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Monday, March 1, 2010

EMS Safety Awareness Up But Wave of Regs Expected

How can HEMS operators balance the competitive nature of business with challenges like the need for the latest safety equipment and the overhead of infrastructure and sufficient crews?

By Charlotte Adams


Flight nurse Jackie Turcotte (left) and flight paramedic Bob Johnson move a patient from LifeFlight of Maine’s AgustaWestland AW109 to the emergency department at Central Maine Medical Center in Lewiston.
After a horrible year in 2008, when HEMS fatalities ballooned to 29, the industry experienced six fatalities in 2009, according to the National Transportation Safety Board (NTSB). While this may be a statistical anomaly, safety awareness is high. Rotor & Wing spoke to NTSB and operators about several NTSB recommendations.

NTSB added HEMS to its Most Wanted List in October 2008 (see sidebar, page 34). The following September the board issued 19 recommendations—to FAA, public operators, EMS agencies, and the Center for Medicare and Medicaid Services (CMS)—ranging from the installation of aircraft safety equipment to evaluation of the government insurance system’s reimbursement rate structure. While agreeing that some progress has been made since then, NTSB member Robert Sumwalt declared: “Six fatalities [in 2009] are six too many. I don’t want people to think … that the system is fixed.”

One disaster in the FAA’s backyard probably cranked up pressure on the agency to address NTSB’s concerns. That was the Sept. 27, 2008, Maryland State Police crash, killing four of the five on board. Last April FAA announced a HEMS rulemaking project covering, among other things, helicopter terrain awareness and warning systems (H-TAWS), radar altimeters, operational control centers, Part 135 weather minimums for all legs, risk management, flight data monitoring, inadvertent IMC currency, and weather reporting relief for IFR operations.

Part 135 vs. Part 91

Although EMS operators can fly under the less stringent Part 91 rules in certain circumstances, the board’s Most Wanted List calls for Part 135 on all flight legs with medical personnel on board. An NTSB report covering 55 fixed-wing and rotary-wing EMS accidents from January 2002 to January 2005 found that 35 of them had occurred while operating under Part 91.

Sumwalt praised the revisions to FAA’s A021 HEMS Ops Spec, which addresses some concerns about weather reporting. A021 states that if a flight or sequence of flights includes a Part 135 segment, then all VFR segments must follow the (higher) weather minimums and flight planning requirements in A021 or be conducted under IFR. And it also gives operators credit for use of night vision goggles (NVGs) or TAWS.

A021 also encourages IFR operations by allowing operators to use weather reporting within 15 miles of the destination area or an area forecast if the former is not available.

The main difference between Part 135 and Part 91 is duty hours, according to Jim Swartz, president and CEO of CareFlite, a small operator with six helicopters. (The maximum duty period for pilots in single-pilot, Part 135 non-scheduled HEMS operations is 14 hours, while Part 91 has no duty time restrictions.) The pilot has to be rested and his situation continuously considered during flight under either regime, Swartz said. But operators ought to be able to reposition aircraft and fly without patients under Part 91.

With four exceptions, CareFlite flies everything to the Part 135 standard, said Ray Dauphinais, vice president and director of operations. These are maintenance flights and training flights, which don’t carry passengers, administrative flights, as approved by the director of operations, and the outbound legs of IFR flights with CareFlite medical personnel on board. Outbound IFR flights use Part 91 for weather requirements, Dauphinais said. Part 91 lets you use an area forecast, he said.

CareFlite schedules 12 hours duty time. But on the final leg, if a pilot “wanted to go 91 back” and if it looks like the pilot might exceed his 14-hour maximum, Dauphinais has to be called. It’s a case-by-case decision, based on the weather, how long you’ve been flying and familiarity with the destination, he said. “They don’t call me very often.” If the company anticipates a duty time issue, it will reposition the aircraft. As far as actual flight time goes, a high-time flight day is typically 3 to 3.5 hours, he said. The average patient transport flight is about 48 minutes.

OmniFlight, a mid-sized operator with around 90 helicopters, flies all legs under Part 135, according to Ray Wall, vice president of flight operations and safety and compliance. The NTSB recommended that EMS operators use Part 135 rules primarily for the weather minimums, he said. OmniFlight’s weather minimums were “a little bit higher” than what NTSB recommended. The company flies VFR and IFR depending on customer need.

Air Methods, a large operator with 301 helicopters and around 15 fixed-wing aircraft, also flies all flight legs under Part 135, according to Ed Stockhausen, director of safety. This includes outbound and positioning legs and even if there are no medical crewmembers on board.

LifeFlight of Maine (LFM), an “indirect operator” that owns its helicopters but contracts with Part 135 operator EraMED to fly them. LifeFlight and Era have policies that anytime anybody other than an Era employee is on the Era-operated aircraft, it’s Part 135, said Thomas Judge, executive director. All flight segments are conducted under full Part 135 requirements. “When medical crew are on board whether it is an outbound or empty leg back home, the flight is Part 135. If I get on the aircraft, it’s Part 135,” he said. 

Safety awareness is high at HEMS operators like CareFlite.

Reimbursement

The flat-rate reimbursement structure of this government program is a sore point with the better-equipped operators. But fixing the system won’t be easy. As of early February, the Center for Medicare and Medicaid Services had not responded to NTSB’s recommendation that they evaluate the rate structure. NTSB recommended, among other things, that CMS establish accreditation standards and make sure that only carriers meeting the standards be reimbursed by Medicare.

“You can fly an old single-engine aircraft that’s been in aviation longer than I have and get paid the same amount … for a twin-engine IFR aircraft,” said CareFlite’s Swartz. “It could be a 206 that’s 30 years old.” In the free enterprise system, he added, “you cannot expect safety to get better when the incentives are against it.”

LFM’s Judge agreed. The current reimbursement system “incentivizes the lowest cost for the most profit—it’s a problem when it comes to safety,” he said. LifeFlight has one of the oldest and poorest populations in the country. Forty-three percent of its patients have no insurance and another 40 percent are on Medicare or Medicaid. So LFM is reimbursed at much less than cost, Judge said. That’s why it has a charitable foundation.

IFR Infrastructure

LifeFlight views IFR infrastructure as its No. 1 priority. Basically a public utility in Maine, LifeFlight owns two full-IFR AgustaWestland AW109 Powers. About 20 percent of its flights are tied to IFR. The nonprofit charitable medical organization has completed 21 GPS approaches, with another 18 in the works. It is building a low-level IFR route structure that will link all the GPS approaches and hospitals. LFM has built 31 hospital helipads and 10 community helipads, and worked to provide fuel trucks at two airports in order to refuel aircraft at remote hospitals. LFM has also finished six of a planned 14 automated weather observation systems (AWOSs) to help fill in the grid.

IFR is important to Air Methods, as well. The company has 61 GPS non-precision approaches and is developing wide area augmentation system (WAAS) IFR infrastructures at two of its programs.

CareFlite is in the midst of an FAA IFR infrastructure program, which is “like a test case,” Swartz said. It already has 17 non-precision GPS approaches. The company flies four AW109 Powers certified for single-pilot IFR and two Bell 222s that don’t fly in weather. At night, outside the local flying area, the company requires pilots to go IFR, Swartz said. “Twin-engine IFR was the single most important safety upgrade.” Every pilot is given about an hour a month to practice IFR without an instructor on board. CareFlite has also added a camera-based recording system on a couple of aircraft and plans to add NVGs.

Tracking and Dispatch

LFM’s Thomas Judge
Although EMS is very competitive in New England, in an ongoing effort to improve safety, LifeFlight collaborates with other providers in the region. All of the programs in New England have agreed to use a Web-based system that allows each program to track the others’ aircraft in real time. This system includes DHART at Dartmouth-Hitchcock in New Hampshire/Vermont (Metro), Boston MedFlight (Era), UMASS LifeFlight, (Air Methods) and LifeStar in Connecticut (Air Methods), as well as LFM. This arrangement lets the control centers know when they have aircraft going to the same location, so that their pilots can communicate with each other. The communications centers can also talk to each other. Both LFM and Era also follow LifeFlight’s helicopters through a satellite tracking system in their respective communications centers. OmniFlight, for its part, has 15 communications centers around the country and a centralized operational control center at corporate headquarters in Addison, Texas. Air Methods likewise has an operational control center that tracks all of its aircraft.

“We have at least one qualified EMS helicopter pilot in the control center at all times,” Stockhausen said. In addition, OmniFlight is in the midst of a Line Operations Safety Audit (LOSA)—the first helicopter company to have done it.

SMS

The big news at OmniFlight is its Safety Management System rollout, the first SMS under the new FAA framework. “The intent is to include every person in that process in every aspect of the organization,” Wall said. In addition to giving risk assessment tools to the employees, there are quarterly audits and daily inputs by employees into a hazard registry. A senior management SMS council reviews all events and the root causes of every type of event.

OmniFlight sifts and analyzes huge amounts of data. Every pilot, technician and clinician has to report anything that seems amiss, from the smallest thing to an incident or higher, Wall said. Weather aborts (with details) and duty time exceedances also are reported. This event reporting database allows OmniFlight to track and trend operational data down to the problem history of an individual piece of equipment like a fuel pump. Communications within the company are also a high priority. There are daily conference calls on maintenance and operations and a monthly telecom to update all employees on operational issues. There is also a compliance hotline run by a third-party vendor for anonymous safety complaints.

CareFlite is implementing an SMS program, as well. And Air Methods is part of FAA’s SMS pilot project, including 68 companies. The SMS encompasses flight operations, communications, maintenance, repair station and product sectors.

No Pressure Initiative

The National EMS Pilots Association (NEMSPA) is attacking the pressure problem through its No Pressure Initiative (NPI). The foundation of NPI was a survey the association conducted of 257 pilots. Thirty-six percent said they sometimes or frequently pressured themselves to accept or complete flights; 24 percent said they sometimes or frequently felt pressured by competition to do so; and 23 percent replied they sometimes or frequently felt pressure from management to do so.

NPI features three layers of protection, including culture, risk assessment and the enroute decision point (EDP). Particularly interesting is the EDP, which “puts hard numbers on a flight, based on airspeed and altitude,” said Kent Johnson, NEMSPA president. Basically, at night it’s cruise airspeed minus 30 knots and 500 feet AGL. So if your airspeed sinks from 120 to 85 knots, the EDP protocol says it’s time to turn around or land.

EDP is meant to keep pilots from plunging ahead on missions in deteriorating weather conditions when, even though they may not know it, they are becoming tentative. It’s analogous to the decision height on an ILS approach. When the pilot reaches the listed limitations, he must make a decision. And continuing on the present course, as before, is not an option, according to NEMSPA literature.

The association also surveyed 13 pilots who have used the EDP protocol for several years. Eight-five percent considered it a very effective aid in deciding whether or not to continue flight into marginal weather conditions and 31 percent said EDP had helped them decide to abort a flight or significantly alter the flight plan route more than five times.

NEMSPA is also working with fatigue expert Mark Rosekind to implement an on-line alertness management program. Johnson hopes to have the “Z-Coach” training program available on the NEMSPA website in the near future.

HEMS Recommendations on NTSB’s Most Wanted List:

* Part 135 during all flight legs with medical personnel on board—open, unacceptable response;

*Flight risk evaluation programs—open, unacceptable response;

*Formalized dispatch and flight following procedures, including timely weather information—open, acceptable response; and

*Terrain awareness and warning systems (TAWS), including training—open, unacceptable response.

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