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Safety Recommendation Details

Safety Recommendation A-09-090
Details
Synopsis: Calendar year 2008 was the deadliest year on record for the helicopter emergency medical services (HEMS) industry, with 12 accidents (8 fatal accidents) and 29 fatalities. As a result of this increase in fatal accidents involving HEMS operations, the National Transportation Safety Board (NTSB) placed the issue of HEMS safety on its Most Wanted List of Transportation Safety Improvements on October 28, 2008, and also conducted a 4-day public hearing to critically examine safety issues concerning this industry. Based on testimony given at this hearing, in addition to findings from recent HEMS accidents, the NTSB believes the Federal Aviation Administration (FAA) needs to take action to prevent additional accidents. These actions include improved pilot training; collection and analysis of flight, weather, and safety data; development of a low-altitude airspace infrastructure; and the use of dual pilots, autopilots, and night vision imaging systems (NVIS). Additional recommendations have been addressed to the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS), the Department of Homeland Security’s Federal Interagency Committee on Emergency Medical Services (FICEMS), and 40 public HEMS operators.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require helicopter emergency medical services operators to install flight data recording devices and establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Washington, DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09SH001
Accident Reports:
Report #: None
Accident Date: 2/3/2009
Issue Date: 9/24/2009
Date Closed: 1/25/2018
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Helicopter Emergency Medical Services

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/25/2018
Response: Although the February 21, 2014, final rule, “Helicopter Air Ambulance (HAA), Commercial Helicopter, and Part 91 Helicopter Operations,” requires HAA operators to equip HAAs with FDM systems, we remain concerned that the rule does not require HAA operators to establish the recommended FDM program. You said that the FAA endorses using voluntary flight operations quality assurance (FOQA) programs to continuously monitor and evaluate operational practices and procedures; however, because the protections of Part 193, “Protection of Voluntarily Submitted Information,” are available only if the data is collected by operators as part of a voluntary FAA-approved program, you do not intend to initiate rulemaking that mandates that HAA operators establish FDM programs. This recommendation does not ask you to require HAA operators to establish a voluntary safety program, such as FOQA, which shares de-identified aggregate information with the FAA. The intent of this recommendation is for HAA operators to establish an internal program that analyzes the recorded FDM system data and monitors trends in their HAA operations. Because the data collected would not need to be shared with you, we do not see the need for protecting it. We continue to believe that HAA operators should be required to establish an FDM program to identify deviations from established norms and procedures and to identify other potential safety issues. However, because you do not intend to take any additional actions in response to Safety Recommendation A-09-90, it is classified CLOSED--UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 11/1/2017
Response: -Michael P. Huerta, Administrator: On February 21. 2014, the FAA published the Helicopter Air Ambulance (HAA), Commercial Helicopter, and Part 91 Helicopter Operations Final Rule. This final rule addresses helicopter air ambulance, commercial helicopter, and general aviation helicopter operations, and amended Title 14, Code of Federal Regulation ( 14 CFR) Part 135 to add section 135.607, Flight Data Monitoring System. HAA-specific equipment and training are required for HAA operations, starting on the effective dates provided in the applicable regulations. No person may operate a helicopter in air ambulance operations unless it is equipped with an approved Flight Data Monitoring System (FDMS) capable of recording flight performance data after April 23, 2018. This system must: (a) Receive electrical power from the bus that provides the maximum reliability for operation without jeopardizing service to essential or emergency loads, and (b) Be operated from the application of electrical power before takeoff until the removal of electrical power after termination of flight. The FAA also published Advisory Circular (AC) 135-1 48, Helicopter Air Ambulance Operations on March 26, 2015. AC 135-148 can be found on our Web site at: http://www.faa.gov/regulationspolicies/advisorycirculars/index.cfin/go/document.information/documentID/I027108. The FAA encourages HAA operators to adopt voluntary safety programs and AC 135-148 recommends that FDMS data should be retrieved periodically and used for safety assurance programs, such as flight operations quality assurance (FOQA). The FAA noted in the above mentioned final rule that part 13, Investigative and Enforcement Procedures, states conditions under which information obtained from an approved voluntary FOQA program will not be used in enforcement actions against an operator or its employees. Additionally, part 193, Protection of Voluntarily Submitted Information. contains provisions for certain protections from public disclosure of voluntarily submitted safety-related information when such information has been designated by an FAA order as protected under that part. As previously stated in the associated notice of proposed rulemaking, these protections are available only if the data is collected by the operator as part of a voluntary FAA-approved program. The FAA will not initiate rulemaking that mandates operators to establish flight data monitoring programs. Maintaining the voluntary nature of the program is key to collecting meaningful data, and the tenets of FOQA do not allow the FAA to mandate FOQA. However, in support of this public safety objective, the FAA endorses using voluntary FOQA programs as a tool for continuously monitoring and evaluating operational practices and procedures. These programs and other voluntary safety programs are helpful to operators as they review data sources to identify deviations from established norms and procedures and other potential safety issues. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 9/11/2014
Response: We are aware that the FAA’s October 12, 2010, NPRM requested comments about whether light weight aircraft recording system (LARS) devices would provide data that would be valuable in an accident investigation and whether operators would use those systems to improve daily operations, including whether operators would be likely to participate in an FAA approved Flight Operational Quality Assurance program. In our comments, we confirmed that LARS devices would constitute a valuable aid to accident investigation and would be capable of supporting a structured FDM program. We are aware that, in section 135.607, the February 21, 2014, final rule requires operators to equip helicopter air ambulances with FDM systems and encourages operators to gather and analyze this information for use in improving safety in their day-to-day operations. Although we are pleased that you included this requirement, we are also aware that the final rule does not require helicopter air ambulance operators to establish the recommended FDM program. We point out that such a program is needed to identify deviations from established norms and procedures and to identify other potential safety issues, and we would like to know details of your plans for addressing this part of the recommendation. Pending our receipt and review of this additional information and completion of the recommended actions, Safety Recommendation A 09-90 is classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 9/6/2013
Response: Our last update from the FAA regarding this recommendation was its May 8, 2012, letter. We are concerned that, although more than 1 year has passed since then, we have received no additional information regarding the agency’s efforts to address Safety Recommendation A-09-90. Pending our receipt of such an update and completion of the recommended action, this recommendation remains classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 7/18/2012
Response: In our January 10, 2011, comments regarding the FAA’s notice of proposed rulemaking (NPRM) titled, “14 CFR Parts 1, 91, 120, and 135 Air Ambulance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135 Aircraft Operations; Safety Initiatives and Miscellaneous Amendments; Proposed Rule,” the NTSB pointed out that, although the FAA appears to be moving toward a requirement to install lightweight aircraft recording systems in helicopters used for EMS operations, such a requirement was not included in the NPRM, nor was a requirement to install these systems in all rotorcraft operating under 14 CFR Parts 91 and 135 with a transport-category certification. Because the technology recommended is currently available, practical, and appropriate, we continue to believe that the FAA should begin the process to mandate that these rotorcraft be equipped with a CVR and an FDR. Accordingly, pending the FAA’s initiating such a requirement, Safety Recommendation A-06-17 remains classified “Open—Unacceptable Response.” Pending our review of the FAA’s proposed rule, Safety Recommendation A-09-90 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/8/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) issued the Air Ambulance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135 Aircraft Operations; Safety Initiatives and Miscellaneous Amendments Notice of Proposed Rulemaking (NPRM) on October 12,2010. The comment period closed on January 10, 2011. The FAA has received and reviewed the comments submitted by the Board as part of the rulemaking process. We have finished drafting a final rule that will address these recommendations. We expect to publish the final rule after it has been cleared by the U.S. Department of Transportation and the Office of Management and Budget later this year. In the NPRM preamble, the FAA specifically requested comments on the potential use of light-weight aircraft recording systems (LARS) in the helicopter air ambulance industry. LARS comprises a system or combination of systems that record a helicopter's flight performance and operational data. The FAA is considering requiring the installation of LARS in order to provide critical information to investigators in the event of an accident. Currently, Title 14 Code of Federal Regulations (14 CFR) §135.151 requires a CVR system in rotorcraft with a passenger seating configuration of six or more seats and for which two pilots are required by certification or operating rules. In addition, 14 CFR §135.152 requires an FDR in rotorcraft with a passenger seating configuration of 10 to 19 seats. Most helicopters used in air ambulance operations are configured with fewer than six seats and, therefore, are not required to be equipped with CVRs or FDRs. According to the NPRM preamble, the FAA is considering requiring the installation of LARS for all helicopter air ambulances regardless of passenger seating capacity or the number of pilots required by certification or operating rules, unless a certificate holder could demonstrate that a CVR or FOR could be used to comply with any requirements. We will keep the Board informed of the FAA's progress on this rulemaking and will provide an update by March 2013.

From: NTSB
To: FAA
Date: 1/10/2011
Response: Notation 8272: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) Notice of Proposed Rulemaking (NPRM) titled "14 CFR [Code of Federal Regulations] Parts 1, 91, 120, and 135 Air Ambulance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135 Aircraft Operations; Safety Initiatives and Miscellaneous Amendments; Proposed Rule," which was published at 75 Federal Register 62640 on October 12, 2010. The FAA states in the NPRM that it is considering requiring certificate holders conducting helicopter air ambulance operations to install lightweight aircraft recording systems (LARS) in their helicopters. The requirement for such a device is not, however, incorporated into the proposed rule. The NTSB is pleased that the FAA appears to be moving toward a flight recorder requirement for EMS helicopters but is disappointed that it is not part of this proposed rule for all helicopters. Safety Recommendations A-06-17 and -18 recommended the installation and use of cockpit voice recorders (CVR) and flight data recorders (FDR) for transport-category rotorcraft, as well as ending exemptions that have been granted by the FAA to large transport category rotorcraft that carry 10 or more passengers. Specific to HEMS operations, the NTSB also issued Safety Recommendation A-09-90, asking the FAA to “require helicopter emergency medical services operators to install flight data recording devices and establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.” Safety Recommendations A-09-9, -10, and -11 are also pertinent to the issue of LARS use in HEMS operation. These recommendations would propose the required installation of crash-resistant recorders capable of audio, video, and data recording, as specified in European Organization for Civil Aviation Equipment (EUROCAE) document ED-155, in both newly manufactured and existing turbine-powered, non-experimental, non-restricted-category aircraft. While these recommendations are not specific to HEMS operations, they address the target population of helicopters. A considerable amount of work has been done by EUROCAE (with full participation by both the FAA and the NTSB) to develop the standards for flight recorder devices, which would fulfill the requirements enumerated in the NPRM for LARS devices. EUROCAE ED-155 is a manufacturing standard, issued in July 2009, for a lightweight, low-cost, robust aircraft recording device. The ED-155 standard covers FDR-like data recording, CVR-like audio recording, cockpit video, and data-like message recording. It also specifies parameters that should be recorded for both airplanes and helicopters and the details of range, resolution, and accuracy that should be required. Several manufacturers are producing ED-155-compliant recorders, even though the FAA has not adopted the ED-155 specification as an approved technical standard order (TSO). The cost of these recorders is less than $10,000. ED-155, in fact, defines a LARS device, and the NTSB believes that it should promptly and efficiently be incorporated into a TSO to unambiguously establish appropriate standards for LARS. In addition to being a valuable aid to accident investigation, an ED-155-compliant recorder would also be fully capable of supporting a structured flight data monitoring program, whether it is implemented as a formal FAA-approved flight operations quality assurance (FOQA) program or a monitoring program that is part of a company safety management system. The benefits of data monitoring programs have been evaluated and documented for commercial airlines. The General Accountability Office (GAO) conducted an evaluation of airline-based data collection and monitoring programs in 1998, shortly after adoption of such programs. The GAO highlighted that such programs provide enhanced safety as well as financial benefits due to increased efficiency of operations. It is likely that the HEMS community, as well as all commercial helicopters, will experience similar benefits. The NTSB continues to believe that recording devices on aircraft can have a significant impact on safety and encourages the FAA to include a requirement for LARS in the final rule. Safety Recommendation A-09-90 is currently classified “Open—Acceptable Response.”

From: NTSB
To: FAA
Date: 10/7/2010
Response: The FAA's issuance of supplemental type certificates for the installation of FDM devices and its plan to require installation and use of these devices with flight operation quality assurance programs are responsive to this recommendation. Pending our review of the FAA’s proposed rule, Safety Recommendation A-09-90 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/23/2009
Response: MC# 2100010 - From J. Randolph Babbitt, Administrator: On February 17, 2009, the FAA began issuing supplemental type certificates for the installation of Flight Data Monitoring (FDM) devices. The FAA intends to address this safety recommendation via rulemaking that would require operators using helicopters in air ambulance operations to install and use FDMs and implement flight operation quality assurance (FOQA) programs. We plan to publish a NPRM for public comment in June 2010.