In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Ai c a -Assis ed Pilo Suicides in he Gene al
A ia ion Inc eased o One-Yea Pe iod a e
11 Sep embe 2001 A ack in he Uni ed S a es
Alpo Vuo io 1,2,*,†, Tanja Laukkala 3,† , Ilkka Jun ila 4, Robe Bo 5,6, B uce Budowle 7,
Ee o Pukkala 8, Pooshan Na a he 9and An i Sajan ila 2
1Mehiläinen Ai po Heal h Cen e, 01530 Van aa, Finland
2
Depa men o Fo ensic Medicine, Uni e si y o Helsinki, 00014 Helsinki, Finland; [email p o ec ed]
3Mehiläinen Kielo ie Heal h Cen e, 01300 Van aa, Finland; [email p o ec ed]
4Facul y o Medicine and Li e Sciences, Uni e si y o Tampe e, Finland and Fimlab Labo a o ies,
33014 Tampe e, Finland; [email p o ec ed]
5Royal F ee Hospi al, Pond S ee , London NW3 2QG, UK; [email p o ec ed]
6Cen e o A ia ion Psychology, London NW3 1ND, UK
7Cen e o Human Iden i ica ion, Uni e si y o No h Texas Heal h Science Cen e , 3500 Camp,
Bowie Bl d, Fo Wo h, TX 76107, USA; [email p o ec ed]
8Facul y o Social Sciences, Uni e si y o Tampe e, 33014 Tampe e, Finland; Ee o.Pukkala@cance . i
9The Mai land Hospi al, Mai land 2320, Aus alia; [email p o ec ed].go .au
*Co espondence: [email p o ec ed]; Tel.: +010-414-2702
† These au ho s con ibu ed equally o his wo k.
Recei ed: 13 Sep embe 2018; Accep ed: 6 No embe 2018; Published: 12 No embe 2018


Abs ac :
Pilo ai c a -assis ed suicides (AAS) a e a e, and he e is limi ed unde s anding o
copyca phenomenon among a ia o s. The aim o his s udy was o e alua e he possible e ec
he 11 Sep embe 2001, e o is a acks had on pilo AASs in he U.S. Fa al a ia ion acciden s in he
Na ional T anspo a ion Sa e y Boa d (NTSB) da abase we e sea ched using he ollowing sea ch
wo ds: “suicide”, “mu de -suicide” and “homicide-suicide”. The imeline be ween 11 Sep embe
1996, and 11 Sep embe 2004, was analyzed. Only hose acciden s in which NTSB judged ha he
cause o he acciden was suicide we e included in he inal analysis. The ela i e isk (RR) o he pilo
AASs in all a al acciden s in he U.S. was calcula ed in o de o compa e he one, wo, and h ee-yea
pe iods a e he Sep embe 11 e o is a acks wi h i e yea s p eceding he e en . The RR o a a al
gene al a ia ion ai c a acciden being due o pilo suicide was 3.68- old (95% con idence in e al
1.04–12.98) du ing he i s yea a e 11 Sep embe 2001, bu he e was no a s a is ically signi ican
inc ease in he la e yea s. This s udy showed an associa ion, albei no de e mina e causal e ec , o a
e y speci ic se ies o simul aneous e o is mu de -suicides wi h subsequen pilo AASs.
Keywo ds: Sep embe 11 e o is a acks; pilo ai c a -assis ed suicide; copyca e ec
1. Backg ound
Copyca phenomenon (suicidal beha io p o oked by media exposu e) in pilo ai c a -assis ed
suicides (AASs) has been s udied since he 1970s wi h inconclusi e esul s [
1
,
2
], while longi udinal
case se ies on pilo AASs ha e shown he di icul y o p edic ing a e e en s [
3
,
4
].We ha e p e iously
analyzed pilo AASs a e he Ge manwings pilo mu de -suicide inciden [
5
], wi h no inc ease in pilo
AASs was obse ed in he U.S. o Ge many du ing a wo-yea pe iod a e he inciden as compa ed o
he p e ious i e-yea pe iod.
In . J. En i on. Res. Public Heal h 2018,15, 2525; doi:10.3390/ije ph15112525 www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2018,15, 2525 2 o 10
The nega i e impac o exposu e o a oci ies on men al heal h is well documen ed, om auma
and-s ess ela ed diso de s, o he le el o copyca suicides [
6
–
9
]. The exposu e o auma ic e en s
h ough media alone is su icien o cause psychological dis ess o e en s ess- ela ed diso de s [
10
].
Copyca beha io can be de ined as suicidal beha io p o oked by media exposu e, also desc ibed
as he “We he e ec ” ( om Goe he’s no el Die Leiden des Jungen We he s). In addi ion, he e m
“Papageno e ec ” has been p oposed o desc ibe p o ec i e media measu es [
7
,
11
]. The name o iginally
e e s o a bi d ca che cha ac e om Moza ’s Magic Flu e, who became suicidal bu eco e ed a e
his iends in e ened [
7
,
11
]. Wo ld Heal h O ganiza ion (WHO) has guidance on esponsible media
epo ing a e suicide, and ecen Na ional Ins i u e o Heal h and Ca e Excellence (NICE) guidelines
on suicide p e en ion ha e also ocused on he impac o media [12,13].
Pilo s a e gene ally ega ded as being psychologically esilien and heal hie han he gene al
popula ion due o ini ial heal h assessmen o specialized ae omedical examine s, which excludes
indi iduals wi h se e e isk ac o s o suicidal beha io , such as epea ed suicide a emp s o cu en
majo dep ession. Manda o y heal h assessmen s a e egula ly epea ed, as eques ed in a ia ion
au ho i ies’ guidance on a ia ion medical examine s (AME)s [
14
,
15
]. A an indi idual pilo le el,
men al heal h i ness assessmen s may ha e an impac on a ia ion sa e y [
16
]. Howe e , he use o
se e al ai c a s in he Sep embe 11 a acks ocused a en ion in e na ionally on he ac ions o a ia o s
and also on he po en ial ulne abili y o a ia ion sa e y wi h excessi e and epea ed media co e age.
In ela ion o mili a y pilo s, he U.S. Ai Fo ce has published ai ly cons an suicide a es o ha ime
pe iod in an analysis o he U.S. Ai Fo ce suicide p e en ion p og am [17].
A s udy by Claassen e al. [
18
] has shown no inc ease in suicide a es in he gene al popula ion
in a eas su ounding he h ee ai line c ash si es in New Yo k, he Pen agon in Washing on D.C,
and Some se Coun y in Pennsyl ania a e 11 Sep embe 2001. Claassen e al. [
18
] concluded ha
geog aphical p oximi y is less impo an compa ed o o he e en cha ac e is ics and mo e esea ch is
needed ega ding ele an social ac o s. This is in line wi h he s udy o Mezuk and cowo ke s [
19
],
who epo ed no inc ease in New Yo k suicide a es a e he a ack. Mon hly homicide s a is ics in
he New Yo k Ci y a ea did no e eal an inc ease in homicide o suicide a es a e 11 Sep embe
2001 [20,21].
Al hough P idemo e and colleagues [
21
] showed ha he a e o homicide o suicide dea hs in
New Yo k was no inc eased ollowing he a acks o 11 Sep embe 2001, Jo dan e al. [
22
] showed
ha he s anda dized mo ali y a io (SMR) o suicide was ele a ed (SMR = 1.82) among escue
eco e y wo ke s, while SMR o all-cause mo ali y was no ele a ed (SMR = 0.69). In ano he s udy
o mo ali y among Wo ld T ade Cen e escue wo ke s, S ein e al. [
23
] epo ed a lowe ed all-cause
and cause-speci ic mo ali y among escue wo ke s du ing a ime pe iod o 2002–2011 and did no
ind any associa ion ela ing o he du a ion o escue wo k and mo ali y. These long- e m ollow-up
s udy esul s a e no conclusi e, in i ing mo e analyses among di e en p o essional g oups ela ed o
simila ypes o inciden s. S a kman [
24
] has epo ed a one-yea inc ease in suicide a emp s a e
11 Sep embe 2001 in Michigan, U.S, and he e ec was g ea es in he mon hs ollowing he a acks.
One aspec o explo e is he esea ch on suicidal idea ion. In a su ey o 871 adul s who expe ienced
loss du ing he Sep embe 11 a acks, indi iduals wi h complica ed g ie had signi ican ly high a es o
suicidal idea ion e en a e adjus ing o como bid dep ession [
25
]. Addi ionally, suicidal idea ion was
inc eased in ano he p ima y ca e coho a e 11 Sep embe 2001 (N= 444) in Manha an [6].
The aim o his s udy is o e alua e possible changes in pilo ai c a -assis ed suicides a e he
11 Sep embe 2001, e o is mu de –suicides in he U.S.
2. Me hods
The U.S. Na ional T anspo a ion Sa e y Boa d (NTSB) da abase was sea ched on 26 June 2018,
using he ollowing sea ch wo ds: “suicide”, “mu de –suicide”, and “homicide–suicide” [
26
]. Fa al
a ia ion acciden s in he U.S, wi h ull o mal acciden in es iga ion epo s inalized a he ime o
he sea ch and he cause o acciden s assessed as pilo suicide in he NTSB acciden in es iga ion,
In . J. En i on. Res. Public Heal h 2018,15, 2525 3 o 10
we e included as index cases o his s udy. These NTSB acciden in es iga ions we e u he analyzed
in-dep h o assess he desc ip i e ac o s in hese suicide p ocesses. Only hose acciden s in which
NTSB judged ha he cause o he acciden was suicide we e included in he s a is ical analysis.
F equency o he ai c a -assis ed pilo suicides ou o all a al acciden s in he U.S was calcula ed
o he e e ence pe iod (5 yea s be o e he 11 Sep embe 2001 e o is mu de -suicides e en ) and
sepa a ely o he i s , second, and hi d yea a e he Sep embe 11 e o is a acks. The ela i e isk
(RR) o he likelihood o an ai c a acciden being due o pilo suicide o he h ee pos -a ack yea s
was calcula ed.
3. Resul s
The numbe o a al a ia ion acciden s and ela i e isks o he likelihood o pilo AAS being
due o suicide h ee yea s a e 11 Sep embe 2001, calcula ed o each yea sepa a ely, is p esen ed in
Table 1. All pilo s who died we e male. The RR was 3.68 in he i s yea and dec eased close o 1.0 in
he hi d yea . Only he obse a ion o he i s yea was s a is ically signi ican .
Table 1.
The numbe and he isk a ios o pilo ai c a -assis ed suicides i e yea s be o e and h ee
yea s a e 11 Sep embe 2001, in he U.S.
Follow-Up
Pe iod Da es No. o
Suicides
No. o Fa al
A ia ion Acciden s FRQ Risk Ra io 95% Con idence
In e al
Re e ence 11 Sep embe 1996–10 Sep embe 2001 6 1861 0.32% 1.00 Re e ence
1s yea 12 Sep embe 2001–11 Sep embe 2002 4 337 1.19% 3.68 1.04–12.98
2nd yea 12 Sep embe 2002–11 Sep embe 2003 3 375 0.80% 2.48 0.62–9.88
3 d yea 12 Sep embe 2003–11 Sep embe 2004 1 354 0.28% 0.88 0.11–7.26
FRQ = equency.
Al oge he 23 a al a ia ion acciden epo s we e ob ained wi h he speci ied sea ch wo ds.
All index cases we e iden i ied wi h he sea ch wo d “suicide”, sea ch wo ds “homicide-suicide”,
o “mu de -suicide” did no yield any addi ional index case inciden s. Fou een o hese inciden s
we e caused by a pilo ’s o co-pilo ’s suicidal ac acco ding o NTSB acciden in es iga ions, and hese
inciden s a e desc ibed in de ail in Table 2. All he inciden s we e ope a ionally ela ed o gene al
a ia ion, al hough h ee pilo s had also Class I (comme cial pilo ) medical ce i ica ion e en hough
hey we e no lying comme cial ai c a a he ime o he suicide c ash. I should be no ed ha h ee
o he deceased pilo s we e also ligh ins uc o s. Al oge he ou een pilo s o s uden pilo s died in
hese inciden s. Thei ages anged om 15 o 69 yea s. Eigh o hese ai c a -assis ed suicides occu ed
a e 11 Sep embe 2001; ou wi hin he i s yea , h ee du ing he second yea , and one in he hi d
yea , while six ai c a -assis ed suicides ook place du ing he i e-yea -pe iod be o e i (see imeline
in Figu e 1). NTSB causes o dea h o excluded cases in his sea ch we e: ou unde e mined causes
o a al a ia ion acciden s, wo ela ed o psychological p oblems (d ugs o alcohol we e men ioned
a leas as a con ibu ing ac o ), in wo epo s wea he condi ions we e men ioned, and in one case
dea h occu ed due o a passenge ’s suicidal ac .
In .J.En i on.Res.PublicHeal h2018,15,x 3o 10
in‐dep h oassess hedesc ip i e ac o sin hesesuicidep ocesses.Only hoseacciden sinwhich
NTSBjudged ha  hecauseo  heacciden wassuicidewe eincludedin hes a is icalanalysis.
F equencyo  heai c a ‐assis edpilo suicidesou o all a alacciden sin heU.Swascalcula ed o 
he e e encepe iod(5yea sbe o e he11Sep embe 2001 e o is mu de ‐suicidese en )andsepa a ely
o  he i s ,second,and hi dyea a e  heSep embe 11 e o is a acks.The ela i e isk(RR)o  he
likelihoodo anai c a acciden beingdue opilo suicide o  he h eepos ‐a ackyea swascalcula ed.
3.Resul s
Thenumbe o  a ala ia ionacciden sand ela i e iskso  helikelihoodo pilo AASbeingdue
osuicide h eeyea sa e 11Sep embe 2001,calcula ed o eachyea sepa a ely,isp esen edin
Table1.Allpilo swhodiedwe emale.TheRRwas3.68in he i s yea anddec easedclose o1.0in
he hi dyea .Only heobse a ion o  he i s yea wass a is icallysigni ican .
Table1.Thenumbe and he isk a ioso pilo ai c a ‐assis edsuicides i eyea sbe o eand h ee
yea sa e 11Sep embe 2001,in heU.S.
Follow‐Up
Pe iodDa esNo.o 
Suicides
No.o Fa al
A ia ion
Acciden s
FRQRisk
Ra io
95%Con idence
In e al
Re e ence11Sep embe 1996–10Sep embe 2001618610.32%1.00Re e ence
1s yea 12Sep embe 2001–11Sep embe 200243371.19%3.681.04–12.98
2ndyea 12Sep embe 2002–11Sep embe 200333750.80%2.480.62–9.88
3 dyea 12Sep embe 2003–11Sep embe 200413540.28%0.880.11–7.26
FRQ= equency.
Al oge he 23 a ala ia ionacciden  epo swe eob ainedwi h hespeci iedsea chwo ds.All
indexcaseswe eiden i iedwi h hesea chwo d“suicide”,sea chwo ds“homicide‐suicide”,o 
“mu de ‐suicide”didno yieldanyaddi ionalindexcaseinciden s.Fou eeno  heseinciden swe e
causedbyapilo ’so co‐pilo ’ssuicidalac acco ding oNTSBacciden in es iga ions,and hese
inciden sa edesc ibedinde ailinTable2.All heinciden swe eope a ionally ela ed ogene al
a ia ion,al hough h eepilo shadalsoClassI(comme cialpilo )medicalce i ica ione en hough
heywe eno  lyingcomme cialai c a a  he imeo  hesuicidec ash.I shouldbeno ed ha  h ee
o  hedeceasedpilo swe ealso ligh ins uc o s.Al oge he  ou eenpilo so s uden pilo sdiedin
heseinciden s.Thei ages anged om15 o69yea s.Eigh o  heseai c a ‐assis edsuicides
occu eda e 11Sep embe 2001; ou wi hin he i s yea , h eedu ing hesecondyea ,andonein
he hi dyea ,whilesixai c a ‐assis edsuicides ookplacedu ing he i e‐yea ‐pe iodbe o ei (see
imelineinFigu e1).NTSBcauseso dea h o excludedcasesin hissea chwe e: ou unde e mined
causeso  a ala ia ionacciden s, wo ela ed opsychologicalp oblems(d ugso alcoholwe e
men ioneda leas asacon ibu ing ac o ),in wo epo swea he condi ionswe emen ioned,and
inonecasedea hoccu eddue oapassenge ’ssuicidalac .

Figu e1.Timelineo ai c a ‐assis edpilo suicides i eyea sbe o eand h eeyea sa e 11
Sep embe 2001.Reda owsindica eai c a assis ed suicides.
Figu e 1.
Timeline o ai c a -assis ed pilo suicides i e yea s be o e and h ee yea s a e 11 Sep embe
2001. Red a ows indica e ai c a assis ed suicides.
In . J. En i on. Res. Public Heal h 2018,15, 2525 4 o 10
Table 2. Ai c a -assis ed pilo suicides in he Na ional T anspo a ion Sa e y Boa d da abase i e yea s be o e and h ee yea s a e he 11 Sep embe 2001.
E en Da e and S a e Medical Ce i ica e *
(Assessmen ) PM Toxicology Heal h be o e
he Fligh Cause o Acciden by NTSB ** O he In o ma ion on E en s be o e he
Inciden Fligh
16 Sep embe 2003,
Geo gia Class 2 (14 May 2002) E hanol No mal In en ional suicidal ligh in o he
g ound while impai ed by alcohol.
Pilo h ea ened o commi suicide by lying in o
a moun ain. No suicide no e.
21 July 2003,
Minneso a Class 3 (9 Ap il 2003)
Ci alop am,
luoxe ine,
diphenhyd amine
Dep ession An ac o suicide.
Suicide a emp wi h medica ion wi hin a week
wi h psychia ic hospi aliza ion, “he wan ed o
ge he cou age o kill himsel ”, le he hospi al
a day be o e he acciden ligh . No suicide no e.
25 Feb ua y 2003,
Flo ida Class 1 (12 Ma ch 2002) Toxicology nega i e No da a The in en ional suicidal ac .
No da a. Au opsy: Manne o dea h suicide. No
suicide no e.
17 No embe 2002,
Texas
Class 2 expi ed
(3 Sep embe 1987) Toxicology no done Dep ession
An in en ional suicide by exi ing
om he ai plane, con ibu o y was
psychological condi ion.
F iends and co-wo ke s: ongoing ea men o
dep ession and a ecen in en o ake his own
li e by using an ai c a . A suicide no e.
12 Augus 2002,
Neb aska Class 2 (7 July 1998) Toxicology done,
nega i e No da a The pilo ’s in en ional ligh in o
e ain in an ac o suicide.
On-going c iminal in es iga ion and was old o
ha e h ea ened o kill himsel by in en ionally
c ashing an ai plane be o e he would go o jail.
No suicide no e.
5 Janua y 2002,
Flo ida
Class 3
(17 No embe 2001)
Toxicology done,
nega i e No da a
The pilo ’s unau ho ized use o an
ai c a o he pu pose o
commi ing suicide.
The ai plane impac ed he o ice building a he
28 h- loo le el. A suicide no e.
5 Janua y 2002,
Colo ado
Class 2
(28 Sep embe 2000)
Venla axine and i s
me aboli e Dep ession
In en ional suicidal ligh in o
e ain. Con ibu ing was
dep essi e s a e, and inapp op ia e
medica ion.
Recei ed psycho he apy o se e e dep ession.
Told ha i he killed himsel , he would c ash a
plane wi h only himsel in i . No suicide no e.
Manne o dea h: suicide.
4 Janua y 2002,
Cali o nia Class 3 (30 Ma ch 2001) Done, no da a gi en No da a In en ional ligh in o e ain in an
ac o suicide.
Subjec o a c iminal in es iga ion, he pilo ’s
compu e was seized om his home in he
acciden day. Addi ional emo ional ea lie
dis ess. Co one : suicide. No suicide no e.
25 Augus 2001,
New Hampshi e Class 3 (15 Ma ch 2000) Done, no da a gi en No da a Suicide, he pilo in en ionally
c ashed his ai plane in o his house.
A day be o e he pilo was issued a es aining
o de a his home and was esco ed o his
p ope y. Cause o dea h: suicide. No
suicide no e.
In . J. En i on. Res. Public Heal h 2018,15, 2525 5 o 10
Table 2. Con .
E en Da e and S a e Medical Ce i ica e *
(Assessmen ) PM Toxicology Heal h be o e
he Fligh Cause o Acciden by NTSB ** O he In o ma ion on E en s be o e he
Inciden Fligh
2 Oc obe 2000,
Sou h Dako a
Class 1
(17 Decembe 1999) Toxicology nega i e No da a Suicide. Manne o dea h: suicide. No suicide no e.
3 July 2000, Alaska Class 1 (2 Ma ch 1999)
E hanol, diazepam,
cocaine, and hei
me aboli es
Subs ance abuse
his o y Suicide.
A his o y o subs ance abuse, p e iously
con ic ed o a son, sough by police. F iend: On
he d i e o he ai po es less, agi a ed,
dep essed. Suicide no e. Manne o
dea h suicide.
11 Oc obe 1998,
Oklahoma Class 3 (7 Augus 1997) Diazepam and i s
me aboli es No da a Suicide.
The acciden si e was loca ed adjacen o a
chu ch whe e a iend, epo ed o ha e
declined pilo ’s ma iage p oposal he nigh
be o e, was a ending se ices. No suicide no e.
6 Sep embe 1998,
Flo ida Class 2 (31 Janua y 1998)
Measu ed e hanol
le el e e ed o
e hanol consump ion
be o e he inciden
No da a The pilo ’s use o he ai c a o
commi suicide.
Suicide no e, “I do no wan o li e”. Manne o
dea h: suicide.
24 No embe 1997,
Cali o nia
Class 3 (4 No embe 1996)
E hanol, pos mo em
p oduc ion
Co one : p e ious
hea a ack
Ac o suicide by in en ionally
di ing he ai c a in o he ocean.
Gi l iend con ac ed he ope a o asking i he
pilo had aken o and exp essed conce n abou
suicidali y. A ecen mo he ’s dea h, wo ied
abou heal h. A will da ed day be o e he
inciden , no suicide no e. Mode o
dea h: suicide.
* Class 1 = Ai line T anspo Pilo ; 2 = Comme cial Pilo ; 3 = P i a e o Rec ea ional Pilo ; ** NTSB = Na ional T anspo a ion Sa e y Boa d.

In . J. En i on. Res. Public Heal h 2018,15, 2525 6 o 10
4. Discussion
The one-yea RR o 3.68 o ai c a -assis ed pilo suicides in he U.S. a e 11 Sep embe 2001, is in
line wi h he esul s o escue wo ke ’s suicide mo ali y epo ed by Jo dan e al. [
22
], and some ea lie
copyca epo s by Fink e al. [
8
]; see also Sisask and Vä nik [
7
]. While a al a ia ion acciden s a e a e,
la ge o long- e m egis e s udies such as he s udy o Ble ne e al. [
27
] and Poli ano and Wal on [
3
]
enable assessmen s o de ec plausible e ec s o such e en s. Gene al popula ion suicide a es ha e
been ela i ely s able du ing he ime pe iod o his s udy, bu ha e inc eased in he U.S. du ing he
las ew yea s [28,29].
In s udies om o he coun ies, in England and Wales no inc ease o suicides was obse ed
a e 11 Sep embe 2001 [
30
] and he e was no de ec able change in he suicide a es in he Ge many
s udy [
31
]. An analysis o suicide a es om he Ne he lands by de Lange and Neeleman [
32
] showed
e idence o an inc ease in he suicide a es in he weeks a e 11 Sep embe . Rega ding auma and
s ess ela ed diso de s, a Danish s udy by Hansen e al. [
33
] epo ed an inc ease in auma and s ess
- ela ed diso de s a e 11 Sep embe 2001, in line wi h se e al U.S. s udies [34,35].
In one suicide ligh in ol ing a young pilo a e 11 Sep embe 2001, he plane c ashed
in en ionally in o a high o ice building. Acco ding o he epo he e was a suicide no e bu i
was no included in he acciden in es iga ion da a. The helicop e pilo s who in e cep ed his ai plane
a emp ed o signal he young pilo o land. Acco ding o he helicop e pilo s, he s uden pilo saw
hei hand ges u es and ges u ed back, bu hey could no de e mine he meaning o he ges u es.
In es iga ion o his inciden led o a Fede al A ia ion Adminis a ion secu i y no ice elease.
In he inciden s in es iga ed in his s udy, p e ious dep ession wi h suicide a emp s was
desc ibed in one case, ongoing ea men o dep ession in wo cases, and a his o y o subs ance
abuse and a son con ic ion in one case. Toxicology e ealed ha in six o hese inciden s he e we e
medica ions o subs ance misuse no compa ible wi h lying acco ding o FAA. Some pilo s wi h no
in o ma ion on p e ious psychological o psychia ic issues had ecen s ess ul pe sonal si ua ions,
such as legal o in e pe sonal di icul ies.
The choice o c ashing an ai c a o commi suicide among some pilo s may in pa be unde s ood
h ough he desi e o combine passion o lying wi h dea h, e lec ing an in ima e bond be ween
he pilo and his means o dying. Occasionally he e may also be a hope ha he inciden would be
cons ued as a medical a ali y i he e idence we e o be des oyed in he c ash ( o ins ance i he
ai c a disappea s).
One o he Class 1 pilo s had a his o y o subs ance dependence. He was con ic ed o d i ing
when in oxica ed on se e al occasions and o a son, and had acu e s esso s. He le a suicide no e.
Ano he Class 1 pilo wi h no known immedia e s ess ul e en s o heal h- ela ed issues asked ai
a ic con ol o call o ai po escue and i e igh ing, and “also i you could ell my amily and
iends ha I lo e hem e y much”. Thus, he could be eached immedia ely be o e he le hal ac .
The hi d Class 1 pilo wi h mili a y helicop e expe ience old he dispa che he was going o mee
someone. A no ime did he display any signs o s ess o unusual beha io . The e we e no eco ds o
p e ious inciden s, and he had ligh expe ience wi h a ious helicop e s. This desc ip ion gi es an
imp ession o a pe son who made a decision and enac ed i ; he was no in con ac wi h any ai a ic
con ol acili y a he ime o he inciden .
P e ious suicide a emp s and majo dep ession a e isk ac o s o comple ed suicide, bu da a on
dep ession among a ia o s is limi ed [
13
,
36
]. In ci il a ia ion, ongoing symp oma ic majo dep ession
is no compa ible wi h lying du ies. A e ull emission and su icien ollow-up, In e na ional
Ci il A ia ion O ganiza ion (ICAO) and a ia ion au ho i ies cu en ly accep psychological and some
pha macological ea men s o a ia o s o p e en ecu ence [14,15].
In a ia ion, ull emission o dep essi e o s ess- ela ed symp oms, good compliance, and a
easonable ollow-up ime pos - eco e y a e a p e equisi e o he conside a ion o an a ia o ’s e u n
o lying du ies [
13
–
15
,
36
–
38
]. Accep ed an idep essan s used o p e en symp oms a e assessed
In . J. En i on. Res. Public Heal h 2018,15, 2525 7 o 10
h ough speci ic p og ams ha ocus on comp ehensi ely assessing i ness o ly, symp oms, ea men
adhe ence, and especially ae o-medically ele an side-e ec s (e.g., a igue).
In ela ion o men al heal h and suicide, i should be no ed ha among pilo s egula heal h
examina ions con ibu e o he ecogni ion o isk ac o s o suicidal beha io . The ac ual isk ac o s
o pilo s may somewha di e om he gene al popula ion, in ela ion o he ole o any de ined
psychia ic diso de s [13,39,40].
The limi a ions o his s udy include he ac ha ou da a a e based on in o ma ion in he acciden
in es iga ions, and we do no ha e access o addi ional medical in o ma ion o de e mining a ia o
suicides no o any in o ma ion on a ia o s’ a emp ed suicides p io o he incidence. The da a a e
elian on NTSB epo s, and hese epo s a e incomple e in some cases and ce ain de ails emain
unknown. The news in o ma ion a e 11 Sep embe and iming o news deli e y was no analyzed,
bu he e a e se e al s udies om he U.S. on psychological e ec s a e 11 Sep embe 2001 [
6
,
25
,
41
].
We do no hink ha any lying pilo in he U.S. could ha e a oided he news, due o immedia e ale s
and ai space closu es in he U.S. The ole o media esea ch and balancing We he and Papageno e ec s
in gene al popula ion suicide p e en ion is mo e ho oughly assessed elsewhe e [
42
–
45
]. Howe e , we
conside ou pilo AAS es ima es o be conse a i e since hose a al a ia ion inciden s whe e au opsy
indica ed suicide, bu NTSB acciden in es iga ions did no ag ee, we e excluded.
5. Conclusions
This s udy showed an associa ion o 11 Sep embe 2001, wi h pilo AASs. The copyca e ec was
p esen o one yea a e 11 Sep embe 2001. The causal ac o s behind his s a is ical associa ion
emain unclea in con ex o he heo e ical app oaches on suicidali y. The use o ai c a as he means
o commi he e o is a acks in he U.S. on 11 Sep embe 2001, may ha e had a nega i e e ec on
a ew acu ely ulne able pilo s. This ulne abili y wa an s u he in es iga ion, pa icula ly wi h
e e ence o he copyca phenomenon and i needs o be aken in o accoun in a ia ion medical sa e y
isk assessmen s.
Au ho Con ibu ions:
A.V. con ibu ed o he s udy design, da a p ocu emen , esul s in e p e a ion and d a ed
he a icle. T.L. d a ed i s e sion o he ms. A.V., T.L., I.J., E.P. we e in cha ge o da a analysis. A.V., T.L., I.J.
con ibu ed o esul s in e p e a ion. All au ho s A.V., B.B., A.S., T.L., I.J., E.P., P.N., R.B. c i ically e ised he
a icle and ga e hei inal app o al o publica ion.
Funding:
The Academy o Finland, Finnish Medical Founda ion, Sig id Juselius Founda ion, and he Tampe e
Tube culosis Founda ion.
Con lic s o In e es : The au ho s decla e no con lic s o in e es .
Abb e ia ions
AAS Ai c a Assis ed Suicide
AME A ia ion Medical Examine
CAA Ci il A ia ion Au ho i y
CI Con idence In e al
FAA Fede al A ia ion Adminis a ion
ICAO In e na ional Ci il A ia ion O ganiza ion
NTSB Na ional T anspo a ion Sa e y Boa d
PM Pos -Mo em
RR Rela i e Risk
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