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HEMS - Regulations and saving life

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Old 16th Jun 2004, 07:21
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Heliport,

Is it possible to post (or point to) the change in regulations that prompted this thread!!
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Old 16th Jun 2004, 09:13
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I find this whole issue of increasing regulation/restrictions in aviation very frustrating.

Professional pilots (in whatever role) are paid to make decisions relating to the operation of their aircraft. Those decisions are based on a risk assessment (nothing formal, but just done in the head) and are influenced by many factors (aircraft type, performance, weather, the "need" etc). Police/EMS and in particular SAR are operations which present an infinite variety of scenarios. You cannot regulate them without compromising capability. Why can't the regulators respect these professional pilots and trust them to make decisions. More regulation will turn pilots into robots (or airline pilots!!! )
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Old 16th Jun 2004, 10:04
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Confusion indicates that the presence of this text is not general known:

ACJ to Appendix 1 to JAR-OPS 3.005(d)
The JAA HEMS philosophy
See Appendix 1 to JAR-OPS 3.005(d)

1 Introduction


This ACJ outlines the JAA HEMS philosophy. Starting with a description of acceptable risk and introducing a taxonomy used in other industries, it describes how risk has been addressed in the HEMS appendix to provide a system of safety to the appropriate standard. It discusses the difference between HEMS, Air Ambulance and SAR - in regulatory terms. It also discusses the application of Operations to Public Interest Sites in the HEMS context.

2 Acceptable risk

The broad aim of any aviation legislation is to permit the widest spectrum of operations with the minimum risk. In fact it may be worth considering who/what is at risk and who/what is being protected. In the view of the JAA Helicopter Sub-Committee (HSC) three groups are being protected:

- Third parties (including property) - highest protection.

- Passengers (including patients)

- Crew members (including task specialists) - lowest

It is for the Authority to facilitate a method for the assessment of risk - or as it is more commonly known, safety management.

3 Risk management

Safety management textbooks[1] describe four different approaches to the management of risk. All but the first have been used in the production of the HEMS appendix and, if we consider that the engine failure accountability of Class I performance equates to zero risk, then all four are used (this of course is not strictly true as there are a number of helicopter parts - such as the tail rotor which, due to a lack of redundancy, cannot satisfy the criteria):

Applying the taxonomy to HEMS gives:

- Zero Risk; no risk of accident with a harmful consequence - Class 1 performance (within the qualification stated above) - the HEMS Operating Base.

- De Minimis; minimised to an acceptable safety target - for example the exposure time concept where the target is less than 5 x 10-8 (in the case of elevated landing sites at hospitals in a congested hostile environment the risk is contained to the deck edge strike case - and so in effect minimised to an exposure of seconds).

- Comparative Risk; comparison to other exposure - the carriage of a patient with a spinal injury in an ambulance that is subject to ground effect compared to the risk of a HEMS flight (consequential and comparative risk).

- As Low as Reasonably Practical; where additional controls are not economically or reasonably practical - operations at the HEMS operational site (the accident site).

It is stated in JAR-OPS 3.005(d) that “...HEMS operations shall be conducted in accordance with the requirement contained in JAR-OPS 3 except for the variations contained in Appendix 1 to JAR-OPS 3.005(d) for which a special approval is required.”

In simple terms there are three areas in HEMS operations where risk, beyond that allowed in the main body of JAR-OPS 3, is defined and accepted:

- in the en-route phase; where alleviation is given from height and visibility rules;

- at the accident site; where alleviation is given from the performance and size requirement; and

- at an elevated hospital site in a congested hostile environment; where alleviation is given from the deck edge strike - providing elements of the Appendix 1 to JAR-OPS 3.517(a) are satisfied.

In mitigation against these additional and considered risks, experience levels are set, specialist training is required (such as instrument training to compensate for the increased risk of inadvertent entry into cloud); and operation with two crew (two pilots, or one pilot and a HEMS crew member) is mandated. (HEMS crews - including medical passengers - are also expected to operate in accordance with good CRM principles.)

4 Air ambulance

In regulatory terms, air ambulance is considered to be a normal transport task where the risk is no higher than for operations to the full JAR-OPS 3 compliance. This is not intended to contradict/complement medical terminology but is simply a statement of policy; none of the risk elements of HEMS should be extant and therefore none of the additional requirements of HEMS need be applied.

If we can provide a road ambulance analogy:

- If called to an emergency; an ambulance would proceed at great speed, sounding its siren and proceeding against traffic lights - thus matching the risk of operation to the risk of a potential death (= HEMS operations).

- For a transfer of a patient (or equipment) where life and death (or consequential injury of ground transport) is not an issue; the journey would be conducted without sirens and within normal rules of motoring - once again matching the risk to the task (= air ambulance operations).

The underlying principle is; the aviation risk should be proportional to the task.

It is for the medical professional to decide between HEMS or air ambulance - not the pilot! For that reason, medical staff who undertake to task medical sorties should be fully aware of the additional risks that are (potentially) present under HEMS operations (and the pre-requisite for the operator to hold a HEMS approval). (For example in some countries, hospitals have principle and alternative sites. The patient may be landed at the safer alternative site (usually in the grounds of the hospital) thus eliminating risk - against the small inconvenience of a short ambulance transfer from the site to the hospital.)

Once the decision between HEMS or air ambulance has been taken by the medical professional, the commander makes an operational judgement over the conduct of the flight.

Simplistically, the above type of air ambulance operations could be conducted by any operator holding an AOC (HEMS operators hold an AOC) - and usually are when the carriage of medical supplies (equipment, blood, organs, drugs etc.) is undertaken and when urgency is not an issue.

5 Search and rescue (SAR)

SAR operations, because they are conducted with substantial alleviations from operational and performance standards; are strictly controlled; the crews are trained to the appropriate standard; and they are held at a high state of readiness. Control and tasking is usually exercised by the Police (or the Military or Coastguard in a maritime State) and mandated under State Regulations.

It was not intended when JAR-OPS 3 was introduced, that HEMS operations would be conducted by operators not holding an AOC or operating to other than HEMS standards. It was also not expected that the SAR label would be used to circumvent the intent of JAR-OPS 3 or permit HEMS operations to a lesser standard.

6 Operating under a HEMS approval

The HEMS appendix originally contained the definitions for Air Ambulance and SAR - introduced to clarify the differences between the three activities. In consideration that, in some States, confusion has been the result, all references to activities other than HEMS have now been removed from the appendix and placed into ACJ material.

There are only two possibilities; transportation as passengers or cargo under the full auspices of JAR-OPS 3 (this does not permit any of the alleviations of the HEMS appendix - landing and take-off performance must be in compliance with the performance subparts of JAR-OPS 3); or operations under a HEMS approval.

7 HEMS operational sites

The HEMS philosophy attributes the appropriate levels of risk for each operational site; this is derived from practical considerations and in consideration of the probability of use. The risk is expected to be inversely proportional to the amount of use of the site. The types of site are:

HEMS operating base; from which all operations will start and finish. There is a high probability of a large number of take-offs and landings at this heliport and for that reason no alleviation from operating procedures or performance rules are contained in the HEMS appendix.

HEMS operating site; because this is the primary pick up site related to an incident or accident, its use can never be pre-planned and therefore attracts alleviations from operating procedures and performance rules - when appropriate.

The hospital site; is usually at ground level in hospital grounds or, if elevated, on a hospital building. It may have been established during a period when performance criteria was not a consideration. The amount of use of such sites depends on their location and their facilities; normally, it will be greater than that of the HEMS operating site but less than for a HEMS operating base. Such sites attract some alleviations under the HEMS rules.

8 Problems with hospital sites

During implementation of JAR-OPS 3, it was established that a number of States had encountered problems with the impact of performance rules where helicopters were operated for HEMS. Although States accept that progress should be made towards operations where risks associated with a critical power unit failure are eliminated, or limited by the exposure time concept, a number of landing sites exist which do not (or never can) allow operations to Performance Class 1 or 2 requirements.

These sites are generally found in a congested hostile environment:

- in the grounds of hospitals; or

- on hospital buildings;

The problem of hospital sites is mainly historical and, whilst the Authority could insist that such sites not be used - or used at such a low weight that critical power unit failure performance is assured, it would seriously curtail a number of existing operations.
Even though the rule for the use of such sites in hospital grounds for HEMS operations (Appendix 1 to JAR-OPS 3.005(d) sub-paragraph (c)(2)(i)(A)) attracts alleviation until 2005, it is only partial and will still impact upon present operations.

Because such operations are performed in the public interest, it was felt that the Authority should be able to exercise its discretion so as to allow continued use of such sites provided that it is satisfied that an adequate level of safety can be maintained - notwithstanding that the site does not allow operations to Performance Class 1 or 2 standards. However, it is in the interest of continuing improvements in safety that the alleviation of such operations be constrained to existing sites, and for a limited period.

It is felt that the use of public interest sites should be controlled. This will require that a State directory of sites be kept and approval given only when the operator has an entry in the Route Manual Section of the Operations Manual.

The directory (and the entry in the Operations Manual) should contain for each approved site; the dimensions; any non-conformance with Annex 14; the main risks; and, the contingency plan should an incident occur. Each entry should also contain a diagram (or annotated photograph) showing the main aspects of the site.

9 Summary

In summary, the following points are considered to be germane to the JAA philosophy and HEMS regulations:

- Absolute levels of safety are conditioned by society.

- Potential risk must only be to a level appropriate to the task.

- Protection is afforded at levels appropriate to the occupants.

- The HEMS appendix addresses a number of risk areas and mitigation is built in.

- Only HEMS operations are dealt with by the appendix.

- There are three main categories of HEMS sites and each is addressed appropriately.

- State alleviation from the requirement at a hospital site is available but such alleviations should be strictly controlled by a system of registration.

- SAR is a State controlled activity and the label should not be used by operators to circumvent HEMS regulations.

10 References

a. Managing the Risks of Organizational Accidents - Professor James Reason.
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Old 16th Jun 2004, 11:08
  #144 (permalink)  
 
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JimL
I can't!!
I post news items from all over the world which relate to helicopters and helicopter pilots. I can't and don't vouch for the accuracy of the stories quoted.
The thread's now moved on from that particuar story to an interesting discussion of the general issues.

boomerangben
Good post.
I can see it's arguable that the person in the best position to make a decision, taking into account all factors/guidelines is the pilot.
If he has sufficient experience and qualifications to be doing the job, then it's arguable his judgment should be respected.

But, that's never been the approach of the UK regulators and it's never likely to be.


Heliport
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Old 16th Jun 2004, 14:36
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Heliport,, you are right in pointing out that it was the CAA's (legal) interpretation and thus their view and open to challenge, however I also said that under the Rule 5 changes planned that this had been clarified as that reference has been removed from the revised Rule 5 (not yet in) and left to Article 84 of the ANO to provide the requirement. ANO Article 84 says (today) that the Rules of the Air can be departed from "for avoiding immediate danger". This is all mentioned in the text introducing the Rule 5 change.

TC when I said before about the Commander considering his actions before 'breaking ' the law, I also said it was similar to the position of an ambulance or fire engine driver going through red lights. Think about it and if you believe you should do it then so be it ...."at your risk". I didn't say 'do it' (and couldn't anyway) but I think that it is highly unlikely that anyone doing it in a sensible way after proper consideration would be at risk of prosecution later. Other correspondents seem to have indicated that this was their experience in reality.

In other words, "yes I broke the law guv but there were strong mitigating factors".

Heliport, the Regulators in UK do try hard to be pragmatic but I'm afraid that HEMS is public transport pure and simple BUT with alleviations for the emergency site where they may well be needed. The police authority (in the form of the Home Secretary) themselves REQUIRED that police should operate to FULL public transport standards unless operationally essential to have exemptions. It ain't just the regulator being a pain.

But why spoil a good rumour and bitch session with facts?
Hope this clarifies and helps.
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Old 16th Jun 2004, 15:30
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SiloeSid. When I fly a non-HEMS transfer between two hospital sites approved by our Company, it is a normal commercial air ambulance flight.
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Old 16th Jun 2004, 16:27
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Old Heliman

Thanks for explaining the CAA's position.
So, following on from what you've said, whatever the position under the law at the moment, when the new Rule 5 comes in 'saving life' of anyone outside the aircraft won't be a defence to breaking Rule 5. eg To rescue someone whose life is in immediate danger.
What's the thinking behind that?

You imply the CAA might decide not to prosecute in circumstances like that, but there's no guarantee they won't so the pilot is still at risk. I realise drivers are in the same position if for example they speed to take someone to hospital urgently, but pilots have proved themselves to a far higher standard to get their licences than drivers.

You say "the Regulators in UK do try hard to be pragmatic".
If you'd said the personnel out in the field (Ops Inspectors etc) try to be pragmatic, I think people would agree that most of them are - with some exceptions. But if you mean the people who write the Regulations which are put into the law, what do you say to the very common complaint from pilots that we're regulated too much and aren't allowed enough discretion to use our training and judgement? (Compared with our American colleagues for example.)
Do you think that's a fair criticism of UK Regulators?

eg The FAA allows helicopter pilots to depart from the low flying rules as long as it can be done safely. If something goes wrong, they have to justify what they did and if they can't, they are prosecuted. Here, pilots are prosecuted for breaking the rules even if nothing goes wrong and even if there was no danger to anyone.
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Old 16th Jun 2004, 17:28
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Heliport:
eg The FAA allows helicopter pilots to depart from the low flying rules as long as it can be done safely.
We have been round this buoy before but, as was previously stated, there are no low flying rules for helicopters in FAR 91.119; i.e. they are not required to apply the ICAO Annex 2 Rules of the Air (except in International Airspace).

You also do an injustice to the Flight Operations Inspectorate in stating that they do not influence what is produced as Regulations - they do.
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Old 16th Jun 2004, 18:35
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Mars

I remember someone claiming there are no low flying rules for helicopters in FAR 91.119.

The UK isn't bound to apply the precise terms of ICAO Annex 2 Rules of the Air. The present Rule 5 doesn't adopt the ICAO low flying rule, nor does the new Rule 5 to the best of my recollection.

You've deliberately misquoted what I said about Flight Ops Inspectors.


Amusing diversion. Now .......... back to the topic please.

Heliport
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Old 16th Jun 2004, 18:51
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Sorry - I forgot that this was a hobby horse.
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Old 16th Jun 2004, 21:14
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Bertie,

And there's me thinking that the title of this thread was 'HEMS and Regulations'.

SS.
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Old 16th Jun 2004, 21:15
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Mars

"There are no low flying rules for helicopters in FAR 91.119".
Sounds to good to be true?
It is.

You have Rule 5 "Low Flying". We have FAR 91.119 "Minimum Safe Altitudes".
What was it Fred Astaire sang?
"You like potato and I like potayto,
You like tomato and I like tomayto;
Potato, potayto, tomato, tomayto!
Let's call the whole thing off!


BTW, the Mods do a swell job getting discussions going and they do it in their free time when they're not flying. Quit the sarcasm.
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Old 17th Jun 2004, 11:05
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Heliport,

I cannot speak on behalf of the CAA, just give my personal view.

You asked:
____________________________________________________

when the new Rule 5 comes in 'saving life' of anyone outside the aircraft won't be a defence to breaking Rule 5. eg To rescue someone whose life is in immediate danger.
What's the thinking behind that?

____________________________________________________

If an aircraft crew are dedicated to a particular task, such as SAR or HEMS, then within the UK they are granted exemptions from the "3rd Party Risk" Rule, (5 (1)(b)) to attend the incident and do what is necessary. This can be contained to appropriate numbers of a/c and pilots etc with full knowledge of the trainng given and a/c types used.

To extend that in law to ALL pilots would be unrealistic and unreasonable to innocent 3rd parties whose helo's might not have the performance margins appropriate at the time or whose pilots were not trained and tested to the same level. Who decides if it appropriate to land with risk to 3rd parties? Should it be a pilot who THINKS someone is in trouble? What happens if he gets it all wrong and it turns out that the person wasn't in trouble anyway? Difficult to decide, if not impossible.

Better I suggest to have a basic Rule that protects 3rd parties from unnecessary risk, exempt those from it who need to be exempted (SAR and HEMS on scene) and, in the (very rare) event that a pilot finds himself having to decide whether or not he puts innocent people at risk by attempting to save someone else's life, that he considers theat risk, uses considered judgement and then argues that as a mitgigating factor; than one that allows a total 'free for all' to allow absolutely any pilot at all to use that as justification for his actions in landing, regardless of his a/c type, his training, his licence qualification, experience, conditions of day/night, the nature of the (congested) landing area, and the numbers of people at risk if he gets it wrong....

I know not all will agree but what would this forum be like if they did?

You asked for a reason and that would be mine. That is NOT a CAA view.



Thanks for responding, and sorry about the clumsy way I asked the question.
It's understood that all views posted in these forums are personal views not the views of the companies/organisations we work for.
Heliport
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Old 17th Jun 2004, 11:11
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HEMS and Regulations

Sorry, just re-read my last, 2nd para is in wrong order and should have read

"To extend that in law to ALL pilots whose helo's might not have the performance margins appropriate at the time or whose pilots were not trained and tested to the same level would be unrealistic and unreasonable to innocent 3rd parties . Who decides if it appropriate to land with risk to 3rd parties? Should it be a pilot who THINKS someone is in trouble? What happens if he gets it all wrong and it turns out that the person wasn't in trouble anyway? Difficult to decide, if not impossible".

Senility or dick lexica? Not sure.
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Old 17th Jun 2004, 12:39
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JimL

I think you answered your own question i.e.

"Is it possible to post (or point to) the change in regulations that prompted this thread!!"

From your next post:

"Even though the rule for the use of such sites in hospital grounds for HEMS operations (Appendix 1 to JAR-OPS 3.005(d) sub-paragraph (c)(2)(i)(A)) attracts alleviation until 2005, it is only partial and will still impact upon present operations.

Because such operations are performed in the public interest, it was felt that the Authority should be able to exercise its discretion so as to allow continued use of such sites provided that it is satisfied that an adequate level of safety can be maintained - notwithstanding that the site does not allow operations to Performance Class 1 or 2 standards. However, it is in the interest of continuing improvements in safety that the alleviation of such operations be constrained to existing sites, and for a limited period. "


Cheers

TeeS
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Old 17th Jun 2004, 17:26
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Thanks Tees,

It is encouraging to see that such a longish post is read. That text was in fact written for a keynote speech at Airmed 2000 and has been incorporated into JAR-OPS 3 since January 1st 2002; it cannot be the trigger for this thread.

It is however a little dated as the restriction on HEMS Public Interest Sites, which was to last until 2005, has (due mostly to the German situation) now been replaced by a continuous alleviation (Amendment 3 as at 01/04/04).

(The text from which the extract was taken, was posted into another thread and was in answer to a question whether transplant organs can be carried by any AOC holder (they can of course) but, due to the sharp eyes of Heliport, has been transferred to this one.)


JimL's post is still in place. I copied it here.
Heliport
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Old 17th Jun 2004, 17:49
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Mars, I am not in a position to get too involved in this topic, however, discussions about this site have been ongoing for a considerable period of time. The information in the ACJ was relevant during the majority of discussion and the continued use of the site is subject to ongoing discussion.

TeeS
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Old 22nd Jun 2004, 18:19
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Why land in Cavendish Square??!!

Hi,

I was just having my lunch in Cavendish Square today and I was told we had to clear out as the Air Ambulance was landing. I was told this happens quite regularly but I am baffled about something. Why risk such a dangerous landing in one of the windiest parts of London with trees and buildings metres away from the rotors? Why not go to Hyde park, Green park etc which are only a stones throw away and would be much easier and safer to land in?

Anyway, I take my hat off to the pilot - pretty impressive flying!!

Cheers

Foz
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Old 22nd Jun 2004, 19:00
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Not knowing the area, I looked it up on Multimap and it looks like Cavendish square is almost a mile from the parks you mention. While that is not far for a gentle walk, it leaves your average paramedic, doctor (and pilot) gasping a bit when they have to run with kit. Life becomes even more interesting if you have to carry the patient back!

From what you say, it sounds like resources on the ground asked for the aircraft to land at Cavendish Square and cleared the area for it's arrival. I suspect that the square was assessed as the most appropriate landing site for the incident location and the Pilot then has the ultimate decision as to whether it is safe.

There really would not be a logical reason to turn down the landing site on the basis of it being "one of the windiest parts of London" and "trees and buildings metres away from the rotors" is generally speaking, par for the course.

Cheers

TeeS
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Old 22nd Jun 2004, 19:24
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"such a dangerous landing"
It's not dangerous to land Cavendish Square.
I've never noticed it's "one of the windiest parts of London" but, even if it was windy, I can't imagine the wind being outside safe operating limits. In the unlikely event that it was, the pilot wouldn't have landed.

"trees and buildings metres away from the rotors?
There are some trees in the Square (not many) but buildings metres away??

"Hyde park, Green park etc which are only a stones throw away and would be much easier and safer to land in?"
A stone's throw away? Are we talking about the same Cavendish Square? Behind John Lewis department store? A suitable landing site in Hyde Park would be about a mile away. If there is a suitable landing site in Green Park, that's the best part of a mile away. I assume the air ambulance was used because it was an emergency - not much point in landing further away than necessary.

One of the great things about helicopters is that they can land virtually anywhere, and in a very small space. From your description, it seems things on the ground were handled efficiently to ensure the helicopter could land safely.
I'm not surprised you were impressed by the flying. Pilots who fly for the emergency services are skilled and experienced.

If it happens regularly, Cavendish Square sounds like a good place to have lunch.
I've never been lucky enough to see it, but I understand the London air ambulance lands at Picadilly Circus when circumstances demand.
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