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Safety Recommendation Details

Safety Recommendation A-09-133
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 THE FOLLOWING ORGANIZATIONS: Install terrain awareness and warning systems on your aircraft and provide adequate training to ensure that flight crews are capable of using the systems to safely conduct helicopter emergency medical services operations.
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 (Open - Acceptable Response)
State of California, City of Los Angeles, Fire Department, Air Operations (Open - Acceptable Response)
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 (Open - Acceptable Response)
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 (Open - Acceptable Response)
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 (Open - Acceptable Response)
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 (Open - Acceptable Response)
State of California, State Police, Highway Patrol, Office of Air Operations (Open - Acceptable Response)
State of Delaware, State Police, Aviation Unit (Open - Acceptable Response)
State of Florida, City of Palm Beach, Health Care District (Open - Acceptable Response)
State of Florida, County of Broward, Sheriff's Office (Open - Acceptable Response)
State of Florida, County of Collier, MedFlight (Closed - Acceptable Action)
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 (Open - Acceptable Response)
State of Georgia, County of DeKalb, Police Department, Special Operations (Closed - Unacceptable Action - No Response Received)
State of Maryland, State Police, Aviation Command (Closed - Acceptable Action)
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 (Open - Acceptable Response)
State of North Carolina, County of Dare, Emergency Medical Services (Open - Acceptable Response)
State of Texas, County of Austin-Travis, Emergency Medical Services, STAR Flight (Closed - Acceptable Action)
United States Department of the Interior, National Park Service, Park Police, Aviation Unit (Open - Acceptable Response)
Keyword(s): Helicopter Emergency Medical Services,Helicopter Emergency Medical Services (Public Operators),Training and Education

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: 1. The LVMPD Air Support Section has been installing RADAR altimeters in aircraft over a period of time and currently half of the fleet has them installed. A RADAR altimeter has been sourced for a fourth helicopter and It is expected that a fifth RADAR altimeter will be sourced by the end of the year. 2. LVMPD patrol flights have a Tactical Flight Officer (TFO) or co-pilot as another safety margin. 3. Rescue flights in the HH-1 H helicopters involved another layer of safety with the crew chief looking for potential hazards.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Las Vegas Metro Police Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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’s current helicopter fleet is equipped with radar altimeters. As part of our fleet refreshment, our new helicopters will be equipped the Garmin G1000 avionic system. This system has terrain awareness installed. All our pilots will be trained to use the G1000 including the terrain awareness functions. This training will be conducted using both computer based training and factory school.

From: NTSB
To: Commonwealth of Pennsylvania, State Police, Aviation Section
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Pennsylvania State Police Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of New Jersey, State Police, Special Operations Section
Date: 7/11/2014
Response: We note that all of the helicopters you use for HEMS are equipped with helicopter TAWS and that your pilots receive initial and recurrent training on this technology. Accordingly, Safety Recommendation A-09-133 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: All AW139 aircraft employed in the New Jersey State Police HEMS are factory equipped with TAWS. Flight crews are trained in the use of the system as part of their annual type rating refresher conducted at RotorSim in Whippany, NJ.

From: NTSB
To: State of New Jersey, State Police, Special Operations Section
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the New Jersey State Police’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
Date: 6/25/2014
Response: We note that your Bell 429 helicopters are equipped with helicopter TAWS and that all pilots are trained on how to use this system. We also note that HEMS missions are conducted using only these helicopters. Accordingly, Safety Recommendation A-09-133 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.) The 429 helicopters operated by Fairfax County are both equipped with HTAWS. The HTAWS verbally announces an obstacle and highlights it on our Garmin 530 and 430 GPS so the pilot can maneuver to avoid the obstacle. It is a very simplistic system that color codes obstacles as yellow or red depending on the potential for impact on the GPS. The audible “Caution Obstacle” or “Warning Obstacle” audio along with the associated highlight of the obstacle on the GPS makes it very intuitive for pilots to maneuver and avoid. The system also provides terrain alerting if the aircraft is descending at too fast of a rate and will alert the pilot with either an audible “Caution Terrain” or “Warning Terrain”. Pilots are trained annually at Bell Helicopter and on annual check rides on how to properly control rates of descent, avoid controlled flight into terrain and Landing Zone Evaluation. The obstacle and terrain databases in the helicopter are checked for updates every 28 days. If an update is available, the new database is installed. Another method to reduce the risk of obstacles and flight into terrain is based on our “fly neighborly” program and landing zone evaluation contained in our SOP’s. With the “fly neighborly” program, to avoid noise complaints from citizens, we mandate through our SOP’s that pilots shall fly the aircraft above 800 feet above the ground level (AGL) unless mission necessity requires us to fly below 800 feet AGL. The highest obstacle located within Fairfax County is 689 feet above ground level. The topography of Fairfax County is generally flat with some portions at sea level and gradually rising to approximately 500 feet above sea level. Training with crews on how to evaluate a landing zone consists of a high and low recon for suitability using all means available to include NVG’s, search light, FLIR camera system and the naked eye. In addition, prior to landing in the LZ, the helicopter is required to receive a “wire report” from either police or fire department ground units who physically walk the potential landing zone. Both police and fire department ground units receive training on landing zone reconnaissance to include size and topography, height of obstacles and wires, sloping angle of terrain, landing and departure path and potential loose items or debris upon landing. The criteria for an acceptable landing zone are also contained in the FCPD General Orders for all police personnel and in a similar document for all Fire Department personnel.

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-09-132, dated January 6, 2010, stated that both of the Police Department’s helicopters are equipped with Chelton Flight Logic Electronic Flight Information Systems that include helicopter terrain and warning system functionality and that the helicopters were equipped with TAWS prior to November 13, 2009, when this recommendation was issued. However, our January 25, 2011, reply requested information regarding the training that is provided to ensure that flight crews are capable of using the system to safely conduct HEMS operations. Pending our receipt and review of the requested information, Safety Recommendation A-09-133 was classified “Open—Acceptable Response” on January 25, 2011. We would like to know about any TAWS training that the Fairfax County Police Department currently provides or has planned.

From: NTSB
To: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
Date: 1/25/2011
Response: The NTSB notes that both of Fairfax County’s helicopters are equipped with Chelton Flight Logic Electronic Flight Information Systems that include helicopter terrain and warning system functionality and that the helicopters were equipped with TAWS prior to November 13, 2009, when this recommendation was issued. However, before we can close Safety Recommendation A-09-133 in an acceptable status, we need to evaluate the training that is provided to ensure that flight crews are capable of using the system to safely conduct HEMS operations; please provide us with this information. Pending our receipt and review of the requested information, Safety Recommendation A-09-133 is classified OPEN – ACCEPTABLE RESPONSE. The NTSB recognizes that the safety recommendation process is new to your organization, and we appreciate your cooperation and efforts to address these recommendations.

From: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
To: NTSB
Date: 1/6/2010
Response: MC# 2100061 - From Paul M. Schaaf, Chief Pilot, Fairfax County Police Helicopter Division: Both of Fairfax County's Bell 407 aircraft are equipped with the Chelton Flight Logic Electronic Flight Information System (EFIS) system. This system includes integral Helicopter Terrain and Warning System (H-TAWS). The Chelton H-TAWS provides pilots with look-ahead predictive terrain and obstacle clearance information as well as synthetic vision. Synthetic vision presents a visual flight path indication to pilots in reference terrain, obstacles and other aircraft as well as Highway In The Sky display that provides redundant GPS derived guidance during all instrument approach procedures. The Chelton EFIS also provides the pilot with hover-vector information which assists pilots in maintaining aircraft control during take-off, landing and hovering phases of flight in adverse conditions. Additionally, the Chelton EFIS serves as the presentation of the ADS-B data for weather and traffic and displays radar altimeter information from the FreeFlight RA-4500 digital radar altimeter. 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 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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the helicopters operated by the Ventura County Sheriff’s Department or Fire Department are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Fire-Rescue Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of North Carolina, County of Dare, Emergency Medical Services
Date: 1/14/2015
Response: We note that, although your current aircraft is not equipped with a helicopter TAWS unit, you intend to include this technology on the helicopter you will be purchasing soon. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

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, there was no onboard terrain awareness and warning system on board Dare Medflight. Dare County will be accepting a new aircraft on or about 1 September 2015, and the terrain awareness and warning systems features will be installed in the new aircraft.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether Dare County EMS’ helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: Commonwealth of Virginia, State Police
Date: 7/11/2014
Response: We note that both of your EC 145 helicopters are equipped with helicopter TAWS units that are compliant with Technical Standard Order (TSO) C-194 and that pilots are trained on how to use this technology. We also note that your Bell 407 helicopters are equipped with global positioning system devices that provide TAWS information. Although we believe that your use of these devices on your Bell 407 helicopters constitutes an acceptable interim solution, we encourage you to consider installing helicopter TAWS units that are compliant with TSO C-194 when it comes time for you to update your fleet. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 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: At the time this recommendation was made, H-TAWS systems were not widely available and affordable for the existing fleet of helicopters. A lower cost solution was sought out and implemented in an attempt to provide terrain information to the flight crew. The Bell 407's had a Garmin 696 GPS installed with terrain awareness as well as having the GNS430 NavComm upgraded to display the same information. The pilot and crew have access to moving map displays of terrain and the units visually warn of potential collision during all modes of operation. The Unit specified terrain awareness when the EC145 were purchased. The EC 145s are equipped with terrain awareness that provides visual and audio warnings of potential hazards. Pilots are trained in the use of the TAWS equipment during annual training flights. In addition, the American Eurocopter training curriculum features emergency procedures for the use of autopilot during simulated transition to IFR conditions in mountainous terrain. Currently, the EC 145 helicopter is the primary ship for HEMS operations and the 8407 helicopters perform backup duty as needed.

From: NTSB
To: Commonwealth of Virginia, State Police
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Virginia State Police’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of Delaware, State Police, Aviation Unit
Date: 6/20/2014
Response: We note that, although all of your aircraft are equipped with TAWS devices, only two of them are equipped with helicopter TAWS units that are compliant with Technical Standard Order (TSO) C-194. We are encouraged to learn, however, that you are in the process of updating your fleet and that the new helicopters will come equipped with helicopter TAWS units that are TSO C-194 compliant. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of Delaware, State Police, Aviation Unit
To: NTSB
Date: 1/28/2014
Response: -From Colonel Nathaniel McQueen, Jr., Superintendent: All Delaware State Police Aircraft are equipped with TAWS devices. The devices vary by model of aircraft and include the following systems: GPWS and EGPWS. The 2 new Bell 429 aircraft will be equipped with the highest level of protection offered through EGPWS. All DSP aircraft are equipped with radar altimeters. Training and use of the equipment takes place during new pilot and medic orientation as well as during recurrent training.

From: NTSB
To: State of Delaware, State Police, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Delaware State Police’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Nassau County Police’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of Texas, County of Austin-Travis, Emergency Medical Services, STAR Flight
Date: 6/19/2014
Response: We note that all your emergency medical services helicopters are equipped with helicopter TAWS and that all pilots are trained on how to use this system. Accordingly, Safety Recommendation A-09-133 is classified CLOSED—ACCEPTABLE ACTION.

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: Travis County STAR Flight installed Helicopter Terrain Awareness Warning Systems in our EC145 helicopters in 2009. All helicopters are equipped with the Honeywell MK-XXI Helicopter Ground Proximity Warning System. Equipment training is conducted during both initial and recurrent pilot training and any time a modification is made to the system. In Addition, Travis County STAR Flight initiated Helicopter Night Vision Goggles Operations into the program in 2006 and from that time forward, all night operation are flown with all crewmembers wearing NVG as appropriate.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated that they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is either necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether STAR Flight’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the New York City Police’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of Florida, County of Miami-Dade, Fire Rescue, Special Operations Division
Date: 6/20/2014
Response: We note that, although your helicopters are equipped with TAWS, the systems are currently inoperable because of equipment and software compatibility issues. We are encouraged that you intend to update your fleet in the near future and will consider also updating your technology at that time. Accordingly, pending our receipt of updates on your progress and the completion of the recommended actions, Safety Recommendation A-09-133 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: All Air Rescue aircraft were equipped with the Honeywell Enhanced Ground Proximity Warning System (EGPWS) in 2005. However, this system was removed from the aircraft in 2011 due to the distraction it created for Air Rescue crews. In 2011, Air Rescue installed the Garmin Helicopter Terrain Awareness Warning System (H-TAWS) which are presently inoperable due to equipment and software compatibility issues.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Miami-Dade County Fire Rescue’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the helicopter

From: NTSB
To: State of New York, County of Suffolk, Police Department, Aviation Section
Date: 7/15/2015
Response: We note that, although the Suffolk County Police Department’s existing helicopters are not equipped with helicopter TAWS, the department is scheduled to receive a new helicopter soon that will have this technology installed. We are also encouraged to learn that you will consider retrofitting the department’s existing fleet with this technology in the future. Pending our receipt of updates on the department’s progress and completion of the recommended actions, Safety Recommendation A-09-133 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. Our new Airbus EC-145, which will be delivered and placed into service later this year, will be equipped with a terrain awareness and warning system. Our pilots have received training on this system during Airbus OEM training, which will be reinforced by additional in-house training. We will research the viability and cost of upgrading our other aircraft to mirror this capability. We are fortunate that our terrain is relatively flat with a range from sea level to 401 feet above sea level. Additionally, all of our aircraft are equipped with moving maps that allow waypoints to be set to alert our pilots of approaching hazards.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Suffolk County Police Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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 Maryland, State Police, Aviation Command
Date: 7/15/2015
Response: We are pleased that the MSP operates only AW-139 helicopters, which are equipped with Helicopter TAWS (H-TAWS) units that comply with the minimum performance standards outlined in the Technical Standard Order titled “H-TAWS,” and that all MSP pilots have been trained to use this technology. Accordingly, Safety Recommendation A-09-133 is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: State of Maryland, State Police, Aviation Command
Date: 5/22/2014
Response: We note that you continue to take delivery of AW-139 helicopters, which are equipped with helicopter TAWS (H-TAWS) units that comply with the minimum performance standards outlined in the Technical Standard Order titled “H-TAWS.” We continue to believe that your use of the Garmin 696 units on the AS-365 helicopters constitutes an acceptable interim solution until your transition to the AW-139 helicopters is complete. Pending confirmation from you that the transition is complete, Safety Recommendation A-09-133 remains classified OPEN—ACCEPTABLE RESPONSE.

From: State of Maryland, State Police, Aviation Command
To: NTSB
Date: 1/14/2014
Response: -From S/T Michael W. DeRuggiero, Safety Management Officer, Aviation Command, Maryland State Police: On October 19, 2010, the Maryland Department of Transportation MDOT signed a contract with the Agusta Westland Philadelphia Corporation (A WPC) to purchase up to twelve AW-139 helicopters for the MSP AC that will meet and/or exceed all NTSB equipment recommendations issued to date for both Public and Commercial HEMS (Air Ambulance) Operators. The MSPAC took delivery of the first nine (9) A W-139 helicopters in calendar year 2013 and expects delivery of the remaining helicopter(s) by the end of FY 2015. In April of 2013, a decision was made by the MSPAC Command Staff to operate the A W -139 helicopters with two pilots. The decision to utilize a two pilot flight crew was made due to the complexity of the helicopter and in part, because the MSPAC concurs with the NTSB's belief that a second pilot may have prevented the fatal accident involving MSPAC's Aerospatiale SA365Nl helicopter, N92MD, which occurred in District Heights, Maryland on September 27, 2008. 1 In April of 2013, the MSPAC began transitioning its pilots into the A W -139 helicopter. Until the transition is complete, the MSPAC will utilize both the SA/AS365 and AW-139 helicopters to conduct HEMS flight operations. The SA/AS 365 helicopters will continue to be operated with a single pilot during the transition. Due to the increased staffing requirements created by the addition of a second pi lot, the MSPAC anticipates completing the transition from the SA/AS365 helicopter into the AW-139 helicopter sometime in FY 2015. In closing, it is the MSPAC's intention to make every attempt to fully comply with each and every NTSB recommendation issued specifically to the MSPAC, Public and/or Commercial HEMS Operators. While it may not be possible to fully comply with each NTSB until MSPAC's transition from the SA/ AS365 helicopters and into the A W -139 helicopters is complete, it is the MSPAC intention to have all NTSB recommendations issued specifically to the MSPAC, Public and/or Commercial HEMS operators classified by the NTSB as "Closed- Acceptable Response/Action." MSPAC RESPONSE: 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 MSP AC's current fleet of SA/ AS-365 helicopters. Prior to 2007, due to State budget constraints, only three of the MSPAC's twelve (12) SA/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 MSP AC helicopters equipped with HT A WS. To bridge the gap after the accident, on January 9, 2009, the Commander of the MSPAC testified before Maryland's EMS Board (SEMSAC) and recommended that funding be allocated to purchase eleven (11) portable Garmin 696 GPS units to provide TAWS information, as well as satellite weather information, to all MSP AC flightcrews unti I replacement helicopters have been identified and purchased by MDOT. The SEMSAC Board approved funding and eleven "Garmin 696" portable GPS units were purchased for the MSP AC and delivered in May of 2009. An aircraft mount for the Garmin 696 was engineered for the SA/ AS-365 helicopters and approved by the local FAA FSDO. The units were placed in service at each operational section in October 2009 after all MSPAC pilots were properly 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. On October 19, 2010, the Maryland Department of Transportation (MDOT) signed a contract with the AgustaWestland Philadelphia Corporation (AWPC) to purchase up to twelve AW-139 helicopters for the MSPAC that will meet and/or exceed all NTSB equipment recommendations issued to date for Public and Commercial HEMS (Air Ambulance) Operators. The MSPAC took delivery the first nine (9) A W -139 helicopters in calendar year 2013 and expects delivery of the remaining helicopter(s) by the end of FY 2015. Each of MSPAC's AW-139 helicopters is equipped with Honeywell's "Enhanced Ground Proximity Warning System" (EGPWS) and "Traffic Collision Avoidance System" (TCAS), both of which are integrated into the AW-139's Flight Management System (FMS). Each pilot is provided with both initial and annual recurrent training on each system. Considering the above, the MSPAC believes that it currently complies with this recommendation. All information provided by the MSPAC in support of the information provided here can be found in "Attachment A-09-133."

From: NTSB
To: State of Maryland, State Police, Aviation Command
Date: 12/31/2013
Response: The Maryland State Police’s only letter concerning Safety Recommendation A-09-133, dated January 4, 2012, stated that, as of November 2009, Garmin 696 portable geographic positioning system units, which provide TAWS information as well as satellite weather information, had been placed in service at each operational section, and all State Police pilots had completed training on the units. The Police also stated that they planned to replace their current fleet of AS-356 helicopters with six AW-139 helicopters, which were to be equipped with Helicopter TAWS (H-TAWS) units that comply with the minimum performance standards outlined in the Technical Standard Order titled “H-TAWS.” Our June 20, 2012, reply to the Maryland State Police stated that the use of the Garmin 696 units constitutes an acceptable interim solution until the organization’s fleet has been updated with AW-139 helicopters that are equipped with H-TAWS. Pending confirmation by the State Police that all helicopters have been equipped with H-TAWS and all flight crews have received training on these systems, Safety Recommendation A-09-133 was classified “Open?Acceptable Response” on June 20, 2012. We would like to know whether the Maryland State Police’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of Maryland, State Police, Aviation Command
Date: 6/20/2012
Response: The NTSB notes that, as of November 2009, Garmin 696 portable geographic positioning system units, which provide TAWS information as well as satellite weather information, had been placed in service at each operational section and all MSPAC pilots had completed training on the units. We believe that the use of the Garmin 696 units constitutes an acceptable interim solution until the existing MSP fleet has been updated with AW-139 helicopters, which are to be equipped with Helicopter TAWS (HTAWS) units that comply with the minimum performance standards outlined in the Technical Standard Order titled “HTAWS.” Accordingly, pending confirmation by the MSP that all helicopters have been equipped with HTAWS and all flight crews have received training on these systems, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE. The NTSB is pleased that MSP acted quickly, effectively, and responsibly to address these safety concerns prior to our issuing these safety recommendations, and we believe that the MSP’s postaccident changes are consistent with the findings of our investigation. In addition, we recognize that our safety recommendation process is new to your organization, and we appreciate your cooperation and your efforts to address these safety concerns in a timely manner.

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 Volusia, Sheriff's Office
Date: 5/27/2014
Response: We note that, although your aircraft are not equipped with helicopter TAWS, you will consider this technology as you upgrade your equipment. Pending our receipt of updates regarding your progress in upgrading your fleet, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of Florida, County of Volusia, Sheriff's Office
To: NTSB
Date: 1/21/2014
Response: -From Ben F. Johnson, Sheriff: VCSO only operates single turbine-engine helicopters having a maximum seating configuration, excluding any required crew member seat, of less than 10 seats and therefore are not required to have Terrain Awareness and Warning Systems installed on our aircraft. VCSO is exempt by 14 CFR Part 135.154. VCSO is looking into the practicality of equipping our aircraft with HTAWS.

From: NTSB
To: State of Florida, County of Volusia, Sheriff's Office
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Volusia County Sheriff’s Office’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of Arizona, Department of Public Safety, Highway Patrol, Aviation Division
Date: 5/22/2014
Response: We note that, although your helicopters are not equipped with TAWS, you will consider implementing this recommendation in the future. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

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 aircraft do not currently have installed TAWS. We support this recommendation and will further pursue means to implement this safety measure. It is the policy statement and stance of AZ DPS Aviation, that the greatest strides in HEMS and aviation safety can be effected with a management driven, safety first/mission second culture. A SMS is paramount, but adherence and ownership in it is imperative to that culture. Please feel free to contact me with any questions regarding our responses to your recommendations.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Highway Patrol Division’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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, although you use portable global positioning devices that provide TAWS information, your aircraft are not equipped with helicopter TAWS units that comply with Technical Standard Order C-194. We encourage you to include this technology on future aircraft as you update your fleet. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 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: While SDFD's aircraft are not equipped with H-TAWS, they do have Garmin GPS moving map with terrain and obstacle database that is updated as new data becomes available. While current H-TAWS would be beneficial for most HEMS operators, due to our limited geographic area of operations and the fact we operate only in VMC and in close proximity to terrain, the alerting function would be distracting to our crews during critical phases of our mission profile, such as hoist rescue and fire fighting.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the San Diego Fire-Rescue Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the San Diego Fire-Rescue Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, County of Los Angeles, Fire Department, Emergency Medical Services
Date: 6/19/2014
Response: We are aware that, although only one of your Bell 412s is equipped with helicopter TAWS that complies with Technical Standard Order C-194, you will consider including this technology on future aircraft as you update your fleet. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

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 Department was already in the process of assisting an avionics manufacturer in obtaining FAA STC approval of the first Bell 412 HTAWS back in 2010. All of the Unit's pilots have had the opportunity to fly the HTAWS equipped aircraft that has the additional capabilities of a Traffic Collision Avoidance System (TCAS) and wire/obstacle avoidance system with NVG compatibility. While the Department understands the position of the NTSB as to the value of the HTAWS system to HEMS safety, the decision to equip the entire fleet with the system has not been finalized as of this date. The Los Angeles County Fire Department has been providing quality HEMS services as well as SAR, hoist and aerial firefighting capabilities to the citizens of this challenging geographical jurisdiction of over 4000 square miles since 1957. The Department is proud of its exceptional safety record in the HEMS mission and is committed to remaining a leader in the public aircraft operations arena for years to come. Procedures in use today by many other public aircraft agencies were first developed and implemented by this Department. The Department welcomes the opportunity to assist the NTSB in working towards the goal of "zero accidents" in the HEMS industry and regrets the delay in responding to the 2009 safety recommendations letter.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the helicopters operated by the Los Angeles County Sheriff’s Department or Fire Department are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Dekalb County Police Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, East Bay Regional Park District Police, Air Support Unit
Date: 5/27/2014
Response: We note that, although your aircraft are not equipped with helicopter TAWS, you will consider this technology as you upgrade your equipment. Pending our receipt of future updates regarding your progress in upgrading your fleet, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

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: The District currently operates two single engine AS350 model helicopters. The first is a 1996 AS350 82 which is not currently equipped with helicopter terrain awareness/warning systems (H-TAWS) or traffic collision avoidance/detection (TCAD) systems. This is largely due to the expense in retrofitting this airframe. The addition of this equipment will likely be included in the specifications for future replacement aircraft. The second aircraft is an AS350 83 model, which is equipped with H-TAWS, TCAD and weather data systems which are displayed via the Chelton Synthetic Vision EFIS Displays and supported with aural warnings through the audio system. All pilots are trained and competent in their use, which is also formalized into our NVG training and operations.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the helicopters of the East Bay Regional Park District Police are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of New York, County of Onodaga, Sheriff's Department, Aviation Unit
Date: 7/30/2014
Response: We note that, although your aircraft are not equipped with helicopter TAWS units that are compliant with Technical Standard Order C-194, you will consider acquiring this technology in the future. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Onondaga County Sheriff's Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133, dated December 21, 2009, stated that it plans to equip both of its helicopters with equipment that meets the technical standard order (TSO) for helicopter TAWS (H-TAWS); however, it is waiting until the FAA has announced publication of the H-TAWS final rule before installing new equipment. Our January 11, 2011, reply encouraged the District to reconsider its position on this matter and proceed with H-TAWS installation. Pending its installation of H-TAWS on its aircraft and implementation of training to ensure that flight crews are capable of using the systems to safely conduct HEMS operations, Safety Recommendation A-09-133 was classified “Open?Acceptable Response” on January 11, 2011. The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the District’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of Florida, City of Palm Beach, Health Care District
Date: 1/11/2011
Response: The District indicated that, although it plans to equip both of its helicopters with equipment that meets the technical standard order (TSO) for helicopter TAWS (HTAWS), it is waiting until the FAA has announced publication of the HTAWS final rule before installing new equipment. Although the District’s decision to wait for this rule to be published is understandable, the NTSB does not believe it is necessary or advisable: The rulemaking process is lengthy, and TSO-approved systems are currently available. Therefore, we encourage the District to reconsider its position on this matter and proceed with HTAWS installation. Pending the District’s installation of HTAWS on its aircraft and implementation of training to ensure that flight crews are capable of using the systems to safely conduct HEMS operations, Safety Recommendation A-09-133 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 currently has installed, on each of its two identical aircraft, radar altimeters with multiple information display locations and separate terrain and obstruction avoidance equipment. Although our current GMX200 is new technology, it does not meet the aural warning requirements specified in the TSO for HTAWS. Funding for additional equipment which meets the TSO for HTAWS is available and we are awaiting issuance of the regulation before selecting and installing new equipment. The District's overnight shift (7:00pm - 7:00am) is a two pilot crew thereby further reducing the likelihood of a CFlT accident during night time operations. Hopefully, I touched on enough of the safety measures the District applies in its operation to provide you with an understanding of how we address the concerns presented in the above referenced NTSB recommendations. It is important to realize that while the NTSB recommendations target specific issues it has determined are significant, other issues are involved. Human Factors play a significant role in safe operations and an understanding of the piece these play in each accident are a key to prevention. It is also critical that crew members and management understand Human Factors. Direct involvement in daily operations by upper management is important. I would recommend to the NTSB that a more thorough review especially in the area of Human Factors be accomplished in all future accident investigations.

From: NTSB
To: State of Florida, County of Collier, MedFlight
Date: 4/30/2014
Response: We note that, in 2011, your helicopter was equipped with a Sandel helicopter TAWS system and that your flight crews are trained on how to use the system as well as the warnings associated with the system announcements. Because these actions satisfy the intent of Safety Recommendation A-09-133, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: State of Florida, County of Collier, MedFlight
To: NTSB
Date: 1/10/2014
Response: -From Steve Adams, County Chief Pilot: A-09-133 Collier County MedFlight installed the Sandel HTAWS system in early 2011. Each pilot and flight medic are trained on the use of the HTAWS system as well as the warnings associated with the system announcements.

From: NTSB
To: State of Florida, County of Collier, MedFlight
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether Collier County EMS’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, City of Los Angeles, Fire Department, Air Operations
Date: 7/24/2014
Response: e note that, although your aircraft are not equipped with helicopter TAWS units that are compliant with Technical Standard Order C-194, you intend to consider this technology as you update your fleet. Accordingly, pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

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 currently does not have TAWS installed on HEMS aircraft. However, the AW139, equipped with the Primus Epic system, includes a traffic collision avoidance system (TCAS) along with GPS Radio Altimeter providing audio warning at 150’ above ground level (AGL). Future aircraft will be purchased with TAWS (for Agusta Aircraft will be identified as Enhanced Ground Proximity Warning System - EGPWS) and it is anticipated that current aircraft will be equipped with EPGWS as soon as possible. Pilots will receive initial and recurrent training in EGPWS when it is installed in the aircraft.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Los Angeles Fire Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of Alaska, North Slope Borough, Search and Rescue Department
Date: 7/11/2014
Response: We note that, in 2011, both of your helicopters were equipped with helicopter TAWS and that your pilots receive initial and recurrent training on this technology. These actions satisfy Safety Recommendation A-09-133, which 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: All aircraft have terrain awareness and warning systems. The flight crews are trained in the use of these systems in the aircraft and in simulators.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the North Slope Borough’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: State of Florida, County of Broward, Sheriff's Office
To: NTSB
Date: 6/4/2014
Response: -From Alphonso Jefferson, Jr., Assistant to the County Administrator: We are in receipt of a letter from the Chairman of the NTSB as a follow-up to information that was provided on January 9, 2014 regarding eight safety recommendations that were issue to the Broward County Sheriff’s Office in 2009. Please be advised that all correspondence on this matter can be directed to the Broward County Sheriff’s Office.

From: NTSB
To: State of Florida, County of Broward, Sheriff's Office
Date: 5/27/2014
Response: We note that, although your aircraft are not equipped with helicopter TAWS, you will consider this technology as you upgrade your equipment. Pending our receipt of future updates regarding your progress in upgrading your fleet, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

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. A09-133: TWAS: We currently do not have TWAS however, each aircraft has TCAS and the moving maps have the ability to identify antennas over 200 ft tall. As we upgrade equipment, it will be a consideration. If there is any further information I can assist you with, feel free to contact me at the below information. You may utilize the information below to update your records.

From: NTSB
To: State of Florida, County of Broward, Sheriff's Office
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Broward County Sheriff’s Office’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Sheriff’s Office’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Maricopa County Sheriff’s Office’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, County of Orange, Sheriff's Department, Air Support Division
Date: 5/22/2014
Response: We note that, although your helicopters are not equipped with TAWS, you will consider implementing this recommendation in the future. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

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 may look at purchasing terrain awareness and warning systems if funding becomes available in the near future.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Orange County Sheriff’s Department’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, County of San Bernardino, Sheriff's Department
Date: 6/26/2014
Response: We note that, although your aircraft are not currently equipped with helicopter TAWS units that are compliant with Technical Standard Order C-194, you intend to install this technology on your existing fleet in the future. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 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 Sheriff's Aviation Unit only uses pilots who are trained within the Unit. This allows them to become intimately familiar with all flight characteristics in the areas that we fly, which includes most of Southern California. This has been a "time tested" flight training operation and maintains the crew's situational flight safety. Each crew member is aware of hazards in every location within the County Operational Area. As we upgrade the equipment and software, we include a H-THAWS component.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the helicopters of the San Bernardino County Sheriff’s Department are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, County of Santa Barbara, Sheriff's Department, Air Unit
Date: 6/19/2014
Response: We note that the helicopters that you use to perform HEMS are equipped with helicopter TAWS and that your flight crews are trained on how to use the system. Accordingly, Safety Recommendation A-09-133 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: Currently we have one helicopter specifically configured for HEMS operations. TAWS is currently installed in this rescue aircraft.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the helicopter

From: NTSB
To: State of California, County of Sonoma, Sheriff's Office
Date: 3/6/2015
Response: We note that, although your helicopter is not equipped with TAWS, you will consider including this technology when you replace it. Pending our receipt of future updates regarding your progress in updating your equipment, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

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 current aircraft is not TAWS equipped. We do not plan or have the ability to install TAWS in our current aircraft. We are investigating the appropriateness of adding TAWS capability to a future replacement aircraft.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the Sonoma County Sheriff’s Office’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, State Police, Highway Patrol, Office of Air Operations
Date: 7/23/2014
Response: We note that, although your aircraft are not equipped with helicopter TAWS units that are compliant with Technical Standard Order C-194, you intend to include this technology in the future as you update your fleet. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, State Police, Highway Patrol, Office of Air Operations
To: NTSB
Date: 3/26/2014
Response: J.A. Farrow, Commissioner: California Highway Patrol aircraft are equipped with devices that provide TAWS-like information. The CHP helicopters use navigation equipment which include terrain mapping and therefore visually indicate if a conflict with terrain exists. California Highway Patrol aircraft are also equipped with radar altimeters which are required to be set at a minimum altitude of 300 feet. The radar altimeters provide an audible warning when the aircraft descends below 3 00 feet above ground. Although current Global Positioning System (GPS) equipment installed in CHP aircraft only provides TA \VS-like information, future aircraft are being specified with models of GPS equipment which can provide TAWS information and are expected to provide CHP air crews with forward looking terrain avoidance, premature descent alert, attention alerts, and indication of imminent contact with the ground.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the California Highway Patrol’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 3/8/2017
Response: Although your aircraft are not equipped with helicopter TAWS, we are encouraged that your fleet modernization program specifies that all future fleet acquisitions will be equipped with this technology. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 remains classified OPEN--ACCEPTABLE RESPONSE.

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: Currently, the unit’s King Air 200s are equipped with TAWS. All nine of our HEMS-equipped helicopters have a portable GPS unit that provides a limited amount of terrain awareness. The unit’s fleet modernization plan would include EGPWS (Enhanced Ground Proximity Warning System) for TAWS in any new helicopter purchase. I value the strong relationship our unit enjoys with the NTSB and the improvements in safety that are enhanced as a result of NTSB progressiveness. I trust that I have explained our unit’s improvements and procedures will be sufficient to satisfy the 2009 NTSB Safety Recommendation. I consider this response to be in compliance with your request for information and consider the matter complete, status of “Closed.”

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 6/20/2014
Response: We note that, although your aircraft are not equipped with helicopter TAWS units that are compliant with Technical Standard Order C-194, you intend to consider this technology as you update your fleet. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 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: NTSB
To: State of New York, State Police, Aviation Unit
Date: 2/10/2014
Response: -From Major Charles E. Guess, NYSP Director of Aviation: Currently the NYSP do not have any TAWS equipment installed on aircraft operating in the HEMS role. All aircraft are equipped with a radar altimeter however. All NYSP stations are provided with a portable GPS that is equipped with terrain mapping and provides a passive view/warning of terrain. The GPS units do possess a proximity warning feature but operational experience indicates that most pilots disregard this feature as the GPS unit tolerances appear to be designed for higher speed fixed wing operations, with their subsequently larger turning radius. The warning is not realistic for helicopter operations. The Unit has explored funding of TAWS equipment for all helicopters. The cost is estimated at $300,000 for the Bell430 fleet and $125,000 for the Bell407 fleet. Due to the aging of the current fleet the NYSP has elected not to proceed with this installation. The NYSP does however recognize the potential life saving potential of TAWS and the specifications developed for future acquisitions include this requirement. In short the NYSP will address the recommendation and put it into effect as new aircraft are brought on-line. I trust that this explanation of our Unit procedures will serve to satisfy your inquiry regarding the 2009 Safety Recommendations. We consider this response to be in compliance with your request for information and consider the matter complete; status "Closed.".

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the New York State Police’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: United States Department of the Interior, National Park Service, Park Police, Aviation Unit
Date: 6/20/2014
Response: We note that, although your aircraft are not equipped with helicopter TAWS units that are compliant with Technical Standard Order C-194, you intend to consider this technology as you update your fleet. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 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 are examining the use of a TAWS system, but does not currently have the funding necessary to accomplish this recommendation.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the United States Park Police’s helicopters are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, County of Ventura, Sheriff's Department, Aviation Division
Date: 6/13/2014
Response: We note that, although you use portable global positioning devices that provide TAWS information, your aircraft are not equipped with helicopter TAWS units that are compliant with Technical Standard Order C-194. We are encouraged to learn that you would like to include this technology on future aircraft as you update your fleet. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-133 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 currently does not have TAWS in any of its aircraft however; the unit does utilize a portable Garmin GPS unit that incorporates TAWS. As a result, this is currently being discussed and we hope that we can accomplish this in the near future as we upgrade or replace our aging fleet of aircraft.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the helicopters operated by the Ventura County Sheriff’s Department or Fire Department are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.

From: NTSB
To: State of California, County of Los Angeles, Sheriff’s Department, Aero Bureau
Date: 1/14/2015
Response: We note that all of your helicopters are equipped with helicopter TAWS and that your flight crews receive initial and recurrent training on this technology. Accordingly, Safety Recommendation A-09-133 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 fleet of three (3) AS332Ll Super Puma rescue aircraft are equipped with a Honeywell Mark XXII helicopter terrain awareness system (HT A WS). All HEMS pilots have received initial and recurrent training on the system.

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-09-133 is to ensure that HEMS helicopters are equipped with a TAWS and that flight crews are properly trained to use it. We believe that a TAWS would provide important aural alerts to pilots that could help them detect terrain or other obstructions along the flightpath, prompting them to take corrective action and prevent accidents. Some of the other operators who received this recommendation have equipped their helicopters with helicopter TAWS (H-TAWS). Other operators have stated they are waiting for the FAA to issue the HEMS final rule before installing equipment. We emphasize that, on December 17, 2008, the FAA issued technical standard order C-194, which standardized the manufacture of H-TAWS within the industry. As a result, approved systems are currently available. Therefore, we do not believe it is necessary or advisable for operators to wait until the HEMS final rule is published before installing H-TAWS. We would like to know whether the helicopters operated by the Los Angeles County Sheriff’s Department or Fire Department are equipped with H-TAWS; we would also like to know about any current or planned TAWS training.