Section 26


Physicians in Canada have the following obligations for patients who are pilots, flight engineers, or air traffic controllers:

  • Physicians are subject to the mandatory reporting requirement outlined in the Aeronautics Act , Section 6.5, which requires that any pilots, flight engineers, or air traffic controllers who have a medical condition that could affect aviation safety be reported to the regional aviation medical officers of Transport Canada.
  • Physicians should remind pilots of their obligations under the Canadian Aviation Regulations, Section 404.06, to not exercise their privileges if they have an illness, injury, or disability; are taking medications or drugs; or are undergoing medical treatment that could impair their ability to function safely.
  • Physicians may countersign medical declarations for lower-risk categories of aviation licences or permits.

26.1 Overview

For the purpose of this guide, all references to “pilots” will apply equally to flight engineers and air traffic controllers, unless otherwise stated. As well, “pilots” include airline transport pilots, commercial pilots, private pilots, student pilots, and recreational pilots. The types of aircraft they may fly include fixed-wing planes (jet and propeller-driven), helicopters, balloons, gliders, ultra-lights, and gyroplanes.

All pilots are holders of Canadian aviation documents that impose standards of medical fitness. Regulation of pilots is under federal legislation (not provincial or territorial, as is the case for motor vehicle drivers).

Periodic examinations of pilots are performed by physicians, known as civil aviation medical examiners (CAMEs), who are appointed by the minister of transport. Episodic care of pilots is often undertaken by community physicians.

Before being examined, all pilots must inform the physician that they hold an aviation licence or permit. When pilots are informed that they have a condition (or treatment is prescribed) that might make it unsafe for them to perform their duties, they must “ground” themselves temporarily, according to Section 404.06 of the Canadian Aviation Regulations (1996) (CARs).

A physician diagnosing a condition that might affect flight safety must report the condition to a regional aviation medical officer ( RAMO) of Transport Canada. See Section 26.7, Contacts, for information about reaching a RAMO.

26.2 Aeronautics Act

All physicians in Canada have mandatory reporting obligations under Section 6.5, “Medical and Optometric information,” of the Aeronautics Act (1985), which reads as follows:

  1. Where a physician or an optometrist believes on reasonable grounds that a patient is a flight crew member, an air traffic controller or other holder of a Canadian aviation document that imposes standards of medical or optometric fitness, the physician or optometrist shall, if in [their] opinion the patient has a medical or optometric condition that is likely to constitute a hazard to aviation safety, inform a medical adviser designated by the Minister forthwith of that opinion and the reasons therefor.
  2. The holder of a Canadian aviation document that imposes standards of medical or optometric fitness shall, prior to any medical or optometric examination of [their] person by a physician or optometrist, advise the physician or optometrist that [they are] the holder of such a document.
  3. The Minister may make such use of any information provided pursuant to subsection (1) as the Minister considers necessary in the interests of aviation safety.
  4. No legal, disciplinary or other proceedings lie against a physician or optometrist for anything done by [them] in good faith in compliance with this section.
  5. Notwithstanding subsection (3), information provided pursuant to subsection (1) is privileged and no person shall be required to disclose it or give evidence relating to it in any legal, disciplinary or other proceedings and the information so provided shall not be used in any such proceedings.
  6. The holder of a Canadian aviation document that imposes standards of medical or optometric fitness shall be deemed, for the purposes of this section, to have consented to the giving of information to a medical adviser designated by the Minister under subsection (1) in the circumstances referred to in that subsection.

26.3 Physician responsibilities

26.3.1 Reporting

If uncertain whether a condition might affect flight safety, then the physician should discuss the case with a RAMO. See Section 26.7, Contacts, for information about reaching a RAMO.

If certain that a condition might affect flight safety, the physician must take the following steps:

  • Advise the pilot of the medical condition.
  • Remind the pilot of their obligations under CARs Section 404.06 to not exercise the privileges of their licence or permit; i.e., to self-ground.
  • Report the case to a RAMO. The report will be confidential and privileged.
  • Once a report under Section 6.5 of the Aeronautics Act has been made, it is the RAMO’s responsibility to take further action. Although Transport Canada may use the reported information as necessary to ensure aviation safety, the report itself cannot be used as evidence in any legal, disciplinary, or other proceedings against the reporting physician.

Physicians may wish to contact the Canadian Medical Protective Association for advice should they have questions about their reporting obligation. See also Section 3, Reporting — when and why, in this guide.

26.3.2 Physician countersignature

Some lower-risk categories of aviation licences and permits do not require applicants for a medical certificate to visit a CAME. A pilot can instead visit any licensed physician in Canada to request that the physician countersign a medical declaration form, indicating they are fit to perform the aviation duties associated with the particular category of licence or permit. If the pilot does not have any of the conditions listed on the declaration, then the physician may countersign the declaration. However, if in the physician’s opinion the applicant may require further assessment for fitness for aviation, the physician may recommend that the applicant seek a medical examination from a CAME.

26.4 Medical conditions

This section of the guide is not intended to replace a textbook on aviation medicine. It is designed simply to alert community physicians to aspects of medical fitness that are of unique importance to aircrew and to list the medical conditions to which the mandatory reporting requirements apply (as detailed in Section 26.5, Conditions that must be reported by the physician).

Any condition or treatment that, in the treating physician’s opinion, may interfere with flight safety but is not found in this listing, should still be reported. If uncertain, the treating physician may contact a RAMO for guidance (see Section 26.3.1, Reporting and Section 26.7, Contacts).

Further information on specific medical conditions may be obtained from the Civil Aviation Medicine branch of Transport Canada:

Pilots with any of the conditions listed in Section 26.5 are obligated not to exercise the privileges of their licence or permit pending assessment by a RAMO.

26.5 Conditions that must be reported by the physician

26.5.1 Vision

Conditions where visual impairment is temporary or vision is temporarily affected by the use of medications need not be reported. Pilots should be advised not to fly until normal vision has returned.

Reporting of the following is mandatory:

  • diplopia
  • monocular vision
  • visual field defects — including partial loss of a visual field or significant scotoma
  • eye injuries or retinal detachment
  • cataract surgery
  • surgical correction of myopia following radial keratotomy, photorefractive keratectomy, laser- assisted in situ keratomileusis, or other refractive eye surgery.

26.5.2 Ear, nose, and throat

Significant deterioration in hearing must be reported. In addition, a normally functioning vestibular system is of the utmost importance, so any condition affecting balance or spatial orientation must be reported.

Reporting of the following is mandatory:

  • hearing loss — sudden loss of hearing or conditions significantly affecting hearing
  • middle-ear conditions — damage to the tympanic membranes or the eustachian tubes
  • inner-ear conditions — any condition affecting or impinging on the inner ear or the vestibular (balance) organs
  • stapedectomy and other ear surgery
  • surgery affecting the nasal passages, sinuses, or eustachian tubes
  • conditions leading to voice distortion or inaudibility.

26.5.3 Cardiovascular conditions

Cardiovascular illness is a significant concern for aviation safety, and a RAMO must be notified. Reporting of the following is mandatory:

  • cardiac inflammation and infection
  • acute ischemic syndromes
  • angina pectoris — chest pain typical or atypical of angina pectoris
  • myocardial infarction
  • revascularization surgery or angioplasty (including stent insertion)
  • cardiomyopathy
  • cardiac transplantation. Blood pressure

Uncontrolled abnormal blood pressure is a concern for aviation safety, as are medications with adverse effects of postural hypotension, arrhythmias, or effects on the central nervous system.

Reporting of the following is mandatory:

  • initial treatment of hypertension with medication
  • symptomatic hypotension or hypertension. Valvular heart disease

Reporting of the following is mandatory:

  • presence of significant heart disease
  • development of new heart murmurs
  • requirement for treatment
  • repair or replacement of heart valves with prosthetic appliances.

    In view of the risk of thromboembolism, associated cardiac dysfunction, valve failure, and bleeding secondary to anticoagulation, candidates for prosthetic valvular replacement must be assessed individually by a RAMO. Congenital heart disease (CHD)

Reporting of the following is mandatory:

  • new diagnosis of CHD
  • development of symptoms in a pilot with known CHD. Cardiac arrhythmia

Even benign arrhythmias can cause distraction, which, during critical phases of flight, may cause an aviation incident or crash.

Reporting of the following is mandatory:

  • premature atrial or ventricular contraction — when symptomatic or medication is required for control
  • paroxysmal tachyarrhythmias — all tachyarrhythmias, even if they appear to be asymptomatic
  • atrial fibrillation and flutter — at initial diagnosis and when any change in treatment is required
  • sinus node dysfunction or sick sinus syndrome — symptomatic bradycardia
  • heart block and bundle branch blocks — second- or third-degree heart block or the development of a new right or left bundle branch block
  • pacemaker or automatic implantable defibrillation device.

26.5.4 Cerebrovascular disorders

Pilots who show any evidence of memory loss, poor concentration, or diminished alertness must be reported.

Reporting of the following is mandatory:

  • transient ischemic attacks or cerebral artery stenosis that has led to confusion, disturbance of vision, attacks of vertigo, or loss of consciousness
  • stroke — completed stroke or any other cerebrovascular accident
  • carotid endarterectomy
  • carotid bruits.

26.5.5 Other vascular disorders

Reporting of the following is mandatory:

  • aortic aneurysms
  • symptomatic or enlarging thoracic aneurysm or abdominal aneurysm 5 cm in diameter or larger
  • recent surgical repair of an aneurysm
  • deep venous thrombosis.

26.5.6 Nervous system

Disorders of the central nervous system can result in subtle or sudden incapacitation, which can be fatal in the aviation environment.

Reporting of the following is mandatory:

  • syncope or pre-syncope
  • seizure disorders
  • head injuries — any significant head injury, particularly if it is associated with unconsciousness or post-traumatic amnesia
  • sleep disorders of any type
  • vestibular disorders — spatial disorientation is a significant cause of aviation incidents/crashes; any condition that interferes with balance or coordination
  • headache — migraine with aura; may include visual loss, cognitive impairment, and other neurologic deficits; any type of severe or prolonged headache requiring medications
  • disorders of coordination and muscular control.

26.5.7 Respiratory diseases

Gradual deterioration of the respiratory system over years may not be obvious, particularly if the pilot does not complain or is using bronchodilator medications.

Reporting of the following is mandatory:

  • chronic obstructive pulmonary disease — significant decreases in pulmonary function, decreased arterial oxygen saturation, increasing hypercapnia, or recurrent infections
  • asthma — on initial diagnosis or if there is an increasing requirement for inhaled bronchodilators, steroids, or other medications
  • pneumothorax — spontaneous pneumothorax, pleural blebs, lung cysts, or other conditions that may lead to problems with expansion of trapped gas
  • pulmonary embolism
  • sarcoidosis.

26.5.8 Endocrine and metabolic disorders

Reporting of the following is mandatory:

  • diabetes mellitus
  • type 1 diabetes — on initial diagnosis; pilots and air traffic controllers with type 1 diabetes are considered for certification by a RAMO, on an individual basis
  • type 2 diabetes — treatment with oral or injected hypoglycemic drugs and/or insulin therapy; changes in type or dose of medication; hypoglycemic attacks requiring treatment
  • thyroid and parathyroid disease — on initial diagnosis of these conditions and when there are significant changes in treatment
  • pituitary disease — on initial diagnosis and investigation; any mass compromising the optic chiasm
  • adrenal disease — on initial diagnosis and investigation
  • use of anabolic steroids.

26.5.9 Renal system

Reporting of the following is mandatory:

  • renal colic or the discovery of kidney or bladder stones
  • development of renal failure or treatment with renal dialysis
  • requirement for renal transplantation; after successful transplantation, when there are significant changes in treatment.

26.5.10 Musculoskeletal system

Reporting of the following is mandatory:

  • recent amputation of a limb or part of a limb
  • arthritis — symptomatic patients whose mobility becomes restricted; those with adverse effects from medications (e.g., non-steroidal anti-inflammatory drugs); those requiring second- or third- stage medications (e.g., gold, azathioprine)
  • any condition that could impair functionality in the aviation environment, such as distracting pain, reduced strength, or reduced range of motion.

26.5.11 Psychiatric and cognitive disorders

Psychiatric or mental illness is concerning for aviation safety. Even when symptoms are effectively treated, the adverse effects of medications used for treatment, such as selective serotonin reuptake inhibitors (SSRIs), may not be compatible with aviation.

Pilots with mental health issues may be reluctant to discuss their conditions with a CAME and may be more likely to seek advice and treatment from a family or community physician. Pilots are generally not permitted to exercise the privileges of their licences or permits until their cases have been assessed by a RAMO.

Reporting of the following is mandatory:

  • cognitive disorders — including dementia, as soon as suspected or diagnosed
  • psychosis — including bipolar affective disorder
  • mood disorders — including anxiety and depression
  • substance use disorders — including episodes of substance use that could be concerning for aviation safety (e.g., impaired driving conviction or substance use while performing aviation duties); see also Section 26.6, Substance use
  • attention-deficit/hyperactivity disorder — either with or without medication for management.

26.5.12 Other medical conditions

Reporting of the following is mandatory:

  • any diagnosis of significant illness that may affect aviation safety, due to either the effects of the underlying illness or the effects of treatment.

26.6 Substance use

Transport Canada uses the following definitions of terms related to substance use (Transport Canada, 2020):

  • Substance: Any alcohol, drug (legal or illegal), medication (prescribed, non-prescribed, herbal, or over-the- counter), or self-administered toxin with psychoactive properties.
  • Substance abuse: A maladaptive pattern or episode of substance use resulting in:
    • continued or recurrent use in situations in which it is physically hazardous or potentially harmful to health;
    • continued or recurrent use despite social, personal, or occupational problems caused or exacerbated by use;
    • excessive use;
    • failure to fulfill major role obligations at work, school, or home;
    • legal problems;
    • violations of provisions of the Aeronautics Act , the CARs, or other Transport Canada regulations or policies related to impairment or substance use; or
    • a verified positive drug or alcohol test conducted for legal, medical, occupational, investigative, or administrative purposes.
  • Alcohol: By law, no one may function as a crew member of an aircraft (or work as an air traffic controller) if they have consumed alcohol within the previous 12 hours. After heavy drinking, even this interval will be too short because alcohol can affect balance and orientation for up to 48 hours.
  • Cannabis: By law, flight crew (pilots and flight engineers) and flight controllers (air traffic controllers) are prohibited from using cannabis for at least 28 days before being on duty. Cannabis use is defined as the use of any cannabis product (including cannabidiol [CBD]) by any method (including smoking, vaping, eating, or applying to the skin) for any purpose (including medical, recreational, or other non-medical reasons). For more details, see the Civil Aviation Medicine cannabis policy (Transport Canada, 2019).
  • Illicit drugs: Illicit drugs impair judgment and coordination; the effects may last for prolonged periods.

Over-the-counter medications, natural health products, and prescription medications may have adverse effects that negatively affect aviation safety. Pilots should not perform their duties while taking any of these medications, unless they have been assessed and cleared by a RAMO.

In cases where local anesthetics have been used for extensive procedures, flying should be restricted for a minimum of 24 hours after the procedure.

26.7 Contacts

Civil Aviation Medicine headquarters:

Civil Aviation Medicine Transport Canada
617-330 Sparks St. Place de Ville, Tower C Ottawa ON K1A 0N8
Email for general inquiries: [email protected] 
Local tel: 613-990-1311
Toll-free: 1-800-305-2059
Facsimile: 613-990-6623

Civil Aviation Medicine branch offices (RAMOs):

See for a complete list of branch offices and current contact information.


*Prepared by Transport Canada.


Aeronautics Act , R.S.C., 1985, c. A-2 (amended 2015). Medical and optometric information . Available: html#docCont (accessed 2022 Oct. 14).

Canadian Aviation Regulations, SOR/96-433, 1996. Subpart 4: Medical requirements. Available: (accessed 2022 Oct. 20).

Transport Canada. Staff instruction 404-002. Civil Aviation Medicine cannabis policy. Ottawa (ON): Transport Canada; 2019. Transport Canada. Staff instruction 424-002. Civil Aviation Medicine directive – substance use. Ottawa (ON): Transport Canada; 2020.

Other resources

Transport Canada. Cannabis legalization. In: General operating and flight rules: Better pilot decision-making. Ottawa (ON): Transport Canada; 2019. Available:… (accessed 2022 Oct. 14).

Transport Canada. Handbook for civil aviation medical examiners . TP 13312. Ottawa (ON): Transport Canada; 2019. Available:… (accessed 2022 Oct. 14).

Transport Canada. Medical fitness for aviation [website]. Ottawa (ON): Transport Canada; 2021 Mar. 19. Available: (accessed 2022 Oct. 14).