Helicopter EMS Issues in the USA

[SASless]

Twin engine machines firstly have two pilots - one of whom can be detailed to get a last minute weather check whilst the other preps the machine.

Except for all of the SPIFR machines....which are in vogue.

[Squeaks]

Epiphany:

All five Victorian EMS helicopters are twin/IFR/Single Pilot.

spinwing,

Australian NVG approved operators can transit at 500' agl NVFR: exact height depends on a variety of factors, including CASA approval criteria

[spinwing]

Mmm ...

Yes and as you say that is specifically approved and only for NVG ops.

It is not an allowable 'STANDARD' for NGT VFR flight as it is in the US of A ... and if IMC is encountered a climb to an appropriate LSALT is required isn't it.

[FH1100 Pilot]

Epiphany, you make a stronger case for two pilots than you do for two engines.

The issues you raise have been brought up before: That all EMS helicopters should be twin-engine/two-pilot/IFR capable/autopilot-equipped. Oh, and no night-VFR.

It's a nice fantasy, but it is just that, a fantasy. Here in the U.S., requiring such things (and the large, expensive helicopter you'd have to have) would mean that many communities would simply be without air ambulance service as the cost would be prohibitive. If you're cool with that, fine. But I don't think that's ever going to happen no matter how much you'd wish it would, and not everyone agrees with your viewpoint in any case.

The bigger issue is flying VFR into fog at night. Whether or not that caused this latest accident in Arkansas is almost beside the point; it would have been an irresponsible thing to do even if there were no crash.

But two-pilot crews are not immune from making such mistakes. I remember a particularly tragic accident some time ago in which an IFR-capable S-76 with two experienced pilots onboard attempted a night takeoff from a fog-shrouded airport runway. All they had to do was take-off straight-ahead with a positive rate of climb, and in less than one minute they would have been above the fog, up in a nice, clear, starry sky. Instead, they inexplicably stopped the climb, then floundered around for some time before crashing headed back toward the airport at an altitude lower than the elevation of the field they departed from! (It was hilly country in Kentucky, U.S.)

If we can keep pilots from making bad decisions, then the accident rate will be reduced, simple as that. Technology and capability can help, but no amount of technology is going to prevent the pilot from screwing up (again, I point to the Maryland State Police SA-365 accident). I don't know what the pilot of this latest EMS helicopter was thinking as he pushed along into the fog that night. We'll never know. But whatever he was thinking, we have to change it.

[Epiphany]

Here in the U.S., requiring such things (and the large, expensive helicopter you'd have to have) would mean that many communities would simply be without air ambulance service as the cost would be prohibitive. If you're cool with that, fine.

Well if the FAA and local authorities are 'cool' with VFR helicopters falling out of the skies with monotonous regularity then I suppose the situation will continue. There comes a point when the argument of having any EMS helicopter rather than the right one just doesn't hold up.

And it is not simply a matter of providing expensive IFR capable machines - the crews need to be well trained and current otherwise when they do fly IFR they may well 'flounder around for a while' before crashing.

[fly911]

Aloutte 3 - Re: No hard feelings...

No hard feelings indeed. I got out of HEMS work about five years ago, and it's probably time for me to leave this thread. I agree with the concepts you describe like not informing the pilot of the type mission until a decision has been made as to whether to accept the flight or not. That's good common sense, as the pilot may have a soft soft spot for say, a child burn victim. But I don't think that it's fair to compare the non-EMS part 135 safety record to the Air EMS part 135 safety record. It's just not a fair comparison. Bad weather causes bad vehicle accidents. Health of a patient doesn't depend upon weather, whereas most air taxi work does indeed depend upon good weather. It's a fact of life, that if you are going to fly HEMS, you will be flying in marginal weather conditions. That is an increased risk factor. Consequently, there will be more HEMS accidents. Alt3, if you don't see this, then read no further. No hard feelings. Before we move on and try to fix it, we have to take our emotions out of the equation. If I appear to be in denial about something, please point it out so that I can recognize it. If I disagree with you about it we can discuss it further. And I ask that you search your own attitudes for signs of denial. There are "White Knights" and "Cowboys" and will be as long as there are helicopters. I'm sure that you don't care for the type in EMS and neither do I. But because we don't care for that type of pilot doesn't mean it's ok to blame all the accidents on them. It could very well be that the "white knight" would be quicker to turn down a marginal mission out of fear of not being able to complete it and looking bad. Come on alt, if I am flying logs, then I want to be the best logging pilot I can be. If I'm fighting fires then I want to be a good fire fighter. I don't want to be a half assed HEMS pilot. Which is not to say that I'm not concerned about safely completing the mission as being the most important thing on the agenda. If you (not you personally) are the type of pilot that will only fly in "clear blue", more power to you. The world needs more pilots like that. But if you are the type of pilot that won't get out of bed in a light drizzle, please don't take an HEMS job and spend all your time complaining that you can only fly patients when it's "clear blue". You're not doing yourself or your profession any favors. We can improve the HEMS safety record, but it's not going to happen by pointing fingers. When I hear counter-productive comments like "If you feel that way, you are part of the problem" I hear him really quoting from the Wizzard of Oz: "If...I...only had a brain...".
I think I'm outta here. If I offended anyone, I'm sorry.

[alouette3]

Fair enough,911. I think you have made your case pretty eloquently. I see lots of points we can agree upon and the chief amongst those is the fact that we want to be the best at whatever we do.Also, there is certainly an increased exposure to risk in HEMS.We, the line pilots have to manage it . Not the FAA or the operators ----just us.
The only place we will have to agree to disagree is the fact that I don't see myself as being in a life saving job.Life altering ,certainly, but life saving ---no. I would like to keep it that way.I will continue to do the best I can under the circumstances and limit myself to the letter and the spirit of the laws that govern my job.I certainly hope everyone else does the same.
There should be no hurt feelings in a professional forum such as this and I hope you will return to this thread because we all have something to contribute to raise the safety standards and perceptions in the US HEMS world.
Fly safe and above all fly smart.
Alt3.

[tottigol]

So,Fly911 your point is that no matter what equipment we are going to make mandatory for the safe conduct of specific EMS operations, there shall always be the White Knight or the Cowboy who's going to want to impress the two SLBs in the back.
YOU ARE ABSOLUTELY RIGHT!
However I believe that it's not merely an equipment standpoint, it's the whole industry mentality that needs to be rearranged, and drastically so. The Aeromedical industry is in reality another expression of the flawed medical structure in the USA, flawed because it's based on protagonism and appearances and not real patient care values.
I have flown EMS for several years and thank God never ones I had to use a VFR only single engine aircraft with no stabilization other than my seat of the pants, however I did feel peer pressure coming from the primadonnas in the back and coming from those pilots who wanted to be counted in "the circle of friends".
That's why I am not there any longer (ask SAS) and that's why I shall keep away from any other EMS job trap again.
The problem is that EMS is run by the customers and as long as there are no structures in place to limit the overbearing intrusion of a non aviation entity in the operational control of an aviation activity we shall continue to see what we see.
Let's change the structure of HEMS, let's isolate the moneymaking from the flying and we shall reap the rewards with drastically decreased accident numbers and RATES.

[QTG]

It doesn't matter what aircraft you fly. If you stick to the rules you should be OK. If you fly for a company which only makes money when you carry a casualty, sooner or later you'll probably crash, or at best frighten yourself silly on regular occasions. Its called commercial pressure. And it doesn't mix with HEMS.

[SASless]

There are hundreds of reasons why crashes occur....and some are very subtle and hard to articulate....particularly when you are the one being confronted with them day after day. (....or night after night)

Commercial pressure is one, having weather go below your limits is one...fatigue is another...night time is a big one....flying over isolated and dark areas is another....unforecast inclement weather is another....variable unforecastable weather due to terrain is yet another. How long a list do we want to create?

The size and numbers of the holes in that old chunk of Swiss Cheese is what matters!

[Gomer Pylot]

Epiphany, I think you have to accept the fact that the US is not Australia, which is not England, which is not anywhere else. Practices in one country have no bearing at all on practices in another country. Culture, tradition, even language is different in different countries, and criticising another country's laws and ways of doing things is not a productive exercise. There have been EMS accidents in Australia, and the rate per hundred thousand hours is likely not significantly higher than the rate in the US. You hear of lots of US HEMS accidents because there are close to a thousand EMS helicopters flying every day here.

I personally think HEMS should be run by the government, at whatever level, but here in the land of the free capitalism rules, so that ain't gonna happen, and making a profit will continue to drive the industry. There are very few HEMS ships flying with two pilots, regardless of the number of engines, because the second salary cuts into profits, and every program would do without pilots at all if they could figure out a way to do it. EMS directors hate pilots, always will, and we get what we get. Take it or leave it.

[spinwing]

Mmmm...

Gomer .... you are quite right there HAVE been EMS accidents in Australia ...
and when you analyse them the reasons look very much like the reasons accidents keep happening within the US industry.

That is the reason things changed in Australia ... over time it was realised that airmanship and professional decision making HAD to overule the so called 'profit incentive' .... until that happens in the US I think history will continue to repeat itself.

[helmet fire]

I differ a little there spinwing: the accidents in Australia did not change much - it steered one state government away from single engine VFR helos, there were only three of those in use in that state, and it did not even mandate NVG! There was nothing ground breaking or monumental in the changes. That is a very different proposition from what the USA is going through - for a start, each helicopter in QLD had only one client and none were competing on a cost basis with any other. There was no loss of work, nor redundencies for machines and operators. Similar changes (mandate IFR Twins) would have a massive impact and are therefore unfortunately unlikely in a for-profit system such as the USA.

I think a whole lot of this thread has been written with passion and intelligence, and it has made a lot of sense from both sides of each discussion point raised. One thing really stands out though - our responses are always shaped by our experiences and our operating cultures; that is why we have such different view points. I will throw a few into the mix from my limited experiences.

Perspective. Australia achieves as much EMS SAR flying per year as they are doing each day and a bit in the USA!!! The USA has over 1000 machines (according to an earlier post - though that seems extreme) and Australia has less than 35. I cannot do the maths, but it seems that we Australia have to look at accident rates over a 40 odd year period to see if it is close to the annual rate for the US. Therefore it an Apples V Oranges arguement to compare anyone else with the US, particularly give the unusual commercial and job competitve nature of a majority of the US industry.

The Golden Hour. There is no evidence indicating a sudden increase in mortality or morbidity in the 61st minute of a reponse. Whilst many response organisations use it as a mantra and marketing tool to easily convey the need for speed to the layman, the reality is so clouded by regional settings as to be almost irrelevant to some. For example, in one part of our area we deliver medical care and capability in the helicopter that exceeds the Emergency Department. So, is the golden hour until we arrive, or until we deliver the patient to lower care levels in the medical facility?? All I am trying to convey is that there are no "absolutes". What "must" be done in one region "should not" be done in another.

The only discussion point that has so far concerned me was inferring that "we never save lives". The use of the royal "we" here is what is incorrect IMHO. I have flown for many organisations that can lay claim to survivors purely because a helicopter was able to bring rescue and/or sufficiently high level of medical care within a time frame that would have otherwise resulted in death. That is not a reason to grab a cowboy hat and show everyone how long your willy is, but at the same time it is inconsistent with the notion that it is like flying logs or rigpigs. I recognise that some organisations do not have high level medical care on board and may only do inter hospital transfers, but that is not a reason to cast an "absolute" that no-one else saves lives. It must be self evident that moving someone to a medical facility "saves lives" - so the question is: what bit of the ED saved the lives? Why was it not bought on the helicopter? Can the helicopter bring SOME of the bits on offer at the ED and thus be in a position to "save lives" ??? Is rescue from an iminent building fire, flooded river, sinking boat, or soccer match "saving lives"???

We have talked in depth about reponse times and how "dangerous" short ones are, but I stick to my previous points on this: time of response does not equal safety of response. Response process ensures safety.

Another absolute that drew my attention was that we pilots should "never" know the condition of the casualty. That has not been an important factor in my experience in influencing a PROFFESSIONAL. I note with some danger of a faded memory that the majority of the US HEMS accidents are on the return leg after patient delivery. In other words - patient condition was NOT a factor in the majority of press on itis accidents in the US. In the organisation I currently work for, patient condition is as openly discussed amongst the crew(aviation and medical) as is the weather and the aircraft performance, how tired we are and how inexperienced we might be at the proposed type of flight. CRM. So I see it would be appropriate in some cultures, but please dont force it on ours by saying "never".

Two other things about this notion to consider are:
1. Why do we never give crew of the year to the guys who had to say "no" in often extremely trying circumstances? I can employ heaps of pilots who will say yes, but where do I find the one big enough to say no?
2. If it was your child dying, would you try harder? Do other peoples children then deserve less effort? Ethically a really tough one I think (and I really struggle with it at times). Absolutes are a big call. What if you say no to a take off because by the time you get back to base you will have exceeded you duty time by 1 hour - and then you find out it was to a severe road accident involving your family to which the the ambulance is more than an hour away. Is that one hour a sound risk V gain decision in light of your family trapped and bleeding? Or is it absolutely innapropriate? Is it really "never" appropriate for aviation and medical professionals to weigh up the risks and make a crew decision on what "is" appropriate??

Lastly, the calls that HEMS must be done "this" way (which nearly always resembles the way the proponent is doing it now!). Here are my calls for moving to the ideal HEMS culture in FULL recognition that I dont know the benefits of other ways NOR will anything I say make the slightest change to other ways of doing it!
Twin engine PC2 preferred. IFR with SPIFR autopilot. SP plus "HEMS crewmember" or co-pilot for operating (not medical) crew, in accordance with EASA's smart and latest requirements (Australian front seat crewies do not comply in nearly all cases). No unaided HEMS/SAR. Primary response at night only by NVG HEMS/SAR, only where trauma rates after dark can be shown to be inadequately covered by road response, and only where helo brings significantly higher levels of medical care than that available on the road. Inter hosptials by night must have NVG. HEMS pilots to be instrument rated and current (yes, even where their area of ops precludes IFR). HEMS crews given extensive CRM training (not the one day giggle over the Air Florida and Tennerife accidents), HEMS organisations run not-for-profit BUT with strict governance regulations in terms of management and board members (no "old boys" clubs), HEMS organisations not to make money from flying - the money is made from standing charges (yes we run a model in Australia where providers lose money each time they fly!).

I know these "are no absolutes" and there will be many other suggestions, but this is my drivel...write your own

[Gomer Pylot]

I generally agree with helmet fire and spinwing. Things aren't likely to change much in the US, because the god Profit is all-powerful, and we will continue to bow down to him regardless of the number of deaths. Profit is far more desirable than safety here. It matters not how many people die, crews, patients, or bystanders, as long as the corporations can make a profit.

I have never claimed that we never save lives, only that I never have that as a goal. I'm not aware of any that I or the med crew have saved, but we're far from the only ones flying. We've got a few to the hospital alive that didn't survive long in the hospital, we just prolonged it for a few minutes, and we've flown many who wouldn't have died if taken by ground. We can mitigate morbidity, especially for stroke and cardiac victims, but we rarely save lives. Again, 'rarely', not 'never'. Painting anything with so broad a brush as to assume absolutes is wrong. But we should play the odds, and look at the most likely outcomes, I think. I almost always know the condition of the patient, because I hear the scanner, and hear the patient report over the radio from the ground EMS units. I just don't let that influence me. I think I do a fairly good job of that, but I'm only human, and I sometimes have to remind myself that it's just another piece of freight.

Things are different in different countries, and always will be. The 'one world' concept is a long way off. I would prefer that things were done differently here, and more like other countries, but my preferences have no influence on anyone or anything. I just try to deal with conditions as I find them, the best way I can, and go home alive at the end of every hitch.

[fly911]

EMS v RESCUE

AUSTIN TEXAS STAR FLIGHT RESCUES 13 FROM FLOOD.
Additional video here---> Starflight rescues 13 from floods | KXAN.com

KXAN (AUSTIN) - Three STAR flight helicopters spent the night responding to 20 calls for rescue as the flood water was rising over vehicles and homes.
“You could see flashing lights everywhere. It was amazing,” said STAR flight senior pilot Chuck Spangler.
A majority of the calls came from Williamson County, where 13 people were extracted from the water and hoisted into the rescue helicopters.
Two Travis County EMS workers and a Weir firefighter were among those who had to be rescued when the zodiac boat they were in took on too much water. They were attempting to make rescues of their own near highway 29.
A family of four was also rescued from a second story window in their home near FM 971.
STAR flight says they have some of the best tools to save lives in emergency situations.
“Thanks to the residents of Travis County, we have the finest equipment in the world,” said Spangler. “It is extremely dangerous. The most dangerous thing I have ever done.”

[Two's in]

FAA proposes new rules for helicopter operations - with EMS focus

WASHINGTON–The U.S. Department of Transportation’s Federal Aviation Administration (FAA) today proposed broad new rules for helicopter operators, including air ambulances, which, if finalized, would require stricter flight rules and procedures, improved communications and training, and additional on-board safety equipment.

Proposal Includes requirements for Air Ambulance Operators to:

Fit Helicopter Terrain Awareness and Warning Systems (HTAWS).
Comment on light-weight aircraft recording systems (LARS).
Conduct operations under Part 135, including flight crew time limitation and rest requirements, when medical personnel are on board.
Establish operations control centers if they are certificate holders with 10 or more helicopter air ambulances.
Institute pre-flight risk-analysis programs.
Conduct safety briefings for medical personnel.
Amend their operational requirements to include Visual Flight Rules (VFR) weather minimums, Instrument Flight Rules (IFR) operations at airports/heliports without weather reporting, procedures for VFR approaches, and VFR flight planning.
Ensure their pilots in command hold an instrument rating.

Also under the proposal, all commercial helicopter operators would be required to:

Revise IFR alternate airport weather minimums.
Demonstrate competency in recovery from inadvertent instrument meteorological conditions.
Equip their helicopters with radio altimeters.
Change the definition of “extended over-water operation” and require additional equipment for these operations.

https://www.faa.gov/news/press_relea...m?newsId=11958

[hostile]

Finally some good news for EMS operations. Same rules, same operation. That's it would be for now. There will be a long way, but this is good start.

[peterprobe]

I like knowing the job we are running to. I have to in the UK. As the pilot I need to know if it is HEMS or Air Ambulance as each has different weather limits, which with a well briefed and CRM'd medical crew all understand when I say nope not today. I have not been asked or questioned once (in a few years now) why we turned back, as sadly with all these crashes going on around the world they are more than aware this game can be fecking dangerous if you push it. Fly safe all.

[BEBEL29]

Hi Alouette 3
Are u french ?

[helmet fire]

A response to the list above from the FAA recommendations with some thoughts based only my opinion (knowing that opinions are like arseholes - everyone has one!) and tempered with my limited experience:

1. Fit Helicopter Terrain Awareness and Warning Systems (HTAWS).
Agree with inference of terrain awareness systems, but do not agree with common manifestations of HTAWS such as EGPWS for HEMS. Aural warning systems work very well for interhospital IFR programs and off shore, but the constant aural warnings from low level operations during primary response missions can be often counter productive. Rather, I would push for visual aides, and preferably for systems that require very little interpretation with little or no false warnings. Check this out from Garmin to see what I am talking about: G600 MFD info and an interactive demo here: G600 demonstration
No interpretation required. Visual. This is the TAWS systems that should be mandated. Well done Garmin!!! Just need the helicopter ceertification to be completed now!!
Add EVIS to this for the ideal cockpit capability..


2. Comment on light-weight aircraft recording systems (LARS).
Agree. Non tamper proof. Tracking systems employed to show track, hieghts and speeds.

3. Conduct operations under Part 135, including flight crew time limitation and rest requirements, when medical personnel are on board.
Agree only if some of the more restrictive Part 135 issues are resolved before mandating requirements. SAR ops to be added to this.

4. Establish operations control centers if they are certificate holders with 10 or more helicopter air ambulances.
Situation dependant upon nature of tasking control.

5. Institute pre-flight risk-analysis programs.
Only agree if this is not a "Pre Take off" risk system where take off is delayed for a game of guesstimating risk values to see if take off is allowed. My experience with this is that invariably (yep, that is invariably) the numbers or ratings or whatever are just altered until take off is permitted, meanwhile take off is delayed and brain power diverted from building Situational Awarenss. I agree however that a comprehensive risk management system is implemented considering missions and implementing controls well before the phone call comes.

6. Conduct safety briefings for medical personnel.
There are really operations out there that do not brief the crews???

7. Amend their operational requirements to include Visual Flight Rules (VFR) weather minimums, Instrument Flight Rules (IFR) operations at airports/heliports without weather reporting, procedures for VFR approaches, and VFR flight planning.
There are really operations out there that have not established such things?


8. Ensure their pilots in command hold an instrument rating.
Agree. Regardless of terrain and environment precluding IFR use, the skill sets provide a coping mechanism for all sorts of unexpected situations: NVG failures, lighting failures, dust out, white out, as well as IIMC. I also personnaly believe that an IFR rating should be required to fly patients at night - even where flown under VFR.


And I have added a few extras as per previous posts:
9. Operate PC2 compliant.
10. Comply with EASA rule of two upfront - either two pilots or pilot plus HEMS Crewmember meeting specified aviation course.
11. Ban unaided HEMS/SAR
12. Conduct NVG primary response only when trauma rates require it, geography and equipment levels translate into low road coverage by ground responders, and where helicopter brings demonstrably higher medical care levels than those deployed by ground.
13. Proper CRM training for ALL crew (including medical crew on board).
14. Never going to happen in the USA: HEMS operators run by NGO with strict and policed governance guidelines and protocols.