Helicopter Emergency Medical Services(HEMS) is an industry at risk. Due to a rash of fatal accidents, the industry is sicker than the patients being flown. The air med business is dying because, instead of saving lives, it’s killing people, namely copheliter crews, and often their patients.
The problem didn’t happen overnight; the solution won’t come quickly, either.
From the beginning, air medical helicopters have experienced a high accident rate. The risk can never be eliminated, but it can be mitigated and reduced to the point where an air med accident is rare. The following treatise tells how that can be done. If all the initiatives listed here were put in place tomorrow, the HEMS accident rate would drop to near zero. Here’s the road map of how that can happen.
” First recommendation: for those programs requesting it, an immediate safety stand-down for FAA or other outside party review on all aspects of the HEMS operation.
One of the difficulties with the accident rate in air medical is simple semantics. What is an accident, and how are the statistics compiled? Here’s the bottom line: the stated expectation must be a zero accident rate.
A Special FAR is needed, a new regulation aimed specifically at air medical operations similar to the regs in place for helicopter tour operators. For years the FAA has been unwilling or unable to simply shut down an operator or individual program site for safety or regulatory violations. There should be the institution of an anonymous tip line to the FAA, a whistle-blower feature for passengers, crew, or other employees of the various operators to use, something similar to the NASA safety reporting form. The potential for abuse is always present with such a system; but the potential for increased transparency is, as well, and the issue is critical.
” Pilots must be better vetted and trained.
There are too many programs, and too many helicopter operators such that the pilot staffing pool is too thin. With lower experience levels, and more programs flying more aircraft more hours, a growing accident rate is almost inevitable. A direct link can be made between the start of hostilities in Iraq, and the latest rise in the rate of air medical accidents. Many veteran pilots with a military affiliation are flying overseas, leaving programs at home understaffed, or with less experienced pilots in cockpits, or both.
Given the fact that most air medical accidents are weather related this makes sense. Military pilots are better able to maintain control in IIMC. The skills military pilots acquire, both in flight and with access to simulators, also confer a level of confidence unavailable to non-military pilots.
Another reason air med requires more professionalism and oversight is, that programs are 24/7 operations, with a high percentage of flying at night. Pilot error is the single most common factor in air medical accidents, and current crew rest rules are inadequate to address that. Shutting down a program after dark is not an option*, as these are emergency response vehicles, and must be staffed accordingly.
” Instrument Flight capability for recovery only in all air medical helicopters.
If used correctly, IFR capability is a powerful risk reducer in HEMS operations. What operators commonly substitute for IFR capability is company policy which demands that pilots avoid instrument weather at all cost. But denial of upgraded capability is inexcusable in a company which offers aviation assets to the public. The FAA should demand IFR capability for air medical helicopters as part of the new SFAR. This would serve two purposes: it would give pilots needed options; it would increase the standard of companies competing for air med business, drive marginal operators away.
Let me be clear about this: I propose IFR capability for recovery only, not for launch. IFR equipment, coupled with ongoing instrument training, will go a long way toward eliminating air med accidents.
Most fatal accidents have happened en-route to a patient pickup, or after a pilot has aborted the flight, and turned toward home base. This says that air med crews are accepting missions in weather that’s marginal at best, an attempt to take off and check conditions over a commonly flown route. Just so, the more emphasis placed on weather avoidance, and dismissal of IFR capability in lieu of weather minimums and dogmatic measures, have made air medical less safe.
Pilots must find the delicate balance between program needs and their professional standing. Air med pilots are just charter pilots with a single client. But the trappings of the air med program, the flight suits, logos, and close interaction with medical staff is a constant enforcement of the team concept at a client hospital. There’s nothing wrong with team spirit. But the elite nature of air med flight crews can dilute a pilot’s command authority in situations where patient need appears to override aviation considerations. Weather factors can be minimized. Nuisance maintenance issues ignored. Crew rest times can be arbitrarily extended to pursue a patient mission at crew change time. At most programs, pilots are shielded from patient information, to avoid undue pressure on them to accept or reject a flight. This is a good protocol. But the simple truth is, that pilot exposure patient medical condition is unavoidable at the onset of the mission, or at any time during the flight. What’s needed is a more professional, more objective pilot in the first place.
Give site managers the authority they need to enforce safe practices. Site managers have little authority to enforce pilot codes, or punish unprofessional behavior. Most accidents begin in the hiring phase, lying in wait for the right conditions. Posting a pilot to a contract site is expensive. But when a client hospital demands a pilot’s removal, or a site manager learns of safety infractions, that manager must be able to take action.
Air medical flying has always had a reputation for having an emergency, rapid-response atmosphere. This sheen of excitement is what attracts certain people to it, the so-called adrenaline junkies. From my 20 years in a HEMS cockpit, I can attest to the high-profile nature of the work. There’s nothing more exciting than having the helicopter clatter out of the sky, arrive on scene, and land to save the day. The feeling is intoxicating, even if it is illusory. It’s easy to lose sight of the aviation aspect of it.
The bottom line is, that pilots at air med programs are locked and loaded to fly, and not every pilot is cut out for it. Accepting a mission is the default mode. But instead of being paid to fly, pilots must understand that they’re being paid for the judgement to not fly at times. FAR part 105, the so-called ‘pilot-in-command’ rule, not only protects pilots and the decisions they make, but it eliminates the potential hazard of a diluted decision, a decision made by a committee. Especially with the rapid growth of the HEMS industry, hour requirements and necessary experience levels have dropped. The pilot pool has shrunk beyond the competence level required.
” Multi-engine aircraft in air medical operations.
All air medical programs should field multi-engine helicopters. If that proves too much for the budget, the hospital should abandon the air medical program, or seek a consortium arrangement.
Having two engines, and the doubling of other on-board systems, simply brings the aviation asset up to par with the medical equipment it carries. Medical staff routinely have backups for everything; their aircraft should have nothing less.
Multi-engine aircraft also obviate additional mechanic staffing. Two mechanics are more efficient, better rested, doubly trained, and have more latitude toward performing required tasks to keep the equipment operating.
Another less obvious benefit to fielding twin-engine aircraft is the potential for pilot training. Depending on the aircraft, an extra seat is available in the cockpit on every flight. That empty seat ought to be used for an observer, a rookie pilot, or a new hire to ride along, to see first hand how the operation works.
Another advantage of this change is, that the copilot could be someone in training. If done properly, this position could be a revenue source for innovative operators willing to help a pilot build up his or her logbook, and willing to pay for the opportunity, to the benefit of the operator’s bottom line.
” CVR/FDR/TAWS/GPS moving map installation in air med helicopter cockpits.
The FAA should mandate cockpit voice recorders, and/or flight data recorders in every HEMS cockpit. This would add transparency to every air med mission. These boxes would have two additional benefits: they would assist in an accident investigation, a use for which they were designed; and they would facilitate maintenance work by recording and archiving system operating parameters. TAWS is nothing more than ground avoidance technology, another layer of protection. GPS should be a requirement in all HEMS cockpits.
” De-emphasize rapid response/takeoff time.
In spite of programs’ PR efforts, and patient impact evidence to the contrary, a rapid response only puts the aircraft and crew at risk, makes negligible difference in patient outcome, and should be de-emphasized. A launch time of ten minutes is not unreasonable. No other part 135 operation would advertise a five minute takeoff time, nor would the FAA grant operations specifications for such a thing. In actual practice, the HEMS mission is, by and large, a transport system to provide a stable, monitored environment for patients between hospitals.
” Higher program weather minimums, and mandatory down-status.
Weather is a factor in 50% of HEMS accidents. Program and FAA-mandated weather minimums are typically stringent, but at most programs they still border on marginal VFR. The environment in which air medical aircraft operate is typically where weather information is least available and/or reliable–below three thousand feet, far from weather reporting outlets, and often below radar coverage.
” Hospital administration must be more involved.
The administration of air med programs must become more intimately involved in day to day operations. Launch decisions should be reviewed; mandatory short takeoff times should be abandoned; borderline pilots, or those who consistently make poor decisions should be held accountable; safety committees should be established, with authority to make major decisions, including the configuration of the aircraft.
Medical directors should apprise physician staff of safety issues concerning air medical, including the need for better triage to eliminate non-emergent air transports. A culture of support must be effected for no-go decisions. The tendency for medical staff receiving a transport request is to use the helicopter if any indication exists that it’s needed. The underlying assumption is, that the patient needs to be flown, or a doctor would not have called.
But patients are often flown only for mundane logistical reasons. Various EMS services are available on a limited basis. Taking a ground rig away leaves the county uncovered for long periods. The helicopter is often used as a substitute in these cases. Thus, the air medical asset closest to the patient is often used when there’s no indication the patient needs to be flown.
I was a pilot in command of an air medical helicopter for twenty years. I understand the pressures and contingencies, regulations, environment and politics that air med pilots are exposed to every day. From my first air medical flight in July 1983, to my last in October 2003 I saw one of every kind of patient mission there is, except one. I never witnessed a birth on board the helicopter. That simple fact, that in 3,200 patient missions I never once witnessed a birth is instructive. It means triage for women about to deliver was done with utmost care. Both attending and receiving physicians knew not to call the helicopter.
The point is, that adequate triage, better consultation, or both, especially with today’s technical ability for doctors to share information, is a key in the air medical safety puzzle, because it means fewer flights, thus more attention to truly urgent flights.
With four pilots per contract, and where program hours are low anyway, the operator may (rightly) be concerned about less flying proficiency. In this case the sponsoring hospital should contract for more training hours, match their assets with another hospital in a consortium arrangement, or cede the air medical transport service altogether, thus saving needed health care dollars.
Do fewer flights mean lowered service to potential clients? No, it means better service to clients who need the service more. While flying a routine, stable hospital transfer patient, the helicopter is out of service to respond to a trauma, or other emergent patient.
“The bottom line must be secondary to safe practices, and hard aviation realities.
Typically, a hospital based helicopter system is set up on a mixed staff basis, with pilots and mechanics employed by the aviation vendor, and the hospital staff employed in house. Sponsoring hospitals can budget for aircraft services; they have the option of renewing a contract with a vendor–or not; they don’t assume the burden of aircraft maintenance, or staff training; and they avoid out of service time by having a backup aircraft within guidelines established in the contract. Leasing the asset also provides a hospital the opportunity to more easily upgrade to additional program functionality, such as IFR, NVG, multi-engine, or other changes.
But contracts offer only so much, and therein lies one of the more entrenched problems, with air medical safety often hanging in the balance: innovation is stifled, and safety initiatives shuttled between client and vendor, with little or no, or extremely slow resolution. There’s no direct connection between funding and safety, of course. But there needs to be more attention paid to backup systems for HEMS operations. No surgeon would operate when the hospital’s standby generator is out of service. No flight nurse would take off with no backup batteries for a heart monitor, or extra oxygen bottles. No hospital would place its million dollar MRI machinery uncovered in the parking lot, exposed to the elements.
But hospitals use single-engine helicopters, with VFR only cockpits, no NVG or GPS or TAWS capability, one electrical system, one hydraulic system, and one pilot on the overwhelming number of air med missions. The aircraft is typically parked on a pad outside, exposed to wind, rain, icing, heat, and all manner of corrosive elements, when hangarage could be acquired for little cost, keeping the helicopter dry, clean, ice and snow free, reducing maintenance issues, and more quickly prepared for flight.
Accountability is a very good thing. But due to the glacial pace of change in any institution, and given today’s focus on reducing health care costs, any innovation, regardless of how appealing or relevant to minimizing risk in the air medical environment, is inevitably caught up in the control/justification/budget triangle, with numerous layers of bureaucracy. In the meantime, needed innovations and safety measures are shelved, or passed between client and vendor, with neither accepting financial responsibility. Until such time as safety prevails in the air medical field, contracts should be renegotiated year to year, with an escape clause for both parties. This would allow clients to better budget for new innovations, and for operators to escape onerous contracts, better serve customer demands, and be more attentive to the bottom line in a field already littered with bankrupt operators.
One beneficial byproduct of yearly contracting would be to drive out marginal operators, by recognizing that only larger, more flexible companies can bid on and expect to win hospital contracts, which require a rapid turnaround of assets. Another advantage to one-year contracts is, that this would force standardization of equipment. Presently, even two aircraft sited at the same hospital often have different medical installations, radio packages, lighting, warning systems and cockpit instrumentation. This may not be a problem for a contract site using the same pilots all the time, (or it may be a major problem), but the lack of standardization precludes another solution to the air medical accident puzzle.
Pilots at a particular program operate with little or no oversight from company headquarters. In such an arrangement, pilots often share only among themselves the various problems, maintenance gripes, and operational glitches. There exists no mechanism for collective focus and sharing of safety information company-wide, except for contact through annual check flights, or a company newsletter of some kind. This is yet another reason client hospitals should employ larger companies, as they have more latitude to hire and employ check pilots and relief pilot staff to float between programs. Doing so would disseminate good data and safety practices across the company.
Larger companies are also better able to use another innovation that would enhance safe operations: the transfer, or shared pilot concept. Transference between contract sites would add to the transparency and oversight of programs, and increase the level of professionalism. This is yet another reason hospitals should field multi-engine aircraft. The unoccupied cockpit seat could be used to orient a relief or transfer pilot, as a company check pilot station, or again, to train a new hire pilot, a functionality unavailable to single-engine operations.
In addition to the transparency and increased knowledge base, visiting pilots would offer the medical staff an objective forum to discuss deficiencies in the program, or challenges with sited pilot staff. It would also have the desirable effect of decreasing whatever level of protective opacity that may exist in the ‘team oriented’ environment.
