Change is coming to the helicopter emergency medical services (HEMS) industry, and once the dust settles there could be fewer providers flying fewer helicopters in a more costly and highly regulated environment.

Late last month top aviation insurance executives met in Dallas to discuss possible stricter underwriting requirements for the rapidly growing medical helicopter industry against the backdrop of seven fatal helicopter EMS crashes so far this year that have killed 28. The recent safety record for helicopter EMS operators has attracted media attention, drawn congressional criticism, precipitated an FAA change in the operating specifications regarding Part 135 and helicopter EMS flights and sparked NTSB demands for more equipment and better training and procedures. The NTSB issued its most recent critical report on, and safety recommendations for, the industry in 2006 and continues to rate the FAA response to most of those recommendations as “open, unacceptable.”

That report recommended that all helicopter EMS operations– rather than only those where patients are aboard–be conducted under some form of Part 135. It also urged operators to implement formal flight-risk evaluation procedures, use consistent flight dispatch procedures and investigate the installation of terrain awareness and warning systems (TAWS) aboard EMS helicopters.

The FAA has been working with the helicopter EMS community voluntarily on some of these issues since 2004 with partial success, but the NTSB and some critics of the helicopter EMS industry clearly would prefer a more aggressive approach. The NTSB is looking to kick-start the process with three days of high-visibility public hearings on helicopter EMS safety in Washington beginning February 3.

“The Board wants [the FAA] to know that we are very displeased and we want them to move forward,” said NTSB vice chairman Robert Sumwalt. He said that helicopter EMS operations have been a major concern at the NTSB for the last two decades and that recent crashes have intensified the Board’s focus on the industry. “We do have a microscope on HEMS operations right now,” said Sumwalt, “due to the sheer number of fatalities that have occurred in the last 10 months.”

He hastened to add that “our public hearing will not be tied to the NPRM [notice of public rulemaking] process” that is the purview of the FAA. But there can be little doubt that an NPRM is on the way.

For one thing, Congress is turning up the heat. Last July, U.S. Sen. Maria Cantwell (D-Wash.) introduced the Air Medical Service Safety Improvement Act of 2008. Cantwell’s bill mirrors the NTSB’s helicopter EMS recommendations. It is unlikely to advance this year, even if Congress convenes a lame-duck session. But next year, with a more activist Congress and a Democratic administration, it could be a different story.  

Just days after the latest fatal helicopter EMS crash–a Bell 222 accident in Aurora, Ill. on October 15 that killed all four aboard–the Air Medical Transport Conference (AMTC) convened in Minneapolis, and the helicopter EMS pilots there were clearly cognizant that exigent change is in the wind. “We are going to be looked at more closely and more carefully by legislative and regulatory branches of government because of our accident rate,” acknowledged Scott Tish, now a certificate compliance evaluator for Air Methods and formerly a helicopter EMS pilot with the University of Wisconsin hospitals.

Meanwhile, in recent months, industry leaders have been quietly meeting with FAA officials to attempt to mitigate the effect of long-rumored potential changes
to Part 135 as it applies to helicopter EMS operations.

“We feel we are making good progress with the FAA,” said Air Methods CEO Aaron Todd. “We are working closely with the agency and the other members of the HEMS community to find appropriate changes to enhance safety without compromising access to these important services.” 

The FAA recently revealed those changes. On November 14, the agency published a proposed revision in the operations specification governing HEMS flights under Part 135 (14CFR 119.51) with regard to flight planning, weather minimums (A021), and the use of night-vision goggles (NVGs–A050).

The A021 revisions specify that if a flight, or sequence of flights, includes a Part 135 segment, then all visual flight rules (VFR) segments of the flight must be conducted within the weather minimums and minimum safe cruise altitude determined in pre-flight planning. Pilots are required to identify a minimum safe cruise altitude during pre-flight planning by identifying and documenting obstructions and terrain along the planned flight path. Helicopter EMS pilots must also determine the minimum required ceiling and visibility to conduct the flight using the revised weather minimums contained in A021. Those minimums range from ceilings of 800 to 1,500 feet, depending on whether the flight is local or cross-country, in daylight or at night, the type of terrain and the equipment aboard (night vision or TAWS).

The revised A021 also permits helicopter EMS in IFR operations at landing areas without weather reporting if an approved weather reporting source is located within 15 nm of the landing area or if an area forecast is available. The revised A050 changes weather minimums for NVG operations conducted in Class G Airspace to be consistent with changes made to the Class G Airspace minimums in A021.

An FAA spokeswoman said that the agency could issue more sweeping changes, in the form of an NPRM governing helicopter EMS operations next year and that it likely would include radar altimeters and H-TAWS.

Beginning in 2004, the FAA embarked on a variety of voluntary helicopter EMS-related initiatives. These included published guidance on helicopter EMS maintenance, operational risk assessment, air medical resource management training, and VFR weather minimums; and RTCA-developed standards to develop FAA requirements for H-TAWS. The agency is also reviewing Part 135 standards as they apply to helicopter EMS.

Two years ago Air Methods, the nation’s largest helicopter EMS company, voluntarily agreed to equip all of its EMS helicopters with tracking systems, night-vision goggles (NVGs) and TAWS “as quickly as resources and access to equipment will allow,” said Todd. Air Methods also is following Part 135 weather minimums for Part 91 repositioning flights as well as for Part 135 flights with patients aboard. The company provides weather tracking from a central flight control center. Todd said Air Methods is also embracing other tools such as FOQA (flight operations quality assurance) and “making good progress” installing new technology.

While Honeywell has been manufacturing H-TAWS for seven years, and Thales is working on its own system, minimum operational performance standards (MOPS) were developed for H-TAWS only this past June. Sumwalt acknowledges that the technology has its detractors because of pilot concerns about the potential for false alarms, similar to the false warnings that occurred in early GPWS systems in fixed-wing aircraft.

Seventeen of the 55 EMS accidents the NTSB cited in its 2006 report could have been prevented with TAWS, according to Sumwalt. “We feel that the FAA has moved very slowly on the rule-making on this,” he said, and between 1994 and 2003, CFIT was the leading cause of all helicopter accidents. “TAWS can prevent accidents. There has never been a CFIT accident involving an airplane equipped with TAWS. However, there continue to be CFIT accidents with airplanes not equipped with TAWS.”

While many EMS helicopters, especially twins, are equipped with radar altimeters, Sumwalt thinks this is insufficient. “A radar altimeter is reactive, not predictive. [It] is not looking for what is out ahead of you; it is looking below you. The advantage of TAWS is the predictive capability. It will give you as much as a 40-second caution that something is out there and a 20-second warning.”

The technical and regulatory challenges for NVGs are less burdensome. The FAA published TSO C164 establishing the minimum standard for NVG/ cockpit lighting in 2004 and numerous installations were done under STC before and since then. Most new helicopters now come with NVG-compatible cockpit lighting from the factory, and individual fourth-generation NVG units are relatively inexpensive. The main issue is one of supply, as the Pentagon has first claim to most manufacturers’ output and consumes an estimated 90 percent of all NVGs produced.

In nighttime VFR in an urban environment, NVGs have been found to provide a marginal safety improvement. They do nothing, however, to address the problem of inadvertent flight into IMC in MVFR/IFR that leads to either a loss-of-control or CFIT accident, another leading cause of helicopter EMS fatalities.

A recent example of such an accident is the September 27 crash of a Maryland State Police AS 365N1 Dauphin that slammed into trees while on an EMS flight. The crash killed four of the five aboard. “Trooper 2” had departed the accident scene VFR, inadvertently encountered IMC en route, diverted from the destination hospital heliport as a result, and was attempting to engage the instrument approach at Andrews AFB when it crashed.

IFR operations are increasing in the helicopter EMS sector, with more than 350 private IFR approaches developed since the mid-1990s, mostly to and between hospitals, nationwide, according to Steve Hickok, whose firm designs many of them. However, Tish of Air Methods cautions that IFR is not an appropriate tool for helicopter EMS operators that do primarily scene work, and that pilots who take off VFR into marginal conditions with the thought that they then pick up an IFR clearance en route are misusing it. At the AMTC Tish cautioned his fellow pilots, “Don’t play that game. The pilot has to recognize early on…that IFR is the only safe, acceptable option when VFR does not exist. It is not a matter of ‘I’ll just go take a look.’”

The Trooper 2 crash ignited a political and media firestorm in Maryland, with public calls for the state police program to be dismantled. Susan Baker of the Johns Hopkins Bloomberg School of Public Health recently noted that 40 percent of the patients aboard the 5,000 helicopter EMS flights inside Maryland each year are discharged from hospitals in fewer than 24 hours.

The “medical necessity, risk versus reward debate” over helicopter EMS operation is not confined to Maryland. Nationally, the number of helicopters flying EMS missions has nearly doubled since 2000, growing to almost 800.

This proliferation has increased competition, reduced operating margins and already led to some industry consolidation. And while the number of EMS helicopters continues to grow, flight hours and net income are already beginning to drop.

While Air Methods remains profitable and revenues are up 32 percent in the third quarter from a year ago, its stock over the last year has plunged from $59 to a low of $14 before rebounding slightly in recent weeks. Aside from the overall stock market slide, key metrics from the quarter tell the story: fuel and maintenance expenses up and net income down 25 percent for the quarter. For community- based services, revenues per transport increased by 7 percent but segment net income dropped 15 percent, and same-base transports fell 16 percent. For hospital-based services, segment net income plunged by 80 percent and flight volume dropped by 11 percent.

The cost of helicopter EMS has attracted both the attention of, and investigations from, various government agencies, and not just for safety reasons. In May 2007, FBI agents raided the headquarters of Air Evac Lifeteam in West Plains, Mo., seeking documents as part of an ongoing federal investigation into Medicare and Medicaid fraud. Air Evac operates community-based helicopter EMS programs in 11 states. For an annual household fee of $60, subscribers can call Air Evac directly, as opposed to 911, for helicopter hospital transport. The company then bills private insurance or the government for the cost of the flight; however, to be reimbursed, Air Evac must document that the flight was “medically necessary.” Critics maintain that the vast majority of helicopter EMS flights are not, while proponents maintain that expedient hospital transport is critical to improved patient survival rates. But helicopter EMS programs are coming under increasing regulatory, financial and competitive pressure.

Sumwalt wonders what the impact of increased competition will be on individual helicopter EMS pilot decision-making and, ultimately, on safety. “Imagine you are a pilot…You want your company to succeed. That competition factor, I think, may very well have something to do with the increased number of [helicopter EMS] flights and the increased exposure. That is something we plan to look at in our public hearing.”