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Fri. Sep 22nd, 2023

Helicopter Emergency Medical Companies(HEMS) is an trade in danger. Because of a rash of deadly accidents, the trade is sicker than the sufferers being flown. The air med enterprise is dying as a result of, as an alternative of saving lives, it is killing individuals, particularly helicopter crews, and sometimes their sufferers.

The issue did not occur in a single day; the answer will not come rapidly, both.

From the start, air medical helicopters have skilled a excessive accident charge. The danger can by no means be eradicated, however it may be mitigated and decreased to the purpose the place an air med accident is uncommon. The next treatise tells how that may be achieved. If all of the initiatives listed right here had been put in place tomorrow, the HEMS accident charge would drop to close zero. Here is the highway map of how that may occur.

” First advice: for these packages requesting it, a direct security stand-down for FAA or different exterior get together overview on all facets of the HEMS operation.

One of many difficulties with the accident charge in air medical is easy semantics. What’s an accident, and the way are the statistics compiled? Here is the underside line: the acknowledged expectation should be a zero accident charge.

A Particular FAR is required, a brand new regulation aimed particularly at air medical operations much like the regs in place for helicopter tour operators. For years the FAA has been unwilling or unable to easily shut down an operator or particular person program website for security or regulatory violations. There needs to be the establishment of an nameless tip line to the FAA, a whistle-blower characteristic for passengers, crew, or different staff of the assorted operators to make use of, one thing much like the NASA security reporting type. The potential for abuse is at all times current with such a system; however the potential for elevated transparency is, as nicely, and the difficulty is vital.

” Pilots should be higher vetted and educated.

There are too many packages, and too many helicopter operators such that the pilot staffing pool is simply too skinny. With decrease expertise ranges, and extra packages flying extra plane extra hours, a rising accident charge is sort of inevitable. A direct hyperlink may be made between the beginning of hostilities in Iraq, and the newest rise within the charge of air medical accidents. Many veteran pilots with a army affiliation are flying abroad, leaving packages at residence understaffed, or with much less skilled pilots in cockpits, or each.

Given the truth that most air medical accidents are climate associated this is smart. Navy pilots are higher in a position to preserve management in IIMC. The talents army pilots purchase, each in flight and with entry to simulators, additionally confer a stage of confidence unavailable to non-military pilots.

Another excuse air med requires extra professionalism and oversight is, that packages are 24/7 operations, with a excessive proportion of flying at night time. Pilot error is the one most typical consider air medical accidents, and present crew relaxation guidelines are insufficient to handle that. Shutting down a program after darkish will not be an possibility*, as these are emergency response automobiles, and should be staffed accordingly.

” Instrument Flight functionality for restoration solely in all air medical helicopters.

If used appropriately, IFR functionality is a strong danger reducer in HEMS operations. What operators generally substitute for IFR functionality is corporate coverage which calls for that pilots keep away from instrument climate in any respect price. However denial of upgraded functionality is inexcusable in an organization which presents aviation belongings to the general public. The FAA ought to demand IFR functionality for air medical helicopters as a part of the brand new SFAR. This might serve two functions: it will give pilots wanted choices; it will improve the usual of firms competing for air med enterprise, drive marginal operators away.

Let me be clear about this: I suggest IFR functionality for restoration solely, not for launch. IFR tools, coupled with ongoing instrument coaching, will go a good distance towards eliminating air med accidents.

Most deadly accidents have occurred en-route to a affected person pickup, or after a pilot has aborted the flight, and turned towards residence base. This says that air med crews are accepting missions in climate that is marginal at finest, an try and take off and test situations over a generally flown route. Simply so, the extra emphasis positioned on climate avoidance, and dismissal of IFR functionality in lieu of climate minimums and dogmatic measures, have made air medical much less secure.

Pilots should discover the fragile stability between program wants and their skilled standing. Air med pilots are simply constitution pilots with a single consumer. However the trappings of the air med program, the flight fits, logos, and shut interplay with medical employees is a continuing enforcement of the crew idea at a consumer hospital. There’s nothing incorrect with crew spirit. However the elite nature of air med flight crews can dilute a pilot’s command authority in conditions the place affected person want seems to override aviation concerns. Climate components may be minimized. Nuisance upkeep points ignored. Crew relaxation occasions may be arbitrarily prolonged to pursue a affected person mission at crew change time. At most packages, pilots are shielded from affected person info, to keep away from undue strain on them to just accept or reject a flight. This can be a good protocol. However the easy fact is, that pilot publicity affected person medical situation is unavoidable on the onset of the mission, or at any time throughout the flight. What’s wanted is a extra skilled, extra goal pilot within the first place.

Give website managers the authority they should implement secure practices. Website managers have little authority to implement pilot codes, or punish unprofessional habits. Most accidents start within the hiring part, mendacity in anticipate the best situations. Posting a pilot to a contract website is dear. However when a consumer hospital calls for a pilot’s removing, or a website supervisor learns of security infractions, that supervisor should be capable to take motion.

Air medical flying has at all times had a status for having an emergency, rapid-response environment. This sheen of pleasure is what attracts sure individuals to it, the so-called adrenaline junkies. From my 20 years in a HEMS cockpit, I can attest to the high-profile nature of the work. There’s nothing extra thrilling than having the helicopter clatter out of the sky, arrive on scene, and land to avoid wasting the day. The sensation is intoxicating, even whether it is illusory. It is simple to lose sight of the aviation facet of it.

The underside line is, that pilots at air med packages are locked and loaded to fly, and never each pilot is reduce out for it. Accepting a mission is the default mode. However as an alternative of being paid to fly, pilots should perceive that they are being paid for the judgement to not fly at occasions. FAR half 105, the so-called ‘pilot-in-command’ rule, not solely protects pilots and the selections they make, but it surely eliminates the potential hazard of a diluted resolution, a call made by a committee. Particularly with the speedy development of the HEMS trade, hour necessities and vital expertise ranges have dropped. The pilot pool has shrunk past the competence stage required.

” Multi-engine plane in air medical operations.

All air medical packages ought to subject multi-engine helicopters. If that proves an excessive amount of for the price range, the hospital ought to abandon the air medical program, or search a consortium association.

Having two engines, and the doubling of different on-board methods, merely brings the aviation asset as much as par with the medical tools it carries. Medical employees routinely have backups for every part; their plane ought to don’t have anything much less.

Multi-engine plane additionally obviate extra mechanic staffing. Two mechanics are extra environment friendly, higher rested, doubly educated, and have extra latitude towards performing required duties to maintain the tools working.

One other much less apparent profit to fielding twin-engine plane is the potential for pilot coaching. Relying on the plane, an additional seat is offered within the cockpit on each flight. That vacant seat ought for use for an observer, a rookie pilot, or a brand new rent to journey alongside, to see first hand how the operation works.

One other benefit of this transformation is, that the copilot may very well be somebody in coaching. If achieved correctly, this place may very well be a income supply for progressive operators prepared to assist a pilot construct up his or her logbook, and prepared to pay for the chance, to the advantage of the operator’s backside line.

” CVR/FDR/TAWS/GPS shifting map set up in air med helicopter cockpits.

The FAA ought to mandate cockpit voice recorders, and/or flight information recorders in each HEMS cockpit. This might add transparency to each air med mission. These packing containers would have two extra advantages: they might help in an accident investigation, a use for which they had been designed; and they’d facilitate upkeep work by recording and archiving system working parameters. TAWS is nothing greater than floor avoidance know-how, one other layer of safety. GPS needs to be a requirement in all HEMS cockpits.

” De-emphasize speedy response/takeoff time.

Despite packages’ PR efforts, and affected person affect proof on the contrary, a speedy response solely places the plane and crew in danger, makes negligible distinction in affected person end result, and needs to be de-emphasized. A launch time of ten minutes will not be unreasonable. No different half 135 operation would promote a 5 minute takeoff time, nor would the FAA grant operations specs for such a factor. In precise observe, the HEMS mission is, by and huge, a transport system to supply a steady, monitored setting for sufferers between hospitals.

” Greater program climate minimums, and obligatory down-status.

Climate is a consider 50% of HEMS accidents. Program and FAA-mandated climate minimums are sometimes stringent, however at most packages they nonetheless border on marginal VFR. The setting wherein air medical plane function is often the place climate info is least obtainable and/or reliable–below three thousand toes, removed from climate reporting retailers, and sometimes beneath radar protection.

” Hospital administration should be extra concerned.

The administration of air med packages should grow to be extra intimately concerned in day after day operations. Launch selections needs to be reviewed; obligatory quick takeoff occasions needs to be deserted; borderline pilots, or those that constantly make poor selections needs to be held accountable; security committees needs to be established, with authority to make main selections, together with the configuration of the plane.

Medical administrators ought to apprise doctor employees of issues of safety regarding air medical, together with the necessity for higher triage to get rid of non-emergent air transports. A tradition of help should be effected for no-go selections. The tendency for medical employees receiving a transport request is to make use of the helicopter if any indication exists that it is wanted. The underlying assumption is, that the affected person must be flown, or a physician wouldn’t have referred to as.

However sufferers are sometimes flown just for mundane logistical causes. Varied EMS companies can be found on a restricted foundation. Taking a floor rig away leaves the county uncovered for lengthy intervals. The helicopter is usually used in its place in these circumstances. Thus, the air medical asset closest to the affected person is usually used when there is no indication the affected person must be flown.

I used to be a pilot in control of an air medical helicopter for twenty years. I perceive the pressures and contingencies, rules, setting and politics that air med pilots are uncovered to daily. From my first air medical flight in July 1983, to my final in October 2003 I noticed one in every of each sort of affected person mission there may be, besides one. I by no means witnessed a start on board the helicopter. That easy reality, that in 3,200 affected person missions I by no means as soon as witnessed a start is instructive. It means triage for ladies about to ship was achieved with utmost care. Each attending and receiving physicians knew to not name the helicopter.

The purpose is, that satisfactory triage, higher session, or each, particularly with at present’s technical means for docs to share info, is a key within the air medical security puzzle, as a result of it means fewer flights, thus extra consideration to actually pressing flights.

With 4 pilots per contract, and the place program hours are low anyway, the operator could (rightly) be involved about much less flying proficiency. On this case the sponsoring hospital ought to contract for extra coaching hours, match their belongings with one other hospital in a consortium association, or cede the air medical transport service altogether, thus saving wanted well being care {dollars}.

Do fewer flights imply lowered service to potential shoppers? No, it means higher service to shoppers who want the service extra. Whereas flying a routine, steady hospital switch affected person, the helicopter is out of service to answer a trauma, or different emergent affected person.

“The underside line should be secondary to secure practices, and onerous aviation realities.

Usually, a hospital based mostly helicopter system is ready up on a blended employees foundation, with pilots and mechanics employed by the aviation vendor, and the hospital employees employed in home. Sponsoring hospitals can price range for plane companies; they’ve the choice of renewing a contract with a vendor–or not; they do not assume the burden of plane upkeep, or employees coaching; they usually keep away from out of service time by having a backup plane inside pointers established within the contract. Leasing the asset additionally offers a hospital the chance to extra simply improve to extra program performance, akin to IFR, NVG, multi-engine, or different modifications.

However contracts provide solely a lot, and therein lies one of many extra entrenched issues, with air medical security usually hanging within the stability: innovation is stifled, and security initiatives shuttled between consumer and vendor, with little or no, or extraordinarily gradual decision. There isn’t any direct connection between funding and security, after all. However there must be extra consideration paid to backup methods for HEMS operations. No surgeon would function when the hospital’s standby generator is out of service. No flight nurse would take off with no backup batteries for a coronary heart monitor, or additional oxygen bottles. No hospital would place its million greenback MRI equipment uncovered within the parking zone, uncovered to the weather.

However hospitals use single-engine helicopters, with VFR solely cockpits, no NVG or GPS or TAWS functionality, one electrical system, one hydraulic system, and one pilot on the overwhelming variety of air med missions. The plane is often parked on a pad exterior, uncovered to wind, rain, icing, warmth, and all method of corrosive components, when hangarage may very well be acquired for little price, retaining the helicopter dry, clear, ice and snow free, lowering upkeep points, and extra rapidly ready for flight.

Accountability is an excellent factor. However as a result of glacial tempo of change in any establishment, and given at present’s concentrate on lowering well being care prices, any innovation, no matter how interesting or related to minimizing danger within the air medical setting, is inevitably caught up within the management/justification/price range triangle, with quite a few layers of paperwork. Within the meantime, wanted improvements and security measures are shelved, or handed between consumer and vendor, with neither accepting monetary accountability. Till such time as security prevails within the air medical subject, contracts needs to be renegotiated yr to yr, with an escape clause for each events. This might permit shoppers to raised price range for brand new improvements, and for operators to flee onerous contracts, higher serve buyer calls for, and be extra attentive to the underside line in a subject already affected by bankrupt operators.

One helpful byproduct of yearly contracting can be to drive out marginal operators, by recognizing that solely bigger, extra versatile firms can bid on and anticipate to win hospital contracts, which require a speedy turnaround of belongings. One other benefit to one-year contracts is, that this may drive standardization of kit. Presently, even two plane sited on the identical hospital usually have totally different medical installations, radio packages, lighting, warning methods and cockpit instrumentation. This is probably not an issue for a contract website utilizing the identical pilots on a regular basis, (or it might be a significant downside), however the lack of standardization precludes one other resolution to the air medical accident puzzle.

Pilots at a specific program function with little or no oversight from firm headquarters. In such an association, pilots usually share solely amongst themselves the assorted issues, upkeep gripes, and operational glitches. There exists no mechanism for collective focus and sharing of security info company-wide, aside from contact by way of annual test flights, or an organization publication of some type. That is but one more reason consumer hospitals ought to make use of bigger firms, as they’ve extra latitude to rent and make use of test pilots and reduction pilot employees to drift between packages. Doing so would disseminate good information and security practices throughout the corporate.

Bigger firms are additionally higher in a position to make use of one other innovation that might improve secure operations: the switch, or shared pilot idea. Transference between contract websites would add to the transparency and oversight of packages, and improve the extent of professionalism. That is but one more reason hospitals ought to subject multi-engine plane. The unoccupied cockpit seat may very well be used to orient a reduction or switch pilot, as an organization test pilot station, or once more, to coach a brand new rent pilot, a performance unavailable to single-engine operations.

Along with the transparency and elevated information base, visiting pilots would provide the medical employees an goal discussion board to debate deficiencies in this system, or challenges with sited pilot employees. It might even have the fascinating impact of lowering no matter stage of protecting opacity that will exist within the ‘crew oriented’ setting.

Yet one more resolution to secure operations is to lower the extent of crew cohesion that will promote a protecting amnesia about unsafe or marginal people, both aviation or medical employees. Shopper hospitals could even think about altering the make-up of flight employees, changing the normal flight nurse crew with floating medical employees to associate with visiting pilot employees. This might place extra emphasis on the ‘air’, and fewer on the ‘medical’ a part of the equation, growing the extent of security. Sufferers and nurses do not crash; pilots and helicopters do.

One resolution to this dilemma has already been listed, an answer that’s open heresy to the air medical group. There are just too many air medical helicopters, working at too many hospitals, by too many distributors. If affected person outcomes, mortality and morbidity had been being positively affected, all to the great. However, after thirty years of working air medical helicopters, there is no goal proof both of these is going on. Meantime, extra air medical crews are dying in accidents. There’s loads of anecdotal info, and lots of of sufferers will testify to the great these plane and crews have achieved, as will I. However the easy, stark actuality is, that air medical aviation is sicker than the sufferers it is trying to achieve. Measures should be taken to alter the scenario.

” Scale back working areas at night time, or use two pilots/ IFR/NVG and TAWS.

One of many boldest options to the air medical accident charge may also be essentially the most controversial. Given the character of air medical, notably in gentle of its picture Vs actuality, hospitals keen on lowering dangers, and elevating the usual of security ought to think about lowering their response radius after a sure time, midnight being the possible cutoff, to a distance of twenty-five miles from the house facility. This restriction would profit security in a number of methods: it will mechanically cut back fatigue ranges in air med crews; it will be an automated triage operate, placing requesting hospitals and physicians on discover {that a} affected person needing air transport should be flown earlier than midnight, or wait until morning. A decreased operations space would reduce the danger of weather-related accidents, placing helicopters nearer to the house hospital, thus obviating the plane’s use for less than emergent sufferers. Shrinking the response space would additionally preclude a lot of the danger related to climate modifications en-route, or on account of lengthy wait occasions at outer hospitals and/or loiter factors. One other profit, notably at packages with two or extra plane, is the elevated availability for upkeep. It might additionally save sponsor hospitals cash, for the reason that income hours flown would possible be much less. Plus, the likelihood exists that fewer pilots can be wanted with a decreased protection space after midnight.

An alternative choice to this proposal is using IFR cockpits, NVG geared up crews (together with medical employees), and adoption of proposed Terrain Consciousness & Warning System in all air medical helicopter cockpits per Part 508 of S. 1300*, a invoice within the U.S. Senate geared toward rectifying the accident charge in HEMS operations**.

Each program’s statistics are totally different, and air medical is, in any case, an emergency rescue service. However limiting the rescue service wouldn’t be the intent; the intent is elevated oversight by way of higher triage of transport requests. At most packages, so-called on-scene missions comprise the bottom proportion of response flights. The bigger quantity is steady, non-emergent affected person missions. It has been debated for years whether or not or not using helicopters impacts affected person mortality and/or morbidity. That debate will proceed. However till the protection situation is sufficiently addressed, it is going to override all others. And till secure flight of air medical helicopters turns into a given, advisability of utilizing them for affected person transport should be watched extra fastidiously.

The HEMS accident charge will solely be decreased when the three legs of the stool are in place: pilots; plane & tools; and hospital/operator oversight. Till the modifications listed herein are accepted observe in air medical flying, accidents will proceed to plague this vital trade. It is my hope that each one concerned can step away from the habits of the previous, and concentrate on the modifications wanted to make HEMS the secure, environment friendly affected person transport system it may be.

Accidents are usually not inevitable; they occur when components conspire towards a program and pilots that are relaxed and complacent in regard to secure practices. Helicopter air medical is very unforgiving of neglect and incompetence; operators, pilots and their colleagues, and sponsor hospitals should be aggressive in figuring out and addressing any and all issues of safety instantly, with out regard to personnel, political, monetary or administrative issues. There’s an excessive amount of at stake to keep up a cavalier angle, or assume that an accident cannot occur. Helicopters are flown safely on a regular basis. But it surely would not occur by chance.

In abstract, my suggestions for elevating the protection stage of air medical helicopters are the next:

*Senate Rule S.1300 is listed.

– For these packages requesting it, a direct security stand-down for FAA or different exterior get together overview and report on all facets of the operation.

– Pilots should be higher vetted, and educated emphasizing climate incursion restoration.

– Instrument flight functionality for restoration solely in all air medical helicopters.

– Greater pilot hours within the plane being flown, to incorporate a minimal of two,000 hours to be employed, 20 hours in kind, 10 hours at night time, and 50 hours of precise or simulated climate time.

– Multi-engine plane in all HEMS operations.

– CVR/FDR/TAWS set up in air med helicopter cockpits + modular installations.

– De-emphasize speedy response/takeoff time.

– Greater program climate minimums, and obligatory down-status.

– Hospital administration should be extra concerned.

– The contract backside line should be secondary to secure practices and onerous aviation realities. Yearly contracts to expedite innovation time for security proposals.

– Scale back working areas at night time, or use two pilots.

– Requirement for availability to all medical crews of a no-flight or abandon-mission protocol with out concern of repercussion.

– Website supervisor a hospital worker with authority to rent and fireplace, with pilot standing a plus.

– FAA SFAR for air medical helicopter operations codifying climate minimums, IFR tools, NVG, TAWS, twin pilot functionality, and op specs required for expanded space operations after darkish or beneath particular climate values.

– All air medical flights carried out below half 135 no matter affected person presence.

Gear Necessities:

Multi-engine plane

IFR for restoration solely

NVG functionality


Wire cutters


GPS shifting map

Climate entry within the cockpit in actual time

*Laws, S. 1300, has been launched within the U.S. Senate to authorize appropriations for the Federal Aviation Administration (FAA) for fiscal years 2008 by way of 2011 to enhance security and capability and to modernize the air site visitors management system. Along with the problems beforehand mentioned regarding consumer charges and surcharges and a rise within the gasoline tax, S. 1300 additionally would mandate important modifications for helicopter emergency medical service operators.

Part 508 of S. 1300 would mandate compliance with Half 135 rules at any time when medical crew are on board, with out regard as to whether there are sufferers on board the helicopter. Inside 60 days of the date of enactment of S. 1300, the FAA can be required to provoke rulemakings to create standardized checklists of danger analysis components and require helicopter EMS operators to make use of the guidelines to find out whether or not a mission needs to be accepted. Moreover, the FAA can be required to finish a rulemaking to create standardized flight dispatch procedures for helicopter EMS operators and require operators to make use of these procedures for flights.

Any helicopter used for EMS operations that’s ordered, bought, or in any other case obtained after the date S. 1300 was enacted would even be required to have on board an operational terrain consciousness and warning system (TAWS) that meets the technical specs of part 135.154 of the Federal Aviation Laws (14 C.F.R. 135.154).

To enhance the info obtainable to Nationwide Transportation Security Board (NTSB) investigators at crash websites, the FAA would even be required to finish a feasibility research of requiring flight information and cockpit voice recorders on new and current helicopters used to EMS operations. Subsequent to the feasibility research, the FAA can be required inside two years of S. 1300’s enactment to finish a rulemaking requiring flight information and cockpit voice recorders on board such helicopters.

All Helicopter Affiliation Worldwide (HAI) operators conducting EMS operations are strongly inspired to overview the provisions contained in *Part 508 of S. 1300. HAI is keen on listening to from you with respect to any considerations you might need over the necessities contained on this laws. Please contact David York or Ann Carroll by way of e mail at david.york@rotor.com or ann.carroll@rotor.com.

HAI continues to investigate laws within the U.S. Home of Representatives and the U.S. Senate with respect to FAA reauthorization and common aviation consumer charges, surcharges, and different security provisions. Extra info might be supplied on the HAI Website as developments happen in Washington.

**Part 508 of S. 1300


Aviation Funding and Modernization Act of 2007 (Launched in Senate)


(a) Compliance With 14 CFR Half 135 Laws- No later than 18 months after the date of enactment of this Act, all helicopter emergency medical service operators shall adjust to the rules partly 135 of title 14, Code of Federal Laws at any time when there’s a medical crew on board, with out regard as to whether there are sufferers on board the helicopter.

(b) IMPLEMENTATION OF FLIGHT RISK EVALUATION PROGRAM- Inside 60 days after the date of enactment of this Act, the Federal Aviation Administration shall provoke, and full inside 18 months, a rulemaking–

(1) to create a standardized guidelines of danger analysis components based mostly on its Discover 8000.301, issued in August, 2005; and

(2) to require helicopter emergency medical service operators to make use of the guidelines to find out whether or not a mission needs to be accepted.

(c) COMPREHENSIVE CONSISTENT FLIGHT DISPATCH PROCEDURES- Inside 60 days after the date of enactment of this Act, the Federal Aviation Administration shall provoke, and full inside 18 months, a rulemaking–

(1) to create standardized flight dispatch procedures for helicopter emergency medical service operators based mostly on the rules partly 121 of title 14, Code of Federal Laws; and

(2) require such operators to make use of these procedures for flights.

(d) IMPROVING SITUATIONAL AWARENESS- Any helicopter used for helicopter emergency medical service operations that’s ordered, bought, or in any other case obtained after the date of enactment of this Act shall have on board an operational terrain consciousness and warning system that meets the technical specs of part 135.154 of the Federal Aviation Laws (14 C.F.R. 135.154).

(e) Enhancing the Information Out there to NTSB Investigators at Crash Websites-

(1) STUDY- Inside 1 yr after the date of enactment of this Act, the Federal Aviation Administration shall full a feasibility research of requiring flight information and cockpit voice recorders on new and current helicopters used for emergency medical service operations. The research shall deal with, at a minimal, points associated to survivability, weight, and monetary concerns of such a requirement.

RULEMAKING- Inside 2 years after the date of enactment of this Act, the Federal Aviation Administration shall full a rulemaking to require flight information and cockpit voice recorders on board such helicopters.

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