Fit for flight? Working conditions and mental health as integrated safety risks in European aviation

<p dir="ltr"><b>Background: </b>Aviation is widely recognized as one of the safest modes of transportation, supported by advanced technology and strong regulatory control. Central to this system are aircrew (i.e., pilots and cabin crew) whose fitness-to-fly is critical for safe operations. Over the past three decades, European aviation has undergone substantial change following market deregulation. New business models and employment forms have emerged, reshaping working conditions and intensifying demands on crew. Drawing on the Job Demands-Resources model, these developments raise concerns about the health of aircrew. As operational margins decrease, attention has also turned to the safety implications of these working conditions, particularly regarding aircrew fitness-to-fly. In this thesis, fitness-to-fly is conceptualized as both mental health and safety behaviors (e.g., attending work while unfit and willingness to disclose mental health issues).</p><p dir="ltr"><b>Aim: </b>The aim of this thesis was to examine how organizational and psychosocial working conditions are associated with mental health and fitness-to-fly safety behaviors. <b>Study I</b> explored pandemic-related changes in work, health, and safety. <b>Study II</b> examined employment arrangements in relation to reporting behavior and presenteeism among pilots. <b>Study III</b> identified psychosocial work environment profiles and their links to fitness-to-fly. <b>Study IV</b> analyzed airline-level differences in mental health, inappropriate presenteeism, and willingness to disclose, in relation to psychosocial working conditions. <b>Study V</b> explored how cabin crew cope with their working conditions in everyday operations, and the implications for health and flight safety.</p><p dir="ltr"><b>Methods: </b>The thesis draws on over 15,000 responses from two large European web surveys (2022 and 2025) and an interview study with 17 Swedish cabin crew. <b>Study I</b> applied a mixed-methods approach to examine pandemic-related changes in working conditions, health, and safety. <b>Study II</b> used descriptive and comparative analyses of underreporting and presenteeism among atypically and typically employed pilots. <b>Study III </b>used latent profile analysis to identify groups of aircrew with similar psychosocial work experiences. <b>Study IV</b> applied multilevel modelling to analyze airline-level variation in fitness-to-fly outcomes alongside variable-centered analyses of psychosocial working conditions. <b>Study V</b> used semi-structured interviews and reflexive thematic analysis to explore coping strategies.</p><p dir="ltr"><b>Results:</b> <b>Study I</b> showed deteriorations in working conditions post-pandemic, including higher effort, reduced rewards, lower managerial support, and increased uncertainty, showing that psychosocial risks tend to co-occur rather than appear in isolation. <b>Study II</b> showed that atypically employed pilots underreported incidents more often and more frequently attended work while unfit, primarily due to fear and financial concerns. <b>Study III</b> identified a mental- health non-disclosure pattern: less favorable psychosocial profiles were associated with more symptoms, higher presenteeism, and lower willingness to disclose mental health issues to the employer. <b>Study IV</b> found similar patterns at the airline level: airlines with higher mean depressive symptoms also had a higher frequency of self-reported inappropriate presenteeism, and a lower willingness to disclose. The results also showed the importance of roster quality for mental health. <b>Study V</b> showed that cabin crew often function as "operational infrastructure"; their strong identification with the profession can prompt absorbing organizational deficits at the cost of health. While some cope through formal boundary-setting, these strategies may conflict with professional identity and perceived role expectations.</p><p dir="ltr"><b>Conclusions:</b> Psychosocial risks tend to co-occur and are associated with poorer mental health and safety behaviors, indicating systemic risk configurations rather than isolated issues. Further, mental health symptoms, presenteeism, and low willingness to disclose do not only occur independently but also tend to cluster. These configurations were associated with organizational, structural, and psychosocial working conditions, highlighting the system-level of fitness-to-fly risk. Qualitative findings further show how crew respond to these conditions through coping strategies that absorb strain and compensate for organizational shortcomings. Together, this thesis advances understanding of fitness-to-fly by reconceptualizing it as an emergent organizational phenomenon and by demonstrating the potential value of complementing regulatory fitness-to-fly controls with preventive approaches targeting working conditions, particularly roster quality and management- employee relations.</p><h3 dir="ltr">List of scientific papers</h3><p dir="ltr">I. <b>Folke, F.</b>, & Melin, M. (2024). Ramp-up in the air: Impairing or repairing aviation crews' working conditions? A mixed-methods survey study on working conditions, health, and safety among cabin crew and pilots in Europe. Journal of Air Transport Management, 119, Article 102642. <a href="https://doi.org/10.1016/j.jairtraman.2024.102642">https://doi.org/10.1016/j.jairtraman.2024.102642</a></p><p dir="ltr">II. <b>Folke, F.</b>, & Melin, M. (2025). Is it safe to be safe? Examining underreporting and presenteeism among European pilots: The role of employment type. Safety Science, 181, Article 106696. <br><a href="https://doi.org/10.1016/j.ssci.2024.106696">https://doi.org/10.1016/j.ssci.2024.106696</a></p><p dir="ltr"><br></p><p dir="ltr">III. <b>Folke, F.</b>, Sorjonen, K., & Melin, M. (2026). Pilots' and cabin crews' psychosocial work environment in relation to mental health and fitness-to-fly safety behaviors: latent profile analyses. Frontiers in Psychology, 17, 1740908. <a href="https://doi.org/10.3389/fpsyg.2026.1740908" rel="noreferrer" target="_blank">https://doi.org/10.3389/fpsyg.2026.1740908</a></p><p dir="ltr">IV. <b>Folke, F.</b>, Sorjonen, K., Enebrink, P., & Melin, M. (2026). Multilevel analysis of psychosocial working conditions and airline differences in aircrew mental health and fitness-to-fly. [Manuscript]</p><p dir="ltr">V. <b>Folke, F.</b>, Hernandez, I., Bergström, J., Enebrink, P., & Melin, M. (2026). Taking it on, pushing it back, staying out of sight: Cabin crew coping responses to intensified working conditions. [Submitted]</p>