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Safety Recommendation Details

Safety Recommendation A-09-099
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 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 your organization needs to take action to prevent additional accidents. These actions include improved pilot training; flight data monitoring; and the use of dual pilots, autopilots, and night vision imaging systems (NVIS). Additional recommendations have been addressed to the Federal Aviation Administration (FAA), 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 40 PUBLIC OPERATORS OF EMS HELICOPTERS: Install flight data recording devices and establish a structured flight data monitoring program that incorporates routine reviews of all available sources of information to identify deviations from established norms and procedures and other potential safety issues.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
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:
Addressee(s) and Addressee Status: Commonwealth of Pennsylvania, State Police, Aviation Section (Closed - Reconsidered)
Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division (Open - Acceptable Response)
Commonwealth of Virginia, State Police (Open - Acceptable Response)
State of Alaska, North Slope Borough, Search and Rescue Department (Open - Acceptable Response)
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 - Unacceptable Action)
State of California, County of Sonoma, Sheriff's Office (Open - Initial Response Received)
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 - Await Response)
State of Florida, County of Broward, Sheriff's Office (Open - Acceptable Response)
State of Florida, County of Collier, MedFlight (Open - Acceptable Response)
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 (Open - Acceptable Response)
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 (Open - Acceptable Response)
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

Safety Recommendation History
From: NTSB
To: State of Florida, County of Miami-Dade, Fire Rescue, Special Operations Division
Date: 6/20/2014
Response: Although you have not yet installed FDR devices on your helicopters, we note that you intend to update your fleet in the future and that you intend to consider this technology at that time. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 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 helicopters are equipped with hoist and cabin cameras as well as engine and vibration recording devices. The data collected is periodically analyzed by the Aircraft Technicians and any deviations are highlighted. Certain time limitations associated with processing the data exist.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Fire Rescue is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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 fleet of helicopters have limited flight data recording. However, we are in the process of refreshing our fleet with helicopters which have the Garmin G1000 avionics system. This system has the capability of recording numerous flight data inputs via an SD card.

From: NTSB
To: Commonwealth of Pennsylvania, State Police, Aviation Section
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Pennsylvania State Police Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, State Police, Highway Patrol, Office of Air Operations
Date: 7/23/2014
Response: We are encouraged to learn that you intend to include FDR devices in the future as you update your fleet, and we look forward to receiving additional information as you progress toward this goal. Although you reported that your current policies address the routine reviews of all available sources of information to identify deviations from established norms and procedures and other potential safety issues, we are curious about what devices you use to collect these data, what parametric data are being collected, and at what frequency. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A 09-99 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: During the 2009 review, flight data recorders were researched. At the time, there were no commercially manufactured flight data recording devices available. In addition, CHP policies were found to address the "routine reviews of all available sources of information to identify deviations from established norms and procedures and other potential safety issues." Currently, the CHP is seeking to replace its fleet of helicopters. The new helicopters will be equipped with helicopter flight data monitoring systems which provide inertial sensing technologies, high resolution images, and audio recording.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the California Highway Patrol is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 3/8/2017
Response: Although you do not have FDR devices installed on any of your existing helicopters, we are encouraged that your fleet modernization program specifies that all future fleet acquisitions will be equipped with this technology. We point out that, to fully satisfy this recommendation, you will also need to establish an FDM program that routinely reviews the collected data. Pending updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 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: The NYSP Aviation Unit does not currently have any flight data recording devices installed on any of our unit’s aircraft. Consistent with our unit’s fleet modernization program, all fleet acquisitions in the future will have FDR devices installed.

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 3/8/2016
Response: Although you do not have FDR devices installed on any of your existing helicopters, we are encouraged that your fleet modernization program specifies that all future fleet acquisitions will be equipped with this technology. We point out that, to fully satisfy this recommendation, you will also need to establish an FDM program that routinely reviews the collected data. Pending updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 remains classified OPEN--ACCEPTABLE RESPONSE.

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 6/20/2014
Response: We note that, although you do not currently have FDR devices installed on your aircraft, you have requested that future aircraft be equipped with this technology. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 is classified OPEN—ACCEPTABLE RESPONSE.

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

From: State of New York, State Police, Aviation Unit
To: NTSB
Date: 2/10/2014
Response: -From Major Charles E. Guess, NYSP Director of Aviation: The NYSP Aviation Unit does not currently have any flight data recording devices installed on any of its aircraft. The Unit has put forth a modernization proposal and flight data recorders are a key component specified in our attempt to modernize and upgrade the fleet. The cost of adding this technology to the current aging aircraft fleet is cost prohibitive. The Unit is in the process of developing a program to utilize small helmet-mounted digital video cameras to capture hoist rescue operations for training and standardization uses.

From: NTSB
To: State of New York, State Police, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the New York State Police are using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, County of Los Angeles, Sheriff’s Department, Aero Bureau
Date: 1/14/2015
Response: We note that your AS332L1 Super Puma rescue aircraft are equipped with FDR devices, and we are pleased that you have established a flight operations quality assurance program that routinely reviews the data collected from the FDR devices to identify deviations from established norms and procedures and other potential safety issues. We understand that setting up an effective program comes with many challenges, and we commend you for your commitment to working through these challenges. Your actions satisfy Safety Recommendation A-09-99, which 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) AS332L1 Super Puma rescue aircraft an "Appareo" flight operations quality assurance (FOQA) system installed on-board. FOQA system and program were put in place to provide our managers with objective flight data regarding the manner in which out HEMS pilots conduct their flights. This device allows us to review that data and assist in detecting and correcting unsafe deviation from operating practices.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Los Angeles County Sheriff’s Department or Fire Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of Florida, County of Collier, MedFlight
Date: 4/30/2014
Response: We note that your current helicopter does not have an FDR device installed. However, we are encouraged to learn that you intend to (1) evaluate aftermarket FDR devices for your existing helicopter, (2) acquire a second helicopter that will have an FDR device installed, and (3) develop a structured flight data monitoring program once you have helicopters that are equipped with an FDR device. We believe that this plan, when implemented, will satisfy the recommendation, and we look forward to receiving future updates regarding your progress. Pending our receipt of such updates and completion of the recommended actions, Safety Recommendation A-09-99 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of Florida, County of Collier, MedFlight
To: NTSB
Date: 1/10/2014
Response: -From Steve Adams, County Chief Pilot: A-09-99 We currently do not have any plans to install a flight data recording system in our current aircraft. I will be evaluating after market units in February. Our planned 2nd helicopter will have flight monitoring equipment pre-installed at which point we will develop a FOQA program for our organization.

From: NTSB
To: State of Florida, County of Collier, MedFlight
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether Collier County EMS is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of New York, County of Onodaga, Sheriff's Department, Aviation Unit
Date: 7/30/2014
Response: We note that your helicopter is not equipped with an FDR device, but we are encouraged to learn that you will consider including this technology in the future. We look forward to receiving additional information as you progress toward this goal. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A 09-99 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of New York, County of Onodaga, Sheriff's Department, Aviation Unit
To: NTSB
Date: 5/22/2014
Response: -From Captain Mike Pellizzari, Onondaga County Sheriff’s Office, Special Enforcement Commander: The Onondaga County Sheriff's Office is in receipt of you letter regarding safety recommendations A-09-97 through 101. It is the policy of the Onondaga County Sheriff's Office (OCSO) to not respond or comment on suggestions, from the NTSB. We are very aware of your report and very cognizant of the incidents you have detailed in that report. It is the intention of OCSO to be fully compliant with all appropriate FAA regulations. When and if the suggestions made by the NTSB, should become regulation, the OCSO will take appropriate action.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Onondaga County Sheriff's Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of North Carolina, County of Dare, Emergency Medical Services
Date: 1/14/2015
Response: Although you do not have an FDR installed on your helicopter, we are encouraged that you will consider 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-09-99 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: No flight data recording devices have been used at Dare Medflight. However, recorded radio traffic, and data from online flight following services is evaluated for possible safety deviations on a regular basis.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether Dare County EMS is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Nassau County Police is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, City of Los Angeles, Fire Department, Air Operations
Date: 7/24/2014
Response: Although we are pleased to learn that your helicopters are equipped with FDR devices, we are concerned that you are using the data gathered only to measure the health of your aircraft systems. We point out that the intent of this recommendation is to (1) install FDR devices and (2) implement an FDM program. Such data would be particularly useful in evaluating daily operations according to such specific parametric operational standards as altitude, bank angle, pitch attitude, and airspeed limitations. Frequent downloading and analysis of flight data from HEMS flights would provide information on aircraft proximity to terrain and weather, which could assist those evaluating pilot performance to determine whether pilots are conducting HEMS flights in accordance with acceptable operating practices. Therefore, we encourage you to establish a structured FDM program, and we look forward to receiving additional information as you progress toward this goal. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A 09-99 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 City Fire Department has installed Flight Data Recorders (FDR) devices in their aircraft used for HEMS transportation of patients. The FDR systems capture cockpit voice recording along with aircraft performance data including engine data, avionics information, and fuel parameters. The data is reviewed on a scheduled periodic basis by maintenance personnel to verify that the performance of aircraft is with in performance norms. Currently, the LAFD does not, on a regular basis, record image data in the cockpit nor is there a camera integrated into the hoist. However, initial and currency hoist training exercises are recorded on a regular basis with cameras mounted in the cockpit, hoist, and helmet in order to evaluate and improve performance and operations.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Los Angeles Fire Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, East Bay Regional Park District Police, Air Support Unit
Date: 5/27/2014
Response: Although you have not yet installed FDR devices on your helicopters, we are encouraged that you will consider this technology in the future. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 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: No dedicated flight data recorders are currently installed in District aircraft. A re-evaluation of the feasibility of the purchase and installation of flight data recorders will likely occur during the development of specifications for future replacement aircraft.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the East Bay Regional Park District Police are using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Ventura County Sheriff’s Department or Fire Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the New York City Police are using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Santa Barbara County Sheriff’s Department or Fire Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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 your helicopters are equipped with devices that measure the health of the aircraft systems, they are not equipped with FDR devices. However, we are encouraged to learn that you will consider including FDR devices in the future as you update your fleet. We look forward to receiving additional information as you progress toward this goal. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A 09-99 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, City of San Diego, Fire Department, San Diego Medical Services Enterprise
To: NTSB
Date: 2/18/2014
Response: -From Javier Mainar, Fire Chief: SDFD currently operates one Bell212HP and one Bell412EP helicopter. Both aircraft have limited flight data recording devices (FDR). Our Bell412EP has a more comprehensive flight data recording system that includes a complete health usage monitoring system (HUMS). As we look at replacement aircraft, all FDR systems provided by the aircraft OEM will be considered.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the San Diego Fire-Rescue Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the San Diego Fire-Rescue Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Dekalb County Police Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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: 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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Las Vegas Metro Police Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
Date: 6/25/2014
Response: We note that you do not currently have FDR devices installed on your aircraft, but that the Helicopter Association International has offered to update your helicopters with these devices. We look forward to receiving additional information from you regarding this sponsorship, and we point out that, to fully satisfy this recommendation, you will also need to establish an FDM program that routinely reviews the collected data. Pending our receipt of future updates regarding your progress in implementing Safety Recommendation A-09-99, it is classified OPEN—ACCEPTABLE RESPONSE.

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.) At this time, Fairfax County does not plan to install any flight data recording devices. However, with the Bell 429, the aircraft itself, through the aircraft flight data bus, records all parameters of flight including environmental conditions, flight control positions, engine, main rotor, tail rotor and transmission parameters and stores the last 75 flight hours of information in 2 separate locations. The only information not recorded is audio.

From: NTSB
To: Commonwealth of Virginia, County of Fairfax, Police Department, Helicopter Division
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Virginia State Police are using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of New Jersey, State Police, Special Operations Section
Date: 11/20/2014
Response: We note that you would like to establish a structured FDM program that incorporates routine reviews of the information being collected by the FDR and cockpit voice recorder devices that are already installed on your helicopters. We agree that setting up an effective FDM program can be challenging, but we are encouraged by your commitment to work through these challenges, and we look forward to receiving updates in the future regarding your progress in doing so. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 remains classified OPEN—ACCEPTABLE REPONSE.

From: State of New Jersey, State Police, Special Operations Section
To: NTSB
Date: 9/25/2014
Response: -From Toby Hill, The New Jersey State Police Aviation Bureau continues to seek ways to improve our operation and provide a safe and efficient service for our state. We are exploring viable options to comply with your recommendation with regard to A-09-99, Flight Data Monitoring program. There are some concerns which need to be addressed and we are looking for funding sources to purchase the required equipment to implement the program. Working through these obstacles, we intend to meet the needs of all parties involved. Once our program is established, we will advise you.

From: NTSB
To: State of New Jersey, State Police, Special Operations Section
Date: 7/11/2014
Response: Although we are pleased to learn that all of the helicopters you use for HEMS are equipped with FDR and cockpit voice recorder devices, we are concerned that you do not routinely review the information that is collected. Frequent downloading and analysis of these data would provide information on aircraft proximity to terrain and weather, which could assist those evaluating pilot performance to determine whether pilots are conducting HEMS flights in accordance with safe operating practices. Therefore, we encourage you to establish a structured FDM program. We look forward to receiving additional information as you progress toward this goal. Pending our receipt of such information and completion of the recommended action, Safety Recommendation A 09-99 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of New Jersey, State Police, Special Operations Section
To: NTSB
Date: 4/7/2014
Response: -From Toby Hill, New Jersey State Police Aviation Bureau, Assistant Bureau Chief: The New Jersey State Police Aviation Bureau is more than happy to share with you the progress we have made in implementing several of your recommendations. Over the past years, much has changed within the Aviation Bureau. The most significant change to the bureau has been the procurement of new AW139 aircraft to replace our aging Sikorsky S76B aircraft. The Aviation Bureau's current fleet is comprised of five (5) Augusta AW139s, one (1) Bell206L4, one (1) Bell206L3 and one (1) OH58A military surplus aircraft. Only the AW139s are utilized for HEMS operations. Below are the responses to your inquiry regarding updates we have made to our aviation program: The New Jersey State Police AW139 helicopters all incorporate Flight Data Recorders (FDR) and Cockpit Voice Recorders (CVR). The FDR and CVR are factory installed during manufacturing. While we do not incorporate routine reviews of the FDR and CVR data, we have reviewed this data in response to unusual circumstances or suspected deviations in an effort to more fully understand these circumstances.

From: NTSB
To: State of New Jersey, State Police, Special Operations Section
Date: 12/31/2013
Response: The New Jersey State Police’s only letter concerning Safety Recommendation A-09-99, dated October 15, 2009, stated that none of the helicopters in its fleet are equipped with the recommended flight data recording devices, but that the State Police were planning to procure new, state of the art helicopters that would include a host of the latest safety systems available, many of which the NTSB recommends. However, our May 11, 2010, reply expressed concern that the State Police had not indicated whether the organization’s new helicopters would be equipped with flight data recording devices. We emphasized that the main focus of this recommendation is the establishment of a structured FDM program, and that installation of flight data recording devices is a necessary first step in establishing such a program. Because we were unable to determine whether the State Police planned to take the recommended action, we requested that the organization submit more specific information in this regard. In the meantime, Safety Recommendation A-09-99 remained classified “Open—Await Response.” We continue to believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the New Jersey State Police is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of New Jersey, State Police, Special Operations Section
Date: 5/11/2010
Response: The NTSB emphasizes that the main focus of this recommendation is on the establishment of a structured FDM program and that installation of flight data recording devices is a necessary first step in establishing such a program. Your letter indicated that, although no helicopters in the New Jersey State Police’s current fleet have these flight data recording devices, the organization is planning to procure new state of the art helicopters that will include a host of the latest safety systems available, many of which the NTSB recommends. Flight data recording devices, however, were not specifically mentioned. The NTSB reiterates that image and data recording devices that are relatively inexpensive and lightweight for installation on existing helicopters are currently available; therefore, it should not be necessary to replace much of your organization’s current fleet of helicopters before initiating the recommended action. We are unable to determine from your letter whether the New Jersey State Police plans to take the recommended action, and we ask that you provide more specific information in this regard. Accordingly, pending such clarification and the establishment of an FDM program, installation of low-cost, lightweight flight data recording devices suitable for use in an FDM program in your existing fleet of helicopters, and procurement of new helicopters equipped with appropriate recorders, Safety Recommendation A-09-99 remains classified OPEN -- AWAIT RESPONSE.

From: State of New Jersey, State Police, Special Operations Section
To: NTSB
Date: 10/15/2009
Response: Letter Mail Controlled 10/21/2009 4:55:01 PM MC# 2090648: - From Major Edward Cetnar, Special Operations Section Commanding Officer and Captain John McKevitt, Aviation Bureau Chief: At this juncture, the New Jersey State Police does not utilize flight data recording devices, although all aircraft are now updated with a digital emergency locator transmitter (ELT). Our medevac program utilizes a single statewide dispatch system, and utilizes the Outerlink aircraft tracking system on all state police medevac aircraft. This displays real time flight information to the dispatch center. We have redundant checks and balances regarding the status of our aircraft. Aviation Central Unit is available to assist, and additionally the New Jersey State Police Regional Operations Intelligence Center (ROIC), which has state of the art monitoring and communications abilities, is prepared should the need present itself.

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, each of which is equipped with an MPFDR, a CVR, a cockpit image recorder, a cabin image recorder, a HUMS, and a satellite flight following system. We also note that you intend to include a helicopter flight data monitoring program (HFDMP) as part of your SQMS (discussed in response to A-14-105). We are encouraged by your progress in addressing this recommendation and your commitment to working through the challenges that come with implementing an HFDMP. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 remains classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: State of Maryland, State Police, Aviation Command
Date: 5/22/2014
Response: We note that you continue to take delivery of new AW-139 helicopters to replace your fleet of AS-365 helicopters and are pleased that your new helicopters are equipped with a MPFR, cockpit video recorders, HUMS, and satellite flight tracking systems. We are also pleased that your SQMS (discussed in response to A-09-98) will include a structured FDM program and that you may include a third party to assist you in analyzing the collected data. We understand that setting up an effective FDM program comes with many challenges, but we are encouraged by your commitment to working through these challenges, and we look forward to receiving updates in the future regarding your progress in doing so. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 is 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." MSP AC RESPONSE: On October 19, 2010, the Maryland Department of Transportation (MDOT) signed a contract with the AgustaWestland Philadelphia Corporation (A WPC) 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 20 13 and expects delivery of the remaining helicopter(s) by the end of FY 2015. Each of MSPAC's A W-139 helicopters is equipped with a Multi-Purpose Flight and Cockpit Recorder (MPFR), a Cockpit Video Recorder, a Health and Usage Monitoring System (HUMS), and a SkyTrac satellite flight tracking system. To help develop a structured flight data monitoring (FDM) program, the MSPAC retained the services of an Aviation Certification Consultant Firm (ICF SH&E). The ICF SH&E consultant group is in the process of developing a Safety Quality and Management System (SQMS) in accordance with (IA W) AC 120-92A for the MSPAC. The SQMS will include a FDM program that will incorporate routine reviews of the A W-139's Multi-Purpose Flight Recorder (FDR/CVR), Cockpit Video Recorder, a Health and Usage Monitoring System (HUMS), SkyTrac satellite flight tracking systems to identify deviations from established norms, as well as other potential safety issues or trends that may occur during flight operations. Initially, the MSPAC anticipates that the FDM program will require a third party to assist the MSPAC in analyzing the collected data. The MSPAC anticipates initial implementation of its new SQMS, which will include our FDM program, by Spring/Summer of20 14. Once implemented believes that it will fully comply with this recommendation. All information provided by the MSP AC in support of the information provided here can be found in "Attachment A-09-99."

From: NTSB
To: State of Maryland, State Police, Aviation Command
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Maryland State Police are using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of Florida, City of Palm Beach, Health Care District
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the District is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of Arizona, Department of Public Safety, Highway Patrol, Aviation Division
Date: 5/22/2014
Response: Although you have not yet installed FDR devices on your helicopters, we are encouraged that you will consider the financial and operational feasibility of installing this technology. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 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 does not currently utilize installed flight data recording devices. We will take this recommendation under advice and further pursue financial and operational feasibility for the AZ DPS.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Highway Patrol Division is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of Florida, County of Volusia, Sheriff's Office
Date: 5/27/2014
Response: We note that, although you do not currently have FDR devices installed on your aircraft, you intend to comply with the FAA’s recently published requirement for part 135 helicopter air ambulances to be equipped with FDR devices. We point out that, to fully satisfy this recommendation, you will also need to establish an FDM program that routinely reviews the collected data. Pending our receipt of future updates regarding your progress in implementing Safety Recommendation A-09-99, it 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 does not have flight data recording devices installed in any of our aircraft We only operate 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 flight data recorders installed. VCSO is exempt by 14 CFR Part 135.152.

From: NTSB
To: State of Florida, County of Volusia, Sheriff's Office
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Volusia County Sheriff’s Office is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of Texas, County of Austin-Travis, Emergency Medical Services, STAR Flight
Date: 6/2/2010
Response: STAR Flight’s system for recording and retrieving data and its practices for reviewing such data, both on a regular basis and in response to any issues concerning flight operations, fully address Safety Recommendation A-09-99. Accordingly, this recommendation is classified CLOSED -- ACCEPTABLE ACTION.

From: State of Texas, County of Austin-Travis, Emergency Medical Services, STAR Flight
To: NTSB
Date: 10/20/2009
Response: Letter Mail Controlled 10/22/2009 11:32:38 AM MC# 2090652: - From Casey Ping, Program Manager, STAR Flight, Travis County: STAR Flight replaced the SkyConnect satellite tracking system with the Outerlink Video and Voice Recording system in 2008. STAR Flight mechanics pull this data at management-prescribed intervals thereby creating a random sample which is then reviewed by the Director of Aviation and Chief Pilot. Additionally, specific flight data is pulled any time there is a discrepancy or question concerning flight operations. We also have a hoist camera that is used during all Public Use responses. This allows us to identify procedural deviations, establish / refine guidelines, improve the training process and address equipment issues.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Martin County Fire-Rescue Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: Commonwealth of Virginia, State Police
Date: 7/11/2014
Response: Although you have not yet installed FDR devices on your helicopters, we are encouraged that you are considering the operational feasibility of installing this technology. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 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: The Unit has assessed various flight recording and satellite tracking devices for the existing fleet of helicopters. As of this time, none have met our needs for installation and ease of use. We continue to evaluate systems and have not made a decision on the direction for this recommendation.

From: NTSB
To: Commonwealth of Virginia, State Police
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Fairfax County Police Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of New York, County of Suffolk, Police Department, Aviation Section
Date: 7/15/2015
Response: We note that, although Suffolk County Police Department helicopters are equipped with devices that measure the health of the aircraft systems, they are not equipped with FDR devices. However, we are encouraged to learn that the police department will be acquiring a new helicopter in the near future that will be equipped with such a device. We are also encouraged to learn that you will consider retrofitting the department’s existing fleet with this technology. We look forward to receiving additional information as you progress toward this goal. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A 09-99 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 will be equipped with flight data recording devices, including a cockpit voice recorder. We will research the viability and cost of upgrading our other aircraft to mirror this capability. The flight data that is currently recorded by our aircraft, including maintenance and exceedance information, is reviewed regularly. The additional data recorded by our new aircraft will also be subjected to routine review once this aircraft is placed into service.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Suffolk County Police Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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: State of Florida, County of Lee, Emergency Medial Services, MEDSTAR
To: NTSB
Date: 6/10/2011
Response: CC# 201100228: Robert (Rob) Fulton, MEDSTAR/ Aviation Operations Manager: We are in receipt of your email of March 17, 2011. This email is the second half of our response to your request as identified in the above subject line. Our contact information has changed and is listed under my name at the bottom of this email. Mr. O’Neal previously held this position and answered the second portion of your request identified as “Safety Recommendations A-09-131 through -133. That reply will be considered Lee County’s official reply to that part of the request. In August of 2009 our program suffered a CFIT accident of our own. Fortunately, no lives or serious injuries resulted from that accident. We attribute the survival of all three crewmembers, post accident, to be a direct result of “water egress” training that had been held just two months previous to the accident (additional training, not previously in place). Although it was a moonless night, overwater, to an out island landing strip, neither the ceiling nor the visibility were low. The aircraft was equipped with TAWS, an autopilot, a radar altimeter, and a Max-Vis (infrared vision) device. Although the aircraft was equipped for NVG use and we owned a pair of certified goggles no training program had been established to make NVG’s available to the pilot. The aircraft struck the water at over 80 mph in a downwind condition and came to rest upside down in 10-15 ft of water. My point in relaying this information is to emphasize that several of the NTSB recommended devices were, in fact, aboard the aircraft. In addition factory training had been accomplished recently and a Flight Safety EMS IFR refresher course had been taken by the pilot within six months of the accident. It appears from the accident report that the pilot did not employ these devices generally and had a misunderstanding of the function of the autopilot although recently refresher trained on its use. This all seems puzzling and alarming at the same time. Training and the recommended tools, howbeit not all of them, were available, but failed to prevent the accident which properly used they could have. It is our belief that something even more difficult to measure than training or electronic device benefits is the attitude of the pilot toward their work, their responsibility, and an evaluation of their personal performance in their own head. Getting at that “attitude information” takes concentrated effort on the part of owners and management. Some of these phrases we use, related to attitude, are like the word “communication” that we all use “to death” but still have a problem with. Nevertheless, getting an honest grip on the attitude of crew and pilots can be elusive, but is the ultimate safety challenge in our view. It is the only measure of how “deep” the training and willingness to carry out training and procedures has penetrated when no one is watching. We now have a replacement aircraft which besides being a single pilot IFR helicopter and our Part 135 being an IFR program (the last five years) is equipped as the NTSB has recommended including the data recording devices. The safety management system is being evaluated for implementation and the risk assessment program is in place. That said we are in the process of establishing a “base line” for our program which will include evaluating individual attitudes in this environment by bringing in specialist in specific fields so we can combine their findings into a workable model for a safe and focused operation. Mr. Hoyt, thank for the opportunity to comment on these issues. This reply constitutes our reply in total to your recommendations. We all hope for a safer future in HEMS, but beyond that are showing support for your efforts by integrating your recommendations.

From: NTSB
To: State of Alaska, North Slope Borough, Search and Rescue Department
Date: 7/11/2014
Response: Although we are pleased to learn that your fixed-wing aircraft are equipped with FDR devices, we are concerned that your helicopters, which are used to conduct HEMS, are not. In addition, we point out that the intent of this recommendation is to (1) install FDR devices and (2) implement an FDM program. Such data would be particularly useful in evaluating daily operations according to such specific parametric operational standards as altitude, bank angle, pitch attitude, and airspeed limitations. Frequent downloading and analysis of these data would provide information on aircraft proximity to terrain and weather, which could assist those evaluating pilot performance to determine whether pilots are conducting HEMS flights in accordance with safe operating practices. Therefore, we encourage you to (1) install FDR devices on those helicopters that are used to perform HEMS and (2) establish a structured FDM program. We look forward to receiving additional information as you progress toward this goal. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A 09-99 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of Alaska, North Slope Borough, Search and Rescue Department
To: NTSB
Date: 3/24/2014
Response: -From Price E. Bower, Director, North Slope Borough Department of Search and Rescue: SAR fixed wing aircraft have cockpit voice recorders (CVR). They also have engine and systems monitoring that is electronically transmitted to maintenance. The flight crew record power assurance checks on the helicopters and trend monitoring reports for the fixed wing aircraft. At this time the installation of further monitoring systems is cost prohibitive for the helicopters.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the North Slope Borough is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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 you have not installed FDR devices on your four helicopters because of the cost of doing so, they are equipped with devices that measure the health of the aircraft’s systems. We are encouraged that you will consider installing FDR technology when you update your fleet, and we look forward to receiving future information regarding your progress. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A-09-99 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. A-09-99: Flight Data Recording devices: In lieu of an independent recording device, The Broward Sheriff’s Office Aviation Unit utilizes the aircrafts internal equipment (FADEC) to let the mechanics and pilots know whether there were any exceedance (ie TQ, TOT, N1 etc). Each aircraft also have a GPS tracking device. (one aircraft is waiting installation) This tracker allows others to see the location, altitude, speed and weather along the route updated every two minutes.

From: NTSB
To: State of Florida, County of Broward, Sheriff's Office
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Sheriff’s Office is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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-09-97 is to ensure that HEMS pilots are adequately trained for the particular types of flight conditions they are prone to encounter, such as inadvertent flight into instrument meteorological conditions. We believe that using simulators and FTDs permits pilots to practice procedures and maneuvers that they would never perform in a helicopter except in an emergency, thereby providing them the best opportunity to apply skills that are not routinely required. Some of the other HEMS operators who received this recommendation have incorporated scenario-based training using simulators and FTDs into their own pilot training programs, and still others have opted to send their pilots to training centers to acquire such training. We would like to know which approach the Sheriff’s Office has taken or will take to address this recommendation, and which training topics are covered during simulator or actual helicopter flight training.

From: NTSB
To: State of California, County of Los Angeles, Fire Department, Emergency Medical Services
Date: 6/19/2014
Response: We note that, although your aircraft do not currently have flight data recording devices installed, you will consider including this technology in the future when you update your fleet. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 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 Unit has had the Altair Avionics Corporation's "Turbine Tracker" maintenance data recording system installed since 2006 on the Bell412s. Both the Bell412 and S-70 aircraft have been equipped with the SkyTrac satellite tracking system since 2008. The SkyTrac system is a real-time Automatic Flight Following (AFF) system through the company's web-based "SkyWeb" portal with the ability to retrieve flight data 30 calendar days prior to current time. The Department's Communications/Dispatch Center has a dedicated console operator and large flat-screen monitor to allow that dispatcher the ability to monitor the Department's aircraft fleet 24/7. In addition, the Air Operations Section has the "SkyWeb" portal service installed and operating on the desktop PCs of the Unit Chief, the Air Captain and the Senior Pilots' workstations. The future acquisition and installation of low-cost, lightweight image and data recording devices that perform the function of a CVR/FDR is under review at this time.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Los Angeles County Sheriff’s Department or Fire Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Maricopa County Sheriff’s Office is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, County of Orange, Sheriff's Department, Air Support Division
Date: 5/22/2014
Response: We note that you intend to install satellite tracking and phone systems on your aircraft, and we point out that the intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Accordingly, we request that you provide additional information regarding the details of the satellite tracking system that you are considering and, specifically, how it will address the intent of this recommendation. Pending our receipt and review of this information, Safety Recommendation A-09-99 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 Homeland Security Division has recently approved the purchase of Satellite Tracking Systems for each ASU Helicopter. The Satellite Tracking System also incorporates a Satellite Phone System for use during flight operations. This system will allow for real time tracking of the helicopter and also allow ASU Helicopters to meet the rigid standards set by the U.S. Department of Forestry and California Fire Departments.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Orange County Sheriff’s Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, County of San Bernardino, Sheriff's Department
Date: 6/26/2014
Response: We note that you intend to install automatic flight-following transponders on your aircraft, but that you do not believe that FDR devices are necessary at this time. We point out that the intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights provides operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information assists operators in detecting and correcting unsafe deviations from operating practices. Accordingly, we encourage you to consider installing aftermarket FDR devices on your existing fleet and/or to include this technology on future aircraft when you update your fleet. Pending our receipt and review of a plan that is responsive to this recommendation, Safety Recommendation A-09-99 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, County of San Bernardino, Sheriff's Department
To: NTSB
Date: 4/16/2014
Response: -From John McMahon, Sheriff-Coroner: The San Bernardino County Sheriff's Department's Aviation Unit is pleased to provide a response to the National transportation & Safety Board's recommendations resulting from an investigative hearing occurring in February 2009. We apologize for the delay as it was not clear, at the closing of the hearing, that a formal response to the recommendations was required. While we recognize the importance of flight safety, in all aspects, we also share the position of our brother public safety agencies that our mission profiles are quite different than that of private HEMS operators. In fact, many of our missions, in particular hoist rescue (day and night), pose a much greater safety risk than our colleagues in the aero-medical transportation industry. Thus, we tend to train harder and respond in many diverse terrain environments than a civilian air transport provider. Public safety or government flight operations are driven by mission and not so much making a profit. Therein lies the potential cause of many of the fatal incidents. Whether it is training, maintenance, or equipment costs, often financial short cuts are realized in the private industry resulting in tragedy as we, too, are charged with aircraft crash investigations. With the aforesaid, many of us in the public safety sector recognize that the private sector will continue to attempt to legislate us out of our missions, our responsibility to our citizens, and our current mandates. Again, we are not profit driven. We have seen that the majority of the fatal incidents are private operators and not public safety. We have noted that a private aircraft operator can contract with a government agency, have an incident, yet, the incident is charged against government or public safety statistics. It is our desire to continue to advocate the separation of private and public safety flight operations, largely based on the fact that our missions and motivations are different. The public safety flight statistics show we have an exceptional flight safety history and should enjoy reasonable exemptions from the private, profit motivated operator. The San Bernardino Sheriff's Aviation Unit does not feel a flight data box for a public safety mission is necessary at this time; however, we are in the process of expanding our EMS program with the County Fire Department and will be installing Automatic Flight Following (AFF) transponders. This installation will provide immediate and accurate location of the EMS assigned aircraft.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the San Bernardino County Sheriff’s Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, County of Santa Barbara, Sheriff's Department, Air Unit
Date: 9/2/2014
Response: We appreciate your efforts to research the possibility of installing FDR devices and autopilots on your helicopters that are used to conduct HEMS. We note, however, that you found installing this technology to be cost prohibitive. We encourage you to notify us if you are able to obtain the necessary funds to address these safety issues. In the meantime, because these safety issues have not been addressed, Safety Recommendations A-09-99 and -101 are classified CLOSED—UNACCEPTABLE ACTION.

From: State of California, County of Santa Barbara, Sheriff's Department, Air Unit
To: NTSB
Date: 7/9/2014
Response: -From Steve Robel, Acting Commander: This memo is in regards to your June19, 2014 letter to Ms. Mona Miyasato, County Executive Officer for Santa Barbara County indicating six safety recommendations being classified as closed. In reference to the two open items: A-09-99 flight data recording devices and A-09-101 auto pilots, we researched the cost of each one. The auto pilot system would cost approximately $300,000 and the flight data recorder would cost approximately $75,000 each being for the least expensive one. At this time it is beyond the parameters of the Santa Barbara Sheriff’s Office budget to purchase any of the items. Thank you for your cooperation and understanding.

From: NTSB
To: State of California, County of Santa Barbara, Sheriff's Department, Air Unit
Date: 6/19/2014
Response: We note that you use two helicopters to conduct HEMS and that one of them is equipped with a device that measures the health of the aircraft systems; however, neither helicopter is equipped with an FDR device. We point out that the intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Accordingly, we encourage you to look at aftermarket FDR options for your existing fleet and/or to consider this technology when it comes time for you to update your fleet. Pending our receipt of future updates regarding your progress in addressing this safety issue, Safety Recommendation A-09-99 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, County of Santa Barbara, Sheriff's Department, Air Unit
To: NTSB
Date: 3/5/2014
Response: -From Lieutenant Steven Johnson, Air Support Unit: We have one helicopter currently specifically configured for HEMS operations. This helicopter has audio and video recording abilities, to include the hoist operations. This helicopter is our primary rescue aircraft. The recordings of actual and training incidents will allow the aircraft crew and management personnel to review the flight in order to identify potential safety issues and re-enforce safety procedures to increase the level of safety during a HEMS operation.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Santa Barbara County Sheriff’s Department or Fire Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, County of Sonoma, Sheriff's Office
Date: 3/6/2015
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. Although the Sonoma County Sheriffs Office performs HEMS, it is not our primary mission. We are considered a law enforcement ALS rescue helicopter; therefore our patient transports are not as frequent when compared to air ambulance HEMS providers. A formal flight data recording system has been considered, however we believe that our current system of video recording of our training and actual rescues using head mounted gear and aircraft mounted equipment is appropriate to our mission. We retain these video recordings to identify procedural deviations, address equipment issues, refine operational guidelines and improve the training process. We are investigating the appropriateness of adding flight data recording 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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Sonoma County Sheriff’s Office is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of Delaware, State Police, Aviation Unit
Date: 6/20/2014
Response: We note that, although your aircraft do not currently have FDR devices installed, you intend to equip your aircraft with technology that is capable of recording flight parametric, voice, and image data. We believe that such technology, once installed, would address the first portion of this recommendation; however, we point out that a structured FDM program that incorporates routine reviews of the data being collected to identify deviations from established norms and procedures and other potential safety issues is also needed to fully satisfy this recommendation. Pending our receipt of updates on your progress and completion of the recommended actions, Safety Recommendation A-09-99 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: Delaware State Police Aircraft are not equipped with flight data-monitoring equipment. The program is scheduled to add Sky Node Flight tracking equipment to the Bell407 aircraft and take delivery of two new Bell 429 aircraft in 2014 that will be equipped with the same device to provide flight data, voice and image recording capability. A policy will be established to monitor the data and use it to improve performance through training.

From: NTSB
To: State of Delaware, State Police, Aviation Unit
Date: 12/31/2013
Response: The intent of Safety Recommendation A-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Delaware State Police are using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: United States Department of the Interior, National Park Service, Park Police, Aviation Unit
Date: 6/20/2014
Response: We note that your helicopters are not equipped with FDR devices. However, we are encouraged to learn that you will consider including FDR devices in the future as you update your fleet. We look forward to receiving additional information as you progress toward this goal. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A 09-99 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 do not currently have Flight Data Recording Devices on board. The USPP utilize a program known as Latitude Technologies to recreate flight paths and missions. Should there be a deviation from the helicopter's intended flight path, the internal systems on board would be able to direct search and rescue personnel to the current location of the aircraft. The USPP also utilize the FAA National Capital Regional Coordination Center (NCRCC) and Maryland State Police Systems Communications (SYSCOM) to track aircraft in the event of an in-flight safety concern. The USPP are currently examining the cost of flight data recorders and similar devices.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the United States Park Police are using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.

From: NTSB
To: State of California, County of Ventura, Sheriff's Department, Aviation Division
Date: 6/13/2014
Response: We note that, although your helicopters are equipped with devices that measure the health of the aircraft systems, they are not equipped with FDR devices. However, we are encouraged to learn that you will consider including FDR devices in the future as you update your fleet. We look forward to receiving additional information as you progress toward this goal. Pending our receipt of such information and completion of the recommended actions, Safety Recommendation A 09-99 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. At the current time, the aviation unit utilizes low cost, high definition rescue hoist cameras that are attached outside the aircraft and record routine training and active mission calls. These videos are reviewed and then discussed as part of the unit’s quarterly safety meetings. In addition, each aircraft is equipped with engine monitoring systems that are recorded for each flight. Recorded data can be inspected and reviewed for further action after the completion of those flights. The unit is also looking at augmenting these types of flight data recording systems to include automated flight following (AFF), which provides real time directional and altitude information that is viewed by the department’s dispatch center.

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-09-99 is to ensure that routine flight data are recorded and analyzed to improve HEMS flight operations and reduce the rate of accidents. We believe (1) that the systematic monitoring of data from HEMS flights could provide operators with objective information regarding the manner in which their pilots conduct HEMS flights and (2) that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from operating practices. Some of the other HEMS operators who received this recommendation have installed low-cost, lightweight image- and data-recording devices on their existing helicopters or have recently placed orders for new helicopters that will be equipped with onboard video/voice-data recording devices. In such instances, these operators have established a structured flight data monitoring program to collect image and recording data at specified intervals for regular review and any time an issue arises concerning flight operations. In addition, some operators use a hoist camera during response operations to identify procedural deviations, establish and refine guidelines, improve the training process, and address equipment issues. We would like to know whether the Ventura County Sheriff’s Department or Fire Department is using any similar flight data recording devices and how any collected data are being assessed and used to improve operations.