EMS aviation operations (conducted with either helicopters or fixed-wing aircraft) provide an important service to the public by transporting seriously ill patients or donor organs to emergency care facilities. The pressure to quickly conduct these operations in various environmental conditions (for example, in inclement weather, at night, and at unfamiliar landing sites for helicopter operations) continues to result in an increasing number of accidents.
Although the NTSB issued recommendations in 2006 to improve EMS helicopter operations safety, 11 fatal helicopter EMS (HEMS) accidents occurred between December 2007 and February 2010, killing 41 people.
The NTSB is concerned that these types of accidents will continue to occur if a concerted effort is not made to improve the safety of emergency medical flights. Specifically, the following actions would help to improve the safety of EMS flight operations: (1) conduct of all flights with medical personnel on board in accordance with stricter commuter aircraft regulations, (2) implementation of a flight risk evaluation program for EMS operators, (3) establishment of formalized dispatch and flight-following procedures including up-to-date weather regulations, and (4) installation of terrain awareness and warning systems on aircraft used for EMS operations.
In August 2004, the Federal Aviation Administration (FAA) convened a Helicopter Air Ambulance Accident Task Force to make recommendations to reduce HEMS accidents; however, in spite of numerous actions to address this issue through notices and guidance, little progress has been made by the FAA to improve the safety of EMS operations.
In 2005, the FAA issued the following three notices addressing HEMS safety; however, all three of the following notices expired after 1 year:
In January 2006, the FAA published Safety Alert for Operators (SAFO) 06001, which incorporated information from both N8000.293 and N8000.301; however, SAFOs are only guidance. Also in January 2006, the NTSB adopted a Special Investigation Report of EMS Operations (!) and issued four safety recommendations concerning EMS flight safety.
In June 2006, at the FAA's request, RTCA, Inc. (formerly the Radio Technical Commission for Aeronautics), established a special committee to develop Helicopter TAWS (HTAWS) standards; minimum performance standards were completed in 2008, and in December 2008, the FAA issued Technical Standards Order (TSO) C-194 to standardize the manufacture of HTAWS within the industry. In January 2009, FAA principal operations inspectors conducted a survey of the 74 HEMS operators to determine how many planned to equip their fleets with TSO-approved HTAWS. That survey revealed that 41 percent were planning to equip their fleets with HTAWS.
In May 2008, the FAA incorporated the contents of Notice N8000.301 into Order 8900.1, encouraging the use of risk assessment models. In addition, the FAA published Advisory Circular (AC) 120-96 regarding operations control centers (OCC) for HEMS, providing a list of tasks that should be completed by OCCs; however, Safety Recommendation A-06-14 asks the FAA to incorporate a requirement for an OCC into HEMS regulations. The January12,2009, survey of all 74 HEMS operators previously included how many had adopted the best practices specified in AC 120-96. It was determined that 94 percent had adopted decision-making skills and risk assessment programs, and 89 percent had integrated an OCC.
In November 2008, the FAA published revised Operation Specification (OpSpec) A021, to specify that, if a flight, or sequence of flights, includes a Part 135 segment, then all visual flight rule (VFR) segments of the flight must be conducted within the weather minimums and minimum safe cruise altitude determined in pre-flight planning. Specifically, pilots must identify a minimum safe cruise altitude during pre-flight planning by identifying and documenting obstructions and terrain along the planned flight path and must also determine the minimum required ceiling and visibility to conduct the flight. As of February 2009, all HEMS operators have complied with this OpSec.
The NTSB concluded in its 2006 report (2) that a requirement for all EMS operators to comply with 14 CFR Part 135 OpSpecs during the conduct of all flights with medical personnel on board, would enhance the safety of EMS operations. The FAA's OpSpecs revision requires all VFR segments of EMS flights that include a part 135 segment to adhere to increased weather minimums. This revision was a positive step; however, in order to fully satisfy Safety Recommendation A-06-12, the FAA must still require the Part 135 flight and duty time limitations for EMS flights.
In February 2009, the NTSB held a 4-day public hearing to learn more about helicopter EMS operations. The NTSB invited expert witnesses-including pilots, medical personnel, managers, and representatives from the FAA-from the EMS community. Most of the witnesses participated on small panels, addressing particular safety issues, and several organizations had an opportunity to question the witnesses directly. Some of the issues discussed during the hearing included operational structure and models, flight operations, aircraft safety equipment, training, and oversight.
In April 2009, the FAA started a formal rulemaking project to address many of the HEMS initiatives and best practices found in advisory circulars, orders, and notices issued over the last several years, as well as the November 2008 revisions to HEMS operating specifications. In November 2009, the FAA stated that its notice of proposed rulemaking (NPRM) will also address a requirement for HEMS operators to equip their fleets with, and use, HTAWS; however, it has been almost a year since the FAA started the rulemaking project, and an NPRM has not yet been published.
The NTSB's recommendations concerning EMS flights were issued on February 7, 2006. In the 4 years since then, the FAA developed voluntary guidance that has not been adopted by all EMS operators; accordingly, the NTSB is concerned that until the FAA institutes the recommended requirements, some EMS operators will continue to operate in an unsafe manner, which could lead to further accidents.
Require all EMS operators to comply with 14 Code of Federal Regulations Part 135 flight and duty time operations specifications during the conduct of all flights with medical personnel on board. Require all EMS operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. Require EMS operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. Require EMS operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations.
A-06-12 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open-Acceptable Response
Require all EMS operators to comply with 14 Code of Federal Regulations Part 135 operations specifications during the conduct of all flights with medical personnel on board. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
A-06-13 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open-Unacceptable Response
Require all EMS operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
A-06-14 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open-Acceptable Response
Require EMS operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
A-06-15 (FAA)
Issued: February 7, 2006
Status: Open-Unacceptable Response
Require EMS operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
