When Joseph Emerson tried to activate the fire suppression system on a Horizon Air flight on Sunday, the off-duty pilot was returning home from an intense and emotional weekend with friends and family of his closest friend, who died unexpectedly five and a half years ago.

The death hit Emerson hard. He became depressed. Emerson’s wife, Sarah Stretch, said that his depression and irritability worsened every year around the anniversary of his friend’s death.

“I had brought up during that, I was like, ‘Maybe you should talk to somebody,’” said Stretch, who also asked her husband if he could take medication for his mental health struggles. “And then he expressed to me, ‘Sarah, I can’t be out of work. We have to pay a mortgage. If I go do that, I have to go through all these other hoops …and we can’t afford to do that.’”

The Federal Aviation Administration, the government agency that regulates pilot licensure and medical clearance, has strict and, many pilots and aviation experts say, onerous and outdated policies around mental health. As a result, commercial airline pilots often avoid seeking help for what would likely be treatable depression or anxiety. A 2016 study found that 12.6% of commercial pilots had depression and 4.1% reported suicidal thoughts in the previous two weeks.

Researchers concluded that hundreds of currently active pilots are managing depressive symptoms and possibly afraid to seek treatment.

“If each aircraft requires two pilots, that means one out of four aircraft that are out there flying, are flying with a pilot that would qualify as clinically depressed,” said Carl Eisen, a retired commercial airline pilot who spent years managing his own anxiety and now teaches meditation to other pilots. “If that were dangerous, airplanes would be raining out of the sky on a regular basis. So it doesn’t seem that this poses a huge safety risk, although it’s less than ideal.”

The FAA relies on pilots to self report any physical and mental health issues. If a pilot reports they have started seeing a therapist for depression, they are pulled from flight status. Regaining medical clearance to fly involves multiple steps — and can take years.

A long, costly process

Pilots and aviation experts told OPB many pilots choose to pay for a therapist out of pocket in order to avoid insurance claims and reporting to the FAA. But it’s a potentially enormous liability for the pilots if an accident were to happen.

If they follow federal policies, pilots must see FAA approved specialists, pass a battery of tests and voluntarily submit their therapist’s notes to the FAA, Eisen said. If they are prescribed medication for their depression, it’s even more complicated. Pilots are only allowed to take one of five selective serotonin reuptake inhibitors, one type of antidepressant among many. If they choose to stay on medication, they must take the drug for six months before they can reapply for their medical clearance. If they stop taking antidepressants, they must wait 60 days before reapplying.

“It is not an easy process for them to get back into the cockpit,” said Dr. Brent Blue, a physician and senior aviation medical examiner who also works with pilots with drug and alcohol issues. “They will have to go through these evaluations by a psychiatrist and a neuropsychologist to do that. … This is a pilot who basically is being responsible saying, ‘I am not up to flying because of my grief or whatever.’”

None of the FAA mandated steps are covered by insurance. And the process — the required tests, psychological evaluations, traveling to specialists — can cost thousands of dollars. It’s all happening while the pilot is grounded and can’t work.

OPB talked to a captain at a major U.S. airline who asked not to be named because they’re afraid it will negatively impact their career. About five years ago, they said, they made the hardest phone call they’ve ever made. After life stresses mounted and their depression became too much, they called a psychiatrist, grounded themselves, and “went through the horrible process of trying to get certified as a pilot on antidepressant SSRIs.”

“It was one of the hardest things I’ve ever done,” they said. “It shouldn’t just be, ‘Here’s some pills. Go fly.’ It should be a process, but it takes three years where you’re not getting an income.”

Pilots can apply for short term and, after six months, long term disability while they wait for their medical clearance. The rates vary by airline but one pilot told OPB their long term disability pay was 50% of their salary.

The pilot said they felt great within six weeks of starting medication but remained grounded for three years while the FAA reviewed their paperwork and worked through the agency’s backlog. They eventually returned to flying but said most pilots still view depression as a career-ending diagnosis. Even if the FAA eventually approves your medical clearance, if you don’t have disability coverage or can’t afford the time away from work, it may be.

The stress of the job

Being a pilot is extremely stressful, Eisen said. That’s not because flying a plane is more stressful than other intense careers. For pilots, all of the mechanisms most people use to minimize stress in their lives are unavailable or difficult to incorporate regularly. Regular sleep and exercise, a healthy diet and vibrant personal life are all challenging because of the demands placed on pilots.

“Sleep patterns are frequently disrupted. That’s kind of a normal thing for airline pilots,” Eisen said. “You’re gone half the time. That’s pretty stressful on your family life now, isn’t it? Have you ever tried to eat food at an airline terminal or the food that they give you on an airline? What about your diet?”

After arriving at a hotel at the end of a 10-hour day, a pilot is more likely to have a glass of wine and watch TV than exercise.

“It’s very, very difficult just to have the foundational blocks in place to maintain good psychological and physical well being,” he said. “Put on top of that the stress of the schedules, the stress of the weather, the stress of the passengers, dealing with multiple crew members, all of these other things. It’s a very, very stressful life.”

The FAA has made some changes. Before 2010, the agency didn’t allow pilots to take any antidepressants. Even pilots who had been on antidepressants in the past were prohibited from flying. The agency still prohibits pilots from taking more than one antidepressant at a time.

Blue, the Wyoming based senior aviation medical examiner, said the FAA’s policies make no rational sense. Being on two medications does not indicate more severe depression, Blue said. He said the agency should accept the judgment of a pilot’s treating psychiatrist.

“The FAA is so worried about a smoking hole in the ground that they’re scared to death that somebody’s going to be held responsible,” Blue said, explaining that it’s very easy to say “no” to a pilot. “So the fallback position is always to say no. That’s why pilots tend to withhold information.”

In a statement to OPB, an FAA spokesperson said most mental health conditions don’t disqualify pilots from flying and that the agency encourages pilots to seek help if needed.

“During the last several years, the FAA has invested resources to eliminate the stigma around mental health in the aviation community so pilots seek treatment,” the spokesperson said.

In 2015, a pilot for Germanwings, a defunct discount airline owned by Lufthansa, crashed his Airbus 320 into the French Alps, killing all 150 people on board. The pilot had previously been treated for depression and his search history in the days leading up to the incident suggested he wanted to take his own life. And in 1994, a FedEx employee facing dismissal attempted to hijack and crash one of the company’s cargo planes to make his death look like an accident, allowing his family to collect life insurance.

Although astonishingly rare, Blue said the FAA is terrified of future similar incidents. Revamping policies, especially if the new policies appear more permissive, carries risk.

“Nobody wants to put their neck on the line, even if the chances are extremely remote that it’s a problem,” Blue said. “The FAA is fairly archaic in almost every regard.”

Mounting stresses

These are the waters in which Emerson and other pilots swim. His friend’s death was one of a number of stressors in Emerson’s life exacerbating his depression, Emerson’s wife said.

He has been a commercial airline pilot since 2001, working for Horizon Air, Virgin America and then Alaska. He became a captain with Alaska Airlines in 2019 and has spent several years working in the airlines’ training department. Although that meant often-irregular hours at work — until recently they ran flight simulator training 24 hours a day, Emerson was still home and fully present for his wife and their two children, 8 and 6, Stretch said. Then, Alaska transitioned to a fleet that consisted entirely of planes built by Boeing. Emerson, an Airbus pilot, had to retrain on an entirely new aircraft.

The stakes were high. He would either pass the training or he would be out of a job.

Starting in May, Emerson was in Seattle training full time with a day or two home in San Francisco each week. For the first time in the eight years since they had their first child, Stretch was essentially a single parent.

“We would have arguments because I don’t understand the stress that he’s going through,” she said. “And I would be like, well, ‘you don’t understand the stress I am going through taking care of these kids.”

Emerson, who had wanted to fly since the fourth grade, began meditating and trying to work on himself on his own instead of seeking professional help — and potentially jeopardizing a career to which he had devoted his life.

It’s common for off duty pilots and flight crew to take flights to or from their work assignments. A short time into the Oct. 22 flight home to San Francisco, Emerson, who at 6′1″ hated riding in the cramped jumpseat, threw off his headset and said, “I’m not OK,” according to court records. He hadn’t slept in 40 hours. He was under tremendous stress at home and work, he was depressed and had just spent a weekend remembering his dead friend.

At some point during the preceding somber two days, Emerson took psychedelic mushrooms, he told investigators. Stretch was shocked when she found that out. She said her husband would never take anything more than allergy medicine and was afraid to be in rooms where people were smoking marijuana because it could have jeopardized his medical clearance.

Emerson told police he thought he had been dreaming when he reached up and pulled the handles activating the fire suppression system. He willingly left the cockpit and asked flight attendants to restrain him, fearing he might do something else.

An FBI affidavit suggested Emerson was on hallucinogenic mushrooms at the time he tried to activate the fuel suppression system. The agent who wrote the affidavit said Emerson told a police officer it was his first time taking the drug. The affidavit does not mention that Emerson told the officer he’d eaten the mushrooms about a day and a half prior or that the officer noted Emerson did not appear under the influence of any substance at the time. Mushrooms’ mind-altering effects last about six hours.

Stretch said her husband is obsessed with safety — so much so that Alaska Airlines made him the airline’s safety representative at San Francisco International Airport.

And he loved his passengers, telling them before each flight that they were all on this plane together and suggesting they “be good to each other.”

Among the dozens of state and federal charges, Emerson faces 83 counts of attempted murder but nothing about his behavior leading up to the incident suggests he had any intention of hurting passengers or himself. The day before returning home, Emerson made lunch plans with a friend. He texted his wife about how excited he was to see her and the kids.

“I want to come home. I want to cuddle,” he texted. “Can we just sit on the couch and cuddle and watch TV when we get home?”