Brainstorming HEMS

[helmet fire]

Hi all,
prompted by many threads on US HEMS accidents I thought it might be educational (or at least of intrest) if we brainstormed some of the concepts that have been discussed as possible ways to mitigate the risks of HEMS, particularly night HEMS. There is no reason why a world wide look at the problem might possibly throw up elements for all of us to learn from for introduction into our own HEMS system.

Australia has not escaped the night HEMS accident scenario. The following is not a comparison of our HEMS system with anyone else's.

I was fortunate enough to be involved in a study tour of HEMS operations in Europe and although I did not do the US leg of the trip, others in my organisation did. I did however spend a year in the US earlier in my flying career. I dont offer this as evidence that what I am saying below is valid, simply that it is an opnion. Inevtiably it will also be a generalisation and suffer there as well. IT IS TO STIMULATE BRAINSTORMING THE ISSUE.

I have drawn heavily on previous threads and posts, particularly those of Nick Lappos and Shawn Coyle: this is a compilation of ideas, not just "my" ideas. Here are some ideas that may, in combination, mitigate the risk of HEMS operations:

1. Night flying requires reference to instruments. If you want to fly at night get an IFR rating. Even just the simplified en route IFR rating. 3 hours instruments required each 3 months to stay current. Renewals required each year.
2. Institute a night lower safe altitude even when VFR. Make it 1000 ft for VFR, and allow a lower one of 500 ft if using NVG or if IFR rated and in an IFR capable aircraft. 500 ft for day.
3. Institute go/no go weather minima. In black and white. Lower weather minima for IFR capable operations. I believe all operational restrictions should significantly advantage IFR programs, thus encouraging the upskilling to IFR and the adoption of autopilot equipped aircraft by outcome - this is the only effective way to get bean counters on board.
4. EASA crew standards implemented: two pilots up the front for all HEMS missions, day, night and IFR. Note: the second pilot may be a HEMS Crew member specifically trained in aviation skills on an approved front seat competency course.
5. Night operations outside of lit, prepared and established HLS or below 1000 ft require NVG.
6. Moving map systems mandatory as is required in several European HEMS programs.
7. The establishment of a low level IFR infrastructure and helicopter specific instrument procedures exploiting the low speed capability of the helicopter.
8. The establishment of ADS-B and GPS - W based infrastructure ASAP.
9. The fitment of an IR vision system and/or EGPWS conferring operational advantages.
10. The fitment of TCAS/TCAD to exploit higher traffic density.
11. Address areas of multiple competing programs to find a solution. I believe the community we are trying to help should not be a commercial battlefield at their expense.
12. Create an agreed HEMS "gold standard", published and in turn advertised by programs. Ie you could be a 5 star operation if you tick all the agreed boxes such as multicrewed, IFR capable, SPIFR autopilot equipped, NVG, TCAS, EGPWS/IR, regular CRM, etc, etc.
13. The removal of different regs standards for different "mother" organisations i.e. public use aircraft have to abide by HEMS regulations if doing HEMS regardless of who owns the aircraft. This includes abolishing different standards for SAR and for return legs in terms of weather and minima. SAR and HEMS should operate to the same standards.
14. The establishment of a risk management system that does not involve the ability to fudge the numbers in order to launch.

Make it a five to ten year project to more slowly absorb costs and operational changes, and away you go!

Yes: some programs will have to merge or be extinguished. You get that.
Discuss.
More beer waiter!

[topendtorque]

HelmetFire,
yes, your post is stimulating.

Can I go slightly outside the square and refer to burocratic ( I hate that word) procedure.

Pretty much all departments of all jurisdictions (weeds, law, capital works, even aviation) work on a very simple principle.

1) Employ sharp people to come up with good ideas.
2) Invite them to put out to public debate those ideas.
3) Formulate a STRATEGIC plan to deal with the pertinent issues.(lay on the delightful luncheon process during that process)
4) Devise a serious implentation plan to teach every m****** f****** just how they are gunna do things right.


DRUM ROLLl :ugh::ugh::ugh:

5) it's now time to call another election and do the same thing again.

What you need to do is fast track to step five. The U.S.A. is not yet in step one mode.

cheers tet

[WhirlwindIII]

tet

Very well said, indeed! Couldn't agree more.

WIII

[TheVelvetGlove]

My God- are there really pilots out there in the world flying HEMS at night without an instrument rating? Where? :eek:

[Gomer Pylot]

There may be a few in the US, because it isn't a regulatory requirement. Most operators won't hire a pilot without an instrument rating, though. Public use (police, etc) operations aren't regulated by the FAA at all, and some of them may be using pilots without an instrument rating.

Many of the models used in HEMS in the US aren't capable of having two crewmembers up front. There is just no second front seat, and no room for one. That's where the patient's feet are. That requirement is a non-starter here. The government can't realistically require that. As good an idea as it might be, it's out of the question. Remember, there is a different philosophy here than in much of the rest of the world. For much of the world, anything not specifically permitted is forbidden. Here, anything not specifically prohibited is permitted. That philosophy is not subject to change, it's built into the Constitution and the entire culture. Capitalism is also enshrined in the culture, and overrides almost everything else. Putting companies out of business is considered socialism or worse, and it won't happen. It's a fact of life, and we have to live with it, regardless of the opinion of the rest of the world.

[Shawn Coyle]

The HEMS operation I flew with had an IFR approved helicopter, but we were not considered an IFR operation, so we legally couldn't file or fly IFR. Would have made my life easier on at least one occasion in my short EMS career. Would also have made it a lot safer.
All for want of some paperwork that management wouldn't go with.

[helmet fire]

Hi Gomer,
Your points are valid and you can see them contributing to the culture that currently pervades US HEMS. When you say that "anything not specifically prohibited is permitted" is the crux. The list I put up did not exclude taking regulatory steps that would prohibit non-compliance, but that regulatory requirement should only be initiated when there is a demonstrable safety case to support it. in other words, change the system to mitigate the risk.

This DOES happen in the USA. 1 in 80,000 of Americans will be killed on the road as a pedestrian this year - almost all of them will be "jaywalking". That is why some places have a "jaywalking" regulation. It is not unconstitutional, against the core values of the USA, nor changing or challenging a culture - it is to reduce risk to the general population. The same can be said for the introduction of seat belt rules, helmets on motorbikes and riding around in the back of utes ("trucks" as you might call them).

There is an identified risk in HEMS, even where that risk is perceptually increased beyond the facts due to media and emotional reactions to lost loved ones. Mitigating that risk is not a business restriction if it can be based on a safety case, such as the two crew in the front. Aircraft not capable of such SHOULD be phased out over the next 10 years, and if the business case (ie benefits) are not large enough for the extra cost, then I would suggest the risk V benefits of the existing model is not supportable.

I suggest that the US Medical fraternity is looking for ways to restrict or stop HEMS (yes, there are gathering loud calls for the cessation of night HEMS and the severe restriction of day HEMS). Lets identify the risks ourselves, produce mitigators and then institute them before we find regulatory knee jerks that do kill the business.

[alouette3]

Saving the Air Medical Industry (http://www.jems.com/news_and_articles/columns/Bledsoe/saving_the_air_medical_industry.html)

The article above has been written by a well known critic of the US HEMS operations. Quite a few interesting points. However, if everything the author suggests is implemented----it will kill the US HEMS industry.
Moreover, folks in Europe must understand the size of this country. There are people living in rural America with access to an understaffed clinic that need helicopters. Even if it is for a "simple" heart attack. A lot of rural ambulance services are staffed by volunteers who have very basic skills and may not be able to baby sit a patient for a three hour drive to a metro hospital.All this has to be taken into consideration. Deregulation is almost killing the airline industry here but it has had great benefits too. So, IMHO,the answer (as always) lies somewhere in between rampant capitalism with deregulation and total govt. subsidized over regulated socialism.
If we want twin engine,two pilot fully IFR capable helicopters to fly only by day or do only IFR approaches to hospitals , then let us call it quits and have only FW operations instead of helicopters for EMS.They can fly patients from airport to airport,IFR only, two pilots all the time and ambulance crews from hospitals or scenes can bus them to and from the local airport.Problem solved.
I am curious how our friends in OZ run the Flying Doctor Service?.Any Aussies here who might like to weigh in ,especially with respect to rural Australia also (or maybe --only?) known as the Outback?
Alt3.
P.S. Disclaimer: None of the above should be construed as me being supportive of the status quo.Our safety record here is dismal and a great deal needs to be done but let us also not go overboard and acknowledge the cultural, geographic ,economic and ,yes , political, differences between the US and the rest of the world.

[Gomer Pylot]

I agree that something different is needed, but I'm not certain exactly what. Alouette3 makes some good points. Many of the hospitals in small towns in rural America have very little capability. They can take care of sprains, small cuts, colds, and other minor ailments, but they're over their heads with heart attacks, strokes, fractures, and lots of other injuries. Ambulance services can't afford to be out of service for many hours driving patients to trauma centers, because often there is only one ambulance, staffed by volunteer crews. There are a few ground ambulance transport services, but not nearly enough, and time can make a huge difference to a stroke or cardiac patient. Even if they're kept alive on the ambulance, the chances of a full recovery diminish steadily as the time to a stroke or cardiac center increases. Often there is no airport available within a reasonable distance, at least one capable of taking the most often used FW EMS aircraft, especially one with IFR approaches. Prohibiting night HEMS will mean that many, many patients will die or never fully recover. We need to balance taking care of patients with safety, and where to come down on that fence is a philosophical question. Here, the philosophy has been to take care of the thousands, and the relatively few accidents are worth the risk. Requiring large helicopters with two pilots and full IFR capability, which can't be used 95% of the time, will mean that most rural areas will be without service, and that covers most of the continent. I understand that other countries have a different philosophy, and that's their business. The current US situation isn't ideal, but it's what we have, and changing it will be a major undertaking. It's not just a matter of the FAA making regulation changes overnight. Under current US law, that isn't possible. It requires notices of proposed rule making, taking comments from the public (including companies impacted) and then implementing the rules over time. I don't see emergency regulations being enacted.

The only way I can imagine providing large helicopters to the entire country is for the federal government to pay for them. The right would immediately cry "Socialism!" and oppose it. :mad: It might happen, and I for one would welcome it, but it would be a nasty fight. Capitalism certainly won't provide it. I'm pessimistic about this, but far more optimistic this week than last week.

[victor papa]

I am not in Aus, but fully agree with you Alo. I have posted before our requirement which is 6000ft, 30 degr(in summer more likely 35-38 inland) and 2.5 hrs fuel carrying plt and 2 med crew and tgis with a full ALS system fitted to the aircraft. We are again now in the twin vs single argument and 2 pilot vs 1 due to lack of capability to carry 2 pilots and IFR capability. We do not operate at night at the moment and if required would go with NVG which we have no regs for yet. Our IFR rated airports for a helicopter is about 4 hours apart at best so true IFR unless we operate a 225 with ferry tanks is a myth. Our hospitals in the major cities are like the airports 4 hours of heli flying apart. In between are intermediate facilities who can if you are lucky stabilise you until you can get to a primary facility were you can survive within the heli's range until the transfer. We got the EC130 to work beautifully capable of carrying 2 pilots and the stretcher and have the legs for the long flights. On the twin side we have to look at the 145 and/or 135 which are maintenance friendly(which are extremely important if you are not allowed to be offline for more than 24hrs in succession without replacing the aircraft) but will have to be nursed 10 times more than the 130 at the alt and temps as well as requiring a total different amount of training and skill due to complexity vs the 350B3 and the 130. On the otherside we have the 109 which with it's fuel burn we will have to put fuel out just about every hour to be safe and not as maintenance friendly but do have the power but will still have to be nursed from 34 degrees with the added complexity factors as stated. In a country with high poverty, fuel drums are not necessarily where you left them! Our average guys are 5ft8 weighing 95 to 110kg if they are in good shape. Patients go easily to 135kgs at 6ft4 or something ridiculous.

IFR and twin engines to me are not necessarily the answer and neither are enforcing 2 pilot ops(different operation). Remember in something like the B4 IMHO the visibilty is probably better from the rearseats than most other helo's sitting in the front at a nose up attitude in the hover. I do believe in a good, reliable, stable platform with added EGPWS, TCAD, radio alt(not preset at 150ft) properly integrated into the intercom and always have a power margin(nothing beats the simplicity of the FLI in a B3/B4) for the unexpected downdraught/wind change/etc.

[David Earley]

Helmet Fire's contribution is well presented as usual. At the recent ISAS conference in Adelaide (Australia) a speaker summarised the distinctives of about 5 US EMS operations he had visited on a "study tour" recently. On the summary of one, appeared the motto
"WE NEVER SAY NO".
That kind of sentiment/motto would be rightly howled down in any safety minded environment . It sums up a culture/attitude of management that seems to be a product of the competitive nature of much of the US health system. Simplistic perhaps, but until there is a fundamental change in that attitude, I can't see Points 1,2,3,5,7,11,13 and 14 of Helmet Fire's recommendations being possible.
It is unrealistic to expect the needed change in that attitude leading to changed behaviour without it being initiated arbitrarily by the regulator. I cannot see industry operators doing it unilaterally unless they are backed by a management structure that can and will support them through a long winter of being uncompetitive with those around them.

[helmet fire]

Agree David.
The points I listed were actually a compilation of ideas across many of the threads at Prune coupled with some of the results of our study tour. I had started another thread with them intending them to apply to HEMS generally, not US HEMS in particular, but in error has left "US" in the title and Senior Pilot moved my post into this thread. My fault entirely, but I am afraid that these ideas will only be discussed by those interested in US HEMS.
I believe that having the discussion about HEMS from an international perspective would allow US operators to see what ideas are going on outside the US, not get threatened by external opinion.

Alo3 points to exactly my concern about the sort of momentum that is gaining credibility within the US, and until the HEMS industry can change either reality of risk or at the very least the perception of that risk, then we are not going to combat that momentum.

I am in Aus. I have been flying EMS for the past 12 years and much of it to remote small town rural communities without adequate medical facilities. Legs of 2 hours each way are not uncommon in our model. We fly twin engine IFR machines and the model works - so I am not convinced the same model is unsupportable in the US, however, there are fundamental differences in the financing structure of our model which make comparisons difficult and unreliable. This is brought out by David's post.

The intent of my post was not to compare Aus V US or Euro V US or anyone V anyone. It was to stimulate discussion about what measures any HEMS program might take. Never the less, I will answer some of the concerns raised: IFR, imposition of regulation, and 2 pilots.

IFR: the fact that there is limited current infrastructure available to US HEMS in terms of where you need it and when, was faced here in Oz. We went out and created a network of IFR infrastructure that still has a long way to go. We have established IFR approaches to hospitals (and therefore fuel) where weather or operational reasons required. Indeed, I now operate at Westmead Hospital in Sydney with a company that developed the first non-airfield, helicopter specific GPS approach, certified in 1997/8. See my earlier point 7 & 8 which were created entirely in response to the concerns you raise about the lack of current infrastructure.

Imposing Regulation: David and Gomer are absolutely right. None of these issues are insurmountable, but you are both right: overcoming them is unlikely. This is true across countries, and the US is not really a special case here - look at the evolution of NVG regulation across countries, the USA got going some 15 years ago, and some countries still don't have permission.
There are probably many ways to overcome this limitation, but the first of which is to create an industry standard. Given the gathering intervention by the medical world onto our industry, perhaps the way forward is to create a standard and present it to the medical world. The long dark winter that David refers to may be a lot shorter if the medical world drive requirements to conform with the industry published standards. This form of economic incentive is far more effective than regulation.
An example is in Australia. For the last 20 years we were stuck in the old argument that poor rural communities could not afford flash aircraft and equipment and that their only hope of life was a Longranger battling fearsome conditions to help them. Two NVFR crashes in QLD changed that paradigm. The standard imposed BY THE MEDICAL SIDE is now twin engine and IFR capable. Not imposed by the regulator, nor the industry. That meant that operators either operated (and charged for) twin engine IFR or they were out of a service! We can exploit that power by establishing standards for the medical side to grasp, adopt and then require. I don't see any other way to convince the regulators or our bean counters en masse.
See point 12 for this appearing in the list.

Two Pilots: I think we need to realise the effect of the EASA regulation: it does not have to be two pilots. Read point 4. The typical Euro crew was only three persons, the same as many of the organisations in the US saying two pilots are unsupportable. The three crew are: pilot, HEMS Crewmember, and Doctor. The HEMS crewmember is a paramedic with pilot theory passes, specific front seat training in VFR, IFR, NVG. Not necessarily flying as well. The point is that there are two aviators in the front. I know that there will be negative argument about what happens when the patient is on board, but it works very successfully in many parts of Europe. Can we learn from them?

Lastly, the implementation timeline of 10 years or so is the sort of long term thinking we need to apply. Both David and Gomer illuminate timeline issues, but perhaps the goals should be set with these firmly in mind: maybe 20 years. In those terms, some of the list points suddenly become a more realistic proposition.

[Gomer Pylot]

Helmet fire, I agree with your desires, and I hope something like that comes to pass here. But it will take a major change in philosophy. Hospitals have little to do with it, because the major operators are standalone commercial operations, not run by nor even affiliated with hospitals. Certainly there are hospital-run operations, but they're increasingly in the minority. The federal government will have to get into the action and provide funding if more capable aircraft are going to be mandated. I'm hopeful that with the new administration the new Congress will enact universal health care, and with it the possibility of federal funding for HEMS operations. Only the federal government has the capability of funding new helicopters continent-wide. It need not be direct funding, just mandating larger helicopters and paying enough for patient flights will do the job. I'm far from certain that we will go that far down the road to gasp, Socialism, though.

[helmet fire]

Agree Gomer,
The accident rate in the US has a surprising ripple effect through HEMS world wide, particularly amongst the general public, and even more specifically amongst the medical fraternity. I understand the prevalence of commercial operations, but I am putting across the idea that their customer - the medical professionals that get on board the helicopters - are the ones that will impact: not the federal government, and not us as a group of peers. We are too busy competing!
That is the experience in one of the states of Australia - Queensland: the paramedic union drove the up spec to twin engine IFR. The industry are still arguing that the job can be done in a Longranger and the regulators are not even seeing a risk. Such experiences are what has prompted me to suggest to you guys an avenue for influencing equipment and spec levels that does not rely on the federal government regulations, nor competitive pressures to keep it cheap. You should be concerned in the States with the momentum from that very same customer to stymie the use of HEMS. Get in first and suggest the standards to them: better to give them risk mitigation strategies like IFR, Twins, etc, etc than the current risk mitigation they are considering (stop night HEMS, restrict day HEMS).
Food for your thought.

PS: thanks Senior Pilot for the restoration:ok:

[alouette3]

Helmet Fire:
Good points. I think you make a very valid point about momentum. When somebody makes a suggestion about how to 'fix' US HEMS and has a 'Dr.' before his name, trust me, he has more credibility than Average Joe The Pilot.
My only concern is (and I believe it is echoed, to an extent,by Gomer) is that we do not end up losing the only benefit the helicopter offers over a Fixed Wing by adding all kinds of equipment and restrictions.As Gomer said earlier, it is not the best system here in the US but it is what we have got and has worked well for a long time. We definitely need to tweak it and improve safety with the assistance of training and technology. But if we mandate all the stuff that Bryan Bledsoe advocates we will end up killing HEMS, as we know it, in the US.
As to comparisons I don't believe you were making any.But there are plenty of folks out there, right here in the US, who do. They talk about how the Brits do it and how the Austrians don't fly EMS by night etc. etc.Comparisons fall apart very quickly when you compare the political and geographical differences between Europe and the US.The only countries that compare favorably in terms of size are Australia and Canada. It would be worthwhile starting comparisons there.
Gomer,
Even if socialized medicine does make it to the US in the near future I believe HEMS subsidies will be at the bottom of the priority list. As an example, we only have to look at Medicaid reimbursements to see that as true. So I would'nt hold my breath.
Final thoughts (and I know I am going to take heat for this) while even one accident is one too many and 2008 has been horrible,one must also objectively compare number of helicopters/hours flown/successful flights vs. accidents before we condemn the US HEMS ops. We do have cultural baggage and we must do better. But 750 helicopters complete millions of flight hours and thousands of patient transfers every year successfully. I think that is awesome.How can we improve without going overboard is the dilema.I don't think any one agency, person or operator has all the answers.
Alt3.

[Gomer Pylot]

Alt3, I'm not holding my breath either. What I really think will happen is little if anything. I agree that the accident rate isn't as bad as people assume, given the number of helicopters flying EMS in total. The largest companies have ~100 each, and there are literally dozens of smaller companies with a few each, some private operations, some operating for hospitals, a few like Maryland done with public use aircraft. The rate needs to go down, but I don't have any answers. The spate of recent crashes has a plethora of causes, and I see no common denominator. Every so often defecation occurs, no matter what is done to prevent it.

[tecpilot]

helmet fire, i don't know which european HEMS you have seen, but what is Europe? Did you mean JAA land? :}

1. "Institute a night lower safe altitude even when VFR. Make it 1000 ft for VFR" - JAA lowered the allowed weather at night for VFR - HEMS from 1500ft to 1200ft, on route shorttimed 1000ft, visibility 3000m - not good
2. There are many HEMS bases without IR pilots (in Germany and Switzerland at least 60%) and sometimes without IFR helicopters in Europe - not good. No sweat, JAA don't want it.
3. There are also single pilot VFR night HEMS flights (also without AP!). The HCM is in the back assisting the MD. JAA have not specified up to today the place of the HCM on a front (copilot) seat. He have "to assist the pilot", what ever that means. - not good
4. There are no HCM "with pilot theory passes", no existing JAA rules about the special and determined HCM training. Mostly they get 20-40h theory and 10 supervision missions (different between the operators) including refueling, pushing a helicopter into hangar, sweeping it and other simple stuff. Especially they will never have IFR theory or NVG hours. - not good
5. Therefore at night the HCM is only a cheap place holder. Pilots are too expensive - not good
6. "The point is that there are two aviators in the front." You are joking?
7. Also Europe has seen devastating VFR night HEMS accidents. Why not so much as in US? I bet, it's only a question of the numbers of flights and some other small points. Only statistics! As example, in the more than 80 million inhabitants Germany you will find only round about 10-12 night HEMS bases. They do not fly really much at night and mostly short hops 50-150km. Jobhopping is not so common in Europe than is the US. Therefore the most pilots in the business in Europe have very much experience in their small mission areas (diameter 100-200km at night), in their helicoptertypes and in their local weather situation. Much alternate landing sites also around! Good ATC and full radar coverage additionally!


I'm not sure if the european system is really better than the american.

And just one last point, in all the last german HEMS VFR night accidents were involved only IR pilots and IFR ships. There are no night accidents with VFR pilots and simple ships. Why? Simple, the IR pilots in trust in their clocks and APs went straight ahead in CFIT, the VFR pilots turned back or canceled the flight before take off after weather check because they fear the clouds ;)

[Devil 49]

7 people killed in a day mid-air crash, in, or very near an airport traffic area;
3 crew die in what appears to have been a structural failure, also in day light- these are very unusual occurrences. They're no less of concern because of their exceptional nature.
Next, 4 fatalities colliding with a tower that, from what I hear, was a known en route hazard. To me, also unusual- except that most wire strikes occur with known obstacles.

Then, Texas/ PHI, Wisconsin/ Air Methods, and the Maryland State Police accidents- 11 lives lost. These fit the stereotype EMS night and weather crashes, except that I think we're missing the forest for the trees in our analysis. These aren't as easily classified as 'night VFR into IMC':
The PHI pilot was an IFR captain in the Gulf for years. He never struck me as a 'cowboy' and his professional skills should have been adequate to the task;
MSP's Trooper 2 seemed to be doing the right things when the flight came to grief;
I know very little about the Wisconsin crash, except that it was an Air Methods EC 135. That airframe is often employed in my company as SPIFR platforms. I don't know if it was an IFR program.
So- Night and day; single and twin; VMC and IMC; VFR and IFR platforms; the one thing missing is two pilot crews. I think it's reasonable that the common element is the human factor. That's the issue that needs to be addressed.

Pretending that EMS is just an on-demand charter is short-sighted. In EMS we have an aviation decision to make, but a responsibility to the patient that over rides all when evaluating a flight- you have to know with reasonable certainty that at the very least, you will get the patient the receiving facility without undue hazard- or you're not doing the job hired for, period. The most conservative response is the best choice for all. When I have doubts, I have no doubts, and no option but to decline.
I shouldn't need a risk assessment matrix or operational control center to know that the proposed flight is not certain- the facts speak for themselves. Muddling the decision allows more flights and more revenue, but dilutes responsibility. EMS is not combat, there are options besides accepting dispatch or proceeding into unfavorable circumstances. Risking 4 to possibly help 1 is very bad math. There's no such thing as “taking a look” or “giving it a shot”, those are excuses for poor decision making.

We in US EMS do the hardest part of our job when we're at our worst, a sweeping generalization- most programs swap mid-hitch, day to night duty, with a 24 hour break between day and night shifts. Circadian rhythm, sleep patterns and rest, all are supposedly covered by the umbrella regulatory requirement for “10 hours of uninterrupted rest”.
Pilots are not blameless in this, I've heard professional pilots say bald-faced that they had plans for the day between two night hitches that meant they wouldn't be sleeping. I've heard of relief pilots reporting for night duty with the plan to sleep because they hadn't done so that day.

NVGs are slowly coming to the fleet. With aided vision, a pilot can see and avoid, almost as well as on a day flight. Right now, at typical unaided night visual acuity ranging from 20/200 to 20/400, we see by using counter-intuitive techniques and crappy lighting. Often, we don't see issues at all until we're in the cloud, hit the hill or the tower. Most pilots I know don't cruise that low at night. I wonder if the CFIT incidents aren't descents to regain contact, a very bad choice.

I'm not an equipment guy, this is all about decisions, how and why they were made, and the planning that results in the flight completed. Throw equipment, procedures and regulations at the problem and it'll have some impact- reducing flights, but not accident rates. More complications means more opportunity for mistakes as the root cause isn't addressed- the human factor.
I'm especially not a fan of IFR as a safety solution. Yes, I've been IIMC, but never had to continue IMC- a return to better weather or a precautionary landing works. Besides, the weather's VFR or better 95% of the time. Do I wish for full IFR capability? Sure. I also wish Carmen Electra would drop by, but I'm not building a business plan around that possibility.
Add that in our area, the average leg length is twenty-two minutes. By the time I check, plan, and fly, the patient could be transported by ground. Which is the case now, because I don't go.

[JimL]

tecpilot,

It may be that you are describing a past issue of JAR-OPS. The latest copy has (and has had for a number of years) Subpart O dedicated to the Crew Member other than Flight Crew.

The requirement for specific HEMS training and checking is contained in Appendix 1 to JAR-OPS 3.005(d) paragraph (e)(2) - you might look at it again because it is quite comprehensive.

Because there may be circumstances where the HEMS crew member may be required down the back, there cannot be an absolute requirement for him/her to be seated in the co-pilots seat; however, it is specified in ACJ to Appendix 1 to JAR-OPS 3.005(d) sub-paragraph (c)(3)(iv), as are the specific duties.

The requirement for two pilots at night is contained in the HEMS appendix - which contains a derogation for a pilot and a HCR under specific circumstances and for which Approval from the operational authority is required (similar to the type of conditions contained in the OpsSpec mentioned below - i.e. for local operations).

No, it is not perfect but does provide a skeleton on which a good HEMS operation can be hung.

As a matter of interest I see that the FAA is just about to publish, for comment, new OpSpecs "A021 Helicopter Emergency Medical Services (HEMS) Operations" and "A050 Helicopter Night Visions Goggle Operations (HNVGO)" which contain detailed site, qualification, dispatch and weather criteria.

What hasn't been established yet is the actual accident rate (only the headline figures); it is also clear that there are few recognisable patterns in the accidents; even the human factors issues are complex. It will take a great deal of analysis before any specific measures can be decided. What does appear to be evident (from the reports as well as from commentaries in this and other threads) is that there needs to be a culture change.

Jim

[Shawn Coyle]

For nearly all HEMS operations, two of the three legs flown do not have a patient in the back. The outbound leg to the scene is the one with the most unknowns (if going to a scene).
It makes sense to train the med person who might be sitting in the left seat to know what's going on. Even if they're sitting in the back, they should be able to be of assistance.

[Bob95fxdl]

Gents (and ladies, where applicable):

Let me first say that with my really vast (:O) HEMS experience (all of a year and a half), I am not an expert in the field. I have, however, been flying helicopters since 1979, served since 1985 as an IP, SIP, and IFE, as well as being a Safety Officer, so I will claim some expertise on that end. I'd like to make a few comments from my perspective in the US on the issue.

First, as to the articles from Dr. Bledsoe: take them with an extremely large bucket of salt. If you read his latest article, "Saving the Air Medical Industry," carefully, you'll notice he has little to say about HEMS that is good. Though he doesn't claim to be an expert, he leads you to think he is. Makes you wonder if there are some sour grapes in there somewhere. Perhaps he was fired because of attitude or something similar; I can't say. I would like to hit on some of the things he and others have addressed, then go to other aspects:
1- HEMS must be dispatched through the local/regional EMS system: I'm not sure what he is referring to. In the Community-Based Systems (CBS), this is already done. The problem actually lies with the EMS Dispatch. They are the ones who do the "copter shopping," not the company dispatch.
2- Require two pilots on every aircraft: this would immediately minimize the effectiveness of almost every CBS and most HBS and probably close them down. Why? Probably the most common and cost-effective aircraft in the HEMS industry is the AS350 and its variants. With an crew of three and two hours of fuel, in most cases, the aircraft is limited to about 200-300 pounds of patient at liftoff. Add in another 150-200 pounds of second pilot and, well, you see the issue. You'd have to get a bigger aircraft, which costs an extreme amount of money when one looks at the number involved, or cut the range drastically by reducing fuel loads to carry the extra pilot weight.
3- Don't attempt scene flights after dark: Is he kidding? That's when we're needed the most. Most EMS services are thoroughly trained by the HEMS providers how to select an LZ, mark it well and park vehicle under or by hazards, in order to ensure the aircrew is aware and avoids the obstacles.
4- Both the transferring and receiving hospitals need to have IFR approaches to their helipads: this one is plain stupid. If he or anyone he knows has ever TERP'd (planned/designed an IFR approach)(I'm also an Instrument Examiner) an approach, in over 98% of the hospitals, it would be impossible to meet FAA-mandated requirements for proximity and safety.
5- Require Night Vision Googles: While I agree about the need, one must also realize that the priority remains with the military. There are other companies working to make more of them, but they must all meet the same standard, lest we create a whole different set of standardization problems.
6- FAA Statutes Need EMS-specific rules and regulations: I do agree with this. The biggest issue I see within the HEMS arena is competition and the lack of standards within the community. My company, the biggest one in the US, has very clearly defined rules and regulations and will not tolerate anyone violating them. They would rather lose a flight than compromise safety. That's why I signed on with them instead of their competition, though I would have been paid more.
7- Weather mnimums must be stricter: Minimums are just that, minimums. Training and common sense must prevail. Within our firm, there is a simple policy of "Three to Go, and One to say No." If anyone feels uncomfortable, he/she has the freedom to turn down the flight, with no repercussions, even if the pilot disagrees and feels comfortable.
8- Limited work periods for mdical crew members: I have mixed feelings on this, but there's already a solution, at least within our company: If a crew is tired after numerous flights, they can stand down and there is no repercussion. By FAA regulation (and company policy), pilots are expected to come to work well-rested and prepared to be on duty and flyable for twelve hours. Currently, there's nothing regulatory that says the same about med crew personnel. I personally know of numerous med personnel who come off their hospital or EMS shift to HEMS and expect to be able to catch naps or sleep during their 24-hour shift. I do consider this a potential for incurring loss of situational awareness, but it is beyond my level to dictate. I don't, however, hesitate to take the station out of service and require the med personnel to get some sleep if I see their alertness (or the lack thereof) becoming a potential safety issue. To date, I've never been challenged on those decisions.

Having said all this, I see three issues being the solution to these problems:
1- Training, and more training. I don't know of any HEMS company that hires anyone without at least a CP rating, which requires them to be instrument rated. A high percentage are ATP-certified.
2- Clearly defined (and standardized) minimums and policies. As much as I hate to say it, if we cannot fix this problem ourselves, the FAA will have to do it for us, and we probably won't like the result.
3- Establish a separate Certificate within the FAA for EMS Flight, covering both RW and FW operations. This will eliminate the competition and resulting shortcuts and pressure (see #2 above).

It's time for me to get off my soapbox. I'm sure there are others who have their own opinions too, so I'll back out for now. Regardless, we do need to work to fix the problems, but we need to keep the rhetoric and inflammatory comments out of the discussion. JMTCW.

Bob in GA

[Gomer Pylot]

I agree that Dr. Bledsoe is pretty clueless. He clearly has an agenda, and (cherry)picks facts and statistics (not the same things) that further his agenda. He seemingly has only limited experience with HEMS operations, mostly hospital-based programs in urban areas. I have read some of his writings, and they just make me shake my head in wonder.

I have to say once again that IFR is not the answer. Having an instrument rating, and the basic instrumentation to recover from inadvertent IMC is essential, but filing and flying IFR is out of the question for scene flights, unless the regulations and technology change drastically. Transfers aren't much different in most cases. Avoiding IMC in the first place is the important thing.

[DTibbals53]

Great comments by all! Very constructive, with a minimal amount of emotionalism involved.

I agree with the regulation as a necessary evil. A timeline for compliance is the norm in the US and there is no reason that an implementation period of 10 years or so would not be effective and prudent.

Dual pilot, twin engine IFR capable aircraft is not only desirable, it is, in my opinion, desprately needed. Airframes are, or should be, updated and upgraded on a recurring basis. 30,000 hours is a bit too much to expect from a rotorcraft performing all of its flights within 3% of max gross weight. Replace them, over time, with more capable airframes. With the huge profits being realized by the operators, this should not be a deal breaker. Even if paring back some of the more densly served areas by closing a base, it can be done, especially if all of the operators must comply.

JimL, you posted: "As a matter of interest I see that the FAA is just about to publish, for comment, new OpSpecs "A021 Helicopter Emergency Medical Services (HEMS) Operations" and "A050 Helicopter Night Visions Goggle Operations (HNVGO)" which contain detailed site, qualification, dispatch and weather criteria."

The A021 proposed is a sweeping reform forcing operators to do away with the Class G operations and MVFR activities. It is proposed that the operators, except when on takeoff or landing, fly at altitudes of 1,000 feet above the highest obsticle, and avoid towers, etc., by 5 miles laterally when below that threshold. With towers at 2,100 feet AGL, that means cruise flight at 3,100 feet. Weather minimums would be 3,600 ceilings. Quite a change from the current 800 day cross country requirements. I think it will benefit the industry greatly.

Fly Safely out there. One more crash is too many.

[Quichotte]

JimL,

in deep respect for you and your knowledge, Tec pointed right.

I'm a HEMS pilot in a JAA Land under the latest OPS 3 Amendment flying single pilot at night with HCM. It's a public operation. We have mountains up to 4000ft in the "specified area".

Sitting on my desk and looking around i see:

my licence: JAA without IR
my logbook: 5000h incl. 1000h VFR night single pilot
trought the window i see: an older twin equipped according to JAA night HEMS, means HSI and AH but without IR certification, without AP and without weather radar or other gimmicks. Radar altimeter not needed on-shore.

Facing me is my HCM, a very warm and nice friend and collegue. Like all of our HCM he is only on freelance here. In their main business our HCMs are paramedics or fire fighters in other ground based public services and do not see helicopters. They have round about 1-4 shifts each month, divided between day and night. If the weather is sometimes to bad to fly in their shifts or we have no requests they fly only one or two night missions in 3 months. They got a initially 3-4 days HCM course approved by the CAA and a refresh one day per year. They know not much about flying (especially at night) and their only way to assist the pilot is to hold a spot light, a map, to turn on a new frequency or the GPS. Under daylight conditions they are able to navigate by map, but mostly not in the dark. They have no flight ops radio certificate. During the patient legs they are sitting mostly in the back.

Safety at first. Therefore we do each year of course the whole CRM and safety courses. Safety courses are much cheaper than better instruments or a second pilot.

I try to understand you and the JAA but there are to much backdoors in OPS3.

[JimL]

Hi Quichotte,

I have sent you a PM but probably need to put something on the record here. Your post has been read with interest but it is not clear what changes you would like to be made.

As was stated earlier in support of Gomer's post, it is not clear to me what useful capability IFR would add to HEMS - particularly as you indicate that you are in a relatively mountainous area. The requirement for an IR and certification for flight into IMC for the aircraft was examined some time ago but were not seen to be cost-effective. In particular, the requirement for instrument recency every six months was inserted because it added instrument competence without the need for the formal procedures - which takes up the majority of time in an IR (and is largely self-serving). The additional time to achieve a pass in the six monthly instrument procedures check and the yearly IR test were seen as problematical (not cost effective) in an operation that is essentially VFR and where recency could not be maintained.

An aircraft that has been certificated for flight in IMC will add the required stablility (the autopilot essentially adds flight director functions) but is unlikely to provide any more instruments - as those specified in Parts 27/29 are essentially the same as those required in JAR-OPS. No small aircraft that I am aware of is equipped with weather radar; RADALTs are essential over water but only useful over land.

If your HCM complies with all of the training and checking requirements of JAR-OPS (Subpart O and elements in the HEMS Appendix - which are almost entirely aviation related) but you consider that he/she is still underqualified (no you did not say that), you need to take that up with your company via the safety reporting system (which needs to address the safety case that should have accompanied the request for the two-pilot derogation). As was stated by Shawn, if the HCM is in the second pilot's seat on the way to the scene, there is value added in the additional pair of eyes; outside to see danger and inside to support and monitor your actions.

If you have a specific request to make then best raise it now and it can be resolved during the three months consultation period for EASA Ops. If I can I would like to assist in any request but first need to understand what it might be.

Jim

[helmet fire]

I am fascinated by the IFR reluctance as I believe that it is a lynch pin in making HEMS safer. I know that individual operating environments will make IFR impracticable and even down right dangerous: the Swiss Alps and Air Zermatt's operating environment springs to mind, as well a the environments you guys are describing above. In fact, the company I work for has it's main area restriced to about 22 minutes flight time radius.

But still I advocate IFR and an instrument rating checked regularly.
IFR gives you an irreplaceable skill set to cope with adverse situations, wether they be deteriorating weather, turning inside bowl feateures in the mountains, ending up in a low speed loss of visual reference event (brown out, white out), a loss of NVG image at low level, Inadvertent IMC, etc. It gives you an appreciation of lower safe altitudes and their employment, it gives you an aircraft with higher instrumentation requirements and eith two pilots or preferably a SPIFR autopilot. All these things will dramatically aid HEMS pilots, no matter what environment they operate in. Once capital expenditure for equipment (aircraft and sim if needed) is taken into account, the skill upkeep costs are not really that expensive. Get in the sim every month, ensure an IIMC event is practiced (with screens and foggles) every checkride you do, etc, etc.

A friend has supplied the following information that I think helps explain the cultural differences about the current US system and what I am advocating in my list:

"What really astonishes me is the almost universal belief among us US EMS pilots that IFR could not possibly add anything useful to our operating environment. And yet, when you talk in depth to them, you realize that their concept of IFR is of a flight ending in an ILS to minima at an airport 10 out of 10 times -- unless they are lucky enough to have a GPS approach to a hospital with minima below the legal VFR ceiling"

I guess that one of the issues, I am advocating IFR for a safety and skill set use primarily, and an operational advantage secondarily. In Oz, we would use the IFR to the nearest approach and transit to the hospital HLS from the break visual point IF THE WX PERMITS. Otherwise we land and road it from the airport or hospital we got into. He continues:

FAR Part 135 contributes to the problem. Under Part 91 you can file to or from a place that doesn't have approved Wx provided you carry an alternate. Part 135 requires an approved weather source at both places without exception -- which excludes most of the hospital helipads. Because IFR is so hard to access and is so rigid -- VFR is seen as the only viable alternative. Couple that with the fact that VFR is VFR whether it is flown in dark air or light air -- and the system just encourages people to rely on the Mark 1 eyeball to spot the radio masts. (Before GPS we had to glance at our maps occasionally and might have noticed the towers -- but now that we don't have to use the maps to navigate many pilots don't bother to consult them for information about obstacles either.)

I think this is the part of our list surrounding IFR Infrastructure. If the above is accurate, it seems that the regulations could possibly be more supportive in this requirement in terms of outcome. In Oz we would get the area forecast if departing from an HLS without a specific forecast or report, then use the forecast for the arrival approach or an aerodrome very close by. That seems to me to meet the intent of the US system without prescribing the exact point of departure/approach and thereby significantly altering the outcome of it's use. I can see the dillema you guys are facing. I believe this is part of the 10 year step toward the creation of a helicopter specific IFR structure.

Am I getting on the right track to understanding the IFR system (or problems) in the US?

Lastly, I think he makes a very intresting point about human factors and the proliferation of GPS systems into our world.

[Shell Management]

hf
You've got it. While as you and I may see INSTRUMENT as the key word in IFR, in the US the key word is RULE. US is still fixated by rules and traditionally the FAA is reluctant to change to make them practical.

NTSB are to have a hearing in February: SB-08-51 (http://www.ntsb.gov/Pressrel/2008/081110.html)

Of course there are regualtors in Europe who get fixated by their rules (though without the reluctance to tinker!) and ignore the implementaion irregularities Quichotte highlights.

It suits most US companies to 'blame' the FAA for tying their hands or their crews for rule-breaking. The FAA's punitive approach encourages this victimisation of crews and a reluctance to report near-misses.

Bob95fxdl
Most EMS services are thoroughly trained by the HEMS providers how to select an LZ, mark it well and park vehicle under or by hazards, in order to ensure the aircrew is aware and avoids the obstacles.
Interesting. To what standard is this done?

[tecpilot]

Of course there are regualtors in Europe who get fixated by their rules (though without the reluctance to tinker!) and ignore the implementaion irregularities Quichotte highlights.

Since OPS 3 with HEMS we had a lot of long faces in Europe. The HEMS market changed completely. Since Appendix 1 to JAR-OPS 3.005(d) HEMS costs strong increased. It's easy to understand that civil and public operators paid some paperfoxes and attorneys to find out the holes in Appendix 1.

One of the holes is the night operation with HCM and no strict requirement where his place have to be.

My most beloved words in OPS 3 are:

"The Authority may exceptionally and
temporarily grant an exemption from the
provisions of JAR-OPS Part 3 when satisfied that
there is a need and subject to compliance with any
supplementary condition the Authority considers
necessary in order to ensure an acceptable level of
safety in the particular case."

We have a lot of exemptions in the member countries of JAA.
A few days ago: Switzerland is now also on OPS 3. :ok:
First thing they have done, is to cancel the need of twins in HEMS under special circumstances. Now let's wait how the things are going on.

A few months ago i have learned that a UK based HEMS operator thinks about to fly without MD (MedPax), only the HCM and the pilot. I don't know if this is still in progress, but such plans seems to be legal on the first view but it's not a step forward in safety. If the HCM is busy with the patient the pilot is alone.

But no blame to the JAA and our respected JimL! JAR-OPS 3 was a big step in the right direction.

[alouette3]

Shell Management:

The dimensions required for an unprepared LZ are typically written down in the company General Opearations Manual and Ops Specs. Both these documents are approved by the FAA and hence carry the full weight of regualtory authority behind them.Now, do the ground units konw of these dimensions or even care? Probably not. But efforts are made to educate them by individual programs on a regulsr basis. After all this , if we show up at an LZ that does not look suitable in size ,shape,slope or obstructions, it is still the PIC 's decision whether to accept or reject the LZ chosen. I have rejected a few in my time and a new LZ that met the criteria was qucikly set up.
So, it is not a complete wild west show out here. There are regualtions and standards which are fairly strictly imposed by the company and the FAA.
Alt.3

[victor papa]

The point was made earlier and I for one would also like to clarify that I am pro IF rated pilots onboard with the necessary instrumentation for inverted IFR ops(not necessarily an iFR certified aircraft). HEMS should in my opinion, based on my region, always remain a VFR ops and should seldom end up in iFR(the unplanned oh Sh:mad:t scenario only). Except for 2 airports in a massive country(not US/Aus) there are no standby radar at any other airports so only 1 aircraft allowed at a time during iFR conditions in the circuit. We have massive traffic flow with 4 airlines covering the country. Despite our distances to be flown, this alone will lead to a emergency out of fuel landing and once the iFR req is satisfied the expectation will be there.

I ask again someone to give me a helicopter in this class that can satisfy the minimum requirement of 2.5hrs range, 6000ft, 35 degrees, 1 plt + 2 crew (100kg/person) and full IFR. Again, I agree with the IF pilot rating +training + experience and as I have said before a HSI, radio alt, EGPWS and tCAS as a must on top of the normal minimum equipment instruments, but in the circumstances above is there an IFR light twin who will enhance the safety in those conditions at the cost and expectation=pressure associated with it?

Maybe I lost the plot somewhere?

[Gomer Pylot]

Helmet fire, my reluctance to require IFR comes from the following. First, the fuel requirements are onerous. We carry just enough fuel to get the fllights done VFR, and if we put more on we can't carry a patient. Second, going IFR to scene flights, which are most of what we do, would often require an IFR flight to an airport 30 miles or more away, then transitioning VFR to a scene 10 or 20 miles in the other direction. When we have fully instrumented aircraft capable of flying ad hoc IFR approaches to an unprepared scene, regulations permitting that, and the fuel/payload capacity to do that, then IFR becomes attractive. That is decades away, at the earliest, IMO. Hospital transfers in my area are pretty much the same - no IFR airports anywhere near them, so IFR just isn't possible. The major receiving hospitals do have IFR airports nearby, but without weather reporting and TERPS application at the local hospitals, it's just not legal to depart from them IFR, nevermind fly there IFR.

[helmet fire]

I see your dilemma Gomer.
I would like to lift the focus off the current "why nots" and into the dreams of how we can makew it better. There is no doubt we need a close examination of the "why nots" so that we can accurately identify the current elements of our system that are inhibiting desired outcome.

I am not professing that you should go IFR everywhere. Such a requirement is purely regional and based on wx, etc, as is pointed out by VP. As to your fuel reserve requirements, that is part of the steps we are dreaming of: upgrade to a more appropriate aircraft! Dream a bit! In our region we regularly go IFR in HEMS. But the actual use of IFR is a secondary advantage to the safety layers it introduces in terms of loss of visual reference events, night operations, and situational awareness of obstcale clearance. Let alone cultural benefits that flow from introducing a professional skill development and retention program for the crews.

VP, you have stated your operational requirements many times and no-one has supplied an answer to satisy your needs. Such an answer is impossible without your detailed knowledge of the environment, wx, terrain, infrastructure, and of course budget. I understand that you are strongly in favour of a high powered single over a medium twin due to cost. To be honest, it sounds like you need to build an airfield and use a fixed wing.

However, a GPS approach costs approx $10,000 USD to set up, and these fundamentally free you from airports. This is part of the IFR Infrastructure that we need to start to dream about. There is no reason that you could not establish GPS approaches to stategic fuel reserves in your environment. It is currently feasable technology (and proven) to do a GPS approach to 85 ft AGL. That is lower than any ILS. And it is certainly lower than any VFR operators should safely be trying to get under. The technology is available now, we just need those willing to implement it. That will power will take on many adversities, not the least of which is cost.

The question then is: are HEMS ops cost effective? I would like someone else to start a thread on that topic so this one is not hijacked by the question, but I believe they are very cost benefitial.

Lastly re the HCM and the rumoured operation in the UK: Such an example (true or not) highlights why we have to make the rules so complicated. There is always someone avoiding intent and literally interpreting rules to their own advantage. Such a disregard of the intent of the HCM requirement will simply result in the best case an ammendment to Ops3 intracately prescribing the requirements and we will all whine about rule complexity. Worse case, it will remove the exemption for a HCM and replace with a second pilot. That is the also the danger of not properly training your HCM in aviation support skills: it will give the critics a reason to force the second pilot requirement on us all.

[WhirlwindIII]

IMHO

HEMS IFR, and the extent to which it is used is one thing. HEMS pilots training to IFR standards (including those on VFR operations to the extent possible) as one precautionary tool to allow them to effectively deal with some principle causes of accidents such as IIMC, altered planes of reference, is another. The latter can be implemented to some degree or other and should be.

Having to divert to an alternate destination, which may or may not have the medical expertise to meet specific needs, is a driving factor in defining the extent to which real IFR ops are utilized. It brings up the term soft IFR as bantered around in HEMS IFR for good reason - i.e. use IFR when one can't safely do the flight VFR, but keep it reasonably conservative on the real weather conditions to assure the patient gets in to the primary destination.

I don't see really low IFR ops in HEMS being medically practical but things do have a way of evolving.

WIII

[victor papa]

Helmet fire- I do not prefer the single for cost, but for range, power margin and simplicity of operation for the pilot. The only 2 singles I would push based on the above is the b3+ and the B4. We operate currently on GPS with terrain warning in all our Squirrels. The b4's have the KN150 and the one the EX500 all inclusive package incl Jepp etc. We do not do night ops currently but was looking at 2 pilot nvg ops in the B4. Budget is an isuue but not the major concern.

As was said before, a dangerto iFR remains mountains and despite us being at 6000ft we have lots of those with clinics in the valleys or mountain tops. Thunder storms and high wind conditions swirling from all directions is a given. We work our fuel range on a 15kt head wind both directions because you are not guaranteed of a head then tailwind scenario.

If I can dream I will take a N3 Dauphin and nurse her when heavy but have the range and IFR. 139 will also do great watching the range. Landing zones and clinic size will keep me stationary though. Most of the clinics are smaller than those 2. We use a Squirrel for a mobile clinic and the people think it is magic?

If I can really dream I will take a 225 in Jigsaw confic.

[helmet fire]

When we can generate threads upon threads and thousands of posts personally attacking each other and opposition companies, yet run out of input into brainstorming a solution to the perception of risk in one of our industry's most important and high profile sectors - do we need to look any further to find the root cause of the problem?

:(

[havoc]

Write Congress...we (the choir) do not have the authority to change things, only the decision necessary to safely complete the flight at hand.


FAA Invites Comment On Changes In HEMS Rules (http://www.avweb.com/avwebflash/news/FAAInvitesCommentOnChangesInHEMSRules_199234-1.html)

[victor papa]

Helmet fire I can not agree with you more.

It is very obvious looking at the amount of people posting on the forums where the accidents are discussed vs those posting when a preventative discussion is going on like this one. We do not necessarily agree but on this topic I am with you 100%.

Maybe it is a case of we are quick to react(safer to hide and blame than to stick your neck out and make statements?) but not to prevent or brainstorm?

[JimL]

Helmet Fire,

It is clear what you are attempting to do but changing the culture by (pseudo) enforcement of an existing system is probably not the best approach. What might be required is to break out the various elements of the existing IFR system into its constituent parts to see what might be usefully employed. If you examine the ICAO Rules of the Air you will see that they are almost exclusively procedural - i.e. fly at a minimum level that achieves obstacle clearance; comply with the ATS system; when not within the ATS system (class G) fly at the correct quadrantal, submit a flight plan, maintain communication and give position reports. Only the first rule - that the aircraft should be adequately equipped with instruments and navaids - is outside the procedural approach. For those reasons, I agreed with Gomer that a wholesale application of the IFR system was not appropriate.

As is clear to most observers, there is a need for a culture change; however, this is made extremely difficult by the business (and political) model that is employed in some States. For the US, the FAA, although wishing to solve the problem, appear not to be able to modifiy FARs and therefore have to resort to exhortation and the provision of guidance. However, there has been a change of tack recently and the FAA have used the OpSpec method of enforcing more appropriate weather limits and departure criteria. Industry have contributed to the discussion of amendment to the OpSpec and their representatives have endorsed the changes. (We will have to see how this revision of the OpSpec plays out.)

One of the main problems that we face is that helicopters are intrinsically unstable. Without improvement in the basic handling qualities (usually provided by control augmentation), helicopters become progressively uncontrollable as the visual cue environment degrades. This is not so for fixed wing, and is the reason why they can be certificated for flight on instruments without the additional (handling quality) requirements that are contained in Appendix B of Parts 27/29. This is particularly an issue when flying at night; although the above codes do specify that flight at night/in IMC does require additional attention, it does not appear that additional rules are specified for flight at night. In fact, it is slightly worse than that because flight in daylight with a degraded visual-cue environment (DVE) is also problematical (but not when the weather limits are observed). For a reason which I have not yet fathomed, accidents that result from these circumstances are still categorised as CFIT when, clearly, control has been lost (perhaps the first thing that needs to be addressed).

What will not improve this situation (unless accompanied by an enhancement of handling qualities) is the addition of sophisticated synthetic vision systems (SVS) or enhanced vision systems (EVS) into the cockpit. Whilst SVS might have prevented the recent accident - where there was a flight into mast wires - it will do nothing for loss of control due to DVE. (Look to the discussion of the addition of GPS to the cockpit and the probable effects on safety.) If obstacles cannot be seen and avoided, then the flight is probably not being conducted under Visual Flight Rules.

Crewing is another issue; although HEMS can be undertaken single pilot, we, in Europe, have implemented a system where the second pilot seat has to be occupied (it is the primary role of the Hems Crew Member (HCM) to assist the pilot; it is this requirement that forces the necessity for adequate aircraft and not just performance - hence the replacement of the 'squirrel' in most European States). There is also a basic rule that, at night, there should be two pilots (although that can be alleviated for local operations - generally accepted to be 20-25nm where there is good cultural lighting). However, the latest HEMS twins are equipped for SPIFR and do not (necessarily) have a full two-pilot panel. There is also a (licensing) rule that requires one of the pilots to have an ATPL when two pilots are required by 'certification' or an 'operational' rule (this is way above the ICAO Standards). In the recent past, the ATPL has been a licence with an IR requirement - thus making the two-pilot rule very expensive.

So far this has been negative and, apart from the mention of improvement in the OpSpecs, doesn't provide many positive messages. However, the first part of the provision of any solution is to really understand the problem (and is the reason why the research being undertaken by the JHSAT was mentioned earlier).

There is no magic bullet but, If I were asked to provide a list of elements that might improve the HEMS accident record, these might be some:

Pilots should be educated on the dangers of not observing the weather limits for VFR.
Where the operation is such that reduced visibility/cloud-ceiling may be encountered (and in any case at night), the helicopter should meet the stability requirements of Appendix B to Parts 27/29.
The European rule for two-up-front should be adopted (and enforced) - any downgrading to one should result in the filing of a discretionary report.
The HCM should be regarded as a crew members and receive appropriate training and checking.
Every HEMS helicopter should be equipped with a full panel for at least the P1.
Every HEMS helicopter should be equipped for SBAS or GBAS.
Every HEMS pilot should be trained and checked for flight in IMC (without the procedural elements) - this should include three monthly refresher training.
All HEMS flights that include a landing at a HEMS Operating Site (scene) at night should be NVIS equipped (scene flights without NVIS should be prohibited)
All HEMS post holders should attend a HEMS management course (run by industry) and be accredited - this should a requirement under provisions of the AOC.
All HEMS operators should provide evidence that they meet the minimum requirements for performance and operations establish by the State.
HEMS operations should have appropriately constructed flight and duty times schemes (standby duties should receive appropriate treatment - i.e. not necessarily counted as full time).
HEMS operations should require a specific approval.EASA have recently proposed an Operational Suitability Certificate to include a number of the elements mentioned above; although not yet published, it is expected next week. HEMS is a prime candidate for the application of such a certificate.

Jim

[Shawn Coyle]

JimL
Nice summary.
Sorry, but my LOTLA (Lexicon of Three Letter Acronyms) is missing the definitions of SBAS and GBAS. Can you please elucidate?

[JimL]

GPS - Satellite Based Augmentation System and Ground Based Augmentation System.

Jim

[Gomer Pylot]

Are those part of the European GPS system? In the US, almost every modern GPS uses WAAS (Wide Area Augmentation System) which is a combination of ground and satellite based augmentation. I haven't heard of GBAS or SBAS before.

[JimL]

They are the accepted generic terms for satellite based and ground based systems.

WAAS is the US implementation of SBAS as is EGNOS in Europe (others are: WAGE - for the DoD; MSAS and QZSS - for Japan; StarFire and Starfix - commercial; and GAGAN - for India).

Whilst SBAS is the generic term referring to any such satellite-based augmentation system, under ICAO Standards, SBAS must transmit a specific message format and frequency which matches the design of WAAS.

Generally, GBAS networks are local (within 20km) using VHF and UHF radio bands.

The reason aumentation systems were suggested was because, not only do they add accuracy and integrity to a GPS system, they are also enabling technologies for more accurate Point in Space (PinS) procedures (which of course can also use the raw GPS signal). If as suggested in an earlier post, there is a proposal to narrow the navigation lanes and hence take advantage of less restrictive obstacle clearance, such accuracy and integrity will be essential.

Whilst formal routing and procedures could benefit from any advance in these systems (and may permit a lower helicopter IFR routing overlay - or is it underlay?), it is not clear how this will have a great impact on the HEMS safety record.

If we go back to the list and rank the elements for potential improvements in safety - this, for me, would be near the bottom.

Jim

[Shawn Coyle]

JimL:
Thanks for the definitions. New to me!
The improvement in safety would be difficult to trace to only using Augmented GPS and much narrower routings. It would be part of a larger package that promoted using IFR techniques, such as pre-planned routes to common points from which to proceed to a scene, etc.
A change in overall mentality is what's needed - anything that can be done to improve our methods would be most useful.

[CYHeli]

The longest journey starts with one step.
If there are fatals that can be attributed to the trip back with patient, then fixing that part of the journey is still needed. (One of the last fatals - doing a missed approach to an airfield 'cause they couldn't get into the hospital)
Remember if you can create precision (GPS) approaches to a hospital, isn't that the most common destination and therefore needs to be dealt with?

I like the idea of having pre detemined routes, but again it comes back to your Area of Ops.

Good luck gents.

[Gomer Pylot]

WAAS was created solely to increase vertical accuracy. For routes in the horizontal plane, it only increases accuracy by a few (less than 10) meters, and does not allow any increase in routing precision. Even without WAAS, GPS is more accurate than ILS in the horizontal dimension. Use of WAAS does permit the GPS to warn of obstacles or not, based on altitude. It was created to allow precision GPS approaches, which are not possible without it, but does little for horizontal accuracy. If the routes are TERPed beforehand, WAAS isn't necessary, but if the routes are going to be flown without being previously checked, then it can help avoid obstacles, as long as the database is completely correct, and nobody has erected anything since it was installed in the GPS. I don't trust obstacle databases completely, at least not enough to bet my life on their accuracy.

[WhirlwindIII]

JimL

From your post of 22 November:

" What might be required is to break out the various elements of the existing IFR system into its constituent parts to see what might be usefully employed. "

Excellent.

WIII

[skadi]

deleted, wrong thread

[SASless]

Might be interesting to look back over five years and see what has happened since all this Brain Storming has taken place. What ideas have been adopted, which ones should have been but were not.....and then analyze the reasons why not.

Has EMS gotten any safer over the five year period?

[400hover]

Well... Portugal change 2 Bell412 for Ka32 last year... someone is not doing the homework...