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Safety Recommendation A-09-095
Synopsis: Calendar year 2008 was the deadliest year on record for the helicopter emergency medical services (HEMS) industry, with 12 accidents (8 fatal accidents) and 29 fatalities. As a result of this increase in fatal accidents involving HEMS operations, the National Transportation Safety Board (NTSB) placed the issue of HEMS safety on its Most Wanted List of Transportation Safety Improvements on October 28, 2008, and also conducted a 4-day public hearing to critically examine safety issues concerning this industry. Based on testimony given at this hearing, in addition to findings from recent HEMS accidents, the NTSB believes the Federal Aviation Administration (FAA) needs to take action to prevent additional accidents. These actions include improved pilot training; collection and analysis of flight, weather, and safety data; development of a low-altitude airspace infrastructure; and the use of dual pilots, autopilots, and night vision imaging systems (NVIS). Additional recommendations have been addressed to the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS), the Department of Homeland Security’s Federal Interagency Committee on Emergency Medical Services (FICEMS), and 40 public HEMS operators.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require helicopter emergency medical services operators to install night vision imaging systems and require pilots to be trained in their use during night operations.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Washington, DC, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA09SH001
Accident Reports:
Report #: None
Accident Date: 2/3/2009
Issue Date: 9/24/2009
Date Closed: 9/11/2014
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Helicopter Emergency Medical Services, Helicopter Emergency Medical Services (Public Operators), Training and Education

Safety Recommendation History
From: NTSB
Date: 9/11/2014
Response: Neither the NPRM nor the final rule included the revisions that we recommended. Consequently, Safety Recommendation A-09-95 is classified CLOSED—UNACCEPTABLE ACTION.

From: NTSB
Date: 7/8/2013
Response: Our last update from the FAA regarding these recommendations was its December 23, 2009, letter. We are concerned that, although more than 3 years have passed since then, we have received no additional information regarding the agency’s efforts to address Safety Recommendations A-09-88, -95, or -96. We are also concerned that these recommendations were not addressed in the NPRM discussed above. Accordingly, pending our timely receipt of an update and completion of the recommended actions, Safety Recommendations A-09-88, -95, and -96 are classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
Date: 1/10/2011
Response: Notation 8272: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) Notice of Proposed Rulemaking (NPRM) titled "14 CFR [Code of Federal Regulations] Parts 1, 91, 120, and 135 Air Ambulance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135 Aircraft Operations; Safety Initiatives and Miscellaneous Amendments; Proposed Rule," which was published at 75 Federal Register 62640 on October 12, 2010. The NTSB appreciates the opportunity to provide comments on this NPRM. HEMS operations and commercial helicopter safety are topics that are of great concern to the NTSB. In the past year, 12 total and 7 fatal HEMS accidents have occurred, some of which might have been prevented with the implementation of these rules. The NTSB believes that the proposed rule changes presented in this NPRM will improve the safety of HEMS and commercial helicopter operations. However, in addition to flight recorders and autopilots for single-pilot operations, as mentioned above, several other NTSB recommendations have not been addressed in this NPRM. These recommendations address safety management systems, activity reporting, the HEMS weather tool, and night vision imaging systems. Each of these issues is also critical to operational safety, and the NTSB urges the FAA to consider them in the final rule. Safety Recommendation A-09-89 asks the FAA to “require helicopter emergency medical services operators to implement a safety management system program that includes sound risk management practices.” Safety Recommendation A-09-91 asks the FAA to “require helicopter emergency medical services operators to report activity on at least an annual basis to include total hours flown, revenue flight hours flown, revenue miles flown, patient transports completed, and number of departures.” Safety Recommendation A-09-92 asks the FAA to “permit the helicopter emergency medical services (HEMS) Aviation Digital Data Service Weather Tool to be used by HEMS operators as an official weather product.” Safety Recommendation A-09-95 asks the FAA to “require helicopter emergency medical services operators to install night vision imaging systems and require pilots to be trained in their use during night operations.” All of these recommendations are currently classified “Open—Acceptable Response.”

From: NTSB
Date: 10/7/2010
Response: The NTSB points out that this recommendation asks the FAA to require the installation of these systems and the appropriate training; however, it does not require these systems to be used during flights operating under instrument flight rules. Pending the NTSB’s review of the FAA's study, Safety Recommendation A-09-95 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
Date: 12/23/2009
Response: MC# 2100010 - From J. Randolph Babbitt, Administrator: The FAA is planning to conduct a study that will assess the feasibility and safety impact of requiring night vision goggles (NVG) in helicopters used in the performance of air ambulance operations. During Fiscal Year 2010, subject matter experts from FAA Flight Standards Air Transportation, Aircraft Maintenance, General Aviation and Commercial Divisions, and the Rotorcraft Directorate will work together to accomplish this task. While NVG can aid pilots in certain visual flight rules operations, some operators are conducting flights under instrument flight rules (IFR) and mandating NVG installations could potentially adversely affect safe IFR flight.