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Safety Recommendation Details

Safety Recommendation A-09-092
Details
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: Permit the helicopter emergency medical services (HEMS) Aviation Digital Data Service Weather Tool to be used by HEMS operators as an official weather product.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Washington, DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09SH001
Accident Reports:
Report #: None
Accident Date: 2/3/2009
Issue Date: 9/24/2009
Date Closed: 12/7/2018
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Helicopter Emergency Medical Services,Helicopter Emergency Medical Services (Public Operators),Weather,Weather Equipment/Products/Reports

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/7/2018
Response: We note that, on May 4, 2015, you transitioned the HEMS tool from experimental to operational, and it is now available to operators at the following website: http://www.aviationweather.gov/hemst. We also note that, on November 13, 2016, you published Advisory Circular 00-45H, Change 1, Chapter 6, “Aviation Weather Tools,” which contains a detailed description of the HEMS tool. These actions satisfy the intent of Safety Recommendation A-09-92, which is classified CLOSED--ACCEPTABLE ACTION. Thank you for taking these actions to improve HEMS safety.

From: FAA
To: NTSB
Date: 10/3/2018
Response: -From Daniel K. Elwell, Acting Administrator: As noted in our previous letter dated January 27. 20 I 5. the Federal Aviation Administration (FAA) pa11icipated in a HEMS weather summit in December 2013. At this summit. the FAA, the National Weather Service (NWS). and HEMS users began to develop a pathway to transition the HEMS Tool from experimental status to operational status on the NWS's Aviation Weather Center (AWC) website. The FAA ·s NextGen Aviation Weather Research Program (AWRP) coordinated with the WS and produced enhancements to the HEMS weather display. These modifications were detailed in our previous letter and included: • Base map upgrades (including terrain. helipads. and rendering control); • Ceiling and visibility (C&V) trending: • Addition of specific location designators: • Storage and retrieval or user preferences; and • A demonstration video illustrating proper utilization of upgrades. After a thorough evaluation by select HEMS users. these enhancements were included in an upgraded version of the HEMS Tool on the Experimental Aviation Data Service website in 2014. Additionally. a specific plan for including the tool on the website was developed collaboratively with the NWS and included: • A WC resource and requirements determinations; • An FAA safety risk management assessment; • Improvement of the C& V product: and • C&V analysis algorithm skill improvements. Following the successful completion of the experimental campaign. the HEMS Tool transitioned from experimental to operational implementation on May 4. 2015. The HEMS tool is available to operators for use on the following website: http://www.aviationweather.gov/hemst. On November 14, 2016. the FAA published Advisory Circular (AC) 00-45H. change 1 chapter 6. Aviation Weather Tools. The AC contains a detailed description or the HEMS tool and can be found at the following website: https://www.faa.gov/regulations_policies/advisory_circulars/index.cfm/go/document.information/documentid/1030235. Based upon the successful transition of the HEMS Tool from experimental to operational use. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 4/1/2015
Response: We note that you have successfully tested several HEMS tool enhancements on the ADDS test platform and that you are currently working to transition to an upgraded version of the HEMS tool on the operational ADDS platform. Pending completion of the recommended action, Safety Recommendation A-09-92 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/27/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) is committed to providing tools that will improve the safety of HEMS operations. We participated in a December 2013 HEMS Weather Summit that brought together the FAA and the National Weather Service (NWS) with users and operators from the HEMS community to address relevant HEMS issues. This information helped the FAA's NextGen Aviation Weather Research Program develop and coordinate enhancements to the HEMS Tool, which include: • Base map upgrades (including terrain, helipads, and rendering control); • Ceiling and visibility trending; • Addition of specific location designators; • Storage and retrieval of user preferences; and • A demonstration video, illustrating proper utilization of upgrades. HEMS Tool testing, which incorporates the above enhancements, has been successful. These tests were run on the Aviation Digital Data Service (ADDS) test platform, which is hosted on the NWS' s Aviation Weather Center Web site. The FAA is currently working with the NWS to finalize this testing and transition to an upgraded version of the HEMS Tool on the operational ADDS platform during 2015. The FAA will report on the HEMS Tool validation in our next update to the Board. I will keep the Board infom1ed of the FAA's progress on this recommendation and provide an update by January 31, 2016.

From: NTSB
To: FAA
Date: 9/11/2014
Response: Neither the NPRM nor the final rule included the revisions that we recommended; however, we are aware of your ongoing efforts to transition the ADDS Weather Tool from experimental to operational and to integrate FAA research into the Localized Aviation Model Output Statistics Product. Accordingly, pending our receipt and review of future updates and completion of the recommended action, Safety Recommendation A-09-92 remains classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 7/8/2013
Response: The NTSB looks forward to reviewing the FAA’s report on the validation of the HEMS Weather Tool. Because of the delays that the FAA continues to encounter, we request periodic updates on the status of the FAA’s efforts to transition the HEMS Weather Tool from experimental to operational ADDS and to integrate FAA research into the Localized Aviation Model Output Statistics Product. Pending our receipt of such updates and completion of the recommended action, Safety Recommendation A-09-92 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/8/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) is undertaking an initiative to make the HEMS weather display (commonly referred to as the "HEMS Tool") a viable safety tool through implementation of robust upgrades, as we have finished our planning phase mentioned in our December 23, 2009, letter to the Board. The HEMS Tool continues to reside on the experimental Aviation Digital Display (ADDS) Web site (www.weather.aero)and is located at: weather.aero/tools/desktopapps/hemstool. A road map will be developed to transition the HEMS Tool from experimental to operational ADDS (www.aviationweather.gov) and integrate FAA research work into a National Weather Service forecast product produced hourly. This product is called Localized Aviation Model Output Statistics Product (LAMP) and produces forecasts hourly for ceiling and visibility on a 2.5-kilometer grid across the continental United States. The LAMP Web site is located at: www.nws.noaa.gov/tdl/lamp/; an operational demonstration is located at: www.mdl.nws.noaa.gov/-glmp/glmp_cxpr.php. We will release a report concerning the HEMS Tool validation in 2013, following the completion of the upgrades. Additionally, following the 2013 publication of the Air Ambulance and Commercial Helicopter Operations; Safety Initiatives and Miscellaneous Amendments Final Rule, we will determine if forming an FAA/industry workgroup is still needed to address HEMS infrastructure, as discussed in our previous response to Safety Recommendation A-09-93. I will keep the Board informed of the FAA's progress on these recommendations and provide an update by March 31, 2014.

From: NTSB
To: FAA
Date: 1/20/2011
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
To: FAA
Date: 10/7/2010
Response: The NTSB notes that the FAA intends to make the ADDS Weather Tool an official source. Because of the delays that the FAA continues to encounter, the NTSB requests periodic updates from the FAA on the status of its efforts until they have been completed. Pending completion of the recommended action, Safety Recommendation A-09-92 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/23/2009
Response: MC# 2100010 - From J. Randolph Babbitt, Administrator: The HEMS Aviation Digital Data Service Weather Tool is currently hosted on the experimental Aviation Digital Data Service (e-ADDS) Web site. The FAA plans to pursue the steps needed to move the ADDS weather tool from an experimental basis to a permanent source of weather information. Initial steps will be to locate a weather information server with sufficient redundancy to provide the necessary continuity and failsafe features. Then it is necessary to transfer the function and software to a permanent location.