The medical examiner did not, and saw no reason to, contact the instructor's GP as part of the medical assessment process. Had he done so, it is likely that he would have learned of the instructor's recent illness and initiated a more formalised review of the instructor's fitness to fly. A procedural requirement for medical examiners to consult GPs would help to ensure that they are fully informed about applicants' health.
On 28 June 2017 the Commission recommended to the Director of Civil Aviation that he review the medical application process:
- to ensure that it promotes a positive reporting culture for applicants
- that is more robust in identifying potentially serious health issues that may interfere with the safe exercise of the privileges to which applicants' medical certificates relate
- to ensure that the system supports medical examiners exercising their discretion to consult medical practitioners when assessing applications for medical certificates.