Helicopter air ambulance operations are unique due to the urgent nature of the flight. The FAA, operators, and the medical community all play a vital role in promoting a positive safety culture that ensures the safety of passengers, flight crews, and medical professional on these flights.
Since August 2004, the FAA’s has:
- Encouraged risk management training to flight crews so that they can make more analytical decisions about whether to launch on a flight.
- Promoted better training for night operations and responding to inadvertent flight into deteriorating weather conditions.
- Promoted technology such as night vision goggles (NVGs), terrain awareness and warning systems (TAWS) and radar altimeters.
- Provided airline-type FAA oversight for operators. Identify regional FAA helicopter operations and maintenance inspectors to help certificate new operators and review the operations of existing companies.
The helicopter air ambulance industry grew by 54 percent between 2003 and 2008. There are currently 74 air ambulance companies that operate approximately 850 helicopters in the United States. The NTSB estimates that 400,000 patients and transplant organs are transported by helicopter each year.
The Role of the Medical Community
Aviation safety decisions are separate from medical decisions. The decision to conduct a flight with a patient on board does not mean that flight safety can be compromised in any way. Once the medical need for air transportation is determined, it is up to the operator to make the air transportation decision based on pre-flight factors such as weather conditions, maintenance, and crew readiness.
The FAA inspects air ambulance operators, but the agency’s oversight goes beyond inspection and surveillance. Rather, the FAA uses a risk-based system that includes the initiatives outlined below which focus on the leading causes of accidents.
- In August 2004, the FAA established a task force to review and guide government and industry efforts to reduce air ambulance accidents.
- On January 14, 2005, the FAA hosted a meeting with industry representatives to discuss safety issues and gain feedback. Representatives from the Association of Air Medical Services, Helicopter Association International, the National EMS Pilots Association and several operators attended.
- Decision-making skills:On January 28, 2005, the FAA published a notice providing guidance for safety inspectors to help operators review pilot and mechanic decision-making skills, procedural adherence, and crew resource management practices. It includes both FAA and industry intervention strategies (Notice 8000.293 Helicopter Emergency Medical Service Operations). These principles were reinforced in the Safety Alert for Operators (SAFO) 06001 issued on January 28, 2006.
- Risk assessment programs: On August 1, 2005, the FAA issued guidance to inspectors promoting improved risk assessment and risk management tools and training to all flight crews, including medical staff (Notice 8000.301 Operational Risk Assessment Programs for Helicopter Emergency Medical Services).
- Air Medical Resource Management (AMRM): On September 22, 2005, the FAA issued guidance to operators establishing minimum guidelines for Air Medical Resource Management (AMRM) training. The training focuses on pilots, maintenance technicians, flight nurses, flight paramedics, flight physicians, medical directors, specialty team members (such as neonatal teams), communications specialists (dispatchers), program managers, maintenance staff, operational managers, support staff, and any other air medical team members identified by specific needs (AC No. 00-64 Air Medical Resource Management).
- Special emphasis inspection program: On September 27, 2005, the FAA issued revised standards for inspection and surveillance of air ambulance operators, with special emphasis on operations control, risk assessment, facilities and training, especially at outer locations away from the certificated holder’s principal base on operations.
- FAA establishes new office: In December 2005, the FAA’s Flight Standards Service’s Air Transportation Division established the new Commuter, On Demand, and Training Center Branch (AFS-250) to work Part 135 and Part 142 policy issues. The FAA has begun hiring aviation safety inspectors with specific “helicopter only” experience in order to keep pace with industry growth.
- Loss of Control (LOC) and Controlled Flight Into Terrain (CFIT): On January 24, 2006 the FAA issued a handbook bulletin to inspectors describing acceptable models for LOC and CFIT avoidance Programs. The bulletin provides inspectors with information to provide to operators for developing LOC/CFIT accident avoidance programs and clarifies existing guidance (HBAT 06-02 Helicopter Emergency Medical Services (HEMS) Loss of Control (LOC) and Controlled Flight Into Terrain (CFIT) Accident Avoidance Programs).
- HBAT 06-01 & OpSpec A021: On January 24, 2006 the FAA issued revised guidance to inspectors regarding HEMS OpSpecs, amending the Visual Flight Rule (VFR) weather requirements for HEMS operations, including consideration of the adverse affects of reduced ambient lighting at night and mountainous terrain (HBAT 06-01 Helicopter Emergency Medical Services; OpSpec A021/A002 Revisions).
- Guidance to Part 142 training centers: On February 24, 2006, the FAA issued a Notice to Training Center Program Managers assigned to oversee Part 142 training Centers advising them of recent changes to air ambulance operations and training standards (Notice 8000.317, Operator Training Provided by Part 142 Training Centers for Helicopter Emergency Medical Services.)
- Public air ambulance operators:On March 2, 2006, the FAA issued guidance to inspectors on the surveillance and oversight of public aircraft operators for air ambulance operations (Notice 8000.318 Public Helicopter Emergency Medical Services (HEMS) Operations).
- Terrain Awareness and Warning Systems (TAWS): On June 27, 2006, at the FAA’s request, RTCA, Inc. established a Special Committee to develop Helicopter Terrain Awareness and Warning System (H-TAWS) standards. These standards will be used to develop FAA requirements for H-TAWS systems, installation and operations.
- Aeronautical Information Manual: In August 2006, the FAA revised the Aeronautical Information manual (AIM) to provide guidance to pilots on assessing ambient lighting for night VFR operations and for off-airport/heliport landing zone operations.
- International Helicopter Safety Team (IHST): The helicopter industry has formed the IHST to gather data and draft strategies to reduce helicopter accidents globally by 80 percent by 2015. The effort is modeled on the Commercial Aviation Safety Team (CAST) which has achieved a significant reduction in the commercial fatal accident rate in the United States. Members include the FAA, European Aviation Safety Agency (EASA), Transport Canada, the International Civil Aviation Organization (ICAO), and industry representatives.
- Surveillance of large HEMS operators: The FAA’s Flight Standards Service established a task group to focus on the certification and surveillance requirements for large air ambulance operators that support diverse medical programs throughout the United States. The group’s findings resulted in the increase in the cadre of inspectors assigned to air ambulance operations.
- Operational Control Centers:On May 5, 2008, the FAA’s Flight Standards Service issued an advisory circular (AC 120-96) highlighting the “best practices” for use by air ambulance operators in establishing their control centers and training their specialists.
- FAA/Association of Air Medical Service (AAMS) Safety Meeting: On July 11, 2008, 80 representatives from the FAA and operators met in response to recent accidents. Discussions focused on night operations in poor or deteriorating weather, risk management, complacency, the agency’s policies on the use of NVGs, as well as helicopter shopping.
- Notice to FAA Inspectors:On January 12, 2009, the FAA issued a notice (Notice 8900.63) to agency inspectors with oversight of air ambulance operators to find out how many operators have adopted FAA-recommended best practices. With reports in from all of the 74 operators surveyed, the percentages that have adopted various programs are:
–Decision-making skills and risk assessment programs – 94 percent
–Response to FAA guidance on Loss of Control (LOC) and Controlled Flight Into Terrain (CFIT) avoidance – 89 percent
–Integration of operation control center – 89 percent
–Installation of Flight Data Recorders and devices that can re-create a flight. – 11 percent
–TAWS equipage – 41 percent
–Use of radar altimeters – 89 percent
On November 14, 2008, the FAA published a Notice in the Federal Register that advised operators of important mandatory changes to air ambulance flights. The agency also included a provision to encourage the use of NVGs and Terrain Awareness Warning Systems. Consistent with NTSB recommendations, all air ambulance operators will comply with Part 135 weather minimums, including repositioning flights with medical crew onboard. The FAA is also providing greater access to weather reporting facilities, and requiring the flight crew to determine a minimum safe altitude and obstacle clearance prior to each flight. The compliance date is no later than February 22, 2009.
In March 2006, the FAA and the University Corporation for Atmospheric Research hosted a weather summit in Boulder, Colorado to identify the air ambulance-specific issues related to weather products and services. Attendees explored possible regulatory improvements, weather product enhancements, and operational fixes specific to HEMS operations. Attendees included the National Weather Service, National Center for Atmospheric Research (NCAR), Helicopter Association International, American Helicopter Society International, Association of Air Medical Services, National EMS Pilots Association, National Association of Air Medical Communications Specialists, manufacturers, and many operators.
As a result, the FAA funded the development and implementation of a graphical flight planning tool for ceiling and visibility assessment along direct flights in areas with limited available surface observations capability. It improves the quality of go/no-go decisions for air ambulance operators. The tool was fielded in November 2006.
Night Vision Goggles
The FAA has a solid record of facilitating safety improvements and new technologies for EMS helicopters, including certification of NVGs. Since 1994, the FAA has worked 28 projects or design approvals called Supplemental Type Certificates (STCs) for installation of NVGs on helicopters. This number includes EMS, law enforcement and other types of helicopter operations. Of the 28 projects, the FAA has approved approximately 15 NVGs STC’s for EMS helicopters. The FAA initiated and wrote (in coordination with RTCA) the minimum standards for NVGs/cockpit lighting.
Technical Standard Order (TSO) C164 was published on September 30, 2004 referencing RTCA document DO 275 Minimum Operational Performance Standards (MOPS), published October 12, 2001. The FAA has hosted workshops to help applicants work with the FAA to obtain NVG certification. One set of NVGs costs approximately $7,000 and an operator must carry multiple sets per flight. Certification is just one step. The operator must also have an FAA-approved training program for using NVGs.
The FAA has revised the NVG guidance in the Operations Inspectors Handbook, Order 8900.1. Produced using considerable industry input, the revision includes the establishment of a cadre of NVG national resource inspectors (Notice 8000.349, Night Vision Imaging Systems).
While the FAA encourages use of NVGs where appropriate, they are not a one-size-fits-all solution. Flying at night is not inherently dangerous if rules and procedures are followed. In fact, many operators who do not use NVGs have never had an accident at night.
Flight Data Recorders
Flight Data Recorders (FDRs) are not required for air ambulance operations. FDRs offer value in any accident investigation by providing information on aircraft system status, flight path and attitude. The weight and cost of FDR systems are factors. Research and development is required to determine the appropriate standards for FDR data and survivability in the helicopter environment, which typically involves substantially lower speeds and altitudes than airplanes. Funds are currently best invested in preventive training.
However, the FAA is considering alternatives to expensive and heavy airliner-style FDRs, especially in light of the relatively low-impact forces in most helicopter accidents. By establishing a standard appropriate to the helicopter flight envelope, the FAA may be able to make meaningful future FDR rulemaking efforts.
Terrain Awareness Warning Systems
The FAA supports the voluntary implementation of TAWS and did consider the possibility of including rotorcraft in the previous TAWS rulemaking process. Through this process, however, the FAA concluded that there are a number of issues unique to VFR helicopter operations that must be resolved before the FAA considers mandating the use of TAWS in this area, such as modification of the standards used for these systems. For example, helicopters typically operate at lower altitudes so TAWS could potentially generate false alerts and “nuisance” warnings that could negatively impact the crew’s response to a valid alert. TAWS use in air ambulance operations required study of TAWS interoperability within the lower altitude environment, and possible modification of TAWS system standards.
At the FAA’s request, RTCA, Inc. established a Special Committee (SC-212) to develop H-TAWS standards for use in future FAA rulemaking projects. The final report was delivered to RTCA in March 2008. Those standards were subsequently reviewed by the FAA’s Aircraft Certification Service and on December 17, 2008, the FAA issued Technical Standards Order (TSO) C-194 to standardize the manufacture of H-TAWS within the industry.