior aviation medical examiner said, “So let us say this pilot has a neck size over 17 inches and a body mass index (BMI) over 40. (BMI was developed and only supposed to be valid for use with populations of people, not individuals. Use with individuals has been shown not to be valid. Tom Cruise’s BMI is 26 putting him in the ‘fat’ category. LeBron James is 27.5—fat as well!) Now the FAA says that I must delay his medical until he sees a ‘sleep specialist’ and either does not have OSA, or is treated successfully.” 

At the Air Safety Institute we keep close tabs on GA accidents, and the number of pilot incapacitation accidents does not appear to support keeping the 3rd class medical in its entirety, let alone adding OSA as a major incapacitation hazard. And if it was such a big problem, how come the GA safety education community wasn’t notified much sooner before an edict was issued? Was this just  a failure to communicate?

Another case of the bureaucracy creating a solution in search of a problem? Maybe the FAA should just work on the backlog of 50,000 special issuances that they claim is overwhelming them.

Don’t misunderstand—we are all for reasonable safety and regulation but the adjective describes all. OSA can be a problem and should be dealt with, but there are other conditions as well that might need attention. We give individuals the latitude to make the right choice. One-off events just are not the basis for good regulation. AOPA is opposing this until compelling and valid data is forthcoming. Join us in this effort, won’t you?


Bruce Landsberg
Senior Safety Advisor, Air Safety Institute

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  • Eric leuty

    I think there are several hundred college and pro football players who will disagree with this ill conceived logic about BMI, neck size and OSA

  • Carolyn Bomberger

    I think being overweight in general is a concern especially for men who carry their weight in the belly area. However the AME’s know this. Pilots know this. I believe for the most part pilots and AME’s deal with this appropriately.

    Falling asleep in the cockpit isn’t always because a pilot has a big neck or sleep apnea. It could just be boredom. Coffee helps!

  • http://Advocatetax.com Louis Meiners

    The neck size is particularly offensive to me. Although I could afford to lose a few pounds, (BMI 30); my neck size is the same as my biceps 17 1/2. I am not obese, I am 6’5″ and work out 6 days a week. The referral to sleep apnea is not BMI of 40 plus a neck size of 17, it is either one. I am working on getting my BMI down below 25, but I will never get my neck below 17.
    This will require a special issuance with annual testing and inordinate delays. It took 3 months to get the special issuance through before the shutdown and I suspect it takes much longer today. The test results will normally need to be within the last 3 months so it will be a never ending cycle, (particularly when the discover that tall guys with BMIs under 40 have big necks.

  • Marc Leasa

    If you think what our government is trying to do here is obsessive wait until they take over healthcare!

  • Desi Bray

    I guess this will end my flying for good. Yes, I could lose a few extra pounds, but I will never get my next size or my BMI below those limits. I will not go through the hassle of a special issuance again, I have one for vision already and it was a pain in the rear. To bad..

  • Chris Rodrigues

    Agree with you on this one, Bruce. I was diagnosed with SEVERE OSA five years ago and went on a CPAP. Have slept well since then. On the other hand, I never had a problem getting sleepy while flying before the CPAP. Of course, since I don’t have an autopilot, I never get bored while flying. What I worry about is the abrogation of the required Federal administrative rule making process. Did our FAA Chief Flight Surgeon implement this as a emergency ruling? If so, where is the supporting data required by Federal administrative rule making process for emergency rulings? Unfortunately, this appears to have the watermark of the current administration, which seems to routinely disregard existing restraining statutory and administrative regulations as “nonbinding suggestions”. Need I provide recent examples (both inside and outside of the field of aviation)?

  • Geff McCarthy

    The negative reaction to this proposed – and valid – medical screening is expected.
    Mr. Landsberg, I am disappointed that you wrote before thinking, and even more so in your medical “expert.”
    OSA occurs in at least 70% of people with BMI >40. Hypertension occurs in a small % of normals, yet we routinely screen for it. Since the EKG is an unreliable predictor for occult heart disease, the FAA requires it only after age 40. Even then, EKG screening is not demonstrably valid. Yet we accept it.Why should screening for OSA be treated differently?
    OSA would not be cited in any accident, nor should it be. The contributing cause would be fatigue, which is chronic in those with OSA, acute in most accident reports. Dr. Tilton and his FAA colleagues have formulated a correct, scientific policy that is clearly derived from the epidemiology of OSA, as they have for all other diseases.
    Remember, this applies only to BMI. 40, the level at which insurance companies will pay for a gastric bypass. The actual number of pilots to which this will apply is miniscule. And as for the threat of requiring screening, I cannot forsee any mandate <35, as the incidence is far lower.
    As for your correspondents with high BMI who are fit and muscular, they should be exempted. The BMI is a gross indicator of body fat %, it does not account for muscle mass.
    Lastly, as a doc I applaud my friend, Dr. Tilton's,effort not only to make flying safer, but to prod the fat to get fit. Stop whining; start walking to your hangar!
    GW McCarthy MD DipAvMed

  • CK

    Several years ago, sleep apnea was the disease-du-jour and sleep centers were popping up like mushrooms after a spring rain. The panic died down and the FAA is now taking up the cause of general health pertaining to overweight and obesity.
    While sleep apnea is a real, and potentially a debilitating condition, everyone who is overweight, obese, or who snores does not have sleep apnea as the FAA would now like the public to believe.
    A major problem with the sleep centers is that they have a conflict of interest in as much as they are the dispensers of the CPAP equipment. No apnea – no sale! My physician once mentioned to me that in every instance, without exception, every one of his patients who had a sleep study done was diagnosed with sleep apnea.
    As mentioned previously, there are many other conditions or situations which can cause drowsiness, whether in the cockpit or not. Indeed, diagnosis of sleep apnea must show wake-time symptoms along with sleep time data. How would people react if they were required to be screened for sleep apnea in order to obtain a drivers license? Is the public any less entitled to be safe from drivers who fall asleep at the wheel?
    The above comment that we screen for hypertension and have EKG’s taken is a red-herring. Both of those screenings are quick, and inexpensive. Similarly, the medications used to treat those conditions are inexpensive, so long as the conditions are mild to moderate.
    While I agree with the FAA’s position of trying to assure that pilots do not experience any sudden incapacitation, this is an ill conceived dragnet approach to something which has not been shown to be or become a problem.

  • Robert


    Thank you for exemplifying the FAA point of view. Namely, since “we” already have unreasonable requirements, it is OK to impose yet further unreasonable requirements. To use your words:

    “Hypertension occurs in a small % of normals, yet we routinely screen for it.”

    Yes “we” do, and that requirement is unreasonable. You, the FAA, and the NTSB have not shown ANY evidence that screening for hypertension has prevented even one accident.

    You write: “EKG screening is not demonstrably valid. Yet ‘we’ accept it.”

    This is an even better example, since EKG’s are not required for 3rd class medicals, but are required for 1st class. I challenge you and your expert buddies at the FAA and NTSB to show differential statistics for accidents caused by heart failure in 3rd class vs. 1st class holders that would have been prevented by EKG screening.

    You love that word “we”, don’t you? “We” do NOT accept it. It is unreasonably forced upon us by presumably well meaning bureaucrats, though I’m beginning to doubt that last part.

  • http://doxeyENT.com Paul Doxey, M.D.

    I am a physician/pilot who specializes in sleep apnea with 28 years of experience treating it. The issue here is whether a pilot has sleep apnea causing significant non-refreshing sleep which impairs safe flying. BMI is a quideline only. So is the neck size. There are plenty of people who have an elevated BMI and large necks who are muscular individuals and have no sleep apnea at all. The problem with obstructive sleep apnea is a collapsing airway during sleep. Obesity and being out of shape contribute signifcantly to this problem. Sleep apneics are usually loud snorers. Only a sleep test will show what is really going on. Again the issue is whether a pilot has sleep apnea or not. The BMI and neck size are “pieces of a puzzle” that may indicate that a pilot needs sleep testing to discover what is really going on. There are other factors which would encourage a physician to order a sleep test. One of those would be how a pilot may answer a short standardized questionnaire about how refreshing sleep is for him or her. I think relying solely on the BMI and neck size is short sighted and incomplete. I think that AMEs need training on how to negognize who may need a sleep test. At the time of an anual exam, the physican can look at the whole health picture and recommend the best way to go. Otherwise, a lot of pilots will open a “can of worms” and now have the feds invloved in their lives and they don’t go away quickly.

  • Mike Duncan

    So tell me Geff do you have a contract pending on OSA with the FAA. This is just the latest example of the government impleting a solution to a problem that doesn’t exist just merely perceived. It’s all about money, always is. I guarantee that anyone who goes in for a sleep study will have sleep apnea. As far as you doctors being the experts I take everything you put out with a grain of salt. I know of three people personally who died within a year of being pronounced perfectly healthy one of which was only days past his physical. If this is allowed to stand there will be pilot openings at the airlines by the thousands and GA will no longer exists. Here’s to hoping AOPA can have some influence and get this stupid decision overturned or at least make the warning sighs that warrant a sleep study be accurate. Lots of luck to us all there.

  • Dr. Julio Quevedo E.,M.D.

    I am writing this as an Otolaryngologist – head & neck surgeon.
    Sleep apnea is a groslly over diagnosed condition, and equally treated wrongly.
    Trouble is that most doctors think that they can perform as OtoRhinoLaryngologist with out any training at all. Probably the worst offenders are the pulmonologists, that really screw up trying to treat sinus problems and sleep problems, while being totally uncapable of doing a nasal and/or pharyngeal examination.
    Obstructive sleep apnea is, by definition, an obstructive problem, and it can be
    anywhere in the respiratory tract: colapsing nostrils, deviated septum, hypertrophic turbinates, nasal polyps, hypertrophic adenoids, flaccid palate, enlarged pharyngeal tonsils, and VERY, VERY important hypertrohic lingual tonsils.
    As you all know, the competence of a neurologist or a pulmonologist and most so called sleep experts to investigate ALL these areas is NON EXISTENT. But they claim to be sleep specialists. All they do is send the patient to a polysomnography test and then prescribe a CPAP device. The information they get from a polysomnograph, just confirms what the wife has been complaining about. The person just SNORES all night long, with irregular breathing, which is normal in most individuals, and mis-diagnose it as sleep apnea.
    They really propose a solution for a, most of the time, non exixting problem.

    I just checked with the doctor in charge of the sleep disorders clinic at the
    Otorhinolayngoly Department of the University of Iowa, USA, where I trained
    50 years ago. He told me that they NEVER use a CPAP. Instead, they check for
    all possible obstructions and correct them surgically. Just as I do.
    So, all this amounts to a money racketing problem, as WADA and drugs in sports is.

  • http://aopa Jim Borger

    I remember when they dictated drug testing for 121 and 135 pilots. The FAA predicted at least 10% of the tests would be positive. Not even close. Now this.

  • Curtis Edwards, MD, FACS

    As a senior AME, and HIMS Independent Medical Sponsor, a boarded general and vascular surgeon, and a former Naval medical officer, I am occasionally perplexed by the laxity and archaic nature of FAA regulations. part 67 rewards little a healthy aviator or aviator with a well controlled medical issue who routinely visits his physician, and supplies records for medical recertification. Experienced AME’s commonly must answer to technicians and Assistant FAA air surgeons who are hide bound by rules. Some have bad habits and occasionally an attitude. Don’t misunderstand, FAA Certification Division plays a necessary role in pilot safety. We don’t fly our airplanes without an annual (at least I don’t).
    Part 67 unfortunately gives a negligent aviator enough rope to hang himself and the three hundred passengers in the jet he collided with in class B airspace. The military standard for over fat in men is BMI = 30; 35 is obese. American Heart Association agrees with this for good reason. But before going to the fat farm, it must be confirmed with a standard skin fold test, a more reliable exam. FAA is asking for BMI = 40 as the cut-off where 75% of pilots WILL HAVE DIAGNOSABLE SLEEP APNEA. Applied with latitude and judgement, its a good rule. A pilot with a BMI = 40 cannot reliably use the rudder pedals and exercise full elevator control simultaneously; his belly is just too big.
    The difficulty for my average aging or medically deferred pilot is appreciating why the rules are there to begin with. First, the rules protect you and also allow you to insure your plane. A pilot like a physician assessing himself medically has a fool for a doctor and a fool for a patient. Unlike driving a “6000 lb. SUV,” when a medical condition inserts itself into the equation during the multitasking of an approach or at 10000 feet – possibly in unanticipated IFR – you can’t pull over to the side of the road. On final, five seconds of inattention allows the law of gravity (and entropy) to take over at 80 knots and 500 feet AGL. Closure with the ground at that speed is about 132 feet/sec/sec. In five seconds, you are already dead. Good literature exists concerning bursts of micro-sleep (only seconds in duration) in the chronically fatigued. This is why the FAA is reluctant to allow aviators to fly while taking many commonly prescribed drugs with proven track records of causing sleepiness as a side effect, “do not operate heavy machinery while taking.” The latter warning gets the drug company off the hook when you turn yourself into a smoking hole or a ball of plastic and steel on the freeway.
    AOPA would be better served if they pursued a policy of modernizing the thinking at FAA certification division. Get rid of antiquated rules like the resting ECG ( a test added in the 1950’s). Good AME’s should be allowed to exercise judgement, bad AME’s should be eliminated. However, an AME looking at a big fat pilot with class 1 hypertension should be allowed to say, “you need a cholesterol level and a treadmill,” currently not allowed. Third class pilots do not merit amateur medical licenses, as I am not allowed to perform my own medical certification exam for good reason. We don’t allow pilots to perform major structural repairs on an aircraft without an A/P sign off, I think a physical every couple of years is a minimum safety requirement. By the way, NTSB does require commercial drivers to have a physical exam every one to two years depending on their health.