NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of September 1, 2009
(Information subject to editing)
Four Safety Recommendation Letters Concerning
Helicopter Emergency Medical Services

This is a synopsis from the Safety Board’s report and does not include the Board’s rationale for the conclusions and safety recommendations.  Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted.  The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible.  The attached information is subject to further review and editing.

SUMMARY AND CONCLUSIONS

Helicopter emergency medical services (HEMS) operations provide an important service to the public by transporting seriously ill patients and donor organs to emergency care facilities, often from remote areas not served by adequate facilities. These operations comprise an estimated 750 helicopters, 70 commercial operators, 60 hospital-based programs, and 40 government-operated, or what is known as “public,” operations.

These operations are unique and complex, mixing highly advanced medical care with the technical challenge of safely operating helicopters 24 hours a day. Each year, approximately 400,000 patients and transplant organs are safely transported by helicopter.  However, the pressure to conduct these operations safely and quickly in various environmental conditions (for example, in inclement weather, at night, or at unfamiliar landing sites for helicopter operations) increases the risk of accidents when compared to other types of commercial flight operations.

The NTSB has had a longstanding concern of HEMS safety. In 1988, the Board adopted a Safety Study, Commercial Emergency Medical Service Helicopter Operations, which reviewed 59 HEMS accidents that occurred from 1978 through 1986.  From that study, the Board issued 19 safety recommendations to the FAA, the National Weather Service, and two associations.  These recommendations covered issues of training and guidance, operating rules, onboard equipment, industry coordination, and workload and fatigue.  The majority of these recommendations have been closed acceptable action.

The late 1990s and early 2000s saw a rapid growth of HEMS operations and the number of accidents began to rise.  Prompted by this rise, the NTSB completed a special investigation report on Emergency Medical Services Operations in January 2006.  This report analyzed 55 EMS accidents (41 of which were HEMS accidents and 14 airplane EMS accidents) that had occurred during the previous 3 years, claiming 54 lives; of these, 39 fatalities occurred during HEMS operations.  Analysis of the accidents indicated that 29 of 55 accidents could have been prevented with corrective actions identified in the report.

Immediately following adoption of the 2006 special investigation report, the number of HEMS accidents decreased.  In calendar year 2006, 3 fatal HEMS accidents occurred with a total of 5 fatalities.  The following year, there were 2 fatal HEMS accidents with a total of 7 fatalities, but in calendar year 2008, there were 8 fatal HEMS accidents, with a total of 29 fatalities.  This was deadliest year on record for HEMS operations.

Prompted by this recent rise in the number of fatal HEMS accidents, the Safety Board held a 4-day public hearing this past February to address the issues associated with HEMS safety. The hearing called upon 41 expert witnesses, representing 8 HEMS operators, 12 associations, 6 manufacturers, and 4 hospitals. Additionally, several organizations had an opportunity to question the witnesses directly. These parties, who were designated for their technical expertise in their respective fields, were the FAA; the Helicopter Association International (HAI); the Association of Air Medical Services; the Professional Helicopter Pilots Association; the National EMS Pilots Association; Air Methods; and CareFlite. A complete summary of the public hearing testimony, all of the exhibits, and the entire written transcript can be found on the NTSB’s web site.

As a result of the hearing, the NTSB identified the following safety issues:

• Pilot Training
• Collection of Flight Operations Data
• Use of Flight Recording Devices and Data
• Safety Management Systems
• Weather Information
• Use of Autopilots or Dual Pilots
• Night Vision Imaging Systems
• Reimbursement Rate Structures
• Federal Policy and Guidelines

RECOMMENDATIONS

The NTSB is issuing the following safety recommendations:

To the Federal Aviation Administration

1. Develop criteria for scenario-based helicopter emergency medical services (HEMS) pilot training that includes inadvertent flight into instrument meteorological conditions and hazards unique to HEMS operations, and determine how frequently this training is required to ensure proficiency. (A‑09-XX)
2. Once the actions recommended in Safety Recommendation (1) are completed, require helicopter emergency medical services pilots to undergo periodic FAA-approved scenario-based simulator training, including training that makes use of simulators or flight training devices. (A‑09-XX)
3. Require helicopter emergency medical services operators to implement a safety management system program that includes sound risk management practices.  (A-09-xx)
4. Require helicopter emergency medical services operators to install flight data recording devices and establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.  (A-09-xx)
5. Require helicopter emergency medical services operators to report activity on at least an annual basis to include total hours flown, revenue flight hours flown, revenue miles flown, patient transports completed, and number of departures. (A-09-xx)
6. Permit the helicopter emergency medical services Aviation Digital Data Service Weather Tool to be used by helicopter emergency medical services operators as an official weather product. (A-09-xx)
7. Conduct a systematic evaluation and issue a report on the requirements necessary for a viable low-altitude airspace infrastructure that can accommodate safe helicopter emergency medical services (HEMS) operations. The evaluation should consider improved collection and dissemination of weather data, the role of automatic dependent surveillance-broadcast, approaches to helipad and designated landing zones, and integration into the National Airspace System. Include in the evaluation process HEMS operators, related industry associations, and hospitals, among others. (A‑09‑xx)
8. Once the evaluation and report as recommended in Safety Recommendation (7) are completed, initiate action to develop this infrastructure. (A-09-xx)
9. Require helicopter emergency medical services operators to install night vision imaging systems and require pilots to be trained in their use during night operations.  (A-09-xx)
10. Require helicopters that are used in emergency medical services transportation  to be equipped with autopilots, and that the pilots be trained to use the autopilot if a second pilot is not available. (A-09-xx)

To Public HEMS Operators

1. Conduct scenario-based training, including the use of simulators and flight training devices, for helicopter emergency medical services (HEMS) pilots, to include inadvertent flight into instrument meteorological conditions and hazards unique to HEMS operations, and conduct this training frequently enough to ensure proficiency. (A‑09‑xx)
2. Implement a safety management system program that includes sound risk management practices. (A‑09‑xx)
3. Install flight data recording devices and establish a structured flight data monitoring program that incorporates routine reviews of all available sources of information to identify deviations from established norms and procedures. (A-09-xx)
4. Install and require that pilots use night vision imaging systems for visual flight rules operations at night. (A-09-xx)
5. Equip helicopters that are used in emergency medical services transportation with autopilots, and train pilots to use the autopilot if a second pilot is not available. (A-09-xx)

To the Federal Interagency Committee on Emergency Medical Services

1. Develop national guidelines for the use and availability of helicopter emergency medical transport by regional, state, and local authorities during emergency medical response system planning. (A-09-XX)
2. Develop national guidelines for the selection of appropriate emergency transportation modes for urgent care. (A-09-XX)

To the Department of Health and Human Services’ Centers for Medicare & Medicaid Services

1. Evaluate your existing helicopter emergency medical services (HEMS) reimbursement rate structure to determine if reimbursement rates should differ according to the level of HEMS transport safety provided. (A-09-XX)
2. If the findings from the evaluation conducted in response to Safety Recommendation 1 reveal that higher levels of reimbursement are required to increase the level of safety, establish a new reimbursement rate structure that considers the level of helicopter emergency medical services transport safety that is required. (A‑09-XX)

      NOTE:  The Board approved additional recommendations regarding safety audit standards to CMS that are being drafted.

Related information:

• Press Release
• Presentations