Only one is really needed.

1) Remove the customer in any possible way from affecting the operational control of the aviation side.

You can only remove that by removing the profit factor.
Hence just like helmet fire said, it shall never happen in the States.

Let's see which program shall be next in creating a smoking hole somewhere in the states.

Let's then listen to the mourning and "they were heroes" bull**** over and over again.

Link from Connect MidMissouri

If you make it through the atrociously-written (OK, I'm being a bit unkind - she's just printing verbatim what the witness said) article, you'll find that "one of the engines" blew up. On a 350, what exactly does that leave the pilot by way of spare power-plants, hmm?

From the photos, it would appear that the pilot did a very good job of keeping the aircraft level after touchdown.

Bell 407 training in the US


I have read that there are going to be many more Bell 407's in the US to cover EMS work. I suppose this must be one of the best EMS helicopters?

Stude,

They are the cheapest....not the best.




As to the FAA comments.....

Truck Drivers have far more strict (read restrictive) Hours of Service than do Pilots.

Bigger EMS helicopters required in US

Patients become too heavy for medical emergency helicopters ? RT USA

With a mega order of 200 B407GXP I don't see Air Methods paying too much attention to passenger size.

Air Methods Buying 200 Bell 407GXP Helicopters | Flying Magazine

I'm surprised to see no comment here on the two fatal HEMS accidents in the US last month.

More US Night HEMS Accidents

But at least the FAA have ensured there will never be another HEMS accident in the US (HAA HAA HAA).:D

On the contrary, that's why the 407 was selected. For most operations (other than hot/high) the 407 provided better metrics than the other choices B2/B3 and 130. CG issues affect the latter such that routinely 250-300lbs are the max passenger weights possible for the sectors flown. It's not just patient weights that are increasing, but in many cases it's the crews as well, with the pilots being the most critical CG wise of course. In addition, there is an ever increasing requirement by regulators to carry more equipment - in many states the air ambulance falls under the same regulation as the ground ambulance with little distinction made. 175-250lbs of equipment is the norm.

In my opinion the EC130 is a good aircraft in the EMS configuration and a better fit for medical care, with improved access over the 407. From a business perspective I can sell that over many other choices including twins eg. 135. Unfortunately experience has shown that the cg issues which impact the B2/B3, remain for the 130. Of course the health care industry in the US has a very different economic model which promotes single use. That's just a reality which accepts the cost/risk benefit.

As for accidents, it remains a challenge for night ops. The new and improved EC130T2 which comes online this year, will see some additional benefits for aviation and medical crews alike with many new airframes and retrofits. This includes G500/G1000 with synthetic vision, and simple auto pilots - more tools and training. One hopes that coupled to NVG's etc this will reduce the inherent risk of single pilot night time ops, but there is always the human element which cannot be removed from the equation. Where many pilots develop their experience in a single pilot VFR environment or enter the industry from a specialized multi crew background, human factors/training/cultural and proficiency considerations weigh heavily. There is also the shear scale of operations in the US to consider, which whilst not mitigating the need for improvement, certainly contribute to the statistical inevitability.

Never Fretter posted:
(1)... "With a mega order of 200 B407GXP I don't see Air Methods paying too much attention to passenger size.

Air Methods Buying 200 Bell 407GXP Helicopters | Flying Magazine

(2)... I'm surprised to see no comment here on the two fatal HEMS accidents in the US last month.

More US Night HEMS Accidents

(3)... But at least the FAA have ensured there will never be another HEMS accident in the US (HAA HAA HAA)."

(1) The 407 vs the 350 was purely a better deal by airframe offering. Announced in the company as saving hundreds of millions of dollars. From the line, it doesn't really make much difference to the pilots if you're not operating in a hot and high environment. The AS350 CG issue is usually a less serious issue than patient girth, our safety belts have a finite length and no approved extenders. I might be able to keep you in CG at 350 lbs, but if you're bigger around than 52-54 inches, you're going by truck. I don't see that changing with the 407 deployment.

(2) Two more HEMS night accidents are not remarked on here?
Okay, one appears weather related by an operator for whom this was the fourth fatal crash of 5 aircraft based in Oklahoma in the last 3, 4 or 5 years. Pick an accident in that series, and there may be a reason to excuse the operator. On the other hand, it could well be that this operator is the coal mine canary for the industry that believes it has no problems. That's my opinion.
The other accident may have a weather factor, but I lean more towards a human factor.
We'll have a better idea when the accident reports come out.

(3) I agree entirely and completely, "HAA, ha ha ha". Now that I no longer operate an "emergency service" it removes so much pressure to go... Not.

US HEMS = Profit, profit, profit
 

This same story has been going for decades. While ever the US HEMS industry continues, (for the most part), to be run by private for-profit operators, a for-profit health care system and companies seeking a way to make a quick buck with less capable helicopters not suited to specific missions and tasking, you will continue the horrific safety record in the US with little or no change. Take out any profit and commercial incentive and your system will become what it can be.

(1) Forgive my naivety but isn't the cabin size a factor too when selecting a medical helicopter. Surely the cabin of a 407 will still be particularly tight with a large patient needing ventilation etc during flight plus medical crew and equipment? After all isn't that Bell's marketing point for the 429? I could see a 407 being slightly easier to justify for short transits but I see that there are cases of patients being flown past the closest hospital.
State Investigates Medical Helicopter Company | KRGV.com | Rio Grande Valley, TX

(2) Is in commercially advantageous to use two helicopters (after a road accident with multiple casualties say) rather than one larger helicopter?

(3) On the point that "take out any profit and commercial incentive", surely that isn't stopping commercial airlines achieve amazing levels of safety. Does this mean that the medical industry in the US are culturally accepting of a certain level of attrition and happy to continue to use providers with a poor safety record without penalty?

(4) Why so many night accidents? More US Night HEMS Accidents Is it a sign of the number of night flights or their relative risk?

Cabin size is sufficient. The problem with size is patient girth, as Devil49 pointed out. That's the only thing that really matters.

Using one big helicopter instead of multiple smaller ones isn't viable economically. You can't plan for a situation that happens only a very few times per year, you have to plan for the everyday case.

Carping about the economic model in the US does no good. I would also like to see the entire medical industry model change, but it's not going to happen. Capitalism will continue to rule, so we need to find the best way to deal with that and its effects. The FAA is required by law to consider economics in its regulations, and can't impose any that would cause severe economic penalties, regardless of whether they would save lives. It's wrong, but it's the reality.

I think the number of night accidents reflect both the numbers, and the relative risk. I almost always had about as many night as day flights, and I suspect the numbers are at least on the same order of magnitude with most programs. But night EMS has its dangers. It's dark. That makes it hard to see. Duh. But it's true. Googles help a lot, but they have their limitations. Everything is one color, and the field of vision is very narrow. It's really easy to miss seeing something that's just a few degrees to one side. The biggest danger, IMO, is the physiological difference. If you're asleep, and wake up from deep sleep for a flight, sleep inertia is difficult to overcome, and can take a long time to pass. Pilots who live locally, and stay on the same diurnal schedule regardless of the work schedule are more likely to be affected, and are also more numerous. Companies want to save money by having crews live locally so they don't have to provide quarters, and pilots don't like being away from home for a week at a time. IMO, this causes accidents, and lives. But it won't change. Money talks.

Night HEMS accidents could be completely eliminated, of course. Just eliminate all night HEMS flying. Lots of people across the pond advocate that, and some don't allow night flights there. But one has to take a broader view, I believe. Of course people die in night HEMS crashes. But the real question is whether those deaths outnumber the lives saved overall. That's a difficult number to quantify. But one still needs to consider the tens of thousands of night HEMS flights annually in the US, and the relatively small number of accidents. I'm certain that night HEMS flights will continue, and continue growing. How to properly regulate them, and minimize the risks, is the question. We will never eliminate risk, we can only minimize it.

There is ALWAYS a profit consideration
 

whether it's public service/government, "not for profit", charity, or a conventional for-profit business model. The profitability is determined in different ways that makes it harder for people to see the decision points.

Public service/government will use a limited budget (hopefully) to provide the best value, another name for profitable application of resources. If the budget "Super Bug Smasher" law enforcement/air ambulance is not justified by providing "x" number of transports to the public at large, that budget will be redirected to something else. There aren't limitless funds, even in enlightened Europe- do you see many air ambulances with flight into known icing capability over yonder? No? I would think it would be very useful...

Not for profit... same-same, only cash flow can be directed to various entities as equipment, salaries and bonuses, whatever makes the bottom line all 'zero-ey". I can't count the number of not-for profits gone belly-up because of what is termed poor profitability in a conventional business scenario.

And finally, the much maligned "for profit enterprise"- Efficient application of resources required or you fail. HEMS/HAA or whatever the PC term is this week can be done safely by a for profit, witness the current airline industry compared to earlier for an idea of possible room for improvement. As in any operation, HEMS/HAA management for safety requires proper prioritizing and management of resources. THAT is not routinely done in the US, Gomer Pylot brings up some of the issues. It's not that management intends to compromise operational safety for profit, it's that they don't SEE the factors acting to increase risk. Another example of that issue as I see it- None (zero, zilch, nada) of my company's management fly the job, ever. All of my company's instructional staff are management. Even my chief pilot, for whom I have great respect, has a historic and dated view of the job and challenges faced.

Another example from night problems in the US HEMS/HAA industry- pilots plan on sleeping on the job (for various reasons, not germaine) and do so. Now at Oh-dark thirty, the request comes in, awakens the pilot, the pilot checks weather and compares METARs to forecast while awakening the crew (response time isn't the criteria except that it IS tracked and used to critique). What was missed that is really, really important? trends. You have to monitor trends to have any real idea of weather. Forecasts are guesses, observations are history, trends show where the weather will probably be going in spite of forecasts...

Devil49, I agree with part of your post, the last part mainly.
The part with which I don't agree is where you refer to the airline industry:

1. Following the Buffalo accidents of a few years back and the uproar that followed it, even the Regionals had to bite the bullet and accept a minimum of an ATP license for their SICs and the flight time experience that comes with it, the HEMS industry is going into the opposite direction with no end in sight.

2. An airline FLIGHT CREW decision to not depart is not usually followed by subliminal or overt pressure by the passengers (read customers) to launch, penalty removal from the position as it often happens with HEMS pilots.

You are right HEMS pilots do not want to travel, but that would remove most cases of get-home-itis (you ARE away for a week or so).
Sleeping quarters need not be anything fancier than a double wide, which is the industry standard anyway.
GomerPylot is correct, have you ever seen your med crew trying to do compressions on a 400 pounder in flight? There just isn't enough space above the poor person and the cabin ceiling.:(

Tottigol:
Devil49, I agree with part of your post, the last part mainly.
The part with which I don't agree is where you refer to the airline industry:

1. Following the Buffalo accidents of a few years back and the uproar that followed it, even the Regionals had to bite the bullet and accept a minimum of an ATP license for their SICs and the flight time experience that comes with it, the HEMS industry is going into the opposite direction with no end in sight.

Look even further back in airline history and the industry's safety wasn't stellar.
The Buffalo accident has much to teach the industry, especially regarding crew rest, yet I haven't heard discussion one from management or my peers. It's like that never happens...

2. An airline FLIGHT CREW decision to not depart is not usually followed by subliminal or overt pressure by the passengers (read customers) to launch, penalty removal from the position as it often happens with HEMS pilots.


I have never had an abort or decline brought up, much less critiqued by AVIATION management. Medical crew is another kettle of fish entirely but I'll chew my lip for a bit on that.

You are right HEMS pilots do not want to travel, but that would remove most cases of get-home-itis (you ARE away for a week or so).
Sleeping quarters need not be anything fancier than a double wide, which is the industry standard anyway.


My base has a pilot suite separate from the operations area.
You're halfway to a point with "get-home-itis" in that the issue of company providing poor support for weather aborts. That can be an issue, whether it's admitted or not.

GomerPylot is correct, have you ever seen your med crew trying to do compressions on a 400 pounder in flight? There just isn't enough space above the poor person and the cabin ceiling.

Yep, I have. The ceiling isn't the issue, it's lateral patient access seems a bigger problem in my unqualified estimation. The 407 won't be an improvement in that regard, but perhaps we'll have "thumpers" and other automation by then.

It is worth watching this the pilot's integrity though his comments after this flight was the flight nurse and paramedic refused to fly with him ever again..

https://www.youtube.com/watch?v=EMxuO77mdQo

I have never had a member of management question, or even comment on, a decision of mine to fly or not fly. I can't say the same for the 25+ years I spent flying in the GOM. The attitude from management is entirely different. I've also never had a complaint from the med crews. They have sometimes commented on other pilots' decisions, but if they ever said anything about mine, it was never related to me by anyone. The med crews knew I would fly if I thought it was safe and legal, and would refuse if not. Med crews, like everyone else, tend to value competence and level-headedness. Being unsure and changing your mind often scares them. If they trust you to know your job, and your commitment to doing it right, they won't question your decisions nearly as much. They can usually tell if you're turning down a flight just because you prefer to sleep, and if you do that a few times, your trust is gone. None of this is unique to flying, it's standard in every industry, every job.

I will say that 3800 hours at retirement isn't much. That says that it was a long time between flights, and it's impossible to stay proficient while not flying. HEMS is not a job for low-time pilots. You don't get a chance to fly that often, and when you do you have to be perfect every time. It's difficult even with tens of thousands of hours.

What roster do US HEMS pilots normally work? I'm struggling to understand the comment above that they are woken up for night flights. Surely they don't work 24 on?

Can any one clarify what percentage of HEMS flights are flown at night in the US?

Never Fretter, an verage of 30% of EMS flights is flown at night in the USA.
The pilots are required to show up rested for night duty.
Normal EMS rotations are 12 hours day shifts and 12 hours night shifts (ie: 07:00-19:00 and 19:00-07:00).
Under part 135.267 unscheduled one pilot operations, minimum rest undisturbed has to be 10 hours in the last 24 hours, with a maximum duty of 14 consecutive hours.

That rest includes driving back and forth from the pilot's domicile.
The pilots are responsible to get their rest once they get home or to their "luxury trailer":E

Thoughts on the video "That Others May Live"

"not much had happened that week, there wasn't a single flight... eager to take the flight."
(Pressure to accept dispatch, self-imposed, also called 'motivated pilot')

"The weather was no good because of the clouds. They asked if..."
(A motivated pilot properly exercises judgement, ultimately proven absolutely correct. The correct decision taken by the pilot is inappropriately influenced.)

"We too off... and there's no way... cancelled, turned around..."
(And again, the pilot's decision is that conditions are not acceptable by the PIC on the scene.)

"Can you maybe go the alternate landing spot? It was clear there, because we had flown over it..."
(The safe conservative decision to not attempt this flight is again inappropriately interfered by the company.)

The pilot's narrative indicates that he is nervous about the situation at the alternate landing site "I'd been looking at that light, it's so dark behind it..." "After several minutes... low level fog developing.."
(I'm not there, so I don't know, but at this point I'm telling the crew they have a choice, they can leave with me or ride the ambulance to the hospital. But this is a 'motivated pilot', not me. The trap is apparent if you will only see it.)

"Yep, there's 'glows around the lights'. Okay, let's go. Get on board. We're leaving and we're leaving now!" "Without the patient on board, Denver had already lifted the helicopter... when they noticed that the ambulance had finally arrived. Well shoot what are we going to do [the decisive error, the decision has been made by the PIC. Now the med crew is flying.]... seven minutes later...
(From this point on, with dispatch and the med crew having put the PIC in the scenario he attempted to avoid, he has to deal with it as it exists.)

Comments:
This pilot made all the right decisions until his foot was in the bear trap. Further, he proved all the capabilities required when tested after the fact. Which proves that nobody in the management chain KNOWS what's wrong. The answer is apparently changing the name of this phase of the industry from HEMS to HAA...

Hire, train and support good people, especially pilots. This pilot had integrity, knowledge, motivation and capability but was betrayed by those he worked with. No means no, shut up or fire somebody if you have the wrong people in the job.

The FAA, Airbus and the industry should be ashamed of the false representations made regarding cockpit videos. The camera was absolutely no help with this pilot's predicament. Airbus's talking heads postulate that management, which positively created this incident should hold more effective tools to blame pilots is wrong as this incident demonstrated multiple times. The answer isn't more outside the cockpit influence on pilot action, it's better training, support and information for the PIC to do the job. Which is expensive and inconvenient and largely a mystery to the industry.


To those discussing HAA/HEMS pilot schedules, the rule cited deals with crew scheduling and assumes rest. This rule works pretty well with daytime operations. My opinion is that the rule fails to deal with night operations generally and HAA/HEMS in particular, perhaps being a primary contributor to the fact the nights are 4 times more dangerous compared to day flights in my work. The rule spectacularly ignores proven physiological issues and presents an illusion of adequacy by doing so.

Devil,
I agree 110% with you on all matters in your post, however this pilot proved he had all the training/experience/information needed and proved again that experience without external pressure leads to correct decision making.

As you say "The answer isn't more outside the cockpit influence on pilot action, it's better training, support and information for the PIC to do the job."

The answer is LESS out of the cockpit influence, by both the flying customer and remote decision making dispatch.

chopper 2004, that's a pretty chilling video to watch. I commend the pilot for being open and upfront about the whole episode. One thing that struck me was his reference to an apparent unreliable attitude indicator and his decision to cage the instrument in flight.

It reminded me of this excellent article by Elan Head in Vertical Magazine about another highly experienced pilot who, after an inadvertent entry into IMC, experiences a mismatch between his vestibular senses and his attitude indicator an proceeds to disable his one and only lifeline.

After eighteen years of flying I have several thousand hours of IFR time; several hundred hours of actual IMC time and probably at least fifty hours of hand flying in IMC. Even so I would estimate my ability to fly an AS350 in IMC conditions at a few minutes tops. Back when I actually did fly EMS in an AS350 I probably would not have lasted for more than a few seconds in IMC.

The thing is, I was instrument rated and -in theory- fully qualified to fly in IMC conditions. Why do I think I would I have only lasted for a few seconds? Because I had zero actual IMC experience and because I had no stability augmentation; no EGPWS or TAWS, no weather radar and only a tiny ADI to look at. Faced with inadvertent IMC I would have likely reached over and caged the ADI too, unable to process the overload of conflicting sights and sensations.

This is, by and large, the current state of the EMS industry: otherwise competent pilots who are not qualified to fly in IMC conditions are being sent out in aircraft that are not properly instrument equipped. It should not be a surprise that this leads to incidents and accidents.

Autopilot needed
 

Having flown EMS for seven years in an AS350, Bell 407, BO and BK, I believe that properly used, an autopilot would have saved many lives over the years. If Insurance companies were of the same mind, I believe that a discount offered for every helicopter sporting an autopilot would encourage operators to install them.

So he caged the AI in flight, stated he didn't look at it again and made a series of random control inputs to rectify his situation without actually looking at the altimeter or AI!

Yes, there were unacceptable ops pressures and the questioning of his decision not to go but he failed on every count to take appropriate IIMC actions. He and his crew were incredibly lucky not to crash.

I think Gomer Pylot's comments about total hours and continuity of flying experience are very germane to this incident.

What was he doing staring at a bright light anyway - no better way of screwing your night vision!

Was the AI problem because he had shut down and not completed the startup checks properly?

A proper set of instrument checks (especially if you think there is a real risk of IIMC) would have been the professional thing to do.

A lot of self-induced pressure here.

I think that small investment in second pilot for night operations (NOT in second engine, one is just enough) would significantly improve the safety record. As it is in Europe. IMHO.

JR

And where would you put this second pilot? In most light helicopters used in HEMS in the US, the patient occupies the left seat. At least the patient's legs, with the rest of him/her in the back seat with the med crew. And the helicopter is departing at or near max gross weight now, and with a copilot on board the patient would have to be a child, no bigger. Replacing that many helicopters with larger models would take years, because they just don't exist now. Helicopters don't just magically appear, they have to be built on a production line, and that takes a long time.

Yes GM, I agree with you. Mission impossible. And again, money talks.

Second pilot?
 

I believe that in an inadvertent IMC situation, a second pilot may only confuse the first pilot and vice versa. At best, maybe encourage the PIC to abort the mission sooner. I would rather have a non-vertigo prone autopilot. One whose default position is wings straight and level. One that is easily overridden in order to climb, communicate and confess. One that will resume straight and level if the pilot gets confused. Most pilots that lose it in IMC do fine in their bi-annual instrument check ride. It's the emotional fear element that trips up the pilot in a life-threatening unfamiliar environment. It's called sensory overload. An autopilot is like that check airman when you are under the hood. You almost never need them, but it's calming to know that they're there.

Yes, it's possible solution...but IIMC is not the main cause of HEMS accidents (at least not in the last two accidents).
As far as I know, in Europe, EASA 965/2012 regulative, PART-OPS, second pilot in night HEMS operations is mandatory. Does that make sense?

JR

An outsider to HEMS and cognizant of the excellent though disturbing video link, but if I were the FAA I think I would mandate within a short period of time, in line with the SMS requirements now demanded from operators, that every member of management, aircrew and operational groundstaff attend a CRM course together with customer management, medical teams discussing past major accidents and their causes with a view to an eventual overhaul of the operator's Safety Case with revision of SOP's as necessary plus encouragement of an individual mission risk assessment performed by operational staff taking into account aircraft limitations, crew training, weather and facilities. Mitigations as the risk increases including saying no should be clearly laid out. Bull**** I hear some cry ..... but nothing else seems to have had sufficient effect - this should be seen as the perfect opportunity to encourage frank discussions and understanding / acceptance, by management from both operator and customer, of the limitations of machine and human which in the end might reduce pressure to get on and complete missions regardless. Even better do this with several operators together if practical, and repeat as necessary. Surely this is a duty of care for the patient?

Fly911 - I completely agree. A decent autopilot offloads the pilot to allow him the extra capacity to make decisions.

Single pilot IFR is difficult enough when you plan it - when it is suddenly forced upon you it can be overwhelming.

A decent autopilot will have a go-around button which will put wings level and capture a sensible climbing speed. If the pilot in this incident had had such a facility (and known how to use it), we wouldn't be reading about it.

Tistisnot - the CRM is a good idea but financial/operational pressures have a way of making people ignore the sort of lessons that are learned on those courses.

CRAB
 

It's easy to forget that a prime cause of disorientation (from our sim training experience) is inadvertent deselection of the AP's because some wizard of a designer put two buttons on the cyclic that pilots confuse regularly, one de-couples the FD and the other (curiously labelled "SAS REL") will simultaneously remove both AP's. The subsequent melee is very exciting IMC and no amount of GA button pushing will help you. If only they had organised the 'AP Release' (my chosen new title for that button) so that one push takes out just one AP and a second push remove the other AP then guys would not get themselves into that situation.

So the message is that you should develop a good recovery strategy for unusual attitudes and practice it regularly in the sim. Forget the GA button, despite the statements in the RFM it may actually add to your problems rather than solve them.

Note - this may not apply to all types but check out your own systems before signing up to the "The GA button will save my life" club.

G.

Geoffers,

I agree that designers often don't understand much about how an aircraft is piloted and that the positioning of important buttons is often rather random.

However, If the pilot is averagely aware of his autopilot functions and uses them regularly then something like the GA button can be a lifesaver - it doesn't beat a decent instrument scan and regular IMC exposure though.

Our GA button is on the collective (even though it works through the cyclic channel) and, providing the AP hasn't been inadvertently selected off, works surprising well as a recovery from UPs.

CRAB
 

Yes but.....

When disorientation bites you may have very little time to gather things up and restore order, ask yourself if you are going to send your thought processes around the 'what is causing this?' circle before adopting a recovery strategy. My suggestion is that you may be better off just sorting the thing out with not even a nano second of delay. I'm not sure about other types but certainly the 139 has a great deal of control power and if the AP misbehaves or drops out the response levels are so high that you can be upside down in two or three seconds. It's been done for real so no hyperbole here.

G.

Geoffers - yes, immediate UP recovery is most definitely the answer which is why it is practised AP out on every military type I have flown - is that the same for the guys that you get coming through?

Unusual Attitude Recovery Training
 

We are currently facing a dilemma insofar as AP out training is not allowed in the aircraft because the certification requires one AP to be serviceable at all times. Luckily we can continue to train AP's out in the sim because we are not covered by the same certification and not exposed to any danger.

Unfortunately the 139 sim, with both AP's out, is not a good training vehicle because it's response is not as good as the real aircraft and is far to difficult for most TR students to manage. We stick with a sample of scenarios that may use SAS only or AP's 'IN' and extreme attitudes. In the training environment there is pay-back for building confidence rather than destroying it. We can save the more demanding stuff for the recurrent sessions where they are appropriate.

G.

So if they do go IIMC or inadvertantly deselect the AP out when IMC, they are probably going to scare themselves or even crash because they haven't been allowed to train for that situation - that is rather worrying.

Geoff/Crab: While interesting, I'm not sure that is relevant to the average low spec US HEMS helicopter with minimal flight simulation available either.

No, but what is relevant is whether or not those HEMS pilots ever get to practice UP recovery on instruments, with or without the AP.

Like so many advanced flying skills, Instrument Flying is a very perishable one.

US Specs
 

Not all helicopter operations in the US are 'low spec', at least in the case of larger operators. AMC operates 100+ 135/145's alone, in addition to other twins. That is certainly more than some countries entire EMS fleet combined. Simulator training is in place on the EC135, and recognizing the benefit of simulator training they had introduced a full motion simulator for singles (unfortunately the OEM was poor). AMC has also purchased 4 full motion Level 'D' simulators for singles and twins to be introduced shortly, with annual training in the sim for all pilots. 3 static 160º view procedural training devices have been in place for a long while further supplementing training on a biannual basis.

It's not all 'low spec' or devoid of training.

https://www.faa.gov/news/press_relea...m?newsId=18634

Press Release – FAA Proposes $1.54 Million Civil Penalty Against Air Methods Corp.
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For Immediate Release
April 13, 2015
Contact: Allen Kenitzer
Phone: 425-227-2015; Email: [email protected]
SEATTLE – The U.S. Department of Transportation’s Federal Aviation Administration (FAA) proposes a $1.54 million civil penalty against Air Methods Corp. of Englewood, Colo., for allegedly operating Eurocopter EC-130 helicopters on dozens of flights when they were not in compliance with Federal Aviation Regulations.
The FAA alleges Air Methods operated two helicopters on 70 passenger-carrying flights for compensation or hire, over water and beyond power-off gliding distance from shore, when they lacked required helicopter flotation devices and flotation gear for each occupant. The agency alleges the company operated another helicopter on 13 such flights when it lacked required flotation gear for each occupant. All 83 flights by the emergency medical transport company occurred around Pensacola, Fla.
“The flying public correctly expects that American operators will place safety above all else,” said U.S. Secretary of Transportation Anthony Foxx. “We will hold operators accountable when they fail to meet those expectations.”
“Operators must follow every regulation and take every precaution to ensure the safety of all those on board,” said FAA Administrator Michael Huerta. “Flying without required safety equipment is indefensible.”
Air Methods has 30 days from the receipt of the FAA’s civil penalty letter to respond to the Agency.