FAA Initiatives to Improve Helicopter Air Ambulance Safety

Thursday, February 20, 2014

Helicopter air ambulance operations are unique due to the urgent nature of the flight. The FAA, helicopter 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.

On February 20, the FAA issued a sweeping final rule that requires helicopter operators, including air ambulances, to have stricter flight rules and procedures, improved communications and training, and additional on-board safety equipment. The rule follows an October 7, 2010 proposal.

Prior to the rule, the FAA focused on working with operators on risk management training for flight crews, training for night operations and responding to inadvertent flight into deteriorating weather conditions, and the promotion of technology such as terrain awareness and warning systems (TAWS), radar altimeters, and night vision goggles (NVGs).

There are currently 75 air ambulance companies that operate approximately 1,515 helicopters in the United States.

Since August 2004, the FAA has promoted initiatives to reduce risk for helicopter air ambulance operations. While accidents did decline in the years following that effort, 2008 proved to be the deadliest year on record with five accidents that claimed 21 lives. The FAA examined helicopter air ambulance accidents from 1991 through 2010 and determined 62 accidents that claimed 125 lives could have been mitigated by today's rule. While developing the rule, the FAA considered 20 commercial helicopter accidents from 1991 through 2010 (excluding air ambulances) that resulted in 39 fatalities.From 2011 through 2013, there were seven air ambulance accidents resulting in 19 fatalities and seven commercial helicopter accidents that claimed 20 lives.

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. 

FAA Oversight
The FAA oversees air ambulance operators, but the agency’s oversight goes beyond inspection and surveillance. The FAA uses a risk-based system that includes the initiatives outlined below which focus on the leading causes of accidents. 

FAA Actions

  • 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.
  • New FAA 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.
  • International Helicopter Safety Team (IHST): Formed in 2005, the IHST promotes safety and works to reduce civil helicopter accidents worldwide. The government and industry group addresses factors affecting an unacceptable helicopter accident rate. The group’s vision is an international civil helicopter community with zero accidents with a goal to reduce the international civil helicopter accident rate by 80 percent by 2016. IHST members establish partnerships with countries with significant helicopter operations and encourage overseas industries to perform accident analysis and develop safety interventions. Worldwide partners include government and industry participants from the United States, Canada, Brazil, Japan, Australia, India, Russia, and multiple countries in Europe, Central Asia, and the Middle East.
  • 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).
  • Weather:  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 helicopter air ambulance 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. The FAA and industry met in 2013 to fine tune the tool.
  • 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.
  • 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 operational 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.
  • Operations Specifications: 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 also provided greater access to weather reporting facilities, and required  the flight crew to determine a minimum safe altitude and obstacle clearance prior to each flight.  The compliance date was no later than February 22, 2009.
  • 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 were:
    - 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
  • Surveillance of large HEMS operators: On January 26, 2009, 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 an increase in the cadre of inspectors assigned to air ambulance operations and the organization of those inspectors into operator-specific oversight teams.
  • Night Vision Goggles (NVGs): 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.

The FAA has a solid record of facilitating safety improvements and new technologies for EMS helicopters, including approval of inflight use of NVGs. Since 1994, the FAA has worked 71 projects or design approvals called Supplemental Type Certificates (STCs) for installation of NVGs compatible cockpit lighting systems on helicopters. This number includes EMS, law enforcement and other types of helicopter operations. Of the 71 projects, the FAA has approved approximately 53 NVG STCs that include EMS helicopter configurations. 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) for Integrated Night Vision Imaging System Equipment, published October 12, 2001. The FAA has hosted workshops to help applicants work with the FAA to obtain NVG approval. One set of NVGs costs approximately $7,000 and an operator must carry multiple sets per flight. Certification of the NVG compatible aircraft lighting system is just one step. The operator must also have an FAA-approved training program for using NVGs as well as specific inspection and maintenance programs for the 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).