Helicopter accident 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 rescue lives, it's killing people, namely helicopter crews, and often their patients.
The qoute didn't happen overnight; the explication 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 protection stand-down for Faa or other surface party quote on all aspects of the Hems operation.
One of the difficulties with the accident rate in air medical is straightforward semantics. What is an accident, and how are the statistics compiled? Here's the bottom line: the stated prospect must be a zero accident rate.
A extra 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 plainly shut down an operator or personel schedule site for protection 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 assorted operators to use, something similar to the Nasa protection reporting form. The possible for abuse is always gift with such a system; but the possible for increased transparency is, as well, and the issue is critical.
" Pilots must be best vetted and trained.
There are too many programs, and too many helicopter operators such that the pilot staffing pool is too thin. With lower caress levels, and more programs flying more aircraft more hours, a growing accident rate is approximately 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 associated this makes sense. military pilots are best able to articulate control in Iimc. The skills military pilots acquire, both in flight and with way to simulators, also give a level of belief unavailable to non-military pilots.
Another theorize air med requires more professionalism and oversight is, that programs are 24/7 operations, with a high ration of flying at night. Pilot error is the single most coarse factor in air medical accidents, and current crew rest rules are inadequate to address that. Shutting down a schedule after dark is not an option*, as these are accident response vehicles, and must be staffed accordingly.
" Instrument Flight potential for rescue only in all air medical helicopters.
If used correctly, Ifr potential is a mighty risk reducer in Hems operations. What operators commonly substitute for Ifr potential is business policy which demands that pilots avoid instrument weather at all cost. But denial of upgraded potential is inexcusable in a business which offers aviation assets to the public. The Faa should question Ifr potential for air medical helicopters as part of the new Sfar. This would serve two purposes: it would give pilots needed options; it would growth the standard of companies contentious for air med business, drive marginal operators away.
Let me be clear about this: I propose Ifr potential for rescue 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 sick person 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 settled on weather avoidance, and removal of Ifr potential in lieu of weather minimums and dogmatic measures, have made air medical less safe.
Pilots must find the delicate equilibrium between schedule needs and their pro standing. Air med pilots are just lease 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 promulgation of the team conception 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 sick person 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 sick person mission at crew turn time. At most programs, pilots are shielded from sick person information, to avoid undue pressure on them to accept or reject a flight. This is a good protocol. But the straightforward truth is, that pilot exposure sick person medical condition is inevitable 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 covenant site is expensive. But when a client hospital demands a pilot's removal, or a site employer learns of protection infractions, that employer must be able to take action.
Air medical flying has always had a credit for having an emergency, rapid-response atmosphere. This sheen of excitement is what attracts inevitable habitancy 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 intriguing 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 possible hazard of a diluted decision, a decision made by a committee. Especially with the rapid growth of the Hems industry, hour requirements and essential caress 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, plainly brings the aviation asset up to par with the medical tool 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, best rested, doubly trained, and have more latitude toward performing required tasks to keep the tool operating.
Another less inevitable advantage to fielding twin-engine aircraft is the possible for pilot training. Depending on the aircraft, an extra seat is ready 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 turn is, that the copilot could be person in training. If done properly, this position could be a income source for innovative operators willing to help a pilot build up his or her logbook, and willing to pay for the opportunity, to the advantage of the operator's bottom line.
" Cvr/Fdr/Taws/Gps intriguing map facility 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 support in an accident investigation, a use for which they were designed; and they would facilitate maintenance work by recording and archiving principles operating parameters. Taws is nothing more than ground avoidance technology, other 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 sick person impact evidence to the contrary, a rapid response only puts the aircraft and crew at risk, makes negligible disagreement in sick person outcome, and should be de-emphasized. A inaugurate time of ten minutes is not unreasonable. No other part 135 operation would advertise a five little takeoff time, nor would the Faa grant operations specifications for such a thing. In actual practice, the Hems mission is, by and large, a converyance principles to supply a stable, monitored environment for patients between hospitals.
" Higher schedule weather minimums, and mandatory down-status.
Weather is a factor in 50% of Hems accidents. schedule 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 control is typically where weather data is least ready and/or reliable--below three thousand feet, far from weather reporting outlets, and often below radar coverage.
" Hospital management must be more involved.
The management of air med programs must become more intimately complex in day to day operations. inaugurate decisions should be reviewed; mandatory short takeoff times should be abandoned; borderline pilots, or those who consistently make poor decisions should be held accountable; protection committees should be established, with authority to make major decisions, including the configuration of the aircraft.
Medical directors should wise up physician staff of protection issues about air medical, including the need for best triage to eliminate non-emergent air transports. A culture of withhold must be effected for no-go decisions. The tendency for medical staff receiving a converyance ask is to use the helicopter if any indication exists that it's needed. The basal assumption is, that the sick person needs to be flown, or a physician would not have called.
But patients are often flown only for mundane logistical reasons. assorted Ems services are ready on a little 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 sick person is often used when there's no indication the sick person 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 sick person mission there is, except one. I never witnessed a birth on board the helicopter. That straightforward fact, that in 3,200 sick person 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 sufficient triage, best consultation, or both, especially with today's technical potential for doctors to share information, is a key in the air medical protection puzzle, because it means fewer flights, thus more attention to truly urgent flights.
With four pilots per contract, and where schedule hours are low anyway, the operator may (rightly) be involved about less flying proficiency. In this case the sponsoring hospital should covenant for more training hours, match their assets with other hospital in a consortium arrangement, or cede the air medical converyance assistance altogether, thus rescue needed condition care dollars.
Do fewer flights mean lowered assistance to possible clients? No, it means best assistance to clients who need the assistance more. While flying a routine, stable hospital transfer patient, the helicopter is out of assistance to write back 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 principles 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 allocation for aircraft services; they have the selection of renewing a covenant with a vendor--or not; they don't assume the burden of aircraft maintenance, or staff training; and they avoid out of assistance time by having a backup aircraft within guidelines established in the contract. Leasing the asset also provides a hospital the occasion to more authentically upgrade to additional schedule 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 protection often hanging in the balance: innovation is stifled, and protection 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 control 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 fabulous whole 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, retention the helicopter dry, clean, ice and snow free, reducing maintenance issues, and more fast ready for flight.
Accountability is a very good thing. But due to the glacial pace of turn in any institution, and given today's focus on reducing condition care costs, any innovation, regardless of how intriguing 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 protection measures are shelved, or passed between client and vendor, with neither accepting financial responsibility. Until such time as protection 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 best allocation for new innovations, and for operators to escape onerous contracts, best serve customer demands, and be more attentive to the bottom line in a field already littered with bankrupt operators.
One useful byproduct of annual 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 wish a rapid turnaround of assets. other advantage to one-year contracts is, that this would force standardization of equipment. Presently, even two aircraft sited at the same hospital often have separate medical installations, radio packages, lighting, warning systems and cockpit instrumentation. This may not be a qoute for a covenant site using the same pilots all the time, (or it may be a major problem), but the lack of standardization precludes other explication to the air medical accident puzzle.
Pilots at a single schedule control with little or no oversight from business headquarters. In such an arrangement, pilots often share only among themselves the assorted problems, maintenance gripes, and operational glitches. There exists no mechanism for communal focus and sharing of protection data company-wide, except for caress through annual check flights, or a business newsletter of some kind. This is yet other theorize client hospitals should hire larger companies, as they have more latitude to hire and hire check pilots and relief pilot staff to float between programs. Doing so would disseminate good data and protection practices across the company.
Larger companies are also best able to use other innovation that would improve safe operations: the transfer, or shared pilot concept. Transference between covenant sites would add to the transparency and oversight of programs, and growth the level of professionalism. This is yet other theorize hospitals should field multi-engine aircraft. The unoccupied cockpit seat could be used to orient a relief or transfer pilot, as a business check pilot station, or again, to train a new hire pilot, a functionality unavailable to single-engine operations.
In increasing 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 ensue of decreasing whatever level of protective opacity that may exist in the 'team oriented' environment.
Yet other explication to safe operations is to decrease the level of team cohesion that may promote a protective amnesia about unsafe or marginal individuals, whether aviation or medical staff. Client hospitals may even think altering the makeup of flight staff, replacing the primary flight nurse team with floating medical staff to go along with visiting pilot staff. This would place more emphasis on the 'air', and less on the 'medical' part of the equation, increasing the level of safety. Patients and nurses don't crash; pilots and helicopters do.
One explication to this dilemma has already been listed, a explication that is open heresy to the air medical community. There are plainly too many air medical helicopters, operating at too many hospitals, by too many vendors. If sick person outcomes, mortality and morbidity were being authentically affected, all to the good. But, after thirty years of operating air medical helicopters, there's no objective evidence whether of those is happening. Meantime, more air medical crews are dying in accidents. There's plentifulness of anecdotal information, and hundreds of patients will testify to the good these aircraft and crews have done, as will I. But the simple, stark reality is, that air medical aviation is sicker than the patients it's attempting to reach. Measures must be taken to turn the situation.
" sell out operating areas at night, or use two pilots/ Ifr/Nvg and Taws.
One of the boldest solutions to the air medical accident rate will also be the most controversial. Given the nature of air medical, particularly in light of its image Vs reality, hospitals interested in reducing risks, and raising the standard of protection should think reducing their response radius after a inevitable time, midnight being the likely cutoff, to a length of twenty-five miles from the home facility. This restriction would advantage protection in any ways: it would automatically sell out fatigue levels in air med crews; it would be an automatic triage function, putting requesting hospitals and physicians on observation that a sick person needing air converyance must be flown before midnight, or wait till morning. A reduced operations area would cut the risk of weather-related accidents, putting helicopters closer to the home hospital, thus obviating the aircraft's use for only emergent patients. Shrinking the response area would also prevent much of the risk associated with weather changes en-route, or due to long wait times at outer hospitals and/or loiter points. other benefit, particularly at programs with two or more aircraft, is the increased availability for maintenance. It would also save sponsor hospitals money, since the income hours flown would likely be less. Plus, the possibility exists that fewer pilots would be needed with a reduced coverage area after midnight.
An alternative to this proposal is the use of Ifr cockpits, Nvg qualified crews (including medical staff), and adoption of proposed Terrain Awareness & Warning principles in all air medical helicopter cockpits per Section 508 of S. 1300*, a bill in the U.S. Senate aimed at rectifying the accident rate in Hems operations**.
Every program's statistics are different, and air medical is, after all, an accident rescue service. But limiting the rescue assistance would not be the intent; the intent is increased oversight through best triage of converyance requests. At most programs, so-called on-scene missions consist of the bottom ration of response flights. The larger whole is stable, non-emergent sick person missions. It's been debated for years whether or not the use of helicopters impacts sick person mortality and/or morbidity. That deliberate upon will continue. But until the protection issue is adequately addressed, it will override all others. And until safe flight of air medical helicopters becomes a given, advisability of using them for sick person converyance must be watched more carefully.
The Hems accident rate will only be reduced when the three legs of the stool are in place: pilots; aircraft & equipment; and hospital/operator oversight. Until the changes listed herein are standard institution in air medical flying, accidents will continue to plague this essential industry. It's my hope that all complex can step away from the habits of the past, and focus on the changes needed to make Hems the safe, productive sick person converyance principles it can be.
Accidents are not inevitable; they happen when factors conspire against a schedule and pilots which are relaxed and complacent in regard to safe practices. Helicopter air medical is terribly unforgiving of neglect and incompetence; operators, pilots and their colleagues, and sponsor hospitals must be aggressive in identifying and addressing any and all protection issues immediately, without regard to personnel, political, financial or menagerial matters. There's too much at stake to articulate a cavalier attitude, or assume that an accident can't happen. Helicopters are flown safely all the time. But it doesn't happen by accident.
In summary, my recommendations for raising the protection level of air medical helicopters are the following:
*Senate Rule S.1300 is listed.
- For those programs requesting it, an immediate protection stand-down for Faa or other surface party quote and narrative on all aspects of the operation.
- Pilots must be best vetted, and trained emphasizing weather incursion recovery.
- Instrument flight potential for rescue only in all air medical helicopters.
- Higher pilot hours in the aircraft being flown, to consist of a minimum of 2,000 hours to be hired, 20 hours in type, 10 hours at night, and 50 hours of actual or simulated weather time.
- Multi-engine aircraft in all Hems operations.
- Cvr/Fdr/Taws facility in air med helicopter cockpits + modular installations.
- De-emphasize rapid response/takeoff time.
- Higher schedule weather minimums, and mandatory down-status.
- Hospital management must be more involved.
- The covenant bottom line must be secondary to safe practices and hard aviation realities. annual contracts to expedite innovation time for protection proposals.
- sell out operating areas at night, or use two pilots.
- Requirement for availability to all medical crews of a no-flight or abandon-mission protocol without fear of repercussion.
- Site employer a hospital employee with authority to hire and fire, with pilot status a plus.
- Faa Sfar for air medical helicopter operations codifying weather minimums, Ifr equipment, Nvg, Taws, dual pilot capability, and op specs required for expanded area operations after dark or below specific weather values.
- All air medical flights conducted under part 135 regardless of sick person presence.
Equipment Requirements:
Multi-engine aircraft
Ifr for rescue only
Nvg capability
Taws
Wire cutters
Cvr/Fdr
Gps intriguing map
Weather way in the cockpit in real time
*Legislation, S. 1300, has been introduced in the U.S. Senate to authorize appropriations for the Federal Aviation management (Faa) for fiscal years 2008 through 2011 to improve protection and capacity and to update the air traffic control system. In increasing to the issues previously discussed about user fees and surcharges and an growth in the fuel tax, S. 1300 also would mandate essential changes for helicopter accident medical assistance operators.
Section 508 of S. 1300 would mandate yielding with Part 135 regulations whenever medical crew are on board, without regard to whether there are patients on board the helicopter. Within 60 days of the date of enactment of S. 1300, the Faa would be required to inaugurate rulemakings to originate standardized checklists of risk estimation factors and wish helicopter Ems operators to use the checklist to determine whether a mission should be accepted. Additionally, the Faa would be required to unblemished a rulemaking to originate standardized flight dispatch procedures for helicopter Ems operators and wish operators to use those procedures for flights.
Any helicopter used for Ems operations that is ordered, purchased, or otherwise obtained after the date S. 1300 was enacted would also be required to have on board an operational terrain awareness and warning principles (Taws) that meets the technical specifications of section 135.154 of the Federal Aviation Regulations (14 C.F.R. 135.154).
To improve the data ready to National communication protection Board (Ntsb) investigators at crash sites, the Faa would also be required to unblemished a feasibility study of requiring flight data and cockpit voice recorders on new and existing helicopters used to Ems operations. Subsequent to the feasibility study, the Faa would be required within two years of S. 1300's enactment to unblemished a rulemaking requiring flight data and cockpit voice recorders on board such helicopters.
All Helicopter connection International (Hai) operators conducting Ems operations are strongly encouraged to quote the provisions contained in *Section 508 of S. 1300. Hai is interested in hearing from you with respect to any concerns you might have over the requirements contained in this legislation. Please caress David York or Ann Carroll via email at david.york@rotor.com or ann.carroll@rotor.com.
Hai continues to analyze legislation in the U.S. House of Representatives and the U.S. Senate with respect to Faa reauthorization and normal aviation user fees, surcharges, and other protection provisions. More data will be provided on the Hai Web site as developments occur in Washington.
**Section 508 of S. 1300
S.1300
Aviation investment and Modernization Act of 2007 (Introduced in Senate)
Sec. 508. increasing protection For Helicopter accident medical assistance Operators.
(a) yielding With 14 Cfr Part 135 Regulations- No later than 18 months after the date of enactment of this Act, all helicopter accident medical assistance operators shall comply with the regulations in part 135 of title 14, Code of Federal Regulations whenever there is a medical crew on board, without regard to whether there are patients on board the helicopter.
(b) Implementation Of Flight Risk estimation Program- Within 60 days after the date of enactment of this Act, the Federal Aviation management shall initiate, and unblemished within 18 months, a rulemaking--
(1) to originate a standardized checklist of risk estimation factors based on its observation 8000.301, issued in August, 2005; and
(2) to wish helicopter accident medical assistance operators to use the checklist to determine whether a mission should be accepted.
(c) allembracing Consistent Flight Dispatch Procedures- Within 60 days after the date of enactment of this Act, the Federal Aviation management shall initiate, and unblemished within 18 months, a rulemaking--
(1) to originate standardized flight dispatch procedures for helicopter accident medical assistance operators based on the regulations in part 121 of title 14, Code of Federal Regulations; and
(2) wish such operators to use those procedures for flights.
(d) enhancing Situational Awareness- Any helicopter used for helicopter accident medical assistance operations that is ordered, purchased, or otherwise obtained after the date of enactment of this Act shall have on board an operational terrain awareness and warning principles that meets the technical specifications of section 135.154 of the Federal Aviation Regulations (14 C.F.R. 135.154).
(e) enhancing the Data ready to Ntsb Investigators at Crash Sites-
(1) Study- Within 1 year after the date of enactment of this Act, the Federal Aviation management shall unblemished a feasibility study of requiring flight data and cockpit voice recorders on new and existing helicopters used for accident medical assistance operations. The study shall address, at a minimum, issues associated to survivability, weight, and financial considerations of such a requirement.
Rulemaking- Within 2 years after the date of enactment of this Act, the Federal Aviation management shall unblemished a rulemaking to wish flight data and cockpit voice recorders on board such helicopters.
No comments:
Post a Comment