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Saturday, October 1, 2005

Staying Safe & Healthy

James T. McKenna and Douglas W. Nelms

Helicopter EMS operators around the world face a host of challenges, including figuring out--in the U.S.--how to boost safety and economic survivability at the same time.

Helicopter emergency medical service providers throughout the world are wrestling with the challenges of how to keep their operations safe and sufficiently funded.

The sector's predicament has vendors of everything from aircraft and EMS equipment to enhanced vision systems, navigation aids and services and flight tracking and communications gear scrambling to convince operators that they have solutions to boost both safety and efficiency.

The challenges take different forms in different parts of the world.

In Europe, for instance, helicopter EMS operators are campaigning for something that would boggle the minds of many of their U.S. counterparts: the preservation of more stringent safety and operational requirements, such as those that limit operations to twin-engine aircraft in most of the region.

In some parts of the Continent, such as in Italy, EMS operators are quietly pushing to take over more of the search-and-rescue missions traditionally performed by government and military agencies. That, in turn, is provoking some in the industry to question the wisdom of turning over often hazardous duties to crews less experienced, skilled and trained than those currently performing them.

In the United Kingdom, many helicopter EMS operations are on sound financial footing, with trusts and community and industry monies ensuring their survival. Still, some operations are struggling to keep their aircraft flying.

U.K. operators and government officials also are confronted now with the question of how to best employ EMS helicopters in response to terrorist attacks such as those that struck London's transportation network in July. One particular concern is how to keep crews safe--and aircraft operational--during responses to incidents that may involve biological or chemical weapons.

U.K. government officials also are beginning to address the question of how to best meld national, regional, local and private emergency helicopters into an effective response to natural disasters such as the flooding that struck the Carlisle region in January.

In particular, they are looking to apply the lessons learned from the response to the Dec. 26, 2004 Indian Ocean tsunami, which wiped out local emergency-response capabilities from Indonesia to Africa and left helicopters as the only viable means of effecting immediate, large-scale rescues and relief. Their counterparts in the United States were forced to a new appreciation for those lessons and the need to make all available helicopters integral to emergency-response plans on Aug. 29, when Hurricane Katrina and the flooding that followed devastated the region around New Orleans.

In Australia, operators are mulling how to better serve markets and communities that expect them to do everything from scene calls, critical-care transports and inter-hospital transfers to offshore, mountain and wilderness rescues. The scale of that nation's geography, the dispersion of its population and scarcity of helicopter EMS resources raise their own set of safety and financing questions.

Nowhere are the challenges facing the EMS sector more stark and immediate than in the United States, where competition can be pitched (and, some say, bloody) and pressure to redress safety problems is intensifying from the media, the public, politicians and, consequently, government regulators.

Safety is clearly the biggest concern facing the U.S. EMS sector, operators, pilots and regulators agree. Some in the business argue that the string of fatal EMS accidents in the last several years is a reflection of the sector's burgeoning growth and doesn't equate to an actual increase in the rate of fatal accidents--a common aviation industry measure of safety.

"That's pretty irrelevant," said Aaron Todd, CEO of Englewood, Colo.-based Air Methods Corp. "Clearly we're having way too many accidents." With a fleet of 200 helicopters, Air Methods is the largest commercial U.S. EMS operator.

That recognition has led to unusual steps for the industry. EMS sector leaders are collaborating with representatives of the U.S. FAA's Rotorcraft Directorate in Fort Worth, Texas and others at the agency's Washington headquarters to develop and publish guidance material for operators and FAA inspectors on "best practices" to foster improved safety. The FAA has published such material on improving risk-management procedures and plans to follow that with ones on avoiding controlled flight into terrain and loss-of-control accidents, among others.

FAA officials last month were to announce the formation of a joint government-industry helicopter safety, modeled on a successful commercial aviation effort and set up with the goal of identifying means of cutting the fatal helicopter accident rate by 80 percent within 10 years.

Industry officials also are embracing Air Medical Resource Management, a version of crew resource management that integrates the medical crew in the back of an EMS aircraft with the pilot up front (and, in ideal cases, the communications specialist working the flight on the ground) in decision-making processes. "The interaction among the pilot, the flight nurse, the paramedic and the communications specialist is critical," said one senior industry official with more than 30 years experience flying EMS missions.

This practice was pushed by Dr. Michelle North, the helicopter pilot and safety pioneer who died in 2004. North essentially wrote the guidance material on Air Medical Resource Management that advocates have long waited for the FAA to publish. In the absence of formal guidance from the agency, numerous operators have adopted the practice on their own.

Many companies are focusing on training. At Shreveport, La.-based Metro Aviation, for instance, in addition to their semi-annual check rides, pilots are required to go out with a safety pilot on a monthly basis and shoot approaches to maintain currency.

"About 90 percent of our pilots get this in each month, and if a pilot misses one month, we make sure he gets it in the next month," Metro President Mike Stanberry said.

The company is awaiting certification of a full-motion EC135/145 simulator that it can use for recurrency training, he said. It has also raised the weather minimums that determine whether or not a pilot can accept a mission, making them even stricter than the FAA minimums.

A more contentious matter is the push by some industry officials for the FAA to raise minimum standards and equipment and weather requirements for EMS operations. Opponents argue that it would be unfair and probably illegal for the agency to adopt standards for EMS operators that are more stringent for non-EMS outfits operating under FAR Parts 135 and 91. Advocates counter that, unlike almost every other type of aviation operation, the passengers carried on EMS aircraft rarely have a choice about when, how and on whom they fly. Since the trip isn't by the passenger's choice, they say, the standards governing it should be more stringent.

"The question is how are we going to handle the safety issue as an industry and as a company," said Larry Pietropaulo, president and chief operating officer of CJ Systems Aviation Group, another top operator of EMS aircraft in the United States.

The pressure to come up with a satisfactory answer is intensifying. The U.S. National Transportation Safety Board was expected to issue by the end of September the results of a special investigation into EMS safety. In part as a response to that year-long investigation, the FAA set up a helicopter EMS safety task force that eventually incorporated the collaborative efforts with industry. In the last several months, major newspapers like USA Today and The New York Times have published special reports on the sector's problems and questioned whether operators and the FAA have done enough to correct them. That has led to a probe of the EMS sector and FAA oversight of it by the U.S. Government Accountability Office, the investigative arm of Congress. Generally, that office begins such probes at the request of a member of Congress, which means the question of EMS safety has captured the attention of someone on Capitol Hill.

Aside from the political attention and the circus atmosphere it may engender, serious efforts to correct safety shortcomings are likely to focus on decision-making techniques and processes and how they might be improved to help crews avoid getting into situations that lead to accidents.

Several groups, including the Air Medical Safety Advisory Council, have been analyzing the root causes of past accidents to identify means of eliminating or mitigating them. Set up in 2000, the council is based on the Helicopter Safety Advisory Council that has had a great deal of success in improving the safety and professionalism of operations in the offshore energy support market in the Gulf of Mexico. But the groups working on the root-cause analyses keep running up against a problem.

"We keep ending up asking ourselves, `What the hell were these people doing out there?'" said Ed McDonald, safety committee chairman of the National EMS Pilots Assn. and a participant in those analyses. "That's why we're having huge difficulty influencing people and decisions out there." It's very difficult to understand human behavior, let alone change it, he said.

The pilots group is pushing for a number of steps that it maintains would boost safety. These include setting stricter standards for ceiling and visibility minimums for use by the Commission on Accreditation of Medical Transport Systems, whose audit process is considered more and more to be the "Good Housekeeping" seal of approval for EMS operations. The pilots group also wants better weather reporting services around the country and greater participation by EMS CEOs and COOs in national EMS conferences like the Air Medical Transport Conference this month in Austin, Texas and the Assn. of Air Medical Services' annual and spring meetings. It likewise is seeking greater analysis of EMS accidents and more widespread dissemination of the lessons learned from those accidents.

Also, "there must be a concerted effort by all parties to eliminate pressure to fly," said Ron Fergie, NEMSPA's president, has said. "Not just corporate or competitive pressure, but self-induced pressure, peer pressure and situational pressure."

There is a disagreement over the degree to which companies push pilots to fly risky missions. Some pilots say they've never encountered it; others feel it happens frequently. When NEMSPA did a survey of industry pilots four years ago, it found "an inordinately high number of pilots who said at one point or another they'd received pressure to fly," said McDonald. The group was wrapping up a new pilot survey at press time and was slated to release it at the AMTC conference this month.

There is little disagreement that the EMS sector is a pressure-cooker when it comes to competition. In addition to the growth of big operators like Air Methods and CJ Systems through acquisition and expansion, PHI Air Medical Group has gotten back into the business in a major way and there has been a virtual explosion of independent EMS programs through the country. That complicates the matter of answering safety concerns with better aircraft and equipment.

"The problem is that if you carry someone in a $4-million, IFR-equipped aircraft with all the bells and whistles or a $1-2 million, basic VFR aircraft, you get paid the same," said CJ Systems' Pietropaulo. "How do we compete and keep this industry from going to lowest common denominator."

The matter is further complicated by the economics of the sector. On average, one senior industry official said, EMS operators only collect about 50 cents of each dollar billed for their services. "We're writing off millions for hardship cases that can't pay."

The intense company-vs.-company competition is aggravated by the fact that many hospitals that are the foundation of "traditional" EMS programs (in which an operator supplies the aircraft and flight crew to a hospital, whose nurses and paramedics fly in the back) are questioning their airside costs. Also, the pool of hospitals with which traditional operators can do business isn't growing.

"Not a whole lot of new hospitals are entering the market, but we see people shopping for price or quality and turning over that way," said Larry Adams, who as vice president and general manager oversees Keystone Helicopter Flight Services' EMS operations. All Keystone's business is in traditional programs, and the company plans to keep it that way. "That's the corner that we're going to live in," said Keystone President Dave Ford.

While much of the explosion in the industry stems from the growth in independent or stand-alone programs that aren't affiliated with a hospital, the trend in the marketplace regarding traditional-vs.-independent programs is far from clear. Independent operators like PHI Air Med and Air Evac Lifeteam have seen steady growth. Many companies have a mix of traditional and stand-alone programs. Addison, Texas-based Omniflight Helicopters, which underwent a buyout in 2003, boosted its prospects last year through the merger with Native American Air Ambulance of Mesa, Arizona. Billed as the largest air medical provider in Arizona, Native Air gave Omniflight a customer base in that state, Montana and Minnesota and added to its Texas customer base. "The merger of these two organizations was the next logical step in our plans to broaden the product offering for Omniflight and its customers," said the company's president, Mark Johnson.

Last April, Air Evac Lifeteam purchased the helicopter assets and rotary-wing operations of Critical Air of San Diego, Calif. This gave it additional Bell 206s, the only type the company operates, and 10 bases scattered throughout rural Texas.

Air Evac Lifeteam President and CEO Colin Collins said the company's purpose is "to serve the health care needs of rural Americans." To do that, he added, "we have to make sure we are as safe as we can be. Many rural Americans do not realize that because they've chosen to live in a rural area, their chances of dying due to a traumatic injury or illness are three times higher than their counterparts who live in metropolitan areas, mainly due to the amount of time it takes them to reach life-saving medical care."

The EMS marketplace can best be described as unsettled. Some leaders talk of prospects for further consolidation among operators, but not just yet. A number of programs are in the process of seeing whether the grass is greener on the other side of the fence. "Some traditional operations are switching to independent," said Keystone's Adams. "Some are coming back the other way."

This uncertain environment is prompting operators to test ways of improving their bottom lines and lowering costs for customers. Keystone recently restructured its billing procedures with long-time customer Hahnemann University Hospital in Pennsylvania to establish a tighter partnership. "So we share the risks and the rewards" of the operation with the hospital instead of being another vendor, said Ford. Keystone was able to do that because it was very familiar with the hospital's management and service area as well as its track record of transports. Not many such opportunities like that exist. Still, Keystone and others are looking for them.

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