Safety of emergency medical services flights
Encyclopedia
Emergency medical services
Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
aviation
Aviation
Aviation is the design, development, production, operation, and use of aircraft, especially heavier-than-air aircraft. Aviation is derived from avis, the Latin word for bird.-History:...
operations, such as air ambulance
Air ambulance
An air ambulance is an aircraft used for emergency medical assistance in situations where either a traditional ambulance cannot reach the scene easily or quickly enough, or the patient needs to be transported over a distance or terrain that makes air transportation the most practical transport....
and MEDEVAC
MEDEVAC
Medical evacuation, often termed Medevac or Medivac, is the timely and efficient movement and en route care provided by medical personnel to the wounded being evacuated from the battlefield or to injured patients being evacuated from the scene of an accident to receiving medical facilities using...
, and the increasing frequency of related accidents.
Background
Emergency medical services (EMS) aviation operations (conducted with either helicopters or fixed-wing aircraftFixed-wing aircraft
A fixed-wing aircraft is an aircraft capable of flight using wings that generate lift due to the vehicle's forward airspeed. Fixed-wing aircraft are distinct from rotary-wing aircraft in which wings rotate about a fixed mast and ornithopters in which lift is generated by flapping wings.A powered...
) provide an important service to the public by transporting seriously ill patients or donor organs to emergency care facilities
Emergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
. The pressure to safely and quickly conduct these operations in various environmental conditions (for example, inclement weather, at night, and unfamiliar landing sites for helicopter operations) makes EMS operations inherently dangerous, and the hazards associated with EMS operations are resulting in an increasing number of accidents. The U.S. National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
(NTSB) conducted a special investigation and issued a report on January 25, 2006 titled: "Special Investigation Report on Emergency Medical Services Operations". The report was not intended to burden operators with undue requirements or to handicap this vital function in any way; rather the purpose of the report was to identify and recommend operational strategies and technologies that will help ensure that these vital EMS flights arrive safely and continue to provide a valuable service to the public.
Between January 2002 and January 2005, 55 EMS aircraft accidents occurred in the United States (this number of EMS accidents had not been seen since the 1980s) these accidents resulted in 54 fatalities and 18 serious injuries (see appendix B of the report for more information). Although the number of flight hours flown by EMS helicopter operations in the United States has increased from about 162,000 in 1991 to an estimated 300,000 in 2005, the average accident rate has also increased from 3.53 accidents per 100,000 flight hours between 1992 and 2001 to 4.56 accidents per 100,000 flight hours between 1997 and 2001. As a result, the National Transportation Safety Board initiated a special investigation of these 55 accidents and identified the following recurring safety issues:
- less stringent requirements for EMS operations conducted without patients on board,
- a lack of aviation flight risk evaluation programs for EMS operations,
- a lack of consistent, comprehensive flight dispatch procedures for EMS operations, and
- no requirements to use technologies such as terrain awareness and warning systemTerrain awareness and warning systemA terrain awareness and warning system aims to prevent "Controlled Flight Into Terrain" accidents. The actual systems in current use are known as ground proximity warning system and enhanced GPWS. The U.S. Federal Aviation Administration developed the TAWS term to encompass all current and...
s (TAWS) to enhance EMS flight safety.
Examples
Of the 55 accidents that occurred between January 2002 and January 2005, the following seven were considered by the NTSB to provide the best examples of the safety issues involved:
- Salt Lake City, UtahSalt Lake City, UtahSalt Lake City is the capital and the most populous city of the U.S. state of Utah. The name of the city is often shortened to Salt Lake or SLC. With a population of 186,440 as of the 2010 Census, the city lies in the Salt Lake City metropolitan area, which has a total population of 1,124,197...
(FTW03FA082). On January 10, 2003, an EMS helicopter crashed into terrain while maneuvering in dense fog on an aborted mission to pick up a patient. The pilot and flight paramedic were killed, and the flight nurse was seriously injured. Another service had attempted the same mission, but aborted due to deteriorating weather. - Redwood Valley, CaliforniaRedwood Valley, CaliforniaRedwood Valley is a census-designated place in Mendocino County, California. It is located southwest of Potter Valley, at an elevation of 722 feet . It comprises the northern portion of the Ukiah Valley. It is about 8 mi north of Ukiah and 12 mi south of Willits. Potter Valley is to...
(LAX04FA076). On December 23, 2003, an EMS helicopter was en route to pick up a patient when it collided with mountainous terrain while operating in high winds and heavy rain. The pilot, flight nurse, and paramedic were killed. - Dodge City, KansasDodge City, KansasDodge City is a city in, and the county seat of, Ford County, Kansas, United States. Named after nearby Fort Dodge, the city is famous in American culture for its history as a wild frontier town of the Old West. As of the 2010 census, the city population was 27,340.-History:The first settlement of...
(CHI04FA066). On February 17, 2004, an EMS airplane crashed about 5 miles beyond Dodge City Regional Airport while on a repositioning flight. The pilot, flight paramedic, and flight nurse, who were at the end of a 14-hour duty day, were killed. - Pyote, TexasPyote, TexasPyote is a town in Ward County, Texas, United States. The population was 131 at the 2000 census.-History:Pyote began as a small town. Its fortunes rose with oil, but its population decreased when the railroad was built away from the town. At one time Pyote had 3,500 residents...
(FTW04FA097). On March 21, 2004, an EMS helicopter crashed into terrain while maneuvering in reduced visibility conditions while transporting a patient. The pilot, flight paramedic, patient, and patient’s mother were killed, and the flight nurse was seriously injured. - Newberry, South CarolinaNewberry, South CarolinaNewberry is a city in Newberry County, South Carolina, 43 miles west -northwest of Columbia. The charter was adopted in 1894. In 1890, 3,020 people lived in Newberry, South Carolina; in 1900, 4,607; in 1910, 5,028; and in 1940, 7,510. The population was 10,580 at the 2000 census. It is the county...
(CHI04MA182). On July 13, 2004, an EMS helicopter collided with trees shortly after picking up a patient from an accident site on an interstate highway. The pilot, flight nurse, flight paramedic, and patient were killed. Three other flight crews previously turned down this mission due to unfavorable weather. - Battle Mountain, NevadaBattle Mountain, NevadaBattle Mountain is an unincorporated community and census-designated place in Lander County, Nevada, United States. The population was 2,871 at the 2000 census. Though it has no legal status as a municipality, it still functions as the county seat of Lander County...
(SEA04MA167). On August 21, 2004, an EMS helicopter crashed into mountainous terrain at night and in deteriorating weather conditions while transporting a patient along a direct route through mountainous terrain rather than taking an indirect route around the high terrain. The pilot, two medical crewmembers, patient, and patient’s mother were killed. - Rawlins, WyomingRawlins, WyomingRawlins is a city in Carbon County, Wyoming, United States. The population was 8,538 at the 2000 census. It is the county seat of Carbon County...
(DEN05FA051). On January 11, 2005, an EMS airplane that was operating in icing conditions crashed when it impacted terrain while en route to pick up a patient. The pilot and two medical crewmembers were killed, and a third medical crewmember sustained serious injuries.
These seven accidents were specifically cited, where applicable, in the report’s discussion of each safety issue. More detailed flight histories, as well as probable cause statements for these accidents, were provided in appendix A of the report.
In 2008, midair collisions of emergency flights caused the deaths of 28 crew members and patients.
Previous NTSB study
The Safety Board examined similar safety issues after the occurrence of 59 EMS accidents between May 1978 and December 1986 and concluded in a 1988 safety study that many areas of EMS operations needed improvement, including weather forecastingWeather forecasting
Weather forecasting is the application of science and technology to predict the state of the atmosphere for a given location. Human beings have attempted to predict the weather informally for millennia, and formally since the nineteenth century...
, operations during instrument meteorological conditions
Instrument meteorological conditions
Instrument meteorological conditions is an aviation flight category that describes weather conditions that require pilots to fly primarily by reference to instruments, and therefore under Instrument Flight Rules , rather than by outside visual references under Visual Flight Rules . Typically, this...
(IMC), personnel training requirements, design standards, crashworthiness, and EMS operations management. As a result of its findings, the Board issued 19 safety recommendations to the U.S. Federal Aviation Administration
Federal Aviation Administration
The Federal Aviation Administration is the national aviation authority of the United States. An agency of the United States Department of Transportation, it has authority to regulate and oversee all aspects of civil aviation in the U.S...
(FAA) and others, which have since been closed (see the report appendix G information about these recommendations and their classifications).
Most of the recommendations to the FAA were closed as a result of the June 20, 1991, issuance of Advisory Circular (AC) 135-14A, "Emergency Medical Services/Helicopter (EMS/H)," which addressed equipment, training, crew resource management
Crew Resource Management
Crew resource management or Cockpit resource management is a procedure and training system in systems where human error can have devastating effects. Used primarily for improving air safety, CRM focuses on interpersonal communication, leadership, and decision making in the cockpit...
(CRM), decision-making, flight-following procedures, weather minimums, and the development of safety programs for EMS helicopter flights operating under 14 Code of Federal Regulations
Code of Federal Regulations
The Code of Federal Regulations is the codification of the general and permanent rules and regulations published in the Federal Register by the executive departments and agencies of the Federal Government of the United States.The CFR is published by the Office of the Federal Register, an agency...
(CFR) Part 135. Although the Safety Board expressed concern at the time that the FAA chose to issue an AC instead of regulations, the number of EMS accidents was decreasing, thus the recommendations were closed.
Despite the guidance provided in AC 135-14A and AC 135-15, EMS aircraft accidents have continued to occur in significant numbers (as shown in table 1 from the report below) for the 15-year period from 1990 to 2005.
| Total Injuries | |||||
|---|---|---|---|---|---|
| Year | # of accidents | # of fatal accidents | Fatal | Serious | Minor |
| 1990 | 1 | 0 | 0 | 0 | 0 |
| 1991 | 1 | 1 | 4 | 0 | 0 |
| 1992 | 3 | 2 | 3 | 4 | 0 |
| 1993 | 3 | 2 | 5 | 3 | 3 |
| 1994 | 4 | 2 | 6 | 0 | 3 |
| 1995 | 5 | 1 | 3 | 0 | 2 |
| 1996 | 5 | 3 | 9 | 1 | 0 |
| 1997 | 3 | 1 | 4 | 0 | 0 |
| 1998 | 11 | 2 | 8 | 5 | 5 |
| 1999 | 6 | 0 | 0 | 6 | 0 |
| 2000 | 6 | 2 | 7 | 0 | 4 |
| 2001 | 13 | 1 | 1 | 2 | 2 |
| 2002 | 13 | 6 | 14 | 8 | 4 |
| 2003 | 19 | 3 | 3 | 2 | 16 |
| 2004 | 19 | 9 | 29 | 7 | 3 |
| 2005 | 13 | 6 | 13 | 5 | 5 |
Other studies
Recent industry publications regarding the safety of EMS aviation operations are consistent with the Safety Board’s findings. For example, after an extensive 2-year safety review and risk assessment of helicopter EMS accidents, the Air Medical Physician Association (AMPA) reported in November 2002 that the time of day that flights occur could contribute to accidents. The report indicated that even though 38 percent of all helicopter EMS flights occur at night, 49 percent of accidents during a 20-year period occurred during nighttime hours. The report also cited controlled flight into terrain (CFIT), in particular during the takeoff or landing sequence, as a common problem, as well as collision with objects (wires were the most common obstacles for EMS helicopters); inaccurate weather forecasts (about 26 percent of helicopter EMS accidents were weather-related, with most occurring because of reduced visibility and IMC while the helicopter was en route); and communications problems with air traffic controlAir traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...
(ATC) or a lack of communications due to remote locations and high terrain.
AMPA’s report also cited time pressures related to the patient’s condition, rapid mission preparation, flight to the patient pick-up location, and low fuel as frequent issues in EMS aircraft accidents. According to a query of the National Aeronautics and Space Administration’s Aviation Safety Reporting System
Aviation Safety Reporting System
The Aviation Safety Reporting System, or ASRS, is the US Federal Aviation Administration's voluntary system that allows pilots and other airplane crew members to confidentially report near misses and close calls in the interest of improving air safety...
, patient condition was cited in 44 percent of the EMS accidents or incidents reports as a contributor to time pressure leading to inaccurate or hurried preflight planning. In addition, the AMPA report stated that accidents occurred more often when flight crews were en route to pick up a patient than at any other time during flight. A white paper published by Helicopter Association International
Helicopter Association International
The Helicopter Association International is a not-for-profit professional trade association of 2,500-plus member organizations in more than 68 nations....
in August 2005 examined many of the same issues as AMPA.
Steps taken
On October 7, 2010, the FAA proposed new warning systems and increased training for emergency medical flights to deal with the spate of recent crashes.See also
- Commission on Accreditation of Medical Transport SystemsCommission on Accreditation of Medical Transport SystemsThe Commission on Accreditation of Medical Transport Systems , is an independent, non-profit agency which audits and accredits fixed-wing and rotary wing air medical transport services as well as ground inter-facility critical care services in the U.S. to a set of industry-established criteria....
- 2006 Mercy Air helicopter accident2006 Mercy Air helicopter accidentThe 2006 Mercy Air helicopter accident occurred on December 10, 2006, about 1755 Pacific standard time, when a Bell 412SP helicopter, call sign "Mercy Air 2," impacted mountainous terrain near Hesperia, California and the Cajon Pass...
- 2006 Eagle III helicopter accident2006 Eagle III helicopter accidentThe 2006 Eagle III helicopter accident occurred at GRBC Rescue Heliport in Green Bay, Wisconsin on April 13, 2006, during a post-maintenance flight of a MBB Bo 105 air ambulance helicopter operated by Eagle III....