In response to the helicopter emergency medical services (HEMS) industry’s spate of fatalities last year, the National Transportation Safety Board (NTSB) held a four-day public hearing last month to delve into all aspects of the industry. While the proceeding was billed as a purely fact-finding exercise, NTSB members repeatedly pummeled regulators for their failure to adopt some of the safety agency’s high-priority recommendations, particularly the board’s call for terrain avoidance systems. The proceeding involved 41 witnesses from HEMS operators, manufacturers, hospitals, associations, regulators and other parties, covering subjects from flight procedures and training to technology and economic factors. The data may lead to additional hearings, reports and other recommendations.
Robert Sumwalt, chairman of the NTSB’s Board of Inquiry, called attention to the industry’s spotty safety record: 85 HEMS accidents, with 77 fatalities, in the past six years. But 2008 was the deadliest year on record, he said, with 13 helicopter accidents and 29 fatalities. That’s more than four times the seven fatalities recorded in 2007. Even before the latest spike, things were not looking good. According to an NTSB special investigative report in 2006, 29 of the 55 accidents between January 2002 and January 2005 were preventable. The accidents in this three-year period resulted in 54 fatalities and 18 serious injuries, the report said, and that number of EMS accidents had not been seen since the 1980s. The NTSB added HEMS safety improvement to its "Most Wanted List" in 2008.
Although the tone of the hearing resembled that of a graduate seminar, the content could not have been more serious. Some of the high points of the proceeding included a report on HEMS accident rates, a comparison of HEMS operations in the U.S. and Canada, and a discussion of the relationship of competition to safety.
Ira Blumen, director of the University of Chicago Hospitals, presented a report on HEMS accidents and accident rates. Although the HEMS fatal accident rate per 100,000 flight hours has declined from almost 10 in 1980 to two in 2008, its fatal accident rate compares poorly with that of other aviation sectors. In 2007 the HEMS accident rate exceeded that of Part 121 scheduled and nonscheduled, as well as that of Part 135 scheduled and nonscheduled operations, as a whole. Dedicated HEMS crews experienced a higher fatality rate than workers in fishing, logging, steel mills, roofing and other risky lines of work. Patients faced less risk than crews: only 34 of the 4.5 million transported over a 29-year period were killed. This may be because EMS helicopters operate many more hours without than with a patient aboard — including the initial flight out and then the return to base.
Canada’s heavily regulated HEMS industry has a far different record. Although Canada boasts only 20 EMS helicopters, compared with the more than 800 HEMS rotorcraft in the U.S., the Canadian industry has logged approximately 230,000 flight hours without a fatal accident, according to Sylvain Séguin, vice president of safety and quality for Canadian Helicopters, the country’s largest EMS operator. There was one accident last year, but it wasn’t fatal. There are other key differences between the two countries. All of Canada’s HEMS services are two-pilot operations, and all the helicopters are capable of instrument flight. Almost two-thirds of flights are conducted in daylight. Services are publicly funded and are managed by provincial health departments.
Effects of Competition
The hearing also focused on business factors that may affect safety. Bryan Bledsoe, an emergency care physician who formerly served as the medical director of a HEMS service in Dallas, argued that the rapid growth of the HEMS industry has taken a toll. The U.S. has too many EMS helicopters, Bledsoe asserted. Arguing by analogy with Canada, which has 20 helicopters for 21 million people, he said the U.S. should have about 300 EMS rotorcraft. But, instead, the U.S. has nearly 850. While competition has helped to encourage HEMS services in rural areas, it has also led to the clustering of multiple operators in affluent areas around Phoenix and Dallas-Fort Worth, he said. "The pressure in terms of recruiting ground providers to call your service over another service, or to position your helicopters in certain areas so you capture certain patient flow patterns, is all part of the competition."
"Payment is the central factor controlling helicopter utilization," Bledsoe said. An environment in which jobs depend on patient transport billing "creates a situation where patients are transported regardless of need." He recalled a flight crew at one base in Texas that tracked the number of flights they needed to achieve each month. "They know what the breakeven point is, the number of flights necessary to keep that base open for a prolonged period of time," Bledsoe said. There was actually a graph on the wall showing how many flights they had done that month and how many more they needed to do.
Bledsoe stated that several accidents have been attributed to "helicopter shopping," where a paramedic at the scene calls two or three services before he gets one to accept the job. As other speakers pointed out during the hearings, the initial requests may have been rejected for good reasons — weather, for example — but this is not always communicated to the operator who accepts the job. Bledsoe also asserted that the medical side sometimes intrudes on the aviation side of an operation. A pilot’s knowledge of a patient’s perhaps dire situation can influence his aviation decision making, which can undermine safety.
Asked whether he would simply dispense with the U.S. free market approach to HEMS, Bledsoe said, "you could keep [it], as long as you centralize dispatch" — have all calls in an area come into a common center — so that the closest operator is sent. Right now, he said, "whoever is on your keychain is who you call." In pursuit of that goal, the capabilities of the various aircraft and crews need to be "quantified" and the information should be kept at a central facility, he added. And a centralized phone number should be used.
Other risks were described by representatives of flight nurses and paramedics. In a recent internal survey by the International Association of Flight Paramedics (IAFP), about 75 percent of the respondents said they felt uncomfortable or otherwise unable to speak out regarding a safety concern. That’s despite the well-known industry mantra, "three to go — one to say no."
In another IAFP survey, cited by Jeff Guzetti, who asked questions as a member of one of the NTSB Technical Panels, 30 percent of the respondents asserted that pilots are aware of patient information. When IAFP asked in a survey whether programs ever pushed aircraft performance limits, the answers were similarly disturbing. Some 10 percent of respondents alleged envelope-pushing behavior regarding weather minimums, 20 percent regarding weight and balance, and 15 percent regarding aircraft range. This is a concern because of the potential for errors in making judgments "that we know lead to unfavorable outcomes," said association president, James Riley.
Training was also discussed at length. Tony Bonham, chief pilot with Air Evac EMS Inc. of West Plaines, Mo., made the comment that his company’s training program helps turn helicopter pilots into EMS helicopter pilots — essentially a culture shift. New hires may come in with an "initial mindset to do whatever to save lives," he said. "They need to be brought down to a level [that their] first and foremost mission is to follow the rules and regulations." Ironically, although Air Evac was an early adopter of terrain avoidance technology, the company’s Garmin systems apparently do not meet the FAA’s new terrain awareness and warning system (TAWS) technical standard order (TSO). So if it becomes mandatory to equip with TSO’d TAWS systems, Air Evac would have "84 TAWS it won’t be able to use any more," Bonham said.
Several witnesses stressed the need for more robust training. "Training is the largest causal factor in the accidents we see today," said Bruce Webb, chief flight instructor for American Eurocoptor, Grand Prairie, Texas. The capability of modern aircraft can exceed the ability of some pilots to operate safely "because people choose, for economic reasons, not to take advantage of all the training available." He suggested that the level of training might need to be graduated, based on the aircraft and the environment in which it flies. For a basic VFR helicopter with conservative weather minimums, once a year may be sufficient, but twice may be requisite. But for an IFR helicopter quarterly training would be "very wise."
Terry Palmer, a manager of rotorcraft programs with FlightSafety International in Texas, stressed simulators as "key to keeping perishable skills up to par." Although there is a perception in the industry that one has to use a simulator that exactly matches the aircraft one is flying, you can use virtually any simulator to look at things like human factors and instrument flight skills, Palmer said.
FAA speakers tended to emphasize the positive. Their back-and-forth with NTSB questioners highlighted the essence of the different agencies — the former a safety gadfly, demanding mandates that would enhance safety, the latter a more conservative, consensus-seeking organization. Dennis Pratte, manager for the FAA’s Part 135 Air Carrier Operations Branch, reported that 94 percent of operators have a risk assessment program, 89 percent are using some form of operations control center, and some 30 percent are using night vision goggles. Although there was a spike in 2008, the trend in accident numbers over the past five years is going down, he said.
Of this country’s more than 800 EMS helicopters, the "vast majority are safe," emphasized John Allen, director of the FAA’s Flight Standards Service, "although [the industry] is not as safe as it could be." When queried why the FAA has not required EMS operators to equip with terrain avoidance systems, Allen replied that rulemaking is a very deliberative process and that the FAA does a rigorous analysis of the impacts on industry and safety. The FAA doesn’t want to provoke unintended consequences and relies heavily on voluntary responses, he said.
When asked about a mandate for night vision goggle equipage, Allen answered that it really depends on the operator, the operation and training circumstances. Vis-à-vis HEMS flight recorders, Allen said that if you require them, you’d get "pushback" because they are expensive. However, he said that the advent of new, lighter-weight technology would provide an "excellent opportunity" to address the issue in the future.
A final exchange between the NTSB’s Sumwalt and FAA’s Allen suggested the possibility of an FAA TAWS rulemaking procedure. Sumwalt pointed out that HEMS patients don’t have the luxury of choice; they can’t be "discriminating consumers." Therefore, those "who can’t be coaxed" need the coercive power of regulation. Since only 28 percent to 30 percent of operators have TAWS, is the voluntary method of compliance working, he asked.
Sumwalt then queried Allen directly on the FAA’s intentions for TAWS. Allen said he thought that the voluntary programs are working, but that "we are actively considering a rulemaking." When reminded that it’s been three years since the NTSB issued a recommendation, Allen said that the agency is "ready to move forward and intends to do so."
The NTSB heard from experts at Honeywell, Appareo Systems and Bell Helicopter concerning terrain avoidance, image and data recording, and wire strike protection technology. Honeywell asserted the effectiveness of its enhanced ground proximity warning system (EGPWS) product, in that no aircraft equipped with an operable EGPWS has had a controlled-flight-into-terrain accident. Honeywell’s helicopter EGPWS systems are now installed in about 200 EMS helicopters.
Recording is also an issue in helicopter safety, as one in five accidents has no data, according to Dave Downey, Bell’s vice president of flight safety. Bell is developing an approximately 4-pound cockpit image recorder that provides four JPEGs, allowing you to see pedals, collective, cyclic and what the pilot’s hands are doing but not the pilot’s body, he said. It could provide operators a means of flight data monitoring, as well as serve as an accident investigation tool. Downey also said that Bell has made the decision to make wire strike protection systems — guides that bring a wire into a cutter — standard on all its aircraft.
Existing flight recorders, however, are very effective, as Dave Batcheller, director of quality, process and program management with Appareo Systems, pointed out. The company designs and manufacturers flight operations quality assurance (FOQA) and other products. FOQA can help reduce operational risk areas, decrease the number of incidents and produce behavioral changes, he asserted. He cited one operator, some of whose pilots were routinely cruising at altitudes lower than the minimums authorized by their standard operating procedures. Incidents of this behavior were decreased by more than 95 percent in less than six months via FOQA, he said. The company hopes to introduce image-recording capability next year.