Thursday, March 25, 2010

EMS helicopter pilot worries; "If they knew what I knew, even the nurse and paramedic wouldn't get on board."

The crash Thursday morning of an emergency medical helicopter in Tennessee is another tragic reminder of the crisis in medical aviation. Three people were killed when a Eurocopter AS350 operated by Hospital Wing crashed near Brownsville, Tennessee after delivering a patient in Jackson. While the crash happened shortly before 7:00 a.m., the bulk of the flight occurred during what is considered "the backside of the clock" the hours between ten p.m. and six a.m.. This is the most dangerous time to fly by helicopter medivac. Nearly half of all the EMS helicopter crashes take place on the backside of the clock.

This statistic comes from the Comprehensive Medical Aviation Services Database (CMAS) which was compiled by Dr. Patrick Veillette and myself. Fatigue is a pervasive problem in these accidents, according to Dr. Veillette, a commercial pilot and former EMS pilot. The situation seems to be getting worse. "In just the last 8 years there have been 48 accidents that occurred on the back side of the clock."

Reviewing the so-far-incomplete details of the accident, it appears notably and tragically typical. The aircraft had already delivered the patient and was returning to base, there was bad weather in the area and the flight was being conducted under visual flight rules, without the assistance of enhanced visibility instruments. Our database shows these are the consistently reoccurring factors in helicopter medivac accidents.

What's so frustrating is that it is no mystery how to make air ambulances safer. When EMS helicopters are required to carry two pilots and equipment to help them fly in limited-visibility conditions safer flights will result.

Since 1987, nearly half of the EMS helicopter accidents occurred either at night or in weather that obstructed the pilot's vision. Our statistics also show that people are twice as likely to die in limited-visibility accidents as in those occurring in good weather during the day. Considering the layers of risk in reduced-visibility flights, one would expect operators of air ambulances to make sure their aircraft are equipped to fly in these conditions. But only a small portion are equipped with enhanced-visibility systems.

The EMS helicopter industry has boomed from a few hospitals in Colorado in 1972 to a multi-million-dollar business which operated nearly half a million flights in 2009. This phenomenal growth has been based on a disturbing business model; fly the helicopters as inexpensively as possible - meaning one pilot and a minimum of safety equipment - even though these are inherently more hazardous missions. As one EMS pilot told me, "If they knew what I knew, even the nurse and paramedic wouldn't get on board."

In a study of turbine engine airplane accidents, a noted aviation research company Robert E. Breiling Associates of Florida, concluded that single-pilot flights are riskier than those with two pilots. The statistics show the risk of a fatal accident is 3.7 times greater with a single-pilot. In publishing these findings, AOPA Pilot magazine wrote "single-pilot operations create higher workloads and greater demands on pilot skill when the chips are down and stress levels run high."

Flying a helicopter - any helicopter- is not like flying an airplane. The pilot is busy from start to finish. To an already higher workload and often under time pressure the EMS pilot has additional concerns, a 24/7 flight schedule, a lack of a weather information for the route or destination, operations in and out of non standard landing zones including rooftops, highways and parking lots and flights that take them through obstacles and obstructions.

It is this last factor that makes the need for two pilots most obvious. Of the accidents over the past 20 years, one in of three - involved the aircraft hitting something. With the exception of a pilot-check ride in Michigan in May 2007, all the others were operated by a single pilot. Medical helicopters in Canada and air rescues conducted by the U.S. Coast Guard already require two-pilots. What do they know that America's air ambulance operators do not?

When it comes to making air-ambulance flights safer, the elephant in the room is money. Nobody wants to talk about it because to do so would be to puncture the myth that no expense is too high when it comes to rescuing those in need.

Bringing complicated medical equipment and highly trained professionals to the skies is already an expensive undertaking. Most EMS helicopter companies are businesses with bottom lines to consider. Often a hospital contract will go to the company that offers the lowest bid, which is why additional equipment and doubling of pilots is such a hard concept to sell.

It is imperative that the industry equip all EMS helicopters for reduced visibility conditions and put two qualified pilots in the cockpit to fly them. It's expensive. But once again, investigators have been called to the scene of the crash that is a tragic reminder of the alternative.

Read more about medical aviation here.


Julianne Cummings said...

Excellent article Christine. In addition to the marginal VFR flying at night and at low altitudes and at times when circadian misalignment is likely, some of the pilots flying these missions are not instrument current rendering them ill-equipped to fly without a visible horizon and in margine VFR conditions... Thanks for posting your aticle.

Christine Negroni said...

Many air ambulance pilots aren't IFR current because the helicopters they fly aren't IFR capable. The trend in EMS helicopters is toward smaller aircraft. This not only hampers progress toward IFR flights, it prevents a move to dual pilot operations.

Unknown said...

Nicely put. In the last quarterly stock comments Air Methods said they would be replacing 18 light twins with single engine helicopters in the near future. It's like being in the airlines during the 1930's. The government doesn't understand the business, the companies are all money driven, and the public is mainly unaware of the hazards.

As a HEMS pilot, we've only gotten token fixes from the FAA. A021, operational control, and the new paperwork drills we must complete haven't done anything to stem the mishaps.

This business is all about the medical side. Most companies have back-up aircraft that lack moving map GPS, have radios that don't fit the program where they're used, and have no standardization as to insturmentation.

Pressure still abounds. Hospitals are all about the numbers. Most programs are seeing a decline in their flights. Pilots are afraid of losing their jobs.

It's a shame that we haven't learned the lessons written in blood by so many flight crews. My thoughts and prayers go out to those who have paid the ultimate price, and their families, lost mainly because they tried to do a tough job without getting every bit of assistance available.

Anonymous said...

I am in England reading this and wondering why the difference between EMS helicopter safety ratings and the US, which always seems to have a safer record on all things aviation (except perhaps regional airlines!)

Why do you think British ambulance helicopters (of which there are plenty but not privately operated as far as I know) seem to have a much safer record - more pilots, less hours? I am really interested in this appalling rate in the US especially after NTSB has shone such a light on the concern. If I come on holiday in the US, is there a way to guarantee I am not airlifted by helicopter in case of an accident?! Seems safer by surface this days; survive the car wreck, and die in the rescue helicopter? No thanks!

Anonymous said...

Thanks for the article!

I agree completely that the reason most EMS companies fly single pilot is money. I wonder what would it take to get companies to switch to a dual pilot mentality. Would it be some sort of government mandate? Normally, I'm not for more, more, more regulation, but perhaps this would be a good time for some new requirements for the EMS industry. I say that not knowing squat about how such a business is run, and I'm sure many out there would say that a requirement like that would bankrupt most companies. As you said, though Ms. Negroni, the alternatives have proven to be tragic.

I have the privilege of flying helicopters for the U.S. Coast Guard right now. You correctly mentioned that we fly dual pilot for all search and rescue missions, a luxury that I truly appreciate. I must say that as I consider employment post-Coast Guard, I am a bit intimidated by flying in marginal conditions by myself, especially in the wee hours of the morning. Boy, when your body "crashes" after the initial adrenaline rush at 2:00 a.m. of bolting out of bed, cranking up the aircraft, and launching, having a partner there sure goes a long way toward safety.

Ken Cox said...

I've flown EMS helicopters for 27 years.

Two pilots in a helicopter only makes the job more complicated.

The solution to the problem:

1. mandatory night vision goggles for all night EMS flights, for all crewmembers;

2. stability augmentation capable of holding a heading and altitude;

3. TCAS;

4. higher and more clearly defined weather minimums; and,

5. a sufficiently high horsepower to weight ratio to guarantee a) out of ground effect hover capability at departure and destination and b) full fuel at departure.

Twin engines and two pilots have zero bearing on safety.

Twin engines only double the probability of an engine failure and,as I wrote earlier, two pilots only complicate the job.

I presently fly a fully-equipped single-pilot IFR EC-145 in a very hostile weather environment, serving the largest EMS service area in the world.

I feel safer in this present job than I have ever felt before in 41 years of flying helicopters, and I attribute that sense of safety to the night vision goggles, the extraordinary surplus of power, a remarkably capable autopilot, and very clear and high weather minimums from my employer.

As for the British and the Canadians, they have a different mission in a different cultural, political and commercial environment, and this has more relevance than the numbers of pilots and engines.

As for the military, we almost all came out of the two-pilot military model, and no one of my acquaintance misses it.

The military teaches a two-pilot model and military pilots feel comfortable in that model.

In the civilian world, once one gets used to flying single-pilot, it becomes the preferred model.

Francho said...

Hello from Spain. I found very interesting your article and agree with their analysis in the sense that something must be done to stop this bleeding. What we do in Spain, isn't really comparable; for example there is only one HEMS service that flight by night, the remaining services develop VFR operations only. However, the introduction of legislation in Europe of JAR OPS3 has provided a significant contribution in this regard, as has been the definition of the type of aircraft and the stablishment of use restrictions based on their performance. Moreover regarding the composition of the crew, two possibilities have been stablished, or is formed by 2 pilots (mandatory in case of IFR operations) or consists of a pilot plus a HEMS crew member, this HEMS crew must be specially formed to assist the pilot in all the flight time and the medical crew sometimes. But once established these criteria, I would draw attention to tell you that JAR OPS3 make special emphasis on CRM, and in my view this CRM involves all the crew, not only the flight crew. The whole crew, including medical assets, must be constantly aware of the situation that happens and be clear about the decisions that ensure the continuation of the flight or cancel it. All people is concerned.

michaelvk said...
This comment has been removed by the author.
Unknown said...

I am looking for the Comprehensive Medical Aviation Services Database (CMAS)mentioned in this article but have not been able to find online reference to it. I would like to review some of the statistics that were referenced and/or alluded to here. How do I access the database?

Christine Negroni said...


The CMAS Database is a commercial product handled through Humanitarian Research Services Inc. You can read more about it at the HRSI website,

Much of the information in the database was discussed in the July 2010 issue of Forum, the journal of the International Society of Air Safety Investigators and in the proceedings of the 2009 annual conference.


ka said...

Ohh... and great article!

KA said...

The Coast Guard does not require two pilots for Search and Rescue, for medevacs, or for most flights. Some AIRCRAFT require two pilots but that is normally due to some emergencies that can not be handled because of aircraft design by one pilot. Helicopters such as the HH65 Dolphin are single pilot and the CG will do any mission with just one pilot. Two pilots are preferred but not required. One reason for having two pilots is the fact that they have hour requirements and pilots want to fly.

S Forrest said...

Wow, am I the only one that recognized Ken's comments were the total antithesis of current industry thinking and against everything the industry has accomplished in terms of crew resource management. If two pilots "complicates" things, you're doing it all wrong.Fortunately these attitudes are slowly vanishing as the "hold outs" on validated human factors principles leave the industry via retirements or accidents.

Phoenix Personal Injury said...

I believe the risk of flying a helicopter ambulance is pretty much higher than driving a regular ambulance on the road. The factors that they need to monitor are more when flying. Not to mention that their focus on flying should be complete while they need to reach the hospital as fast as they could.

Anonymous said...

Ontario, Canada, specifically, not only uses two pilots but also:
1) No scene calls after dusk. Period. They will only fly to airports, and Transport Canada approved helipads. Do people get hurt at night? Sure they do, but they can get stablized at a local hospital and flown fixed wing if need be.

2) Two pilots, all the time. Not only are they both IFR rated, but before they'll even look at your application you need at least 2000+ hours on type and 500+ PIC. A few hundred hours can get you hired elsewhere. So the experience is there as well.

3) 85+% of US air ambulance accidents occur enroute to the call. While not proven, one can suggest that this is because pilots may push weather if it's a "bad" call - peds, mva, whatever. In Ontario, the pilots are not made aware of any call details period. Do a weather check for "here", done. Only the medic gets any type of dispatch info. This ensures the pilots will never ever be influenced as to the type of call.

Lessons can be learned from Ontario - where we cover over a million square KM from 6 bases across the province, yet since 1977 have had only three incidents and one crash.

Anonymous said...

I'm afraid you're incorrect regarding Coast Guard crewing requirements. I flew Coast Guard HH-65A helicopters for the better part of 20 years. The only single pilot missions are day, VFR flights. Never at night, never IFR. The aircraft was certified single-pilot, but the Coast Guard Air Operations Manual M3710.1 series is very explicit on the point and more restrictive than the aircraft certification.

Single-pilot IFR in single engine aircraft is indeed statistically less safe than multi crew multi engine work, regardless of how comfortable one 'feels' in the environment. There are reams of studies and data backing that up.

As long as hospital administrators and marketing departments are driving EMS operations and the helicopter is used as a competitive differentiator for hospitals, the U.S. EMS accident rate will remain far worse than it has need to be.

The Canadian model is indeed better managed and demonstrably safer. I have thousands of hours of helicopter flight time in every imaginable climate, hold ATP licenses under a number of regulatory authorities and there's no way I'd work in a SPIFR EMS job in the U.S.

Unknown said...

I was thinking of hiring a nurse to do medical flight when I bring new clients in town. Just for an image booster. Make them feel cared for and safe with the business.

Unknown said...

One winter, I went sledding in the canyon and a guy cracked his head open on a pole! I don't know how he even hit it, but they had to bring a medical flight in and helicopter him out of there. It was really intense!

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Anonymous said...

I'm with Ken. More pilots doesn't equal more safety...just higher workload and perhaps less complacency (although I have my doubts about the complacency, especially for a crew who's "used to" each other). Of course dual-pilot is more complicated than single pilot. Dual pilot is a working relationship, and the divorce rate in the US should tell you how good most of us are at that. If people can't get their "lifelong" commitments to work, how smoothly do you think most cockpits run?
For those reading this who don't fly: consider driving. How would you like to have a mandatory co-pilot while you're trying to parallel park? One who gets nervous whenever another car enters your blind spot or you get down to 1/4 tank of gas? Or incessantly points out that you're going too fast/too slow/should have taken a different route/using the brakes too much/"gun it, you could have made that light"? Get through a few days of this and tell me your stress levels haven't gone through the roof and that you're not now questioning all of your driving instincts.