Rethinking the Safety of Medical Helicopters

Taking a closer look at the troubling rates of air ambulance accidents

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The five members of the National Transportation Safety Board seated at the semicircular dais are demanding answers. Inside the theater-style auditorium at 429 L'Enfant Plaza in Washington, D.C., they grill safety experts and industry leaders for four long days. Their mission: to understand why the previous year was the deadliest ever for emergency medical helicopter flights. One witness solemnly tells the board that, in 2008, the job of EMS helicopter pilot ranked as the most dangerous in America, eclipsing traditionally risky professions like logging, steelworking, deep-sea fishing and coal mining. In the course of 12 months, the expert says, the situation has escalated into a full-blown public health crisis.

Accident statistics don’t lie. And in 2008, the picture they painted was a grim one: Twelve air ambulance helicopter crashes claimed the lives of 29 crew members and patients. Every single one of them made national headlines. At the NTSB hearings in February 2009, board members wanted to know why fatal EMS helicopter crashes suddenly were on the rise. Was it the start of a disturbing new trend or merely an anomaly? What could be done to make sure the industry never experienced a repeat of what happened that year? Experts testified it was time for the air ambulance industry “to change the way it does business” by focusing more on safety and less on profits.

Helicopter EMS safety officially made it onto the NTSB’s “Most Wanted” list of improvements in the fall of 2008. Dozens of recommendations were under consideration as the news media reported the most heart-wrenching details from each of the crashes that occurred that year. Voluntary industry efforts to reverse the accident trend were having little effect, witnesses told the board. Some advocated for forcing medical helicopter operators to become safer through regulation.

The emotionally charged hearings shed light on an important issue, but they also failed to tell the whole story. While it's true that the number of fatal air ambulance helicopter crashes was up in 2008, lifesaving flights by EMS helicopter crews were actually becoming safer over time. In fact, an examination of the accident rate per 100,000 hours of flying — the typical barometer for measuring safety in aviation — shows that EMS flying is one of the safer types of operations helicopters are pressed to ­perform. The most dangerous? Personal helicopter flying by nonprofessionals.

So how then do we explain what happened in 2008? For a start, the air ambulance industry has experienced rapid growth in recent years. In 1980, for example, there were fewer than 50 EMS helicopters operating in the United States. By 1986 the figure had tripled to 150 EMS helicopters. Ten years later there were nearly 300. By the time 2008 rolled around, there were an incredible 668 dedicated EMS helicopters flying for more than 200 hospitals and emergency medical service providers across the nation.

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So was 2008 merely a statistical blip, or was it the start of a trend? Again, the numbers paint a more complete picture. In the late 1980s, when there were far fewer EMS helicopters in operation, the total number of fatalities linked to the helicopter EMS industry was actually higher than in the years just prior to 2008, as well as the years after. For example, from 1985 to 1989, there were 52 fatalities caused by EMS helicopter crashes compared with 41 from 2004 through 2007. Total annual flight hours for the helicopter EMS industry, meanwhile, tripled between these time periods.

When we look at the data this way, we can see that the HEMS fatal-accident rate has actually been in steady decline over the past 30 years. Even the serious spike in crashes experienced in 2008 was lower on a 100,000-flight-hours basis than any year in the 1980s. In fact, the overall HEMS accident rate has been consistently lower compared with almost all other types of helicopter flying. The fact is, calling EMS flying the most dangerous job requires a heavy reliance on hyperbole and a creative manipulation of the numbers.

DISTORTED REALITY?

Still, when you read about an EMS helicopter crash, the chances of it involving fatalities will indeed be higher than for most other types of flying. EMS helicopters experience around 2.0 fatal accidents per 100,000 hours of flying versus about 1.3 for general aviation. The reasons should be fairly obvious: More than half of all EMS helicopter crashes happen at night or in poor visibility, and nearly half of all fatal HEMS crashes occur at accident scenes where the terrain and power lines can pose risks. As a result, when an EMS helicopter goes down, it’s often with catastrophic results.

But let’s face it. Hearing that EMS helicopter flying can be dangerous probably isn’t news to you. Still, it’s reasonable to pose the question of whether the air ambulance industry is sometimes unfairly judged because of its high visibility. For decades, professionals within the industry have been seeking to make aeromedical flying safer, yet we rarely see news reports about the tens of thousands of uneventful flights of patients who are safely transported to hospitals by helicopter. When there’s a crash of a medical helicopter, we can’t avoid hearing about it.

Especially in rural areas with population centers spread far apart, the arrival of an emergency medical helicopter often can mean the difference between life and death.|

“Despite what we might see on the news, the truth is that the helicopter EMS sector of the industry is not experiencing a disproportionate number of accidents,” said Matt Zuccaro, president of the Helicopter Association International (HAI). “It’s just that these accidents are so high profile that people assume EMS operations have a poor accident history.”

In reality, he notes, personal flying and helicopter flight instruction account for the majority of helicopter accidents. In the first half of this year, there were four EMS helicopter crashes, three of them with fatalities. Yet air ambulance flying is near record levels. Obviously, we'd all like to see the accident rate drop as close to zero as possible, but the good news is that air ambulance safety is improving all the time.

Yet it would be unfair to blame the public for having a false impression of EMS helicopter safety, or even the media for reporting on air ambulance crashes. Especially when a patient is on board, a fatal EMS helicopter crash is inevitably going to attract notice. One tragedy in particular — the Sept. 28, 2008, crash of a Maryland State Police helicopter on an EMS mission at night that killed four people, including an 18-year-old automobile-accident victim — likely caused the NTSB to react with greater scrutiny than others. The story made front-page news in Washington for weeks, after details emerged that the pilot inadvertently flew into fog and three times asked ATC for help diverting to Andrews Air Force Base before crashing into trees in a park.

It was just weeks after this accident that the NTSB added helicopter EMS operations to its Most Wanted list and set the agenda for its four-day EMS helicopter safety hearings. Within a year of the Maryland State Police helicopter crash, the NTSB had developed a long list of safety recommendations for the FAA and EMS helicopter operators, as well as the center that governs Medicare and Medicaid reimbursements. The suggestions ran the gamut, from better cockpit technology to more use of simulators in training to changes in the way the government reimburses for EMS helicopter flights.

But the NTSB does not have the power to enforce its recommendations. That responsibility belongs to the agencies within the Transportation Department. The FAA has proposed new regulations for the air ambulance industry, and groups including HAI, the International Helicopter Safety Team and the National EMS Pilots Association have presented data ­showing that the industry has been proactive about improving safety, especially in the time since the NTSB issued its recommendations.

Last year, air ambulance crews transported more than 300,000 patients to hospitals across the United States, with just two fatal crashes, resulting in four deaths.|

AIR AMBULANCE CRITICS

Yet not everyone agrees with the assessment that helicopter safety is improving. Michael Slack, an aviation trial lawyer who represents victims and their families in personal-injury lawsuits involving EMS helicopter crashes, said pilots continue to make the same mistakes and get themselves into the same predicaments they have for 30 years.

“Generally, the same factors continue to appear in NTSB accident reports over and over,” Slack said. “There are variations on low light, low visibility, flight into IMC — all of this is very prevalent in the cases I handle.”

Slack said he sees a "disturbing lack of discipline" among pilots involved in fatal EMS helicopter crashes. The most recent example, he said, was the case of a Missouri pilot who the NTSB says was texting on his smartphone before and even during a flight. Investigators said the pilot engaged in an "extensive text conversation" with a female colleague about dinner plans while he was preflighting his helicopter in August 2011. Because he was distracted, the pilot missed opportunities to note that his helicopter lacked enough fuel for the mission, investigators said. All four aboard the helicopter were killed when it crashed after running out of fuel a mile short of the destination.

“How in the world has this sort of thing crept into air ambulance flying?” Slack asks. “Maybe using a personal electronic device in an airliner is OK, but these are pilots who are flying close to the ground in inherently unstable aircraft. It’s incredible that this would even be an issue.”

Finally, Slack subscribes to a growing philosophy even within the EMS community that pilots should be kept out of the medical-information loop, so that a go/no-go decision is never based on a situation where, say, the patient is a child who is unlikely to survive unless he or she reaches a hospital quickly. The only choice the pilot should make is whether it’s safe to accept the flight. He should not assess the condition of the patient. Slack goes a step further, arguing that first responders at the scene shouldn’t be allowed to call for a helicopter either, because their judgment may be clouded as well. The final call about whether to transport a patient by air or ground ambulance, he says, should only come from a doctor at the hospital.

Experts believe increased use of simulators with pre-loaded mission scenarios can help improve air ambulance safety.|

Any EMS pilot who's been flying long enough will tell you that the choices they sometimes face can be difficult, regardless of whether the patient is an 8-year-old boy or a 50-year-old man. The National EMS Pilots Association is confronting this issue through its No Pressure Initiative (NPI), launched after a survey of members showed that more than a third "sometimes or frequently pressured themselves to accept or complete flights" and sometimes felt pressure from management to do so. NPI features layers of protection, including risk assessments and en route decision-making tools that are designed to keep pilots from forging ahead into deteriorating weather conditions. The en route tools are similar to the decision height on an ILS approach — if the weather drops below a certain predetermined level, the pilot must turn back.

The largest EMS helicopter operators, meanwhile, are implementing a wide range of safety improvements voluntarily. Based in part on the NTSB’s EMS safety recommendations, providers are developing operational Safety Management Systems, investing in cockpit technologies and turning more to simulation in pilot training. At EMS helicopter giant Air Methods’ base in Colorado, the company has established an Operations Control Center that is staffed 24/7 to provide pilots with weather reports and other resources they can access before and during a flight. The company recently attained the FAA’s highest level for its voluntary Safety Management System.

IMPROVING SAFETY

Poor weather obviously is the biggest challenge EMS helicopter pilots face, especially when conditions start to deteriorate at night. Accurate weather information is essential to flight safety, because inadvertent flight into clouds or fog can be deadly. While weather information is available for most airports, it's rare at off-airport locations like the scene of a car crash. That's a big part of the reason for the development of the HEMS Weather Tool (available online at weather.aero/hems). Designed to serve the special needs of low-altitude VFR first responders, the tool is capable of overlaying ceiling, visibility, winds, relative humidity, temperature and Nexrad images onto high-resolution base maps, including all streets, hospitals and heliports.

Another special danger to EMS helicopter pilots involves operations into accident scenes and other unprepared landing sites. Helipads are designed on level ground in areas free of wires, trees or other obstacles. When responding to an on-scene call, EMS helicopter pilots often must set down at landing sites that have been neither surveyed for hazards nor otherwise prepared for helicopter traffic. In most cases pilots must rely on what they can see or what first responders on the ground can spot. That’s a primary reason many EMS pilots have such bright searchlights and wear night-vision googles.

Still, even with a 100-million-candlepower Nightsun searchlight switched on, terrain can pose a threat, especially in low-visibility conditions. Not surprisingly, controlled flight into terrain is a leading cause of EMS helicopter crashes. All that flying at night can also lead to crew fatigue. Statistics show that almost half of EMS helicopter crashes occur on the "back side of the clock" — the eight hours between 10 p.m. and 6 a.m., the most dangerous time for EMS helicopter operations, since fatigue and darkness are a deadly combination.

The FAA has responded to the NTSB’s recommendations with proposals for new regulations aimed at improving EMS helicopter safety. These include a ­proposed mandate for helicopter terrain awareness and warning systems (HTAWS) in air ambulances; radar altimeters for all Part 135 helicopters; Part 135 weather minimums for all legs of helicopter air ambulance flights; implementation of risk management programs; flight data monitoring devices, such as cockpit voice recorders and digital flight data recorders; and a requirement that pilots in commercial operations demonstrate recovery from inadvertent flight into IMC during annual training.

Another FAA proposal seeks to change the industry’s terminology from “helicopter EMS” to “helicopter air ambulance.” The change is designed to eliminate references to “emergency,” since that can put extra pressure on a pilot to complete a given mission. It all goes back to changing the culture of the industry, which some people wrongly still equate with medevac flying in Vietnam.

Regardless of what critics of the industry might say or the media might report in an overly sensationalist news story, the truth is you can call this type of operation whatever you like, but you have to acknowledge what it really is: For rural communities with population centers spread far apart, an air ambulance can truly mean the difference between life and death when minutes count. In large urban centers, EMS helicopters can respond rapidly to the scene of an accident or quickly transfer a patient from an outlying hospital to a major trauma center with specialized capabilities.

EMS helicopters aren’t a marketing gimmick for hospitals, and they don’t fly purely to generate profits for their operators. When it comes right down to it, these medical helicopters exist for one purpose: to save lives. And when we look at all of the data, and not just snippets that suit a particular viewpoint, we find that they perform this mission exceptionally well.

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