Children with neuromuscular weakness or central hypoventilation often require nocturnal ventilation. Children with these conditions are living longer and the numbers of children affected are increasing. The challenges associated with managing ventilation at home have been documented; however, there has been limited investigation into accessing wider experiences such as travel. Air travel, in particular, may be considered challenging for children with these conditions because oxygen levels are lower in airplane cabins than at sea levels.
We sought to understand experiences of and attitudes towards travel amongst families of children using nocturnal ventilation for neuromuscular weakness or central hypoventilation.
Two semi-structured interviews were conducted amongst participants enrolled in a trial of a new pre-flight assessment of their tolerance of reduced oxygen levels during flight (known as a hypoxic challenge test). Children participating in the trial were aged 19 months to 18 years. Parents were interviewed and provided proxy views for younger children, and older children were encouraged to present their own views during these interviews. One interview was conducted immediately after the assessment, and a second 3 months later. Data were analysed utilising the framework approach to thematic analysis.
Seventeen families participated in the first interview with 14 of these families completing the follow-up interview. Three further families participated in the follow-up interview only. Here, we report three themes relating to participant experience of travel and how this is impacted by their condition. The three themes and their sub-themes were (1) insight into children\'s lives: hospital attendances, gaining knowledge and confidence, and child as a person; (2) travelling with your child: planes, trains and automobiles, rules of air travel, and uncertainty; and (3) the meaning of travel: normalisation, connection to extended family, expanded experiences, and freedom and equality.
This population of children and their families aspire to travel but face challenges from clinical and social barriers. It is essential that we further our understanding of the physiological, social and cultural aspects of their experience to facilitate their access to broadened life experiences.

Guidelines for air passengers with respiratory disease focus on primary lung pathology. Little evidence exists to guide professionals advising children needing ventilatory support because of neuromuscular or central hypoventilation conditions; these children might risk hypoxia and hypercapnia if unable to mount an adequate hyperventilation response.
This study assessed the response to low ambient oxygen using a modified hypoxic challenge test. In addition to measuring pulse oximetry and response to supplementary oxygen, we also measured transcutaneous carbon dioxide and response to ventilatory support.
Twenty children on nocturnal ventilatory support aged 1.6-18 years were recruited in a pragmatic sample from outpatient clinics; 10 with neuromuscular weakness and 10 with central hypoventilation. Participants underwent a two-stage, modified hypoxic challenge test; a conventional stage, where oxygen alone was titrated according to SpO2, and a new stage, where participants used their routine ventilatory support with oxygen titrated if needed. Participants were interviewed to understand their experiences of testing and of air travel.
Thirteen participants needed supplemental oxygen during the conventional stage, but only two did when using ventilatory support. Transcutaneous carbon dioxide remained within normal range for all participants, on or off ventilatory support. Whilst some participants found testing challenging, participants generally reported both testing and air travel to be valuable.
Evaluating response to patients\' usual ventilation through \"fitness-to-fly\" assessment aids decision making when considering whether children who receive nocturnal ventilation can travel by air, since for some using a ventilator reduces or avoids the need for supplemental oxygen.

OBJECTIVE: This study examines whether the pilot flying\'s (PF) scanning behavior is affected by the absence of the pilot monitoring (PM) and aims at deriving implications for the design of single-pilot cockpits for commercial aviation.
BACKGROUND: Due to technological progress, a crew reduction from two-crew to single-pilot operations (SPO) might be feasible. This requires a redesign of the cockpit to support the pilot adequately, especially during high workload phases such as approach and landing. In these phases, the continuous scanning of flight parameters is of particular importance.
METHODS: Experienced pilots flew various approach and landing scenarios with or without the support of the PM in a fixed-base Airbus A320 simulator. A within-subject design was used and eye-tracking data were collected to analyze scanning behavior.
RESULTS: The results confirm that the absence of the PM affects the PF\'s scanning behavior. Participants spent significantly more time scanning secondary instruments at the expense of primary instruments when flying alone. Moreover, the frequency of transitions between the cockpit instruments and the external view increased while mean dwell durations on the external view decreased.
CONCLUSIONS: The findings suggest that the PM supports the PF to achieve efficient scanning behavior. Information should be presented differently in commercial SPO to compensate for the PM\'s absence and to avoid visual overload.
CONCLUSIONS: This research will help inform the design of commercial SPO flight decks providing adequate support for the pilot particularly in terms of efficient scanning behavior.

BACKGROUND: Health care providers are often called to respond to in-flight medical emergencies, but lack familiarity with expected supplies, interventions, and ground medical control support.
OBJECTIVE: The objective of this study was to determine whether a mobile phone app (airRx) improves responses to simulated in-flight medical emergencies.
METHODS: This was a randomized study of volunteer, nonemergency resident physician participants who managed simulated in-flight medical emergencies with or without the app. Simulations took place in a mock-up cabin in the simulation center. Standardized participants played the patient, family member, and flight attendant roles. Live, nonblinded rating was used with occasional video review for data clarification. Participants participated in two simulated in-flight medical emergencies (shortness of breath and syncope) and were evaluated with checklists and global rating scales (GRS). Checklist item success rates, key critical action times, GRS, and pre-post simulation confidence in managing in-flight medical emergencies were compared.
RESULTS: There were 29 participants in each arm (app vs control; N=58) of the study. Mean percentages of completed checklist items for the app versus control groups were mean 56.1 (SD 10.3) versus mean 49.4 (SD 7.4) for shortness of breath (P=.001) and mean 58 (SD 8.1) versus mean 49.8 (SD 7.0) for syncope (P<.001). The GRS improved with the app for the syncope case (mean 3.14, SD 0.89 versus control mean 2.6, SD 0.97; P=.003), but not the shortness of breath case (mean 2.90, SD 0.97 versus control mean 2.81, SD 0.80; P=.43). For timed checklist items, the app group contacted ground support faster for both cases, but the control group was faster to complete vitals and basic exam. Both groups indicated higher confidence in their postsimulation surveys, but the app group demonstrated a greater increase in this measure.
CONCLUSIONS: Use of the airRx app prompted some actions, but delayed others. Simulated performance and feedback suggest the app is a useful adjunct for managing in-flight medical emergencies.

This study reports the global occurrence of in-flight emergency births on commercial airlines. To date, no existing research investigating in-flight emergency births has been published.
A retrospective study was conducted of all known in-flight births on commercial airlines between 1929 and 2018.
Between 1929 and 2018, there were 74 infants born on 73 commercial flights. Seventy-one of the infants survived delivery, two died shortly after delivery and the status of one is unknown. Seventy-seven percent of the flights were designated international flights, and 26% of all flights were diverted due to the in-flight emergency births. The gestational age at delivery ranged from 25 to 38 weeks with 10% of the infants born at 37-38 weeks, 16% born at 34-36 weeks, 19% born at 31-33 weeks and 12% born prior to 32 weeks. Physicians, nurses, the flight crew and other medical personnel provided medical assistance in 45% of the births.
In-flight emergency births are infrequent but not trivial. Commercial airlines are dependent on physicians and other medically trained passengers to help with in-flight deliveries.Despite US Federal Aviation Authority and Joint Aviation Authority standards, on-board medical and first aid kits are depleted and inadequate for in-flight deliveries.

Knowledge about cabin crew fatigue associated with ultra-long range (ULR) flights is still limited. Current ULR scheduling for cabin crew is therefore predominantly based on flight crew data. Cabin crews\' views on fatigue, and their strategies for mitigating it, have seldom been sought. To better understand the causes and consequences of cabin crew fatigue, semi-structured focus group discussions were held. Thematic analysis was undertaken with data from 25 cabin crew. Participants indicated that the consequences of fatigue are twofold, affecting 1) cabin crew health and wellbeing and 2) safety (cabin, passenger and personal) and cabin service. While the primary causes of fatigue were sleep loss and circadian disruption, participants also identified other key factors including: insufficient rest, high workload, the work environment, a lack of company support, and insufficient fatigue management training. They highlighted the importance of sufficient rest, not only for obtaining adequate recovery sleep but also for achieving a work-life balance. They also highlighted the need for company support, effective communication, and management\'s engagement with cabin crew in general. We recommend that priority is given to fatigue management training for cabin crew, which may also enhance perceived company support and assist with achieving a better work-life balance.

UNASSIGNED: The 2015 Germanwings Flight 9525 disaster, in which 150 people were killed after the co-pilot may have intentionally crashed the plane in a suicide attempt, highlights the importance of better understanding the mental health of commercial airline pilots. However, there have been few systematic reviews investigating the topic of mental health in commercial aviation. This systematic review aims to identify the types and prevalence of mental health disorders that commercial airline pilots experience with a focus on mood disorders and suicide risk.
UNASSIGNED: A systematic literature search was performed using PubMed, EMBASE, and PsycINFO databases. Eligible studies were assessed and data was extracted and analyzed.
UNASSIGNED: 20 studies were identified. The prevalence of depression experienced by commercial airline pilots in this review ranged from 1.9% to 12.6%. Factors that negatively impacted the mental health of pilots included substance abuse, experiencing verbal or sexual abuse, disruption in sleep circadian rhythms and fatigue.
UNASSIGNED: This systematic review identifies that commercial airline pilots may experience depression at least as frequently as the general population. Commercial airline pilots experience occupational stressors, such as disrupted circadian rhythms and fatigue which may increase risks of developing mood disorders. Most studies identified in this review were cross-sectional in nature with substantial limitations. There is a clear need for further higher quality longitudinal studies to better understand the mental health of commercial airline pilots.

The growing number of anti-terrorism policies has elevated public concerns about discrimination. Within the context of airport security screening, the current study examines how American travelers value the principle of equal protection by quantifying the \"equity premium\" that they are willing to sacrifice to avoid screening procedures that result in differential treatments. In addition, we applied the notion of procedural justice to explore the effect of alternative selective screening procedures on the value of equal protection. Two-hundred and twenty-two respondents were randomly assigned to one of three selective screening procedures: (1) randomly, (2) using behavioral indicators, or (3) based on demographic characteristics. They were asked to choose between airlines using either an equal or a discriminatory screening procedure. While the former requires all passengers to be screened in the same manner, the latter mandates all passengers undergo a quick primary screening and, in addition, some passengers are selected for a secondary screening based on a predetermined selection criterion. Equity premiums were quantified in terms of monetary cost, wait time, convenience, and safety compromise. Results show that equity premiums varied greatly across respondents, with many indicating little willingness to sacrifice to avoid inequitable screening, and a smaller minority willing to sacrifice anything to avoid the discriminatory screening. The selective screening manipulation was effective in that equity premiums were greater under selection by demographic characteristics compared to the other two procedures.

Fatigue is a risk factor for flight performance and safety in commercial aviation. In US commercial aviation, to help to curb fatigue, the maximum duration of flight duty periods is regulated based on the scheduled start time and the number of flight segments to be flown. There is scientific support for regulating maximum duty duration based on scheduled start time; fatigue is well established to be modulated by circadian rhythms. However, it has not been established scientifically whether the number of flight segments, per se, affects fatigue. To address this science gap, we conducted a randomized, counterbalanced, cross-over study with 24 active-duty regional airline pilots. Objective and subjective fatigue was compared between a 9-hour duty day with multiple take-offs and landings versus a duty day of equal duration with a single take-off and landing. To standardize experimental conditions and isolate the fatiguing effect of the number of segments flown, the entire duty schedules were carried out in a high-fidelity, moving-base, full-flight, regional jet flight simulator. Steps were taken to maintain operational realism, including simulated airplane inspections and acceptance checks, use of realistic dispatch releases and airport charts, real-world air traffic control interactions, etc. During each of the two duty days, 10 fatigue test bouts were administered, which included a 10-minute Psychomotor Vigilance Test (PVT) assessment of objective fatigue and Samn-Perelli (SP) and Karolinska Sleepiness Scale (KSS) assessments of subjective sleepiness/fatigue. Results showed a greater build-up of objective and subjective fatigue in the multi-segment duty day than in the single-segment duty day. With duty start time and duration and other variables that could impact fatigue levels held constant, the greater build-up of fatigue in the multi-segment duty day was attributable specifically to the difference in the number of flight segments flown. Compared to findings in previously published laboratory studies of simulated night shifts and nighttime sleep deprivation, the magnitude of the fatiguing effect of the multiple take-offs and landings was modest. Ratings of flight performance were not significantly reduced for the simulated multi-segment duty day. The US duty and flight time regulations for commercial aviation shorten the maximum duty duration in multi-segment operations by up to 25% depending on the duty start time. The present results represent an important first step in understanding fatigue in multi-segment operations, and provide support for the number of flight segments as a relevant factor in regulating maximum duty duration. Nonetheless, based on our fatigue results, a more moderate reduction in maximum duty duration as a function of the number of flight segments might be considered. However, further research is needed to include investigation of flight safety, and to extend our findings to nighttime operations.

In recent years, the U.S. commercial airline industry has achieved unprecedented levels of safety, with the statistical risk associated with U.S. commercial aviation falling to 0.003 fatalities per 100 million passengers. But decades of research on organizational learning show that success often breeds complacency and failure inspires improvement. With accidents as rare events, can the airline industry continue safety advancements? This question is complicated by the complex system in which the industry operates where chance combinations of multiple factors contribute to what are largely probabilistic (rather than deterministic) outcomes. Thus, some apparent successes are realized because of good fortune rather than good processes, and this research intends to bring attention to these events, the near-misses. The processes that create these near-misses could pose a threat if multiple contributing factors combine in adverse ways without the intervention of good fortune. Yet, near-misses (if recognized as such) can, theoretically, offer a mechanism for continuing safety improvements, above and beyond learning gleaned from observable failure. We test whether or not this learning is apparent in the airline industry. Using data from 1990 to 2007, fixed effects Poisson regressions show that airlines learn from accidents (their own and others), and from one category of near-misses-those where the possible dangers are salient. Unfortunately, airlines do not improve following near-miss incidents when the focal event has no clear warnings of significant danger. Therefore, while airlines need to and can learn from certain near-misses, we conclude with recommendations for improving airline learning from all near-misses.