U.S. looks to boost safety rules for medevac flights

A National Transportation Safety Board report issued last month called on the Federal Aviation Administration to pass new safety regulations governing the emergency medical service aircraft known as medevac. The report showed that between 2002 and 2005, 55 medevac crashes killed 55 people and injured 18 others, about double the rate found in the 1990s.

After an 18-month study of the 55 crashes, 20 of which occurred with patients on board, the NTSB found that some safety issues cropped up again and again, including:

• Fatigued pilots flying in bad weather conditions, thanks to less-stringent FAA requirements for medevac when patients are not on board.
• A lack of programs to help dispatchers and pilots evaluate the risk of a given flight.
• No consistent flight dispatch procedures for medevac operations.
• Little or no onboard technology such as terrain awareness warning systems, known as TAWS, to help pilots avoid mountains, hills and trees when visibility is poor.

In its report, the NTSB highlighted seven crashes it said typified these safety problems. For example, an EMS airplane crashed Feb. 17, 2004, after the pilot flew five miles past the Dodge City Regional Airport in Kansas. He had been on duty for 14 hours and awake for 20. The pilot, a flight paramedic and a flight nurse died.

In Battle Mountain, Nev., an EMS helicopter crashed in deteriorating weather conditions on the night of Aug. 21, 2004. The NTSB said the pilot -- who was transporting an 11-day-old patient to a hospital in Reno -- likely couldn't see the mountainous terrain ahead of him and improperly took a direct route over the mountains rather than going around them "due to the nature of the EMS mission." The pilot, two members of the medical crew, the mother and her infant were killed.

"The very essence of the EMS mission is saving lives," NTSB Acting Chair Mark Rosenker said in a statement. "Operating an EMS flight in an unsafe environment just makes no sense."

Overseeing a growing industry

The number of medevac operators has boomed in the last decade, with the FAA putting the number of EMS helicopters at 650. The number of EMS helicopter flight hours has nearly doubled since 1991, jumping from 162,000 then to 300,000 in 2005, the NTSB estimates.

The jump in medevac crashes is "disturbing," said Robert Bass, MD, executive director of the Maryland Institute for Emergency Medical Services Systems, a state agency that regulates medevac operators. "There is clearly a need for both state and federal oversight."

While all states license medevac operators, only seven states and a few county agencies require companies to be certified by the Commission on Accreditation of Medical Transport Systems. CAMTS trains programs in all aspects of medevac operations, not just flight safety. About a third of medevac operators are CAMTS-accredited, according to the group's executive director, Eileen Frazer, a former flight nurse.

Dr. Bass, president of the National Assn. of State EMS Officials, is working on a set of recommended state regulations to be released midyear. He said the NTSB recommendations are "not unreasonable."

Medevac response coming

An analyst for the Assn. of Air Medical Services, which has about 250 medevac operators as members, said the group planned to file formal comments in response to the NTSB recommendations. The group's initial response is that the safety recommendations could be problematic.

In particular, operators have reservations about a move to force EMS helicopters to operate under Part 135 of the FAA regulations at all times rather than only when patients or live organs are on board.

Part 135 requires an FAA-approved weather station near a flight's destination, but such stations often are absent from the remote areas to which medevacs are called to pick up patients, according to Christopher Eastlee, a government relations assistant for AAMS.

Eastlee also said TAWS, the onboard technology suggested by the NTSB, could cost as much as $250,000 to purchase and install and was ill-suited to helicopter operations.

"These systems beep when you're close to the ground, which is wonderful at 25,000 feet but can be counterproductive when you fly at 1,000 or 2,000 feet, as many of our aircraft do," Eastlee said.

The FAA supports voluntary implementation of TAWS, but "the systems are built for airplanes, not helicopters," said Alison Duquette, an agency spokeswoman. "We don't want helicopter pilots to get too many false warnings."

Striving for guidelines that make sense

The FAA formed an EMS helicopter task force in August 2004 and throughout 2005 released several notices for FAA inspectors to discuss with medevac operators. They focused on pilot decision-making skills, crew resource management, the use of risk-assessment models and guidance for inspectors on the use of weather information by flight crews and management. In late March, the FAA will co-host a summit in Boulder, Colo., to examine weather issues specific to medevac operators.

"[The FAA] is not rushing out there and putting regulations in place that might affect a lot of people in a negative way," CAMTS' Frazer said. "They're trying to work with the industry."

That's part of the problem, according to the NTSB, whose report said the FAA's notices are "simply information" and that "without requirements, some EMS operators will continue to operate in an unsafe manner."

The FAA's Duquette said the agency formally would respond to the NTSB's recommendations within 90 days and that any rule-making process could take as long as two years.