HIMS Program steps...ing signs of alcoholism that show up in the airline pilot community. Early signs, often ignored, include tardiness, in-creased use of sick leave, obvious inat-tention

24 • Air Line Pilot November/December 2007

apt. Dana Archibald (Amer-ican Eagle) carries his ter-mination letter from Amer-ican Eagle with himwherever he travels. Incertain circles, he intro-duces himself with the

statement, “Hi—I’m Dana, and I’m analcoholic and an addict.” Based in NewYork, N.Y., he flies Embraer 145s forAmerican Eagle.

If you think those three facts don’tsquare, you don’t know enough aboutthe HIMS Program.

The acronym doesn’t tell you athing. Neither do the words from whichthe acronym is derived—Human Inter-vention and Motivation Study. That’s bydesign.

HIMS is the FAA-funded substance-abuse treatment program for airlinepilots, which, according to the HIMSwebsite (www.himsprogram.com), “co-ordinates the identification, treatment,and return to the cockpit of impairedaviators. It is an industrywide effort inwhich companies, pilot unions, and theFAA work together to preserve careersand further aviation safety.”

“Back in 1973, when the HIMS Pro-gram started, you couldn’t mention pi-lots and alcoholism or addiction in thesame sentence,” explains Dr. DonaldHudson, ALPA’s Aeromedical Advisorand head of the ALPA Aeromedical Of-fice, located in a suburb of Denver,Colo. He adds, “This program benefitsthe entire airline industry, but it was notstarted by doctors or the FAA—it wasstarted by the pilots themselves.”

Since the HIMS Program began, ithas periodically hosted seminars for pi-lot volunteers who support the Pro-gram within their pilot group and otherinvolved parties, including physicians,some of whom work for the FAA.

Archibald, the chairman of ALPA’sHIMS Committee, and Dr. Hudson wel-comed 270 attendees to the 12thHIMS Seminar, held September 10-12in Denver. The group included 55 phy-sicians, many attending the Seminarto receive certification as HIMS-quali-fied aeromedical examiners (AMEs).Before the Seminar, only 51 of the4,447 AMEs in the United States wereHIMS-trained.

Hudson stressed, “The main thingwe want you to leave here with is thatalcoholism and other types of chemi-

cal addiction are a disease, not acharacter flaw.”

Because alcohol is “the drug ofchoice” in the airline industry, mostHIMS cases involve alcoholism. Addic-tion experts estimate that about 5 per-cent of the U.S. adult population hasthe disease of alcoholism. “Wings andstripes do not confer immunity,” as oneHIMS Seminar instructor quipped, sothe same percentage of airline pilotsare believed to be afflicted.

Having the disease of alcoholism(or other chemical dependency) is con-sidered a diagnosis for life, and no“cure” for the disease is known. Butthat does not mean that those with thedisease cannot beat it.

Hudson reported that the number offlightcrew members who have enteredthe HIMS Program since it began re-cently passed the 4,000 mark. The life-time relapse rate of those airmen, hesaid, was somewhere around 10–12percent. Put another way, an estimated88-90 percent have not relapsed.

How has the HIMS Program achievedthis remarkable record, which is sub-stantially better than recovery programsfor the general population?

HIMS Program steps“The industrial setting has proven to bethe most effective place to intervene inthe addiction process,” said Dr. MichaelBerry, manager of the FAA’s MedicalSpecialties Division. “The success of in-dustrial programs in dealing with chemi-cal dependencies has far exceeded pro-

grams set outside the job site. This isdefinitely true of airline programs.”

The HIMS Program involves a provensequence of steps—peer identification,intervention, evaluation and diagnosis,treatment, and recertification.

Dr. Quay Snyder, Associate Aero-medical Advisor in ALPA’s AeromedicalOffice, pointed out that the expensive,federally mandated alcohol and drugtesting conducted by the U.S. airline in-dustry catches fewer than 12 pilots peryear. The HIMS Program, because it in-volves peer identification, brings about100 flightcrew members per year intothe recovery program.

Some participants come to HIMS ontheir own, because they realize theyhave a problem and need to do some-thing about it. More common, however(because denial is both a major symp-tom of addiction and a major obstacleto treating it), pilots enter the HIMS Pro-gram as a result of an intervention byfellow pilots who support the Programas peer volunteers and by HIMS-trainedairline management personnel.

As Archibald pointed out, the worstcase is for the employee to be caughtunder the influence of drugs or alcoholwhile on duty—via reports from other em-ployees or passengers, TSA screeners,random drug tests, or other sources. Insuch situations, the airline usually firesthe employee, and the FAA suspends orrevokes the pilot’s airman certificates.Pilots have entered the HIMS Programand gotten back into the cockpit afterbeing caught, but the path is very difficult.

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Dr. Donald Hudson, ALPA’s Aeromedical Advisor, HIMS Program manager, and head ofthe ALPA Aeromedical Office, moderates an evening session for physicians.

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First Officer Dave Fredrickson, whoheads up the HIMS Program for Ameri-can Airlines pilots, declared, “Punitiveprotocols only do one thing—they driveaddiction underground.” He made astrong case for the financial benefitsof HIMS to the airline. Laying out a de-tailed analysis, he concluded that,with 142 American Airlines and Ameri-can Eagle pilots in the HIMS Program,that Program is saving AMR Corpora-tion almost $360 million—savings of$37.30 return on investment for everydollar spent. The savings come fromsuch sources as reduced sick leave,the cascade of training costs associ-ated with a pilot leaving the airline, as-set restoration and preservation, andrehabilitation cost savings.

Hudson stressed the importance offriends, family, and coworkers acting toaddress addiction because early inter-vention can prevent company disci-pline and save the pilot’s career or life.Also, untreated addiction is an aviationsafety issue—and in some ways not im-mediately obvious to the layman.

Snyder outlined the common warn-ing signs of alcoholism that show up inthe airline pilot community. Early signs,often ignored, include tardiness, in-creased use of sick leave, obvious inat-tention to personal grooming, trainingproblems, complaints about personal/family problems, errors and omissions,hostility and blaming, and other pilotsdeclining trip pairings with the alco-holic. Later signs, often denied, includeheavy use of aftershave or cologne,heavy drinking on layovers, hangoveron the day of flight, alcohol on breathor clothing, and arrests for driving un-der the influence (DUI). Very late signsinclude testing positive for alcohol andlosing FAA medical certification.

Pilot-peer monitors and AMEs withlong experience in identifying flightcrewmembers with a substance-abuse prob-lem said they receive tips from manysources; often spouses or other familymembers make the first call. Experi-enced HIMS coordinators cautionedthat they will act on such calls only afterthey have received three or more inde-pendent, verifiable reports of incidentsin which the pilot was involved.

As mentioned, denial plays a majorrole in addiction. That’s why interventionis so important. Dr. Lynn Hankes pointedout, “Lying is a conscious distortion of re-

ality; denial is a subconscious distortionof reality.” Intervention, he added, “isabout motivating patients to change”and “is necessary because the alcoholicis blinded to reality.”

Hankes said the “myths” about treat-ing addiction include the notion that thepatient must “hit bottom” before begin-ning recovery. The point of intervention,he said, is to “raise the ‘bottom.’”

Capt. Fred Beardsley (Delta, Ret.)was one of the many rescued beforereaching that point. He declared, “ThisProgram has saved a lot of lives.

“I was the product of a [Delta AirLines] intervention in 1984. I wentthrough a full intervention with thechief pilot and four of my friends. WhenI walked through the door, I knew thecat was out of the bag.

“The lady who assessed me is heretoday—she saved my life. This programsaved my life, saved my career, savedmy marriage. It made me a better fa-ther, a better husband. I’m a betterman for it.”

Several presenters stressed that, in

an intervention, one must preserve thepilot’s dignity and be very careful not totrigger defiance.

During an intervention, Fredricksonwill sometimes drop some plastic icecubes into a glass and ask the pilot topour water into the glass to show thesize of his typical drink. “I guarantee,they’ll go at least three for one,” he re-ported. “If they say they’re drinking ajigger, they’re probably drinking atleast three.”

Intervention usually leads directly toevaluation and diagnosis by a physicianor other professional health care pro-vider with special training in addiction;the process can take a couple of days.If the evaluator diagnoses the airmanwith a chemical dependency, the pilotwill be removed from flight status andbegin treatment.

Capt. Jeff Kilmer (FedEx), chairmanof the ALPA Human Performance Group(which includes the following commit-tees: Aeromedical, Critical Incident Re-sponse Program, HIMS, Pilot Assis-tance, and Professional Standards),

HIMSThe Quiet Success

StorySince 1973, more than

4,000 pilots haveentered a unique program

to save their careersand, in some cases,

their lives.By Jan W. Steenblik

Technical Editor



emphasizes, “During this offline, short-term disability period, the paycheck,seniority number, vacation, and sickbank accruals of a pilot in the HIMSProgram are protected and remain inforce uninterrupted.”

TreatmentThe goals of treatment, Hankes ex-plained, are to “penetrate denial, con-ceptualize the disease, reconnect thepilot to his or her feelings, and find thecore issues. It’s also important to in-volve the family, develop relapse strat-egies, and inculcate mutual-helpgroups.”

He added that treatment must be“tri-dimensional,” necessarily involvingthe body (detoxification and ending or-gan damage), mind (cognitive restruc-turing and emotional rebalancing), andsoul (spiritual restoration). The formaltreatment program usually lasts be-tween 3 weeks and 3 months.

Of the various types of treatmentavailable, intensive inpatient treatment(usually for 28 days) is by far the mostsuccessful, and therefore the “goldstandard” for the FAA. Why 28 days? To“match the intensity of treatment tothe severity of the disease,” saidHankes.

After the 4 weeks of inpatient treat-

ment, the HIMS participant begins aprogram of comprehensive continuingcare, such as daily AA or NarcoticsAnonymous meetings. Pilots in recov-ery are strongly encouraged to go di-rectly from inpatient treatment to “90in 90”—i.e., attending 90 AA or NAmeetings in 90 days. Hudson pointedout, “About 70 percent of recovery oc-curs after leaving the inpatient treat-ment facility.”

Hankes asserted, “AA is empiricallyvalidated as the best form of mainte-nance treatment developed to date.”

He said the famous 12 steps of theAA program could be summarized asfour major stages in an AA member’spath to recovery—”giving up, cleaningup, making up, and growing up.”

Formal treatment, he added, em-phasizes “I can not drink,” while AA fo-cuses on “I can not-drink.”

Hankes attributed the success ofthe HIMS Program to “three things—monitoring, monitoring, and monitor-ing,” a reference to the FAA’s require-

Dr. Kevin McCauley was a U.S. Navyflight surgeon and F/A-18 pilot.Given the painkiller Demerol aftersurgeries of his own, he became anaddict, “spiking” the drug intra-venously. He wound up in the mili-tary prison at Ft. Leavenworth,Kans., where he began to dig intosomething he was never taught in

McCauley said. “We believe that thecortex is always stronger than the mid-brain (i.e., that the cortex has ‘topdown’ control over the midbrain). Neu-rologic evidence proves otherwise.”

The addicted brain is quantitativelydifferent from the normal brain. AsMcCauley said, for the alcoholic, “It’snot just a beer anymore—it’s the mainway of coping with life.”

At the core of every pleasurable ex-perience is release of a chemicalcalled dopamine in the brain. Chronic,severe, unmanaged stress changes thebrain’s ability to process dopamine.The patient develops “anhedonia,” or“pleasure deafness,” and can nolonger derive normal pleasure fromthings that have been pleasurable inthe past. Thus addiction is a stress-in-duced “hedonic dysregulation.”

Drugs cause dopamine surges inthe midbrain reward system. Thesurges cause the midbrain to tag thedrug as the new primary coping mecha-nism for all incoming stresses.

The second part of addiction, saysMcCauley, is that after the midbrain

This Is Your Brain on Drugsmedical school—what science haslearned about addiction.

At the 2007 HIMS Seminar,McCauley gave a riveting presentation,“Is Addiction Really a ‘Disease’?

Dr. McCauley asserted, “I think theentire credibility of addiction medicinerests on how we answer that question.This is really a question about causality.”

The boiled-down version: Addictionis a brain disease. Drugs don’t work inthe frontal cortex (the part of the brainthat confers emotional meanings ontoobjects, is the seat of self and morality,and is the source of love, morality, de-cency, responsibility, and spirituality).Drugs work in the midbrain, alsoknown as the “limbic” brain.

The midbrain is the survival brain;not conscious, it is a life-and-death pro-cessing station for arriving sensory in-formation. The midbrain acts immedi-ately, with no future planning or assess-ment of long-term consequences. Ithandles three basic functions—eat, kill(or defend), and sex.

“We like to think we are fully con-scious of all our brain’s activities,”

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Capt. Dana Archibald (American Eagle)



ment that the pilot have monitoringmeetings every 30 days for at least 2years with his or her sponsoring AMEand, separately, with a peer monitor.

As part of the overall monitoring pro-cess, the pilot must be evaluated and

monitored by a specially trained AMEwho acts as the pilot’s sponsor. Therole of the AME is to evaluate the qual-ity of the airman’s recovery programand make a recommendation to theFAA regarding the agency’s granting

misperceives the hedonic/survival im-portance of the drug, the median fore-brain delivers that misperception to thefrontal cortex. The drug then takes onpersonal meaning—the addict devel-ops an emotional relationship with thedrug and derives his or her sense ofself from it.

The argument—”using drugs is achoice”—fails, says McCauley, becauseit does not take into account craving, astate in which the frontal cortex largelyshuts down.

the pilot a Special Issuance (SI) FAAairman medical certificate.

Total abstinence is required; the pi-lot may neither try to cut back to “mod-erate” drinking, or substitute sub-stances. If the pilot’s original problem

tendees, “The pain of an addictis as great as that of any cancerpatient.”

He noted, “If addiction is a dis-ease, then addicts are patients andhave the same rights as all patients.All the ethical principles that applyto treatment of other patients nowalso apply to addicts, and physicianshave a duty to defend addicted pa-tients from those with agendas thatwould do them harm.”

But what’s to keep the addictfrom using “I have a disease” as anexcuse? The problem, saysMcCauley, is not that addictiondoesn’t fit the disease model (itdoes), but that the disease modelitself (though powerful and useful)has inherent problems. The worstproblem is that the disease modeltransfers power from the patient tothe doctor and absolves the patientof responsibility. Alcoholics Anony-mous and other “12 step” pro-grams, however, place considerableemphasis on personal responsibilityand accountability.—JWS

“It’s not that the addict doesn’thave ‘values,’” Dr. McCauley explains.“It’s that in the midst of the survivalpanic of craving, the addict cannotdraw upon those values to guide be-havior. The midbrain now reigns, andconscious thought becomes con-stricted—and free will fails.

“With installation of coping mecha-nisms (Alcoholics Anonymous), thefrontal cortex comes back ‘on line,’ andfree will returns.”

The two tasks of addiction treat-ment, says McCauley, are to (1) givethe addict workable, credible tools toproactively manage stress and de-crease craving, and (2) find the thingthat, for the individual addict, is moreemotionally meaningful than the drug—and displace the drug with it.

Closely related to the first task is un-derstanding that punishment won’t stopdrug use, because the drug equals sur-vival in the addict’s brain, and survivaltrumps every other human need or de-sire. The addict must secure survival be-fore attending to anything else.

McCauley told the HIMS Seminar at-

Drugs causedopaminesurges in themidbrainreward

system. The surges causethe midbrain to tag thedrug as the new primarycoping mechanism for allincoming stresses.

F/O Dave Fredrickson (American)Dr. Lynn Hankes Paul Hoover



involved prescription drugs, he or shecan’t substitute alcohol for them, orvice versa; the point is that the airmanhas a clinically demonstrated problemwith chemical dependence, so switch-ing chemicals won’t work.

Hudson discussed two basic mod-els for peer monitoring: (1) individual,and (2) group (“the gaggle”), which hasthe “multiple eyeball” advantage ofparticipants monitoring each other.Each approach has its pros and cons.

Paul Hoover, who was the first HIMSdirector during the mid-1970s, ac-knowledged, “The monitoring model istough for pilots to accept for a coupleof reasons: (1) It requires baring yoursoul to an authority figure, and (2) pi-lots are cognitively oriented—i.e., theylike facts and fixing stuff; interpersonalrelationships are not their strong suit.”

No one says it’s easy. But one rea-son for the HIMS Program’s success isthat pilots in the Program have somuch to save by achieving and main-taining their sobriety—including theirability to continue in their chosenprofession.

RecertificationOne of the FAA’s requirements for giv-ing an alcoholic or addicted pilot an SIairman medical certificate is post-treatment “P&P” (i.e., psychologicaland psychiatric evaluations), whichnormally takes 2 days. The process in-volves reviewing records, testing, andinterviews.

Psychologist Robert W. Elliott, Ph.D.,

Birds of a Feather, International(BOAF) is a self-help group—Alcohol-ics Anonymous (AA) for pilots. BOAFis a closed, nonsmoking AA meetingfor pilots and cockpit crewmemberswho are active or inactive in any seg-ment of aviation (general aviation,airlines, or military).

Five recovering pilots (three ac-tively flying, two not flying) startedBOAF in the Pacific Northwest in1975. The next year, the fledglingprogram received the support of Dr.H. I. Reighard, the FAA Federal AirSurgeon at the time.

Today, BOAF has “nests”—citieswhere BOAF meetings are held—throughout North America and Eu-rope. Nests are expected soon inAustralia and New Zealand.

Dr. Lynn Hankes says, “AA is thecake; Birds of a Feather is the frost-ing.” Capt. Rusty Noble (a corporatepilot for Quien Sabe Corporation),the current BOAF secretary or “BigBird,” cautions, “We don’t recom-mend to new members that the

BOAF nest be their home group.” Hankes adds, “We tell doctors in re-

covery that they can’t just go to IDAA[AA for physicians]—they also have togo to ‘street’ AA, because if they just goto IDAA, they’re at risk of continuing tobelieve in their ‘terminal uniqueness.’Same thing for pilots.”

The Bird Word, the BOAF newsletter,is published quarterly. It contains per-sonal stories of sobriety from pilots, let-ters to the editor, nest news, articles ofinterest to airmen, and lists of nestsand contacts worldwide.

BOAF has a treatment scholarshipprogram that will help defray the costsof sending a recipient to the FatherMartins Ashley 28-day intensive treat-ment program in Havre de Grace, Md.(45 minutes north of BWI). Noblenotes that, of the six pilots to whomBOAF has given these scholarships,five have received SI medical certifi-cates from the FAA and returned to thecockpit; the sixth is still sober, but de-cided to leave aviation as a profession.

For more information about Birds of

a Feather, visit www.boaf.org. Thecurrent BOAF secretary, Capt. RustyNoble, Box 1486, Ardmore, OK73402, can be reached [email protected] or 580-221-4588 (cell) or 580-653-2814(home).—JWS

The BOAF lapel pin incorporates theAlcoholics Anonymous logo’s triangle(service, unity, and recovery) and is adiscreet testament to the wearer’sdetermination to live a life free ofchemical dependency.

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Dr. Quay Snyder, left, ALPA’s Associate Aeromedical Advisor, speaks with an attendee.



The “standard” drink contains 0.6ounce of ethyl alcohol (C2H50H, alsocalled ethanol)—the same productof fermentation that is added tosome gasolines. And 0.6 ounce ofethanol is contained in• 1.5 ounces of distilled liquor (i.e.,80 proof, which is 40 percent etha-nol by volume),

weight, gender, presence or ab-sence of food in the stomach, andfrequency of alcohol ingestion cansignificantly affect the actual meta-bolic rate.

According to FAR Part 121, Ap-pendix J, V.F.1,, a flightcrew memberwith a BAC greater than 0.02 per-cent is not ready for duty; when theBAC exceeds 0.04 percent, the air-man is unfit to fly, and reporting towork in that condition is a clearcutviolation of FAR 121.458(b). Thus“legal” drinking—i.e., abiding by the“eight hours bottle-to-throttle” rulealone—can result in a BAC greaterthan 0.02 percent.

In some high-profile cases of pi-lots flying while impaired by alcohol,the pilots’ BAC exceeded 0.06 per-cent because they had consumed8–14 drinks the evening before re-porting for duty.—JWS

What’s “a Drink”? and Other Important Stuff to Know• 12 ounces of beer (5 percent alco-hol), or• 5 ounces of wine (12 percentalcohol).

Each of these, in this age of super-sized everything, is much smaller thanwhat many people think of as “a drink.”

Perhaps more important, howquickly does ingested ethanol affectyour body, and how quickly does yourbody metabolize it?

A “standard” drink (see above) willraise the blood alcohol concentration(BAC) of an average 160-pound adultto 0.03 percent in one hour. The aver-age rate at which men metabolizeethanol is 0.3 fluid ounces (i.e., halfthe “standard” drink) per hour, or0.015 percent BAC per hour; forwomen, the average rate is a littlefaster—0.018 percent BAC per hour.

The average metabolic rate is justthat, however—an average. Body

said he encourages physical presenceof the patient’s spouse or “significantother” during the P&P. He interviewsthe spouse or SO to validate factual in-formation, evaluate the pilot’s familysupport system and codependencytraits, unearth issues between airmanand spouse/SO, and support recovery/reinforcement.

P&P testing is conducted no soonerthan 30 days after the end of inpatienttreatment, or 60 days of sobriety.

The sponsoring AME collects and re-views the pilot’s records, conducts anFAA medical exam, and forwards thefile to FAA headquarters. After head-quarters review, the case goes to theFAA’s Airman Certification Branch inOklahoma City.

The total time involved from inter-vention or self-disclosure to receivingthe SI certificate from the FAA is severalmonths in a noncomplicated case; asHudson noted, “Patience is required.”

RelapsesWhat about the relatively small per-centage of HIMS participants who re-lapse? Hankes noted, “We aren’t sur-prised when cardiac patients and dia-betics relapse. But people act

shocked when addicts relapse.”The relapse “risk points” include re-

lease from inpatient treatment; theairman’s first “sober” FAA physicalexam; arrival of the FAA SI airman medi-cal certificate; the first “sober” trip; anni-versaries; and stressful life events,which vary widely among individuals.

The keys to preventing or managingrelapses, Hudson explained, are earlydetection and intervention; withdraw-ing the SI certificate; and pursuingretreatment options (no limit on thenumber, but retreatment tends to belonger and more intense each time).Dr. Hudson noted, “A relapse is not theend of the pilot’s career, but it does re-quire retreatment and an intensifiedmonitoring structure.”

Though the FAA typically requiresmonitoring for 3 years, the agency hasrequired monitoring for the duration ofa pilot’s flying career when the circum-stances warranted doing so.

Fredrickson says, “We maintainabout a 1 percent long-term failure ratewithin HIMS at American Airlines. Thisoccurs through repeated relapse untilthey leave aviation, noncompliancewith a course of treatment, or early re-tirement to avoid treatment.

“When a pilot fails to recoverthrough HIMS, it usually includes thedestruction of the family unit. At Ameri-can, [untreated pilot alcoholism] is100 percent fatal within three years.”

For the great majority of pilots withchemical dependency, however, the Pro-gram has been a tremendous success—which also benefits the airline industryas a whole and the traveling public.

Hudson declared, “So far, wehaven’t had a single accident or inci-dent involving a pilot flying with an alco-hol- or drug-related SI certificate sincethe Program began. Right now, about athousand active airline pilots have SIs.”

They’re out there, living in thepresent, getting through the day, oneday at a time—thanks to the HIMS Pro-gram, started not by doctors or the FAA,but by pilots helping each other.

So how to square the fact that Capt.Archibald still flies for American Eagle,despite the termination letter in hisflight bag? His chief pilot had the lettertyped up and ready to deliver, butArchibald agreed to enter the HIMS Pro-gram; the chief pilot withdrew the let-ter, which Archibald got to keep as a re-minder of the day he came to the ma-jor crossroads in his life.

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Documents

HIMS Program steps...ing signs of alcoholism that show up in the airline pilot community. Early signs, often ignored, include tardiness, in-creased use of sick leave, obvious inat-tention