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Safety Recommendation Details

Safety Recommendation A-09-131
Details
Synopsis: On September 27, 2008, about 2358 eastern daylight time, an Aerospatiale (Eurocopter) SA365N1, N92MD, call sign Trooper 2, registered to and operated by the MSP as a public medical evacuation (medevac) flight, impacted terrain about 3.2 miles north of the runway 19R threshold at Andrews Air Force Base (ADW), Camp Springs, Maryland, during an instrument landing system (ILS) approach. The commercial pilot, one flight paramedic, one field provider, and one of two automobile accident patients being transported were killed. The other patient being transported survived with serious injuries from the helicopter accident and was taken to a local hospital. The helicopter was substantially damaged when it collided with trees and terrain in Walker Mill Regional Park, District Heights, Maryland. The flight originated from a landing zone at Wade Elementary School, Waldorf, Maryland, about 2337, destined for Prince George's Hospital Center (PGH), Cheverly, Maryland. Night visual meteorological conditions prevailed for the departure; however, Trooper 2 encountered instrument meteorological conditions en route to the hospital and diverted to ADW. No flight plan was filed with the FAA, and none was required. The MSP System Communications Center (SYSCOM) was tracking the flight using global positioning system data transmitted with an experimental automatic dependent surveillance-broadcast (ADS-B) communications link.
Recommendation: TO 40 PUBLIC OPERATORS OF EMS HELICOPTERS: Develop and implement flight risk evaluation programs that include training for all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in helicopter emergency medical services flight operations if the risks reach a predefined level.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: District Heights, MD, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: MIA08MA203
Accident Reports: Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD
Report #: AAR-09-07
Accident Date: 9/27/2008
Issue Date: 11/13/2009
Date Closed:
Addressee(s) and Addressee Status: Commonwealth of Pennsylvania, State Police, Aviation Section (Closed - Reconsidered)
Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division (Closed - Acceptable Action)
Commonwealth of Virginia, State Police (Open - Acceptable Response)
State of Alaska, North Slope Borough, Search and Rescue Department (Closed - Acceptable Action)
State of Arizona, County of Maricopa, Sheriff's Office, Aviation Services Division (Closed - Reconsidered)
State of Arizona, Department of Public Safety, Highway Patrol, Aviation Division (Closed - Reconsidered)
State of California, City of Los Angeles, Fire Department, Air Operations (Closed - Acceptable Action)
State of California, City of San Diego, Fire Department, San Diego Medical Services Enterprise (Open - Acceptable Response)
State of California, County of Los Angeles, Fire Department, Emergency Medical Services (Closed - Acceptable Action)
State of California, County of Los Angeles, Sheriff’s Department, Aero Bureau (Closed - Acceptable Action)
State of California, County of Orange, Sheriff's Department, Air Support Division (Closed - Acceptable Action)
State of California, County of San Bernardino, Sheriff's Department (Open - Acceptable Response)
State of California, County of Santa Barbara, Fire Department, Air Unit (Closed--No Longer Applicable)
State of California, County of Santa Barbara, Sheriff's Department, Air Unit (Closed - Acceptable Action)
State of California, County of Sonoma, Sheriff's Office (Closed - Acceptable Action)
State of California, County of Ventura, Fire Department (Closed--No Longer Applicable)
State of California, County of Ventura, Sheriff's Department, Aviation Division (Open - Acceptable Response)
State of California, East Bay Regional Park District Police, Air Support Unit (Closed - Acceptable Action)
State of California, State Police, Highway Patrol, Office of Air Operations (Closed - Reconsidered)
State of Delaware, State Police, Aviation Unit (Closed - Acceptable Action)
State of Florida, City of Palm Beach, Health Care District (Open - Acceptable Response)
State of Florida, County of Broward, Sheriff's Office (Closed - Reconsidered)
State of Florida, County of Collier, MedFlight (Closed - Reconsidered)
State of Florida, County of Lee, Emergency Medial Services, MEDSTAR (Closed--No Longer Applicable)
State of Florida, County of Martin, Fire-Rescue Life Star (Closed - Reconsidered)
State of Florida, County of Miami-Dade, Fire Rescue, Special Operations Division (Open - Acceptable Response)
State of Florida, County of Volusia, Sheriff's Office (Closed - Acceptable Action)
State of Georgia, County of DeKalb, Police Department, Special Operations (Closed - Unacceptable Action - No Response Received)
State of Maryland, State Police, Aviation Command (Closed - Reconsidered)
State of Nevada, City of Las Vegas, Metro Police Department, Air Support, Search and Rescue (Closed - Reconsidered)
State of New Jersey, State Police, Special Operations Section (Closed - Acceptable Action)
State of New York, City of New York, Police Department, Aviation Unit (Closed - Unacceptable Action - No Response Received)
State of New York, County of Chautauqua, Sheriff's Office (Open - Await Response)
State of New York, County of Nassau, Police, Aviation Unit (Closed - Unacceptable Action - No Response Received)
State of New York, County of Onodaga, Sheriff's Department, Aviation Unit (Open - Acceptable Response)
State of New York, County of Suffolk, Police Department, Aviation Section (Open - Acceptable Response)
State of New York, State Police, Aviation Unit (Closed - Acceptable Action)
State of North Carolina, County of Dare, Emergency Medical Services (Closed - Acceptable Action)
State of Texas, County of Austin-Travis, Emergency Medical Services, STAR Flight (Closed - Reconsidered)
United States Department of the Interior, National Park Service, Park Police, Aviation Unit (Open - Acceptable Response)
Keyword(s): Helicopter Emergency Medical Services

Safety Recommendation History
From: NTSB
To: State of Nevada, City of Las Vegas, Metro Police Department, Air Support, Search and Rescue
Date: 1/14/2015
Response: On October 14, 2014, we informed you that, because we had received no reply from you, these recommendations were classified “Closed?Unacceptable Action/No Response Received.” We appreciate your notifying us that you do not conduct HEMS operations. Accordingly, Safety Recommendations A 09-97 through -101 and A-09-131 through -133 are classified CLOSED—RECONSIDERED.

From: State of Nevada, City of Las Vegas, Metro Police Department, Air Support, Search and Rescue
To: NTSB
Date: 11/10/2014
Response: -From Jack Clements, Lieutenant, Air Support/ Search and Rescue and Charles Hank, Captain, Support Operations Bureau: Response: 1. The LVMPD Air Support/Search & Rescue Section assigned a permanent employee as the Safety Officer for the unit. This officer has prior experience in the section and was reassigned to the unit based on his background to institute a safety program. This officer has attended safety classes at the HAl Conference. 2. The safety officer and section lieutenant worked collaboratlvely to change policy and procedures which mirror best practices in the law enforcement aviation field. This information was obtained from the Airborne law Enforcement Association (ALEA) Conference attended by the section lieutenant. as well as from the ALEA website. 3. The safety officer and the Division's chain of command have contacted other law enforcement aviation units to inquire on their safety practices. 4. Section personnel received outside specialized safety training from the San Diego County Sheriff Department. 5. The LVMPD purchased and implemented the PRISM Safety Management System. Pilots are required to complete a Flight Risk Assessment Tool (FRAT) at the beginning of every shift and prior to all rescue missions involving a helicopter.

From: NTSB
To: State of Nevada, City of Las Vegas, Metro Police Department, Air Support, Search and Rescue
Date: 10/14/2014
Response: We have received no reply from you regarding actions you have taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, followup request for such information. Because we have received no reply from you to our request, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. If you have completed, or plan to complete soon, any actions to address these recommendations, please submit details of your actions or plans to correspondence@ntsb.gov. If we receive a timely reply from you, we may reclassify one or more recommendations.

From: NTSB
To: State of Nevada, City of Las Vegas, Metro Police Department, Air Support, Search and Rescue
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Las Vegas Metro Police Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Police Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: Commonwealth of Pennsylvania, State Police, Aviation Section
Date: 1/14/2015
Response: On October 14, 2014, we informed you that, because we had received no reply from you, these recommendations were classified “Closed?Unacceptable Action/No Response Received.” We learned from your letter, however, that, although you conduct both ground and flight operations, you do not conduct HEMS. Accordingly, Safety Recommendations A-09-97 through 101 and A-09-131 through -133 are classified CLOSED—RECONSIDERED.

From: NTSB
To: Commonwealth of Pennsylvania, State Police, Aviation Section
Date: 10/14/2014
Response: We have received no reply from you regarding actions you have taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, followup request for such information. Because we have received no reply from you to our request, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. If you have completed, or plan to complete soon, any actions to address these recommendations, please submit details of your actions or plans to correspondence@ntsb.gov. If we receive a timely reply from you, we may reclassify one or more recommendations.

From: Commonwealth of Pennsylvania, State Police, Aviation Section
To: NTSB
Date: 1/17/2014
Response: -From Trooper Reeve A. Mott, Aviation Safety and Training Officer, Bureau of Emergency and Special Operations: 1. This correspondence is in response to a request for information from the National Transportation Safety Board (NTSB). The NTSB correspondence addresses eight safety recommendations that were issued on October 1, 2009, as a result of a February 3-6, 2009, NTSB investigative hearing held in response to an increase in helicopter emergency medical services (HEMS) accidents in calendar year 2008. 2. The NTSB correspondence is primarily directed towards HEMS operations. The Pennsylvania State Police (PSP) is a law enforcement entity operating under Federal Aviation Regulations (FAR) Part 91 and does not conduct emergency medical services as a common practice. The PSP helicopters are not equipped with the necessary equipment and the pilots/crews are not trained in HEMS operations. PSP has only participated in emergency medical transports on rare or extreme cases. In fact, PSP has not conducted an emergency medical transport dating back to 2008. 3. The following is PSP’s response to the NTSB’s eight safety recommendations: PSP completes a risk assessment matrix for every flight. The matrix evaluates weather, day/night operations, crew rest, duty day, mission type, pilot experience and time since last factory training. Based on these inputs, the flight is determined to be low, medium or high risk. The approval authority required to conduct the flight is based on the risk level. Low risk requires Pilot in Command approval, medium risk requires Unit Supervisor approval and high risk requires Section Commander or Safety and Training Officer Approval. The risk level for each flight is recorded in an aviation database.

From: NTSB
To: Commonwealth of Pennsylvania, State Police, Aviation Section
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Pennsylvania State Police Department has developed a similar program and how the Pennsylvania State Police Department has defined the program’s operating parameters. Specifically, we would like to know how the Pennsylvania State Police Department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Pennsylvania State Police Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of New Jersey, State Police, Special Operations Section
Date: 7/11/2014
Response: We note that, in 2011, you implemented a web-based risk assessment program, which incorporates an effect/probability?type risk assessment and predetermined levels of risk that require management approval if the risk reaches an established level. We also note that the risk assessment program is part of your overall SMS program, and that you provide the recommended training. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of New Jersey, State Police, Special Operations Section
To: NTSB
Date: 4/7/2014
Response: -From Toby Hill, New Jersey State Police Aviation Bureau, Assistant Bureau Chief: The New Jersey State Police Aviation Bureau is more than happy to share with you the progress we have made in implementing several of your recommendations. Over the past years, much has changed within the Aviation Bureau. The most significant change to the bureau has been the procurement of new AW139 aircraft to replace our aging Sikorsky S76B aircraft. The Aviation Bureau's current fleet is comprised of five (5) Augusta AW139s, one (1) Bell206L4, one (1) Bell206L3 and one (1) OH58A military surplus aircraft. Only the AW139s are utilized for HEMS operations. Below are the responses to your inquiry regarding updates we have made to our aviation program: The New Jersey State Police Aviation Bureau incorporates this as part of our SMS (see A-09-98). We have developed mission specific flight risk assessments that are done via web browser and which are recorded for later review. This training has been provided to all employees and is shared via a web site with all three aviation bases. The flight risk analysis tool computes a numerical grade to assess risk. If the risk grade is too high, crews may not launch without prior approval from a higher authority. To date, there have been no waivers granted for out of spec risk grades.

From: NTSB
To: State of New Jersey, State Police, Special Operations Section
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe that such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the New Jersey State Police have developed a similar program and how they have defined the program’s operating parameters. Specifically, we would like to know how their flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the State Police currently use or are in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Florida, County of Martin, Fire-Rescue Life Star
Date: 3/27/2014
Response: We note that Martin County does not operate public-use helicopters and that you have always contracted with a corporate vendor for HEMS. Accordingly, Safety Recommendations A 09 97 through -101 and A-09-131 through -133 are classified CLOSED—RECONSIDERED.

From: State of Florida, County of Martin, Fire-Rescue Life Star
To: NTSB
Date: 1/6/2014
Response: -From Joseph V. Ferrara, CFO, MPA, Fire Rescue Chief: This is a follow up to our conversation regarding the letter received by our County Administrator on December 31st, 2013 which was a follow up letter requesting information and action on the Fire Rescue Department’s part dating back to 10/1/09 and 11/13/09. In 2009 our department received the letters and forwarded them to our aviation vendor Air Methods Inc. Since Martin County government is not a Public Helicopter Emergency Medical Services (HEMS) Operator as defined in your documents. We have always contracted with a corporate vendor for the purposes of providing HEMS. Martin County provides the medical care only and the aviation vendor provides the helicopter, the pilots and the maintenance and is the Part 135 operator. We have had such a program in place since October 1st, 2000 and we have never been an operator of Public Helicopter Emergency Medical Services. We have acted only as the medical service provider and not the Part 135 or Part 91 provider. I hope this helps to clear up any confusion and please feel free to contact me if you have any further questions. Otherwise, I trust you will remove reference to Martin County Fire Rescue Department as a Public HEMS Operator and consider this issue closed.

From: NTSB
To: State of Florida, County of Martin, Fire-Rescue Life Star
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Martin County Fire-Rescue Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Fire-Rescue Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of North Carolina, County of Dare, Emergency Medical Services
Date: 1/14/2015
Response: We note that, in 2013, you implemented a flight risk evaluation program consistent with the guidance contained in the FAA’s Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of North Carolina, County of Dare, Emergency Medical Services
To: NTSB
Date: 10/14/2014
Response: -From John J. Watts, MPH, NRP, Chief Officer, Dare County Emergency Medical Services, Dare MedFlight: Prior to 2013, Dare Medflight did not fully incorporate safety recommendation A-09-131. A basic risk evaluation program was in place and was utilized by Dare Medflight pilots. Beginning in March 2013, with the approval of the FAA for the Part 135 Air Carrier Certification, an appropriate risk evaluation /mitigation program was implemented. Please refer to answers under sections addressing A-09-97 and A-09-98 for additional explanation.

From: NTSB
To: State of North Carolina, County of Dare, Emergency Medical Services
Date: 10/3/2014
Response: We have received no reply from you regarding actions you have either taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, followup request for such information. Because we have received no reply from you to our request, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of North Carolina, County of Dare, Emergency Medical Services
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether Dare County EMS has developed a similar program and how you have defined the program’s operating parameters. Specifically, we would like to know how your flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that Dare County EMS currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of New York, County of Nassau, Police, Aviation Unit
Date: 10/14/2014
Response: We have received no reply from you regarding actions you have taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, followup request for such information. Because we have received no reply from you to our request, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. If you have completed, or plan to complete soon, any actions to address these recommendations, please submit details of your actions or plans to correspondence@ntsb.gov. If we receive a timely reply from you, we may reclassify one or more recommendations.

From: NTSB
To: State of New York, County of Nassau, Police, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Nassau County Police have developed a similar program and how they have defined the program’s operating parameters. Specifically, we would like to know how their flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Police currently use or are in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: Commonwealth of Virginia, State Police
Date: 7/11/2014
Response: We are pleased to learn that, in 2012, you implemented a flight risk assessment program that includes predetermined levels of risk and involves a supervisor once the high risk level is reached. We note that pilots complete a flight risk assessment form at the beginning of their shift and update the form throughout their shift to reflect any conditions that may have changed. We also note that training on the program will be included as part of the SMS program you are currently developing. Pending confirmation from you that all employees involved in HEMS operations have received training on the use of your flight risk evaluation program, Safety Recommendation A-09-131 is classified OPEN—ACCEPTABLE RESPONSE.

From: Commonwealth of Virginia, State Police
To: NTSB
Date: 3/27/2014
Response: -From Colonel W.S. (Steve) Flaherty, Superintendent: In 2012, the Unit revised its Aviation Unit manual to address several policies regarding safety and operations. As part of this, the Unit developed a risk assessment form to aid pilots in evaluating the risk for a given mission. The tool uses a numeric value from various factors added together to classify the operational risk of a flight. Risk is classified as Normal operations (low), Elevated (medium) and above that, supervisor notification and approval is required (high). The pilots refer to this at the beginning of a shift and reevaluate throughout the shift as conditions change. In addition, the Unit is participating is a program with the Virginia Office of EMS that utilizes an online website to make notifications of weather turn downs for EMS flights. This system aims to collect real-time data of agencies that may be "helicopter shopping" when the initial request is turned down for weather related reasons. The Unit is currently working on a formal SMS system in conjunction with the Virginia Department of Aviation. Below is a copy of our risk assessment tool: Night Unaided .................................. +5 Night NVG ....................................... +2 Ceiling w/i 200' of mins ........ ........... . +2 Visibility w/i 2 SM of mins ......... ....... . +3 Temp/Dewpoint w/i 2 dgrs ..... ........ .. +1 High Winds ..................................... +2 Unimproved or Unfamiliar LZ .. ...... ... +2 Mountainous terrain ........................ +2 Mission Tasked in excess 8 hrs ......... +2 Mission Tasked in excess 10 hrs ...... +3 TOTAL RISK LEVEL 0-5 Normal Ops 6-10 Elevated- Be Vigilant 11-15 Supervisor notification required 15+ Extreme-Consider CX Flight, Supervisor approval required

From: NTSB
To: Commonwealth of Virginia, State Police
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Virginia State Police have developed a similar program and how they have defined the program’s operating parameters. Specifically, we would like to know how their flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the State Police currently use or are in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Delaware, State Police, Aviation Unit
Date: 6/20/2014
Response: We note that you use a web-based risk assessment program that incorporates an effect/probability?type risk assessment and predetermined levels of risk that require management approval if the risk reaches an established level. We are also aware that this program falls under your SMS program and that you provide training in it. Accordingly, Safety Recommendation A 09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of Delaware, State Police, Aviation Unit
To: NTSB
Date: 1/28/2014
Response: -From Colonel Nathaniel McQueen, Jr., Superintendent: Currently the Delaware State Police Aviation section utilizes a web-based risk assessment program through PRISM Aviation Research. We have customized the program to our specific operation and divide risk assessments into 3 categories: helicopter, airplane, and maintenance operational check flights or ground runs. When the program is utilized by a section member it calculates a numeric risk value for a flight that is categorized as low (green), medium (yellow) or high (red). Upon completion of a risk assessment, the system will send immediate notification to section leadership that an assessment has been completed for review. When assessments are categorized as medium or high the system sends a second alert indicating that the assessment is of greater risk requiring attention. Medium risk flights require notification of section leadership and high-risk flights require approval of section leadership before launch. The PRISM software compiles submitted risk assessments into reports to assist management and trainers with implementing training programs to address assessed risk.

From: NTSB
To: State of Delaware, State Police, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Delaware State Police have developed a similar program and how they have defined the program’s operating parameters. Specifically, we would like to know how their flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the State Police currently use or are in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Texas, County of Austin-Travis, Emergency Medical Services, STAR Flight
Date: 6/19/2014
Response: We note that, in February 2009, you developed and implemented a flight database program that includes a risk assessment tool. We believe this program is consistent with the guidance contained in FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services. We also note that training on the program is provided to all individuals involved in HEMS operations. Because these actions were completed before Safety Recommendation A-09-131 was issued, the recommendation is classified CLOSED—RECONSIDERED.

From: State of Texas, County of Austin-Travis, Emergency Medical Services, STAR Flight
To: NTSB
Date: 3/4/2014
Response: -From Casey Ping, Program Director, Travis County STAR Flight: STAR Flight developed a new Flight Database Program in 2009 that includes a fully developed Risk Assessment tool that pilots must fill out to cover every flight. The Risk Assessment tool incorporates the following line items: 1. Aircraft assignment 7. Visibility (in lowering increments) 2. EMS helicopter experience (in years) 8. Area of operation (as defined by topography) 3. Base location 9. Temp/dew point spread 4. EC145 experience (in hours) 10. Winds (in increasing increments) 5. Day vs night operations 11. Potential for storms along route 6. Ceiling (in lowering increments) 12. Local vs. cross-country operations Upon completion, a score is internally/automatically derived and specific instructions displayed which range from flight clearance to the requirement to contact aviation management for clearance. Pilots update the Risk Assessment when there is a change in weather or day vs night operations. The Risk Assessment is a defined portion of the crew brief for each shift. Training for this tool is performed as a part of new-crew orientation, and pilots are trained in the use of the tool throughout their initial training. Additional training is performed when there is a functional change to the program.

From: NTSB
To: State of Texas, County of Austin-Travis, Emergency Medical Services, STAR Flight
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe that such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether STAR Flight has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how STAR Flight’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that STAR Flight currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, East Bay Regional Park District Police, Air Support Unit
Date: 5/27/2014
Response: We note that, in 2012, you implemented a flight risk assessment program that incorporates the use of the Helicopter Association International Flight Risk Assessment Tool and requires approval from management if the risk associated with a mission reaches a predetermined level. These actions satisfy the intent of Safety Recommendation A-09-131; accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, East Bay Regional Park District Police, Air Support Unit
To: NTSB
Date: 2/3/2014
Response: -From William Probets, Sergeant, Chief Pilot, Air Support Unit: I am responding to your December 13, 20 13 letter on behalf of General Manager Robert Doyle. It appears that your initial 2009 inquiry was sent during a period when the former Chief Pilot was on an extended job injury leave, from which he eventually retired. The East Bay Regional Park District operates two Eurocopter AS350 helicopters in support of its public safety responsibilities within Alameda and Contra Costa Counties, California, which is the District's jurisdictional area. Additionally, the helicopters respond to mutual aid requests for law enforcement assistance, fire suppression and occasional EMS calls within the immediate San Francisco Bay area. The helicopters are classified by formal agreement with Alameda County as Advanced Life Support "rescue aircraft" and provide these services, subject to strict scene response protocols, free of charge to the patient and incidental to our primary law enforcement role. Our operations are conducted entirely in visual flight (VFR) conditions and the great majority of missions are flown during daylight hours. Crews are comprised of experienced commercial, instrument rated pilots, who are also sworn police officers, and volunteer flight medics who are sourced from local fire departments and ambulance operators. I will address each specific safety recommendation and outline the steps that have been taken in response to the recommendations and in the normal course of operations: As part of the work being done in preparation for ALEAC accreditation, a formal preflight preparation and risk assessment tool has been developed, tailored to our specific operating environment, which provides a fixed numerical value. This number correlates to increasing levels of review and flight authorization, up to prohibition of the flight. A draft version is attached for your review. The structure of this tool encompasses a range of static, dynamic, training, qualification, experience and currency factors and provides a standardized set of metrics through which risks can be identified and appropriately managed. During the interim, ASU personnel have adopted a policy of completing pre-flight risk assessments utilizing the on-line HAI Flight Risk Assessment Tool. All flight and supervisory staff will be trained in the interpretation and utilization of the final preflight risk assessment tool.

From: NTSB
To: State of California, East Bay Regional Park District Police, Air Support Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the East Bay Regional Park District Police have developed a similar program and how they have defined the program’s operating parameters. Specifically, we would like to know how their flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the East Bay Regional Park District Police currently use or are in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of Ventura, Fire Department
Date: 9/10/2014
Response: Notation 8597, adopted 9/10/2014: We issued these recommendations to both the Ventura County Sheriff’s Office and the Ventura County Fire Department; however, the Ventura County Sheriff’s Office and Fire Department have since combined their air support units to form the Aviation Search and Rescue Unit, under the direction and management of the Ventura County Sheriff’s Office. Because the Ventura County Fire Department no longer operates an air operations unit, Safety Recommendations A-09-97 through -101 and -131 through -133 are classified CLOSED—NO LONGER APPLICABLE.

From: NTSB
To: State of California, County of Ventura, Fire Department
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Ventura County Sheriff’s Department or Fire Department has developed similar programs and how each department has defined the program’s operating parameters. Specifically, we would like to know how each department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that either department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of New York, City of New York, Police Department, Aviation Unit
Date: 10/14/2014
Response: We have received no reply from you regarding actions you have taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, followup request for such information. Because we have received no reply from you to our request, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. If you have completed, or plan to complete soon, any actions to address these recommendations, please submit details of your actions or plans to correspondence@ntsb.gov. If we receive a timely reply from you, we may reclassify one or more recommendations.

From: NTSB
To: State of New York, City of New York, Police Department, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe that such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the New York City Police hves developed a similar program and how they have defined the program’s operating parameters. Specifically, we would like to know how their flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Police currently use or are in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Florida, County of Miami-Dade, Fire Rescue, Special Operations Division
Date: 6/20/2014
Response: We note that you are in the process of developing and formally incorporating a risk assessment program into your operation. We are encouraged that your plan will require flight crews, before every flight, to complete a digital flight risk assessment form that will include predetermined levels of risk and that the chief pilot will become involved once a specified risk level is reached. Pending confirmation from you that this program has been implemented and that all employees involved in the operation have received training in the new procedures, Safety Recommendation A-09-131 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of Florida, County of Miami-Dade, Fire Rescue, Special Operations Division
To: NTSB
Date: 1/24/2014
Response: -From Dave Downey, Fire Chief: Air Rescue is in the developmental stage of formally incorporating a risk assessment form into a version compatible with our computer-based operations and maintenance software (see attached Digital Airware form).

From: NTSB
To: State of Florida, County of Miami-Dade, Fire Rescue, Special Operations Division
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Miami-Dade County Fire Rescue has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Fire Rescue currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of Santa Barbara, Fire Department, Air Unit
Date: 6/19/2014
Response: We note that, in July 2012, the Santa Barbara County Sheriff’s Department and Fire Department combined their air support units to form the Santa Barbara County Air Support Unit, which is under the direction and management of the Santa Barbara County Sheriff’s Department. Because the Santa Barbara County Fire Department no longer operates an air operations unit, Safety Recommendations A-09-97 through -101 and -131 through -133 are classified CLOSED—NO LONGER APPLICABLE for this department.

From: NTSB
To: State of California, County of Santa Barbara, Fire Department, Air Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Santa Barbara County Sheriff’s Department or Fire Department has developed a similar program and how each department has defined the program’s operating parameters. Specifically, we would like to know how each department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that either department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
Date: 6/25/2014
Response: We note that, in 2011, you implemented an online risk assessment tool, which incorporates predetermined levels of risk and requires management approval if the risk reaches an established level, and started providing training on its use. We also note that the risk assessments are completed at the beginning of a flight crew’s shift and are updated throughout the working hours to reflect any changes in risk factors. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
To: NTSB
Date: 2/20/2014
Response: -From Edwin C. Roessler, Jr., Chief of Police: The Fairfax County Police Department has been conducting Public Helicopter EMS (HEMS) operations since 1983 and has seen significant upgrades since our 2009 response with safety as the driving factor. We now operate two Model Bell 429 helicopters purchased in 2011 and 2012. The Fairfax County Police Department no longer operates the two Bell 407 helicopters as described by Mr. Paul Schaaf in the 2009 response. Both 429 helicopters are configured with dual engines, NVG compatible glass cockpit, auto pilot, Traffic Collision Avoidance System (TCAS), HTAWS, Garmin 530 and 430 GPS, Westcam MX-10 FLIR camera system, Trakka 800 search light and operated with a minimum crew of three and the use of NVG’s at night is mandatory. The size of Fairfax County is approximately 400 square miles located in northern Virginia with a level one trauma center centrally located in the county. Nearly all of HEMS flights are less than 20 minutes in length total time (outbound to landing zone and to the level one trauma center). The population of Fairfax County is approximately 1.2 million and has some of the worst traffic in the nation. Approximately 97 percent of the flying is within 20 nautical miles of the level one trauma center, with the remaining 3 percent to surrounding counties who request assistance on for law enforcement events, maintenance ferry flights, and on the rare occasion a private HEMS operator is unavailable, HEMS flights. The vast majority (99%) of flights consist of no more than a 7 minute flight to the Law Enforcement (LE) mission location or HEMS landing zone. The Fairfax County Police Department considers itself to be in reasonable compliance with the recommendations issued in the NTSB letter dated December 31, 2013 in follow-up to NTSB inquiries in 2009 and 2011. All pilots of Fairfax County’s hold an FAA Commercial license with Instrument endorsements and receive annual simulator events unique to HEMS, bi-annual inadvertent flight into IMC training, bi-annual autopilot and HTAWS training. We have also implemented a comprehensive SMS with an online incident and hazard reporting tool, a thorough risk management tool that is archived daily and have incorporated the use of NVG’s since 2005. Our current SOP’s mandate weather minimums that are higher than current part 135 HEMS operations by the FAA and we are testing cost effective real time flight tracking of our helicopters. Also, we have sought out the guidance of our local Flight Standards District Office (FSDO) to ensure compliance with the final rule recently issued by the FAA regarding Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Operations (RIN 2120-AJ53.) In January of 2011, along with the implementation of the SMS program, the FCPD Helicopter division implemented an on line risk management assessment tool that is completed and archived as part of each on coming crews preflight and preflight planning and is updated throughout the working hours if any risk factors change. This risk evaluation includes weather, NOTAMS, operations outside of 20 nautical miles of Fairfax Base, night operations, reduced crew readiness (illness, fatigue, etc.), mission equipment functionality, Landing Zone operations, aircraft status and discrepancies, or other special operations. All FCPD Division members are trained annually in the risk management assessment tool, HEMS flight operations and risk assessment. If the crew has reached an unacceptable level of risk for any reason, the risks must be mitigated prior to flight to an acceptable level or the helicopter does not fly. If an elevated level of risk is identified, the crew and possibly the Division Commander and/or Safety Officer are notified and the issue is discussed to determine its level of acceptability and possible ways to mitigate risk factors to ensure all flying crew members are aware of the elevated risk level. The final decision to fly, in an elevated level of risk, is determined by the crew (3 yes to fly, only one to say no) with consultation from the Division Commander and/or the Division Safety Officer. The Fairfax County Police Department does not charge the public for HEMS operations and therefore has no financial gain or loss in accepting or denying a HEMS flight.

From: NTSB
To: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
Date: 12/31/2013
Response: The Fairfax County Police Department’s only letter concerning Safety Recommendation A-09-131, dated January 6, 2010, stated that the procedures included in the Police Department’s Risk Factors and Assessment Matrix do not prompt flight crews to consult with an individual who is trained in HEMS flight operations once the risk level reaches a predefined level nor do they require a consultation before resuming flights previously categorized as high risk. As a result, flight crews may accept a mission without having a complete understanding of the level of risk that is involved. We were unable to determine from the Department’s letter whether it had implemented a flight risk evaluation program that addresses (l) training for all employees involved in the operation, (2) procedures that support the systematic evaluation of flight risks, and (3) consultation with others trained in HEMS flight operations if the risks reach a predefined level. As a result, this recommendation was classified “Open—Await Response” on January 25, 2011. The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Fairfax County Police Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how the Police Department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
Date: 1/25/2011
Response: The NTSB is pleased that Fairfax County recognizes the safety benefits of incorporating a safety management system into its operations; however, we are concerned that the actions you described may not be sufficient to address the intent of Safety Recommendation A-09-131. Specifically, the procedures included in your organization's Risk Factors and Assessment Matrix do not prompt flight crews to consult with an individual who is trained in HEMS flight operations once the risk level reaches a predefined level nor do they require a consultation before resuming flights previously categorized as high risk. As a result, flight crews may accept a mission without having a complete understanding of the level of risk that is involved. We are unable to determine from your letter whether Fairfax County has implemented a flight risk evaluation program that addresses (l) training for all employees involved in the operation, (2) procedures that support the systematic evaluation of flight risks, and (3) consultation with others trained in HEMS flight operations if the risks reach a predefined level. Therefore, we ask that you provide more specific information in this regard. For additional guidance on establishing an acceptable operational risk assessment program, the NTSB suggests FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services.1 Pending our receipt of the requested clarification, Safety Recommendation A -09-131 remains classified OPEN—AWAIT RESPONSE.

From: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
To: NTSB
Date: 1/6/2010
Response: Letter Mail Controlled 2/23/2010 2:51:07 PM MC# 2100061 - From Paul M. Schaaf, Chief Pilot, Fairfax County Police Helicopter Division: In August 2009, the Fairfax County Police Department voluntarily funded and submitted to a safety audit conducted by industry leader, Craig Geiss, President of the California Training Institute. Mr. Geiss provided numerous recommendations, one of them being development of a Safety Management System, a significant part of which is flight risk evaluation and a risk assessment procedure for flight crews. This has been instituted as policy within our Division and I have attached our Risk Factors and Assessment Matrix. This matrix is completed by each crew at the beginning of their shift. A laminated copy of this matrix is in the cockpit of each of our two aircraft in order to re-assess risk as factors and missions change. In Fairfax County we are responsible for a basic area of response of less than 500 square miles and operate under a clearly defined set of missions. Therefore, we believe a minimalist, simplied method of tactical risk assessment provides the best results. Strategically, we are vigilant in reassessing risk and modifying our practices to mitigate the impact of changes in the risk factors as well as adopting new technology to enhance safety. NVGs - In 2005, the Helicopter Division completed Night Vision Goggle (NVG) cockpit modifications and crew training and conducts all night operations aided by NVGS Pilot Training - Fairfax County Police Helicopter Pilots all possess FAA Commercial Rotorcraft Licenses with Instrument Ratings. All pilots maintain instrument proficiency by completing regular instrument procedures and an annual instrument proficiency check. Annually, each pilot completes Bell Helicopter Factory Refresher training, scenario-based internal NVG check ride, scenario-based emergency procedures check ride and written test. Voice-alerting system - Each Bell 407 aircraft is equipped with a voice alerting system that audibly warns pilots of transient power, engine overspeed, fuel low and master caution conditions. This system enables more "eyes-out" time during critical phases of flight. Wescam MX-15 Large Format Triple Sensor - In 2007, the Helicopter Division equipped each aircraft with the Wescam MX-15 system which due to it's high degree of stability and surveillance quality optics enable flight crews to effectively perform all manner of search and surveillance missions from significantly higher altitudes, thus providing an addition measure of safety. Standard Operating Procedures - Over the past several years, the Helicopter Division has completely re-written it's internal SOP governing Division administration, flight operations, maintenance and training with the primary goal of enhancing safety though additional directives and clarification of existing procedures. Safety Management System principals were assimilated into this SOP. In summary, the Fairfax County Police Department considers itself in full compliance with the safety recommendations issued in the NTSB's letter dated 13 November, 2009. If there is any further information that you would like us to provide, please let us know. Additionally, if there is anything that the Fairfax County Police Helicopter Division can do to assist the NTSB in it's mission of improving Helicopter EMS Safety, we hope that you will feel free to visit with us or call upon us at any point.

From: NTSB
To: State of Maryland, State Police, Aviation Command
Date: 6/20/2012
Response: The NTSB is aware that the MSP developed and implemented the recommended mission-specific flight risk assessment program before this recommendation was issued. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—RECONSIDERED.

From: State of Maryland, State Police, Aviation Command
To: NTSB
Date: 1/4/2012
Response: -From Major Mark E. Gibbons, Commander, Aviation Command, Maryland State Police: In 2007, the Maryland Department of Transportation (MDOT) was tasked by the Maryland State Legislators to begin development of a “Request for Proposal” (RFP) to replace the MSPAC’s current fleet of AS-365 helicopters. In response to this recommendation, as well as NTSB recommendation A-06-15, the MSPAC requested that any helicopter procured by MDOT to replace the MSPAC’s current fleet of helicopters be equipped with the following: Autopilot (AP), Flight Director (FD), Helicopter Terrain Awareness Warning System (HTAWs), Traffic Collision Avoidance System (TCAS), Cockpit Voice Recorder (CVR), Health and Usage Management System (HUMS), Satellite Flight Tracking and cockpit image recorder(s), in both the cockpit and cabin, as well as be certified to conduct night flight operations with Night Vision Google (NVG). Prior to 2007, due to State budget constraints, only three of the MSPAC’s twelve AS-365 helicopters were equipped with a Honeywell “Enhanced Ground Proximity Warning System” (EGPWS) which is comparable to the “Terrain Awareness Warning System” (TAWS) recommended by the NTSB in A-06-15. Regrettably, the helicopter involved in the “Trooper 2” accident (N92MD) was not one of the helicopters equipped with HTAWS. To bridge the gap after the accident, on January 9, 2009, the Commander of the MSPAC testified before Maryland’s EMS Board (SEMSAC) and requested that funding be allocated to purchase 11 portable Garmin 696 GPS units to provide TAWS information, as well as satellite weather information, to all MSPAC flightcrews until replacement helicopters have been identified and purchased by MDOT for the MSPAC. The SEMSAC Board approved funding and eleven “Garmin 696” portable GPS units were purchased for the MSPAC and delivered in May of 2009. An aircraft mount for the Garmin 696 was engineered for the AS-365 helicopters and approved by the FAA. The Garmin 696 units were placed in service at each operational section in October 2009 after all MSPAC pilots were trained on its operation. The policy, process, and procedures concerning the utilization of the Garmin 696 GPS/TAWS unit by MSPAC flight crews were officially codified when the Commander of the MSPAC signed Active Flight Policy #80 on January 28, 2010. MSPAC Comment: On October 20, 2010, MDOT signed a contract with the Agusta Aircraft Corporation (AAC) to purchase six with the option to purchase a maximum of twelve, AW-139 helicopters to replace the MSPAC’s current fleet of AS-365 helicopters. Each AW-139 helicopter purchased will be delivered to the MSPAC with the following equipment installed: Four Axis Autopilot, Helicopter Terrain Awareness Warning System (HTAWs), Traffic Collision and Avoidance System (TCAS), Cockpit Voice Recorder (CVR), Health and Usage Management System (HUMS), cockpit image recorder and be certified to conduct night flight operations with Night Vision Google (NVG). When delivered, each MSPAC AW-139 helicopter will meet and/or exceed all NTSB equipment recommendations issued to Public, Commercial HEMS Operators and the FAA to improve the operational flight safety of the HEMS industry. Contractually, the aircraft manufacturer (AAC) will be responsible for providing all initial helicopter ground and flight training in the AW-139. The manufacturer will utilize an AW-139 Level D, Full Flight Simulator to conduct this training, to include training on the operation and management of the installed helicopter terrain awareness and warning systems (HTAWS). Attached to this document is Active Flight Policy #80 GARMIN 696 (Incorporation into MSPAC aircraft – Helicopter/Cessna/King Air) for your review.

From: NTSB
To: State of Florida, County of Lee, Emergency Medial Services, MEDSTAR
Date: 2/10/2014
Response: We are aware that, on August 1, 2013, LeeFlight became Lee County’s provider of medevac services. We are also aware that it is operated by Air Methods, a private civil air medical transport company that is required to comply with Federal Aviation Administration (FAA) rules and requirements and is subject to extensive FAA oversight and surveillance. We continue to support the safety improvements discussed in these safety recommendations, but because Lee County no longer conducts public flight operations, these recommendations no longer apply to your organization. Accordingly, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—NO LONGER APPLICABLE.

From: NTSB
To: State of Florida, County of Lee, Emergency Medial Services, MEDSTAR
Date: 9/26/2011
Response: The NTSB appreciates receiving Lee County EMS’s initial responses to these recommendations. We note that the county has included, in at least one of its aircraft, additional safety features, including a flight data recorder, night vision goggle equipment, and an autopilot. In addition, we note that Lee County is working with an outside consultant to develop a full SMS program that is appropriate for the size and type of operations performed. We commend you for these efforts to improve the overall safety of your organization in response to our safety recommendations. However, in an August 18, 2011, phone discussion with you, NTSB staff discussed additional information that we need, regarding actions that you either have taken or plan to take, before we can classify your actions in response to these safety recommendations. Accordingly, pending our receipt and review of this information, Safety Recommendations A-09-97 through -101 and -131 through -133 remain classified OPEN—AWAIT RESPONSE.

From: NTSB
To: State of Florida, County of Volusia, Sheriff's Office
Date: 5/27/2014
Response: We note that you have a flight risk evaluation program in place that is consistent with the guidance contained in FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of Florida, County of Volusia, Sheriff's Office
To: NTSB
Date: 1/21/2014
Response: -From Ben F. Johnson, Sheriff: VCSO has formal procedures and techniques as well a risk assessment matrices contained in our General Operations Manual. Risk Assessment is only a small part of Crew Resource Management Training, which the Department has conducted in accordance with 14 CFR 135.330 (Crew Resource Management Training) prior to the March 22, 2013 dead line. The training is conducted in accordance with the VCSO's, FAA "Initially approved" Training Program Manual in accordance with 14 CFR 135.325(b). Additionally, since we only operate aircraft with one pilot, we also include Single Resource Management training as well. The Department also has formal Loss of Control and Controlled Flight into Terrain Avoidance Procedures contained in our General Operations Manual for Inadvertent Instrument Meteorological Conditions. VCSO utilizes the Matrices contained in example 3(A) and 3(8), in Appendix 2 of Notice N8000.301 dated 08/01/2006, for Risk Assessment tool for all Part 135 and HEMS flights.

From: NTSB
To: State of Florida, County of Volusia, Sheriff's Office
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Volusia County Sheriff’s Office has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Sheriff’s Office currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, City of San Diego, Fire Department, San Diego Medical Services Enterprise
Date: 6/19/2014
Response: We note that your operations manual instructs pilots and crew members on how to comply with operational control and risk management. We also note that, once you have developed and implemented an SMS program, you intend to incorporate the risk management tools associated with that program. Pending our receipt and review of future updates and confirmation that you have completed the recommended actions, Safety Recommendation A 09 131 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, City of San Diego, Fire Department, San Diego Medical Services Enterprise
To: NTSB
Date: 2/18/2014
Response: -From Javier Mainar, Fire Chief: SDFD's internal Air Operations Manual provides our pilots and crewmembers with standard instructions on how to comply with operational control and risk management I mitigation measures. Currently, we use a "Go/No Go" checklist that is completed daily and is based on crew competency; aircraft equipment; and, forecasted and actual weather prior to aircraft dispatch. Once an SMS system is implemented, SDFD will transition to and utilize the SMS risk management tools provided.

From: NTSB
To: State of California, City of San Diego, Fire Department, San Diego Medical Services Enterprise
Date: 1/14/2014
Response: SENT TO THE MAYOR OF SAN DIEGO: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the San Diego Fire-Rescue Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Fire-Rescue Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, City of San Diego, Fire Department, San Diego Medical Services Enterprise
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the San Diego Fire-Rescue Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Fire-Rescue Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Arizona, Department of Public Safety, Highway Patrol, Aviation Division
Date: 5/22/2014
Response: We note that, in October 2008, you implemented a flight risk evaluation program consistent with the guidance contained in the Federal Aviation Administration’s Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services. We also note that you have an aviation safety council that oversees this program and provides recurrent training. Because your program was in place before we issued Safety Recommendation A-09-131, the recommendation is classified CLOSED—RECONSIDERED.

From: State of Arizona, Department of Public Safety, Highway Patrol, Aviation Division
To: NTSB
Date: 1/14/2014
Response: -From Terry Miyauchi, Aviation Administrator, Aviation Bureau: AZ DPS has a risk management practice/policy in place as part of its SMS. That policy incorporates a four step process including identification, assessment, risk decision and implementing controls. We incorporate an effect/probability type risk assessment matrix and associated elevation in the management level of decision. The policy includes measures for rapid, deliberate and in-depth risk assessment. A copy of the policy is attached to this letter. AZ DPS utilizes an in house aviation safety council for the training and direct oversight of the risk management practice/policy as well as all of its aviation activities. A copy of that program is additionally attached.

From: NTSB
To: State of Arizona, Department of Public Safety, Highway Patrol, Aviation Division
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Highway Patrol Division has developed a similar program and how the Highway Patrol Division has defined the program’s operating parameters. Specifically, we would like to know how the Highway Patrol Division’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Highway Patrol Division currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of Los Angeles, Fire Department, Emergency Medical Services
Date: 6/19/2014
Response: We note that, since 2013, you have been using a flight risk assessment tool and providing training on its use. We also note that this tool can be customized to reflect changing factors such as mission type, location, weather, crew experience and training, aircraft capabilities, and fatigue management factors. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, County of Los Angeles, Fire Department, Emergency Medical Services
To: NTSB
Date: 2/24/2014
Response: -From Daryl L. Osby, Fire Chief: The Unit has implemented a FRAT as mentioned in the response to item #2 regarding the SMS program. The FRAT is a web-based and mobile platform application that can be completed quickly and updated as necessary prior to a requested flight mission. Because the Unit has a "multi-mission" responsibility (HEMS, SAR, Fire), the FRAT is customizable to reflect changing factors such as mission type and location, weather, crew experience and training, aircraft capabilities as well as fatigue management factors. Additional resources can be requested to assist the flight crew at any time depending on the type of mission, its location and number of patients.

From: NTSB
To: State of California, County of Los Angeles, Fire Department, Emergency Medical Services
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Los Angeles County Sheriff’s Department or Fire Department has developed a similar program and how each department has defined the program’s operating parameters. Specifically, we would like to know how each department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that either department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Georgia, County of DeKalb, Police Department, Special Operations
Date: 10/3/2014
Response: We have received no reply from you regarding actions you have either taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, followup request for such information. Because we have received no reply from you to our request, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Georgia, County of DeKalb, Police Department, Special Operations
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Dekalb County Police Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Police Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of New York, County of Onodaga, Sheriff's Department, Aviation Unit
Date: 7/30/2014
Response: We note that you are in the process of updating your procedures for determining flight risk. We point out that a formal flight risk evaluation program should incorporate an effect/probability?type risk assessment and predetermined levels of risk that require approval from an individual familiar with HEMS if the risk reaches an established level. In addition, training should be provided to all employees involved in the operation. We encourage you to review FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, to ensure that your program is consistent with these guidelines. In the meantime, pending our receipt of updates on your progress and completion of the recommended action, Safety Recommendation A-09-131 is classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: State of New York, County of Onodaga, Sheriff's Department, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Onondaga County Sheriff's Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Sheriff's Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of New York, County of Suffolk, Police Department, Aviation Section
Date: 7/15/2015
Response: We note that the Suffolk County Police Department has standard operating procedures in place that address risk mitigation. However, we would like to know whether the department has a formal flight risk evaluation program that incorporates an effect/probability?type risk assessment and predetermined levels of risk that require approval from an individual familiar with HEMS if the risk reaches an established level. We point out that some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We encourage the police department to review FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, and to use this guidance to develop an acceptable program. In the meantime, pending our receipt of updates on its progress and completion of the recommended action, Safety Recommendation A 09-131 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of New York, County of Suffolk, Police Department, Aviation Section
To: NTSB
Date: 2/23/2015
Response: -From Edward Webber, Police Commissioner:, County of Suffolk, Police Department: County Executive Steve Bellone referred your letter of October 30, 2014 to me for response. The eight safety recommendations that you outlined in your correspondence were reviewed by the Suffolk County Police Department. Our Aviation Section has an exceptional safety record and I am cognizant that a continual and ongoing focus on safety is necessary to maintain this going forward. We have monitored the recent spate of tragic HEMS crashes and the tragic loss of life, and we are aware why this inquiry is necessary. We have a robust pilot training program, which includes both initial and recurrent original equipment manufacturer (OEM) training on the two airframes that we operate. We have intentionally configured our helicopter fleet with uniformity in mind. When we take delivery of our new Airbus EC-145 later this year, our fleet will be comprised of two EC-145s and two Airbus A Stars. We generally fly with two pilots or one pilot and a tactical flight officer (TFO) (all TFOs hold at least a private helicopter rating). I believe that we utilize a conservative approach in our aviation section and safety is always a paramount concern. With respect to the specific safety recommendations contained in your letter, I would like to address each one individually. Section crew members regularly receive formal risk evaluation training. This training is conducted by the Section's Chief Pilot and the Section's Certified Flight Instructors (CFI). Crew members are all required to discuss all risks associated with a flight prior to that flight with non-flying Section personnel if warranted.

From: NTSB
To: State of New York, County of Suffolk, Police Department, Aviation Section
Date: 10/30/2014
Response: We have received no reply regarding actions you have taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, request for such information. Because we still have received no reply from you, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of New York, County of Suffolk, Police Department, Aviation Section
Date: 10/14/2014
Response: We have received no reply from you regarding actions you have taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, followup request for such information. Because we have received no reply from you to our request, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. If you have completed, or plan to complete soon, any actions to address these recommendations, please submit details of your actions or plans to correspondence@ntsb.gov. If we receive a timely reply from you, we may reclassify one or more recommendations.

From: NTSB
To: State of New York, County of Suffolk, Police Department, Aviation Section
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Suffolk County Police Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how the Police Department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Police Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Florida, City of Palm Beach, Health Care District
Date: 12/31/2013
Response: The District’s only letter concerning Safety Recommendation A-09-131, dated December 21, 2009, stated that risk is managed within the District’s Aeromedical Program through an organized process which includes a flight risk evaluation training program for all operational employees. The letter also stated that the District’s preflight risk evaluations are accomplished on all flights and procedures are in place that require consultation and approval from others trained in helicopter emergency medical services flight operations when a flight that is outside of specific parameters is considered for acceptance. However, the letter did not define these parameters or include a copy of its risk assessment matrix. Our January 11, 2011, reply requested this additional information along with information regarding whether the District’s flight evaluation risk program includes training for all employees involved in the operation. Pending our review of this information, Safety Recommendation A-09-131 was classified “Open—Acceptable Response” on January 11, 2011. The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the District has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the District currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Florida, City of Palm Beach, Health Care District
Date: 1/11/2011
Response: The NTSB is pleased that the District recognizes the safety benefits of incorporating a flight risk evaluation program that requires consultation and approval from others trained in HEMS operations when missions have exceeded predetermined parameters for safe operations. However, the District did not define these parameters or include a copy of its risk assessment matrix. Also, the NTSB has been unable to detennine whether your flight risk evaluation program includes training for all employees involved in the operation. Accordingly, we ask that you provide more specific information in this regard. For additional guidance on establishing an acceptable Operational Risk Assessment Program, the NTSB suggests FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services. Pending our review of this information, Safety Recommendation A-09-131 is classified OPEN – ACCEPTABLE RESPONSE.

From: State of Florida, City of Palm Beach, Health Care District
To: NTSB
Date: 12/21/2009
Response: MC# 2100068 - From Gerald M. Pagano, DO: The District manages risk within its Aeromedical Program through an organized process which includes a flight risk evaluation training program for all operational employees. In addition, preflight risk evaluations are accomplished on all flights and procedures are in place that requires consultation and approval from others trained in helicopter emergency medical services flight operations when a flight which is outside of specific parameters is considered for acceptance.

From: NTSB
To: State of Florida, County of Collier, MedFlight
Date: 4/30/2014
Response: We note that, in 2009, you developed and implemented a flight risk evaluation program that is consistent with the guidance contained in FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services. We also note that training on the program is provided to all individuals involved in HEMS operations. Because these actions were completed before Safety Recommendation A-09-131 was issued, the recommendation is classified CLOSED—RECONSIDERED.

From: State of Florida, County of Collier, MedFlight
To: NTSB
Date: 1/10/2014
Response: -From Steve Adams, County Chief Pilot: A-09-131 We have developed an extensive pre-mission risk assessment tool – built in house. Our system is computer based and is used prior to every flight. The Risk Assessment takes into account all of the minimum elements listed in the FAA Notice N8000.301 and builds upon that with our area specific needs. Our crews (pilots and flight medics) are trained on this system and its as well as the SOP that covers the intent of the system and the safe guards that are built into it.

From: NTSB
To: State of Florida, County of Collier, MedFlight
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether Collier County EMS has developed a similar program and how ithas defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that Collier County EMS currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, City of Los Angeles, Fire Department, Air Operations
Date: 7/24/2014
Response: We note that, in 2011, you implemented a web-based risk assessment program that incorporates an effect/probability?type risk assessment and predetermined levels of risk that require management approval if risk reaches an established level. We are also aware that you provide training on risk assessment. These practices satisfy Safety Recommendation A-09-131, which is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, City of Los Angeles, Fire Department, Air Operations
To: NTSB
Date: 3/10/2014
Response: -From Peter Benesch, Battalion Chief, Air Operations: The Los Angeles Fire Department uses the Prism Flight Risk Analysis Tool (FRAT) to evaluate mission specific flight risk. Pilots are required to determine flight risk using the FRAT which identifies a matrix of factors which are each given a score. The matrix is broken down into specific categories; • Pilot Qualifications PIC with less thean 100 hours in type PIC with greater than 250 hours in type Dual pilot operation Instrument Rated CFI Current • Weather Elements Surface winds greater than 40 knots Ceiling less then 1000’ Visibility less then 3 miles • Night Operation Night Ops Dispatch 2300 – 0500 hrs NVG rated NVG aircraft • Equipment Elements TCAS/Mode-S • L/Z Elements (Mission specific) Improved L/Z Unimproved L/Z • Crew Briefing Crew Fatigue Check Crew Currency Check Each factor is assigned either a negative or positive score. For example, night operations are assigned a factor score of 3. NVG rated factor is assigned a score of -1. After completing the matrix, the total factor score is added up. If the score is greater than 10, the pilot must confer with another pilot and take the necessary steps to mitigate the risk. Such mitigation factors might include adding a second pilot or changing the landing zone. If the factor score is greater than 20, the mission is considered a no-go. The results of each FRAT are electronically forwarded to the Aviation Section Safety Officer, along with the Chief Pilot and the Section Commander for review. Furthermore, the FRAT data is stored electronically on the Prism data base. Every Pilot receives initial and annual training in use of the FRAT. Furthermore, the assigned Safety Officer analyzes and reviews, on an annual basis, the factors and associated scores that form the matrix and assigns the risk used in the FRAT. Attached is a sample of the FRAT matrix with factors and their associated scores.

From: NTSB
To: State of California, City of Los Angeles, Fire Department, Air Operations
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Los Angeles Fire Department has developed a similar program and how the Los Angeles Fire Department has defined the program’s operating parameters. Specifically, we would like to know how the Los Angeles Fire Department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Los Angeles Fire Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Alaska, North Slope Borough, Search and Rescue Department
Date: 7/11/2014
Response: We note that, in 2011, you implemented a web-based risk assessment program that incorporates an effect/probability?type risk assessment and predetermined levels of risk that require management approval if risk reaches an established level. We are also aware that you provide training on risk analysis, aeronautical decision making, and crew resource management. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of Alaska, North Slope Borough, Search and Rescue Department
To: NTSB
Date: 3/24/2014
Response: -From Price E. Bower, Director, North Slope Borough Department of Search and Rescue: SAR evaluates all flights for specific risk factors common to our region, environment and equipment using our flight risk assessment tool (FRAT). The FRAT resides on our electronic flight bags (EFB) which are iPad minis. Each assessment is emailed to the Chief Pilot (CP). If a specific value is obtained the CP must be consulted prior to dispatch. If the assessment goes even higher then both the Director and CP must concur on the release of the flight. All flight crews are trained in the risk analysis process. All crew members, including the Fire Department Medics, have the authority to cancel a flight. All flight crews are trained in aeronautical decision making and crew resource management (ADM/CRM). Pilots are afforded protected rest periods and SAR has established flight and duty parameters.

From: State of Alaska, North Slope Borough, Search and Rescue Department
To: NTSB
Date: 1/29/2014
Response: -From Katherine Ahgeak, Chief of Staff, North Slope Borough, Office of the Mayor: The Mayor of the North Slope Borough, Charlotte E. Brower is in receipt of your letter dated December 31, 2013 regarding eight safety recommendations issued to the North Slope Borough in 2009. Electronic copies of this correspondence are being provided to the following staff who will prepare a formal response to NTSB for the Mayor’s signature no later than April 1, 2014: Dawn Winalski, Interim Borough Attorney Price Brower, Director of NSB Search & Rescue Dennis Tiepelman, Deputy Director of NSB Search & Rescue John Boyle, Chief Advisor to the Mayor Hugh Patkotak, 2009 Director of NSB Search & Rescue If you have any questions concerning this email, please do not hesitate to call my office at 852-0200 and request to speak to John Boyle, Chief Advisor to the Mayor.

From: NTSB
To: State of Alaska, North Slope Borough, Search and Rescue Department
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the North Slope Borough has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Borough currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Florida, County of Broward, Sheriff's Office
Date: 5/27/2014
Response: We are aware that, in 2005, you adopted a flight risk evaluation program consistent with the guidance contained in FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, and that you incorporate risk assessment training at your quarterly safety meetings. Because this program was in place before we issued Safety Recommendation A-09-131, the recommendation is classified CLOSED—RECONSIDERED.

From: State of Florida, County of Broward, Sheriff's Office
To: NTSB
Date: 1/9/2014
Response: -From Alphonso Jefferson, Jr., Assistant to County Administrator: I am in receipt of your letter dated December 31, 2013 to Ms. Bertha Henry, County Administrator, referencing responses to recommendations that were issued by the National Transportation Safety Board (NTSB) to the Broward County Sheriff’s Office in 2009. This letter is intended to inform you that responses to the recommendations will be forthcoming. If you have any questions please contact me. -From Sergeant Christine Ponticelli, Supervisor, Aviation Unit: I just received a letter dated December 31, 2013 regarding your Safety Recommendations for A-09-97 through A-09-133. A09-131: Flight risk evaluation program: The Broward Sheriff’s Office Aviation Unit has had a mission assessment chart that the crews follow prior and during each flight. See attached.

From: NTSB
To: State of Florida, County of Broward, Sheriff's Office
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Sheriff’s Office has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Sheriff’s Office currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of New York, County of Chautauqua, Sheriff's Office
Date: 5/22/2014
Response: We note that, on February 24, 2014, Chautauqua County Sheriff’s Office was awarded a commercial air carrier Part 135 certificate. Although we are encouraged to learn that you now operate under these more stringent regulations, we would like to know, specifically, what actions you have taken to address the recommendations listed above. Pending our prompt receipt of this information and our subsequent review of it, Safety Recommendations A-09-97 through -100 and A-09-131 through -133 remain classified OPEN—AWAIT RESPONSE.

From: State of New York, County of Chautauqua, Sheriff's Office
To: NTSB
Date: 1/21/2014
Response: -Joseph A. Gerace, Sheriff: Thank you for your inquiry regarding the safety recommendations issued to the Chautauqua County Sheriff's Office (CCSO) regarding our HEMS operation. I apologize for the delay in responding to your initial letter. I did not interpret it as a document that required a follow-up, but rather an informational notice and it was forwarded to my aviation division. At the time of your correspondence, we were operating as a public aircraft entity and working extensively to qualify for a commercial air carrier certificate. Our primary focus was to achieve a higher degree of safety by coming into compliance with 14 CFR Part 119 and Part 135. After several years of planning, training and developing our program, we were ultimately awarded a commercial air carrier certificate on February 24t\ 2011 (CCOA-015Z). I am proud of the fact that our HEMS program only operates in a dual pilot configuration. In my opinion, this is a significant measure for the safety of our crew and the patients we fly. We have strict weather minimums and only fly visual flight rules (VFR) flights. As you may be aware, the Federal Aviation Administration (FAA) is actively addressing similar recommendations to those you provided in your letter. They (FAA) have issued a Notice of Proposed Rule Making (NPRM) which provides background and proposed regulatory changes to address the NTSB' s recommendations. Please be assured that CCSO is working directly with our Principal Inspectors from the Rochester Flight Standards District Office to prepare for implementation of these proposals should they indeed become regulatory. CCSO has voluntarily achieved advanced compliance with several of the proposed rules. However, as a small operator, we are financially limited in our ability to voluntarily address all of the recommendations at this time. As a part 135 operator, we will be required to comply with all finalized regulations in the time frame established within those regulations if and when the NPRM becomes law. I hope that this information is helpful to you. As a certificated air carrier, we will be held to the same standard as all other carriers regarding the timeline for compliance with and implementation of the adopted portions of NPRM. We will continue to work diligently to implement as many as we can within our financial ability to do so.

From: NTSB
To: State of New York, County of Chautauqua, Sheriff's Office
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Sheriff’s Office has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Sheriff’s Office currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of Los Angeles, Sheriff’s Department, Aero Bureau
Date: 1/14/2015
Response: We note that you have a flight risk evaluation program in place that is consistent with the guidance contained in FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, County of Los Angeles, Sheriff’s Department, Aero Bureau
To: NTSB
Date: 10/23/2014
Response: -From Roberta A. Abner, Chief, Homeland Security Division: The LASD HEMS pilots utilize the flight includes electronic reporting and tracking. This new fleet of rescue aircraft each flight, a flight assessment is completed. Our risk assessment program calculates a percentage (number) associated with operational risk of each flight. The unit commander must approve and flights a score above 25. Any flight with a score above 16 requires use of mitigation procedures and re-evaluation. rescue sergeant, safety sergeant, and unit commander all receive real-time electronic copies of each completed risk assessment.

From: NTSB
To: State of California, County of Los Angeles, Sheriff’s Department, Aero Bureau
Date: 10/3/2014
Response: We have received no reply from you regarding actions you have either taken or planned to take in response to these recommendations since we issued them, despite our December 31, 2013, followup request for such information. Because we have received no reply from you to our request, we conclude that you have neither acted nor plan to act to address these safety issues. Consequently, Safety Recommendations A-09-97 through -101 and A-09-131 through -133 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of California, County of Los Angeles, Sheriff’s Department, Aero Bureau
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Los Angeles County Sheriff’s Department or Fire Department has developed a similar program and how each department has defined the program’s operating parameters. Specifically, we would like to know how each department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that either department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of Arizona, County of Maricopa, Sheriff's Office, Aviation Services Division
Date: 4/4/2014
Response: We are pleased to learn that you are committed to providing safe ground and flight operations, but we note that you do not provide HEMS services. Accordingly, Safety Recommendations A 09-97 through -101 and A-09-131 through -133 are classified CLOSED--RECONSIDERED.

From: State of Arizona, County of Maricopa, Sheriff's Office, Aviation Services Division
To: NTSB
Date: 1/24/2014
Response: -Paul Chagolla, Deputy Chief, Maricopa County Sheriff’s Office: My letter is in response to written correspondence sent to Maricopa County Sheriff Joseph M. Arpaio, dated December 31, 2013; a letter regarding 2009 safety recommendations for the Sheriffs Aviation Services Division from the National Transportation Safety Board. This correspondence was also sent to the Maricopa County Board of Supervisors. I write to resolve the matter brought forward. We too believe the four-year "Open- Awaiting Response" classification for the recommendations is certainly unusual. Unfortunately, the Maricopa County Sheriff's Office (MCSO) has no record of receiving the NTSB recommendations, and I am unable to determine where the original communique was delivered. However, our response to both the original letter and the follow-up inquiry is that the MCSO Aviation Services Division (ASD) does not operate as a Helicopter Emergency Medical Service (HEMS) provider. The MCSO ASD oversees and manages a helicopter unit which provides support for basic law enforcement services, such as crime suppression and traffic enforcement. Also, our rotor-craft unit conducts technical Search and Rescue operations only in a law enforcement capacity, as mandated by Arizona State statutes; meaning rescued citizens are turned over to awaiting medical personnel for treatment and transportation by ground or by air­ ambulance. Nonetheless, MCSO has reviewed your correspondence with the idea in mind of improving upon safety. MCSO is committed to both safe and efficient ground and flight operations. I am pleased to inform you that our current training regimen provides our rotor-pilots biennial flight training at Bell Helicopter School; Bell Helicopter is the manufacturer of the primary helicopters operated by the MCSO. Over the last year, while budgetarily possible, our pilots attend additional flight simulator training at Flight Safety International. These training courses provide instruction in the following areas: • Aircraft Emergency procedures, both in a classroom and flying the actual aircraft. • Aircraft systems management, both in the classroom and in flight. Moreover, MCSO ASD has integrated and implemented a safety management program (SMS) within its aviation operations through standardized operating procedures. MCSO flight crews conduct risk assessments specific to the mission at hand, with final determinations being made by the pilot in command and/or Chief Pilot. Flight risk assessments include the continuous review of available weather information, and/or contact with Flight Service Stations prior to flight operations. MCSO pilots seek real-time weather conditions, and while en route to their destination, investigate updated information available through tablet and smart phone technologies. With respect to aviation maintenance operations, ASD commanders utilize a subscription based aviation software program (Digital Air-Ware) to evaluate pilot and aircraft performance. This software provides ASD supervisors time-sensitive information, including information such as 90-day training update notices for operational systems; example, night vision equipment (NVG). Though MCSO helicopters do not possess autopilot or terrain avoidance equipment, ASD continuously deploys two-member flight crews. With an eye to the future, MCSO may seek these options in future aircraft purchases. We appreciate your follow-up correspondence and hope this response will allow for closure of the recommendations. Lastly, in consideration of this response, the Maricopa County Sheriffs Office respectfully requests that the NTSB remove our agency from the list of HEMS operators, as we are a government law enforcement agency with statutorily mandated Search and Rescue duties. I have enclosed my business card and make myself available to answer any further inquiries that serve to gain closure.

From: NTSB
To: State of Arizona, County of Maricopa, Sheriff's Office, Aviation Services Division
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Maricopa County Sheriff’s Office has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Sheriff’s Office currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of Orange, Sheriff's Department, Air Support Division
Date: 5/22/2014
Response: We note that, in 2011, you implemented a flight risk evaluation program consistent with the guidance contained in the Federal Aviation Administration’s Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services. Because your program addresses the intent of Safety Recommendation A-09-131, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, County of Orange, Sheriff's Department, Air Support Division
To: NTSB
Date: 1/19/2014
Response: -From William D. Fitzgerald, Jr., Aviation Support Unit, Operations Sergeant: We received the letter dated December 31, 2013, reference the eight NTSB safety recommendations for the Orange County Sheriff’s Department Aviation Support Unit. These safety recommendations were sent to Sergeant Han 0 who is no longer the unit. Unfortunately, the information was never passed on. I am currently the Operations Sergeant for the Aviation Support Unit and an Airborne Law Enforcement Association (ALEA) Accreditor for unit standards. Our unit now has a fully implemented Safety Management System (SMS) exceeding the standards set by ALEA and the International Helicopter Safety Team (IHST). We also have conducted full accident rehearsals for the past two years in order to improve our emergency response plan. We have had Elliot Simpson and Patrick Jones from the NTSB monitor both of our exercises. The Orange County Sheriff’s Department Aviation Support Unit has a fully implemented Safety Management System (SMS). As part of the Safety Management System, ASU utilizes a Risk Assessment Sheet (Enclosure 3) and Risk Management Worksheet (Enclosure 4).

From: State of California, County of Orange, Sheriff's Department, Air Support Division
To: NTSB
Date: 1/9/2014
Response: -From Sergeant William Fitzgerald, Aviation Support Unit, Orange County Sheriff’s Department: We received the letter dated December 31, 2013, from Paula Sind-Prunier reference the eight NTSB safety recommendations for the Orange County Sheriff’s Department’s Aviation Support Unit. These safety recommendations were sent to Sergeant Han O who is no longer the unit. Unfortunately, he never passed on the information. We look forward to informing the NTSB about our Aviation Safety Program. I am currently the Operations Sergeant for the Aviation Support Unit and an Airborne Law Enforcement Association (ALEA) Accreditor for unit standards. Our unit now has a fully implemented Safety Management System (SMS) exceeding the standards set by ALEA and IHST. We also have conducted full accident rehearsals for the past two years in order to improve our emergency response plan. We had Elliot Simpson and Patrick Jones from the NTSB monitor both of our exercises. I will have a formal letter sent to your office detailing how we addressed the eight NTSB safety recommendations within 2 weeks. If the NTSB has any future correspondence for our unit, please email me or mail to our hangar.

From: NTSB
To: State of California, County of Orange, Sheriff's Department, Air Support Division
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Orange County Sheriff’s Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Sheriff’s Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of San Bernardino, Sheriff's Department
Date: 6/26/2014
Response: We note that, although your crew members complete pre- and post-mission briefs, you do not have a formal flight risk evaluation program that incorporates an effect/probability?type risk assessment and predetermined levels of risk that require approval from an individual familiar with HEMS if the risk reaches an established level. We point out that some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. We encourage you to review FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, and to use this guidance to develop an acceptable program. In the meantime, pending our receipt of updates on your progress and completion of the recommended action, Safety Recommendation A-09-131 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, County of San Bernardino, Sheriff's Department
To: NTSB
Date: 4/16/2014
Response: -From John McMahon, Sheriff-Coroner: The San Bernardino County Sheriff's Department's Aviation Unit is pleased to provide a response to the National transportation & Safety Board's recommendations resulting from an investigative hearing occurring in February 2009. We apologize for the delay as it was not clear, at the closing of the hearing, that a formal response to the recommendations was required. While we recognize the importance of flight safety, in all aspects, we also share the position of our brother public safety agencies that our mission profiles are quite different than that of private HEMS operators. In fact, many of our missions, in particular hoist rescue (day and night), pose a much greater safety risk than our colleagues in the aero-medical transportation industry. Thus, we tend to train harder and respond in many diverse terrain environments than a civilian air transport provider. Public safety or government flight operations are driven by mission and not so much making a profit. Therein lies the potential cause of many of the fatal incidents. Whether it is training, maintenance, or equipment costs, often financial short cuts are realized in the private industry resulting in tragedy as we, too, are charged with aircraft crash investigations. With the aforesaid, many of us in the public safety sector recognize that the private sector will continue to attempt to legislate us out of our missions, our responsibility to our citizens, and our current mandates. Again, we are not profit driven. We have seen that the majority of the fatal incidents are private operators and not public safety. We have noted that a private aircraft operator can contract with a government agency, have an incident, yet, the incident is charged against government or public safety statistics. It is our desire to continue to advocate the separation of private and public safety flight operations, largely based on the fact that our missions and motivations are different. The public safety flight statistics show we have an exceptional flight safety history and should enjoy reasonable exemptions from the private, profit motivated operator. The San Bernardino County Sheriff's Aviation Unit trains all its personnel in these procedures. Using the "Go-No Go" concept, every crew member can decline a call or rescue based on the known facts of the incident and their level of experience. Each crew member is trained on every facet of the flight operation and for every type of call we could handle. This is completed by pre-mission briefings and post-mission debriefs. All crew members go through repetitive training of the various calls we respond to prior to being released to full duty. Additionally, our air rescue helicopters fly with a crew chief who is dedicated as a flight crew member not a medical crew member. This concept, historically, makes for a safer and more efficient EMS air craft.

From: State of California, County of San Bernardino, Sheriff's Department
To: NTSB
Date: 1/6/2014
Response: -From Janice Rutherford, Board of Supervisors Chair, Second District Supervisor, County of San Bernardino: Thank you for your letter dated Dec. 31, 2013, regarding recommendations the National Transportation Safety Board has made to the San Bernardino County Sheriffs Department. I took steps to ensure San Bernardino County Sheriff John McMahon is aware of the NTSB's recommendations and the agency's desire to receive a response from the Sheriffs Department as soon as possible. Again, thank you for your letter and for your efforts to improve safety among emergency medical service operators. Please let me know if I may be of any further assistance.

From: NTSB
To: State of California, County of San Bernardino, Sheriff's Department
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the San Bernardino County Sheriff’s Department has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Sheriff’s Department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of Santa Barbara, Sheriff's Department, Air Unit
Date: 6/19/2014
Response: We note that, in 2013, you implemented a web-based flight risk assessment tool that incorporates an effect/probability?type risk assessment and predetermined levels of risk that require management approval if the risk reaches an established level. We are also aware that training on risk assessment is provided on a recurrent basis. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, County of Santa Barbara, Sheriff's Department, Air Unit
To: NTSB
Date: 3/5/2014
Response: -From Lieutenant Steven Johnson, Air Support Unit: We are currently using a Flight Risk Matrix on all flights. This is in addition to Crew Resource Management, which encompasses communication with all crew members, situational awareness, teamwork amongst the crew, safety management system, risk analysis, leadership and decision making. (See attached Risk Assessment Matrix).

From: NTSB
To: State of California, County of Santa Barbara, Sheriff's Department, Air Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Santa Barbara County Sheriff’s Department or Fire Department has developed a similar program and how each department has defined the program’s operating parameters. Specifically, we would like to know how each department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that either department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of Sonoma, Sheriff's Office
Date: 3/6/2015
Response: We note that you have a risk assessment program in place, which incorporates an effect/probability?type risk assessment and predetermined levels of risk that require management approval if the risk reaches an established level. We are also aware that this program falls under your SMS program, and that you provide risk assessment training to your employees. Accordingly, Safety Recommendation A-09-131 is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, County of Sonoma, Sheriff's Office
To: NTSB
Date: 12/9/2014
Response: -From Steve Freitas, Sheriff-Coroner: We are in receipt of your letter dated December 31, 2013 and are pleased to report that all NTSB recommendations have been addressed as requested. We are hopeful that upon reviewing our work and progress on these eight NTSB recommendations you will feel confident in reclassifying our program as "compliant" with all NTSB HEMS recommendations. The Sonoma County Sheriffs Office operates a 1996 Bell407 helicopter with approximately 8,500 flight hours. The Sheriffs Office has launched a formal project to replace the Bell407 with a category "A" twin engine helicopter and anticipates a new or nearly new helicopter will be purchased within the next 18-24 months. We want to emphasize that our helicopter (Henry-1) is multi-mission program incorporating Advanced Life Support (ALS) capability, rescue and law enforcement missions. We do not operate primarily as an HEMS provider; that role is filled by two regional HEMS providers REACH and CALSTAR. Henry 1 provides emergency medical transport when primary providers are unavailable or when urgent transport is required in the interest of patient care. Most importantly, as a public use helicopter program, the Sheriffs Office does not seek compensation for medical transports and is prohibited from doing so by law. It appears that many of the NTSB safety recommendations directed at HEMS operators focus on safety management and risk assessment where profit was the motivating factor driving poor decisions to accept risky missions. Therefore, we believe our compliance with these NTSB recommendations is voluntary and not mandated. We appreciate the eight recommendations as best practices that all helicopter operators should strive for, however our aircraft is not capable of supporting some of the technical recommendations at this time. The Sonoma County Sheriffs Office attained full accreditation by the nationally recognized ALEA (Airborne Law Enforcement Association) in May 2014. Our successful accreditation by an independent, nationally recognized panel of experts validates the revision and rewriting of our Flight Operations Manual (FOM) and creation of a formal Safety Management System (SMS). The process was a multi-year endeavor developed with the assistance of aviation consultants, California Training Institute. We are extremely proud of our program and the service we provided to the public. With over 40 years of experience operating rescue helicopters on the northern coast of California we are recognized as the leaders in rescue safety. The Sonoma County Sheriff's Office has developed in our SMS Manual section Annex C and D utilizing a Risk Assessment Code (RAC) as needed. All involved crewmembers are SMS trained and understand our FOM. We are considered a law enforcement ALS rescue helicopter; we do not operate as a HEMS operator however we have these items in place for flight risk evaluation. Please see attached packet.

From: State of California, County of Sonoma, Sheriff's Office
To: NTSB
Date: 3/26/2014
Response: -From Lieutenant Mark Essick, Manager, Helicopter and Marine Operations, Sonoma County Sheriff’s Office: The Sonoma County Sheriff’s Office is in receipt of your letter dated December 31, 2013. We are preparing a detailed response addressing the eight safety recommendations made by the NTSB to HEMS operators. We anticipate having our final response to you no later than December 31, 2014. In our review of the eight safety recommendations made by the NTSB we believe the recommendations have either been addressed or do not apply to our aircraft. We look forward to providing you detail on the actions we have taken.

From: NTSB
To: State of California, County of Sonoma, Sheriff's Office
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Sonoma County Sheriff’s Office has developed a similar program and how the Sonoma County Sheriff’s Office has defined the program’s operating parameters. Specifically, we would like to know how the Sonoma County Sheriff’s Office’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Sonoma County Sheriff’s Office currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, State Police, Highway Patrol, Office of Air Operations
Date: 7/23/2014
Response: We note that, prior to 2009, you implemented a flight risk assessment program that incorporates an effect/probability?type risk assessment and predetermined levels of risk that require management approval if the risk reaches an established level. We are also aware that you provide training on this program to all employees involved in HEMS. Because your program was in place before Safety Recommendation A-09-131 was issued, the recommendation is classified CLOSED—RECONSIDERED.

From: State of California, State Police, Highway Patrol, Office of Air Operations
To: NTSB
Date: 3/26/2014
Response: J.A. Farrow, Commissioner: The CHP Air Operations Manual and standard operating procedures of each air unit require the risk level of each mission be ascertained. Crew members are required to gain supervisory approval before flying any high-risk mission. Each air unit outlines the locations in their areas of operation which are of higher risk to air crews. The CHP places restrictions on pilots and flight officers based on their experience level and training which specifically prohibits flight operations by crew members under certain conditions including weather, density altitude, and mission type. The CHP also requires air unit safety officers to attend human factors training. This training provides safety officers a background in human factors which is used to positively impact the systematic evaluation of flight risks. The SMS program adopted by CHP includes proactive risk alerts, the involvement of all crew members, and a risk assessment matrix.

From: NTSB
To: State of California, State Police, Highway Patrol, Office of Air Operations
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the California Highway Patrol has developed a similar program and how it has defined the program’s operating parameters. Specifically, we would like to know how its flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the California Highway Patrol currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 3/8/2017
Response: We note that, in April 2016, you implemented a flight risk evaluation program, which incorporates an effect/probability?type risk assessment and predetermined levels of risk that require management approval if the risk reaches an established level. We are aware that this program falls under your SMS program, and that you provide your employees with adequate training. Because your program addresses the intent of Safety Recommendation A-09-131, the recommendation is classified “Closed—Acceptable Action.” We also note that Federal Aviation Administration-licensed flight dispatchers relay up to date weather information to flight crews and use flight-tracking software, a computer-aided display, and a satellite phone to follow flights and maintain communication with flight crews for the entire flight duration. In addition, your standard operating procedures include formalized dispatch and flight following procedures that include a formal incident response protocol. These measures satisfy Safety Recommendation A-09-132, which is classified CLOSED--ACCEPTABLE ACTION.

From: State of New York, State Police, Aviation Unit
To: NTSB
Date: 11/3/2016
Response: -From Major Brent B. Gillam, Director of Aviation, New York State Police: In April, 2016, the New York State Police purchased and implemented a formal SMS program from ARGUS International, Inc., 4240 Airport Road Suite 300, Cincinnati OH, 45226. PRISM is fully integrated into the planning and completion of every flight. Included in PRISM is a flight risk assessment tool (FRAT) that is electronically completed by the flight crew, and electronically delivered to the command staff, duty officer, and dispatchers. All employees received initial and yearly training on PRISM and FRAT. Flight risk factors are thoroughly assessed before every flight, and a reaching predefined threshold triggers the automatic involvement of the duty officer and command staff for approval of the flight.

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 6/20/2014
Response: We note that, although you have standard operating procedures (SOP) in place that address risk mitigation, you do not have a formal flight risk evaluation program that incorporates an effect/probability?type risk assessment and predetermined levels of risk that require approval from an individual familiar with HEMS if the risk reaches an established level. We point out that some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We encourage you to review FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, and to use this guidance to develop an acceptable program. In the meantime, pending our receipt of updates on your progress and completion of the recommended action, Safety Recommendation A-09-131 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of New York, State Police, Aviation Unit
To: NTSB
Date: 6/13/2014
Response: -From Major Chuck Guess, Detail Commander, New York State Police Aviation: Received. We will review, assess and follow up on all outstanding recommendations. The NYSP Aviation Unit recognizes the importance of assimilating and implementing Best Practices. Safety remains our number one priority. Thank you.

From: State of New York, State Police, Aviation Unit
To: NTSB
Date: 2/10/2014
Response: -From Major Charles E. Guess, NYSP Director of Aviation: The NYSP Aviation Unit conducts semi-annual safety training and has recently implemented a section in the Unit SOP that addresses risk mitigation for any specific flight. The Unit operates in five different geographic regions throughout New York State and conducts a variety of missions in both airplanes and helicopters; in addition to HEMS. In lieu of a formal risk matrix, Risk Management is recognized as a joint Command, Operations and Pilot-in-Command responsibility. Naturally, Unit SOPs specify operating parameters regarding required weather for launch or continuing flight, in addition to numerous planning considerations such as: FAA Regulations, mission complexity/duration, crew composition, experience & coordination, crew rest, environmental factors, preflight discrepancies, limitations, fuel, equipment and passenger loading; to name a few. As the Unit operates in many high risk environments, in addition to HEMS, risk management is addressed at our semi-annual safety day presentations to ensure effective pass down of information learned, based upon after action review.

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the New York State Police have developed a similar program and how they have defined the program’s operating parameters. Specifically, we would like to know how their flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the State Police currently use or are in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: United States Department of the Interior, National Park Service, Park Police, Aviation Unit
Date: 6/20/2014
Response: We are pleased that you are developing a threat assessment tool to accompany your existing procedures for determining flight risk and that the members of your aviation unit are required to conduct a crew briefing of high-risk missions prior to accepting such missions. We point out that a formal flight risk evaluation program should incorporate an effect/probability?type risk assessment and predetermined levels of risk that require approval from an individual familiar with HEMS if the risk reaches an established level. In addition, training should be provided to all employees involved in the operation. We encourage you to review FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, to ensure that your program is consistent with these guidelines. In the meantime, pending our receipt of updates on your progress and completion of the recommended action, Safety Recommendation A-09-131 is classified OPEN—ACCEPTABLE RESPONSE.

From: United States Department of the Interior, National Park Service, Park Police, Aviation Unit
To: NTSB
Date: 2/27/2014
Response: -From Robert MacLean, Acting Chief, United States Park Police: The USPP has developed, and is currently revising the Aviation Unit guideline manual which contains standards of operation procedures for determining flight risk. Included in this guideline manual are recommendations for weather evaluation, hoist operations, rappel operations, all aspects of low level flight, and conformance with National Park Service Special Use Flight. The members of the USPP Aviation Unit are required to conduct a crew briefing of high risk missions prior to undertaking and accepting the mission. The USPP also have a threat assessment tool that is being developed in addition to current guidelines.

From: NTSB
To: United States Department of the Interior, National Park Service, Park Police, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the United States Park Police have developed a similar program and how they have defined the program’s operating parameters. Specifically, we would like to know how their flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that the Park Police currently use or are in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.

From: NTSB
To: State of California, County of Ventura, Sheriff's Department, Aviation Division
Date: 6/13/2014
Response: We note that you developed a flight risk evaluation program that is currently being reviewed for implementation and that all crew members receive training on threat and error management. We would like to know whether the program incorporates an effect/probability type risk assessment, predetermined levels of risk, and a requirement for management approval if the risk reaches an established level. Pending our receipt of this additional information and completion of the recommended action, Safety Recommendation A 09-131 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, County of Ventura, Sheriff's Department, Aviation Division
To: NTSB
Date: 2/11/2014
Response: -From Bill Ayub, Captain, Ventura County Sheriff’s Office: The Ventura County Sheriff’s Office operates the only public safety aviation program, hereinafter referred to as “aviation unit,” in Ventura County, California. The aviation unit performs law enforcement support, medevac, search and rescue operations, and aerial firefighting support. Although the aviation unit is managed by the Ventura County Sheriff’s Office, it is a blended unit staffed by Sheriff’s Office members as well as Ventura County Fire Department members with the shared common goal of providing for public safety. As the manager of the aviation unit, I am responsible for the oversight of the program and am therefore responding to the NTSB safety recommendations on behalf of both the Ventura County Sheriff’s Office and the Ventura County Fire Department. The unit has developed a flight risk evaluation program that is included in the safety management system document. The document is currently being reviewed for final approval and implementation. The unit also incorporates Human Factors (CRM) and Threat & Error Management training on a bi-annual basis to all of its crew members. In addition, pilots receive Crew Resource Management Training when attending Flight Safety International for recurrent simulator training. Note: Recommendation is to complete this type training at FSI on an annual basis along with manufacturer’s flight training every twelve months.

From: NTSB
To: State of California, County of Ventura, Sheriff's Department, Aviation Division
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-131 is to ensure that HEMS operators have flight risk evaluation programs in place that adequately train employees to systematically evaluate risk and consult with others after flight risk exceeds an established level. We believe such programs are necessary to accurately assess and mitigate flight risk during HEMS operations. Some of the other operators who received this recommendation have developed mission specific flight risk assessment tools that they require pilots to use before all flights. In addition to classifying the risk level as low (green), medium (yellow), or high (red), the tool calculates a percentage associated with the operational risk. High-risk flights must be approved by the director of flight operations or a designee before they are accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs the dispatch service that any change in flight conditions, such as deteriorating weather, could render the flight high risk, thus requiring approval before the flight may continue, or even cancelling the flight. Moreover, the dispatch service notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if operation risk increases. We would like to know whether the Ventura County Sheriff’s Department or Fire Department has developed similar programs and how each department has defined the program’s operating parameters. Specifically, we would like to know how each department’s flight risk evaluation program incorporates training for all employees involved in HEMS operations, assesses and interprets flight risk, and facilitates information sharing and assessment assistance among various roles involved in flight operations. Please also submit for our review any risk assessment matrices that either department currently uses or is in the process of developing. Please see FAA Notice N8000.301, Operational Risk Assessment Programs for Helicopter Emergency Medical Services, issued August 1, 2005, for additional guidance on establishing an acceptable program.