PPRuNe Forums - View Single Post - How to improve the HEMS safety record in the USA?
Old 11th March 2005 | 16:19
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Mars
 
Joined: Jun 2003
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From: Off the Planet
This might be of interest to you - check how many of these recommendations have been carried out!

Background

Between 1987 and 1997, there were on average four air medical helicopter accidents per year for the industry. By 1997, the accident rate for helicopter AMS operations had been reduced to 1.97 accidents per 100,000 flight hours from a high of 17.08 in 1987. In 1998, however, the number of accidents rose to a nine year high of seven, but more alarming was the rise in fatalities to fourteen, the highest number since the peak year of 1986. In 1999, the number of accidents rose even further to ten, the highest also since the peak year of 1986. Fatalities were down to ten but still higher than the average of six.

To address the issue of safety, the Association of Air Medical Service, in consult with HAI, the National EMS Pilots Association (NEMSPA), the National Flight Paramedics Association (NFPA), the Air & Surface Transport Nurses Association (ASTNA), the major air medical service operators and aircraft manufacturers, convened the Air Medical Safety Summit in Dallas, TX, on April 7, 2000, to discuss safety within the air medical service industry.

In a process very similar to that used by the FAA’s “Safer Skies” Joint Safety Analysis Teams (JSATs) in their recent study of weather and controlled flight into terrain (CFIT) accidents, the Safety Summit attempted to identify what prevalent factors existed in AMS operations that tended to degrade safety. With insufficient time at this particular meeting to conduct an in-depth cause analysis, the identification of accident causes was based primarily on opinions and speculation. However, several broad areas were identified, including: a lack of training (recurrent, CRM, weather, decision making, etc.); an administrative culture that too often does not place safety first; inadequate technologies; and other human factors (fatigue, cockpit overload, sense of mission urgency, inadequate piloting skills, etc.)

Although the Summit arrived at a variety of perceived causes of air medical accidents, no comprehensive analysis of accidents had been conducted. Therefore, the Air Medical Service Accident Analysis Team was formed to conduct an in-depth analysis of air medical helicopter accidents to identify the chain of events that has led to accidents and to identify intervention strategies that would be both effective and feasible in preventing such accidents in the future.
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Recommendations - It is the recommendation of the Air Medical Accident Analysis Team that the Air Medical Safety Advisory Council (AMSAC) review these findings and focus efforts within the air medical service industry on the development of implementation strategies for those interventions that are highly effective and highly feasible. AMSAC should also consider interventions that are highly effective but moderately feasible, as well as interventions that are highly feasible but moderately effective. When time and resources permit, AMSAC should also consider interventions that are moderately effective and moderately feasible, as some of these interventions may require only modest implementation but may have some impact upon the enhancement of safety. However, those interventions that are identified as low in effectiveness, low in feasibility, or both, should not be pursued.

LIST of RECOMMENDED INTERVENTION STRATEGIES:

Interventions that ranked High Effectiveness and High Feasibility:

• Enhance the training for night flying operations
• Enhance the training for mountain flying operations
• Equip aircraft with Terrain Avoidance Warning Systems (TAWS)
• Equip aircraft with Radar Altimeters
• Provide aircraft with mission essential equipment
• Improve the content of weather briefings

Interventions that ranked High Effectiveness and Moderate Feasibility:

• Conduct/enhance annual IFR proficiency checks
• Conduct/enhance training to improve the understanding of weather briefings
• Enhance overall training: recurrent, professional knowledge, etc.
• Conduct/enhance training in Aeronautical Decision Making (ADM)
• Establish an integrated and structured Pilot Training Program
• Conduct/enhance mission oriented training
• Conduct/enhance Crew Resource Management (CRM) training
• Equip aircraft with Moving Map Displays to provide weather, obstacle and terrain data
• Equip aircraft with avionics to provide a vertical awareness display or warning
• Standardize cockpits of similar make/model used in similar operations
• FAA to enhance/improve contents of annual IFR proficiency checks
• Establish a national criteria for the marking of wires and towers

Interventions that ranked Moderate Effectiveness and High Feasibility:

• Enhance the awareness of accident causes
• Improve physiological training
• Improve training with avionics equipment: usage, capabilities, etc.
• Improve weather radar
• Encourage greater utilization, interaction with and assistance from Air Traffic Management
• Improve/enhance training of ATC personnel in rotorcraft operations and capabilities
• FAA to enhance training elements of Biennial Flight Reviews and Pilot Training Standards

Interventions that ranked Moderate Effectiveness and Moderate Feasibility:

• Operators to enhance training for Biennial Flight Reviews and Pilot Training Standards
• Develop helicopter-specific, mission-specific computer based Emergency Procedures Simulators
• Develop satellite-based Communications, Navigation and Surveillance (C/N/S) technology
• Increase the rate of commissioning of new AWOS/ASOS facilities
• Improve aeronautical charts (symbology, data, etc.)
LIST of INTERVENTIONS NOT RECOMMENDED FOR IMPLEMENTATION:

Intervention Strategies Scoring Low Effectiveness:

• TRN-11: Improve Pilot Handbooks
• EQ-3: Data-Link Technology
• EQ-18: Readily available passenger/crew briefing cards
• EQ-22: Fuel Flow indicators
• ATC-3: Simplify contacting FSS
• REG-7: Require annual calibration of fuel quantity gauges
• REG-9: Publish a Mountain Flying Advisory Circular
• REG-10: Publish a “Flat Light/Whiteout” Advisory Circular
• REG-11: Require flight plans
• NAS-2: Provide more UNICOM frequencies

Interventions Scoring Low Feasibility:

• EQ-1: Avionics to provide horizontal awareness of terrain
• EQ-4: Synthetic Vision
• EQ-6: ADS-B technology
• EQ-8: Heads-Up Display
• EQ-9: Night Vision Devices
• EQ-11: Automated Voice Callouts
• EQ-12: Over-Bank Warnings
• EQ-13: Excess terrain closure warning
• EQ-21: Equip aircraft with state-of-the-art technology
• EQ-24: Avionics to enhance detection of wires and towers
• REG-2: Prohibit night flying by non-IFR rated pilots
• REG-6: Require human factors/ergonomics in cockpit designs
• MISC-2: Change corporate/management mindset
• MISC-3: Improve safety culture
• MISC-5: Improve safety programs

Interventions Scoring Low Effectiveness and Low Feasibility:

• TRN-12: Increase Dual-Pilot time prior to solo PIC
• TRN-13: Increase time requirements for “mission certification”
• EQ-7: Obstacle Database
• EQ-17: Enhanced ice detection equipment
• ATC-5: Raise Minimums for night instrument approaches
• ATC-6: Require ATC monitoring of instrument approaches
• REG-1: Prohibit night VFR
• REG-5: Update FAR Part 135 requirements
• REG-8: Require crashworthy fuel tanks for certification
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