Advisory 

Circular

 

Subject: Air Medical Resource 

Management

Date: 9/22/2005

Initiated by: AFS-300 

AC No:

00-64 

1. PURPOSE. This Advisory Circular (AC) provides guidance and information to 

establish minimum guidelines for Air Medical Resource Management (AMRM) training. 

The focus of this training is for all air medical service (AMS) operations team members, 

including pilots, maintenance technicians, flight nurses, flight paramedics, flight 

physicians, medical directors, specialty team members (such as neonatal teams), 

communications specialists (dispatchers), program managers, maintenance staff, 

operational managers, support staff, and any other air medical team members identified 

by specific needs. Like all AC material, this AC is not mandatory and does not constitute 

a regulation. This AC is issued for guidance purposes to outline one method of best 

practice for compliance to the rules.

2. APPLICATION. These guidelines recommend training in AMRM for all air medical 

team members of air ambulance carriers and providers operating under Title 14 Code of 

Federal Regulations (14 CFR) parts 43 (Maintenance, Preventive Maintenance, 

Rebuilding, and Alteration0, 91 (General Operating and Flight Rules), and 135 

(Operating Requirements: Commuter and On-Demand Operations and Rules Governing 

Persons on Board such Aircraft). Public service and governmental operators such as fire 

and law enforcement agencies conducting air medical transport as part of their mission 

profile should also consider incorporating this type of training. 

3. REGULATIONS AND GUIDANCE MATERIAL. 

a. Related 14 CFR Parts Include: 

(1) Part 1, Definitions and Abbreviations. 

(2) Part 43, Maintenance, Preventive Maintenance, Rebuilding, and Alteration 

(3) Part 61, Certification of Pilots, Flight Instructors, and Ground Instructors. 

(4) Part 65, Certification: Flight Crewmembers other than Pilots. 

(5) Part 91, General Operating and Flight Rules. 
AC 00-64 9/22/05 

(6) Part 119, Certification: Air Carriers and Commercial Operators. 

(7) Part 135, Operating Requirements: Commuter and On-Demand Operations 

and Rules Governing Persons on Board such Aircraft. 

(8) Part 157, Notice of Construction, Alteration, Activation, and Deactivation of 

Airports. 

b. Related Guidance Materials (as revised) include: 

(1) AC 00-6, Aviation Weather For Pilots and Flight Operations Personnel. 

(2) AC 00-24, Thunderstorms. 

(3) AC 0045, Aviation Weather Services. 

(4) AC 00-54, Pilot Windshear Guide. 

(5) AC 00-57, Hazardous Mountain Winds and they’re Visual Indicators. 

(6) AC 60-22, Aeronautical Decision Making. 

(7) AC 61-134, General Aviation Controlled Flight into Terrain Awareness. 

(8) AC 90-87, Helicopter Dynamic Rollover. 

(9) AC 90-95, Unanticipated Right Yaw in Helicopters. 

(10) AC 91-32, Safety in and Around Helicopters. 

 (11) AC 91-42, Hazards of Rotating Propeller and Helicopter Rotor Blades. 

 

(12) AC 91-65, Use of Shoulder Harness in Passenger Seats. 

(13) AC 120-51, Crew Resource Management Training. 

(14) AC 120-54, Advanced Qualification Program. 

(15) AC 120-71, Standard Operating Procedures for Flight Deck Crewmembers. 

(16) AC 120-72, Maintenance Resource Management Training. 

(17) AC 135-14, Emergency Medical Services/Helicopter (EMS/H). 

(18) AC 135-15, Emergency Medical Service/Airplane (EMS/A). 

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9/22/05 AC 00-64 

(19) FAA-H-8083-21, Rotorcraft Flying Handbook. 

(20) FAA-H-8261-1, Instrument Flying Handbook. 

(21) FAA Order 8300.10, Airworthiness Inspector’s Handbook. 

(22) FAA Order 8400.10, Air Transport Operations Inspector’s Handbook. 

(23) FAA Order 8700.10, General Aviation Operations Inspector’s Handbook. 

NOTE: We encourage interested persons to access FAA publications at the 

following URL: http://www.faa.gov . Persons may purchase copies of FAA Orders from

the Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. The 

Government Printing Office (GPO) online bookstore is at 

http://bookstore.gpo.gov/index.html . 

 

 c. Other Related Reading Materials. 

(1) Driskell, J., Adams, R., and John, A. (1992). Crew Resource Management: 

An Introductory Handbook, Final Report, DOT/FAA/RD-92/26.

(2) Orlady, H. W. (Eds.)(1986). Cockpit Resource Management Training: 

Proceedings of a NASA/MAC Workshop, NASA Conference publication No. 2455. 

Moffett Field, CA, NASA Ames Research Center. 

(3) Federal Aviation Administration (1990). National Plan for Aviation Human 

Factors, Washington, DC. 

(4) Helmreich, R., and Wilhelm, J. (1991). Outcomes of crew resource 

management training, International Journal of Aviation Psychology, 1 (iv), 287-300. 

(5) Helmreich, R. and Foushee, H. C. (1993). “Why Crew Resource 

Management: Empirical and Theoretical Bases of Human Factors Training in Aviation.” 

from E. Wiener, B. Kanki, and R. Helmreich (Eds.), Cockpit Resource Management, pp. 

3-41. San Diego, CA, Academic Press. 

(6) Gregorich, S., and Wilhelm, J. (1993). “Crew Resource Management 

Training Assessment,” from E. Wiener, B. Kanki, and R. Helmreich (Eds.), Cockpit 

Resource Management, pp. 173-198. San Diego, CA, Academic Press. 

(7) Wiener, E., Kanki, B., and Helmreich, R. (Eds.)(1993). Cockpit Resource 

Management. San Diego, CA, Academic Press. 

 (8) Helmirich, R., and Merritt, AC, (1998). Culture at Work in Aviation and 

Medicine, Burlington, VT, Ashgate Publishing. 

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AC 00-64 9/22/05 

 (9) Helmreich, R. L, Wilihelm, J.A., and Merritt, A. C., Culture, Error and Crew 

Resource Management. 

 (10) E. Salas, C.A. Bowers, and E. Edens (Eds.), Applying resource management 

in organizations: A Guide for Professionals. Hillsdale, NJ, Erlbaum

 (11) ICAO (1998), Human Factors Training Manual Doc 9683-AN/950. 

Montreal, Canada, International Civil Aviation Organization. 

 (12) Air Transport Association (1998), ATA Specification 104 Guidelines for 

Aircraft Maintenance Training. Washington, DC, Air Transport Association. 

www.airlines.org 

4. BACKGROUND. Air Ambulance Emergency Medical Service is a very demanding 

and time critical/mission orientated operation. One consistent priority that needs to be 

addressed by each individual air ambulance organization is the safety of the flightcrew, 

medical crew, patient passengers, and support personnel. No operator goes out 

anticipating the occurrence of an accident, and like most aviation accidents there is rarely 

a single event that is the cause of an accident. It is usually a multitude of contributing 

factors that lead to potentially catastrophic results. Preventing accidents is the 

responsibility of everyone involved and takes the dedicated involvement of all of the 

aviation and medical professionals involved in the operation to provide the public the 

safest possible air ambulance service. Remember, the patient does not get a choice of 

when or where they may have to take an air ambulance flight, the carrier and service 

involved, or even if they will take a flight. 

5. PHILOSOPHY OF AMRM. Air Medical Resource Management has been 

conceived to enhance the safety culture within the Air Medical Community by promoting 

team cohesiveness and adaptation during change through management of all available 

resources. 

6. DEFINITIONS. The following terms have been defined specifically for the purpose 

of this AC:

a. Air Medical Resource Management (AMRM). AMRM addresses the challenge 

of optimizing the human/machine interface and related interpersonal issues, with 

maximum focus on communication skills and team building curricula. These issues 

include effective teambuilding, information transfer through communications, problem 

solving, decision-making, maintaining situational awareness, and establishing an 

operational environment conducive to optimal human performance even in challenging 

situations. AMRM is comprised of four elements: 

(1) Presentation Skills Profile (Train the Trainer), 

(2) Initial Indoctrination/Awareness, 

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9/22/05 AC 00-64 

(3) Recurrent Practice and Feedback, and 

(4) Continuing Reinforcement. 

 

 b. Assertiveness. This is the ability to verbalize a series of “rights” that belong to 

every team member. Some of these “rights” include: the right to express feelings and 

ideas, the right to ask for information, and, most importantly, the ability to question 

decisions when in doubt. Assertiveness also includes achieving and maintaining a proper 

balance between respecting authority, practicing assertiveness, and recognizing when a 

crewmember is exercising assertiveness in an appropriate manner. Accomplishing the 

right task, at the right time, for the right reason, every time is necessary for effective 

AMRM. 

c. Communication. This is the means or process of exchanging information which 

conveys meaning from one team member to another. 

d. Complacency. This is a condition where a person is satisfied with a situation to 

the extent that a degradation of vigilance occurs. 

e. Human Factors. Human factors is the multidisciplinary field devoted to 

optimizing human performance and reducing human error. It incorporates the methods 

and principles of the behavioral and social sciences, engineering, and physiology and is 

the applied science that studies people working together in concert with machines. 

Human factors embraces variables which influence individual performance and/or team

or crew performance. Inadequate system design or inadequate operator training can 

contribute to individual human error that leads to system performance degradation. 

Further, inadequate design and management of crew tasks can contribute to group errors 

that lead to system performance degradation. Human Factors entails a multidisciplinary 

effort to generate and compile information about human capabilities and limitations and 

to apply that information to equipment, systems, facilities, procedures, jobs, 

environments, training, staffing, and personnel management for safe, comfortable, 

effective human performance. 

f. Situational Awareness. Situational Awareness is the accurate perception of the 

factors and conditions currently affecting the safe operation of the aircraft and crew. 

g. Team Members are a group of independent individuals working together to 

complete a specific task. 

h. Teamwork is joint action by a group of people, in which each person subordinates 

his or her individual interests and opinions to the unity and efficiency of the group in 

order to complete the specific task at hand. 

i. Team Situation. This is maintaining a collective awareness across the entire team

of important current and predictable job-related conditions. 

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AC 00-64 9/22/05 

7. BASIC CONCEPTS OF AMRM. AMRM concentrates on air medical team

member attitudes and behaviors and the effects they have on others. 

a. Operational Environment. The operating environment comprises and demands 

interactions among: 

(1) Chief Pilots, 

(2) Chief Flight Nurses, 

(3) Executive Administrators, 

(4) Directors of Operations and Safety, 

(5) Medical Directors, 

(6) Maintenance Technicians/Aircraft Maintenance Staff, 

(7) Communications Specialists including Medical, Dispatch, and Flight 

Following, 

(8) Program and Operations Managers, 

(9) Pilots, 

(10) Flight Nurses, 

(11) Flight Paramedics, 

(12) Flight Physicians, 

(13) Field Services, Local Agencies, 

(14) Meteorology Services, and 

(15) Support and administrative staff. 

b. Communications. Communications training should include, but is not limited to: 

(1) Assertiveness. Assertive people have personality characteristics that 

maintain higher levels of awareness of the issues or situation leading to more successful 

outcomes and better decision making. Assertiveness can increase an individual’s 

confidence in analyzing situations and making good decisions. 

(2) Conflict Resolution. Conflict can be useful when viewed as an opportunity 

for discussion and managing problems that are inevitable. Team conflict could be caused 

by personality, values, perspective, goals, or cultural differences. Steps to manage team

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9/22/05 AC 00-64 

conflict are to clarify the issue, set goals, consider options, remove barriers, make 

agreements, and acknowledge the solution. 

(3) Barriers. Barriers result from the inability of team members to distinguish 

the various communication channels in which we speak. These channels include facts, 

feelings, values, and opinions. When two or more are in a discussion, any one of the 

channels can cause distortion. 

(4) Culture Change. Embracing a culture that values all team members’ input is 

necessary for effective AMRM. Every member of the team must be valued for insight 

and input from top to bottom and bottom to top. Effective AMRM requires organizations 

to evaluate and often change their culture of decision making and their hierarchies. 

Organizations may be plagued with a high proportion of negative norms based within 

their bureaucratic cultures. An important step to take is for all cultural change work 

group members to discuss where the organization is headed and what type of cultural 

change behavior is necessary to move it forward. Even when a very dysfunctional 

culture is inherited from the past, individual employees are often aware of the cultural 

change needed in order for the organization to adapt and survive. Similarly, they are also 

aware of what work environment they prefer for their own sanity and satisfaction and 

how cultural change could achieve it. A certain amount of planning and problem solving 

may have to occur before any new directions can be articulated. 

(5) Feedback. Giving feedback should be based on specific actions, be 

descriptive, not evaluative (describe actions in observable terms rather than judgemental 

terms), timely, and ongoing. Giving feedback reduces uncertainty, solves problems, 

builds trust, strengthens relationships, and improves work quality. 

(6) Communications Skills at Work. Be aware of both verbal and body 

language being used, how they are used, and their impact on others. Use validated 

techniques for giving/receiving as a tool for developing open channels of communication 

to enhance the flexibility and performance of the team members. It is important to 

remember that while new forms of electronic media can increase and speed

communications, non real time and faceless communication carry risks of increased 

misunderstanding. 

c. Team Building. Team Building should include, but should not be limited to: 

(1) Definition of Team Roles. A team is identified as a group of interdependent 

individuals working together to complete a specific task. A team works together in a way 

to address the challenge of optimizing the human/machine interface and accompanying 

interpersonal activities. These activities include team building, information transfer, 

problem solving, decision-making, and maintaining situational awareness. 

(2) Individual Competencies are a complex combination of an individual’s 

knowledge, skills, and abilities, as demonstrated to the team’s members, which are 

critical to the effective and efficient function of the team or organization. 

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AC 00-64 9/22/05 

(3) Commitment. All team members must depend on one another’s knowledge, 

skills, and abilities to complete the mission. 

(4) Inclusiveness. An effective team has to take into consideration or account 

for all factors within its scope, including the specified extremes or limits as well as all 

areas between them. 

(5) Team Identification. Taken together, a team is defined as a group of 

individuals working together to complete a specific task. All team members depend on 

one another’s knowledge, skills, and abilities to complete the task in the safest manner 

possible. 

(6) Team Mission Statement. The team mission statement should address the 

need to prevent aircraft accidents by improving team performance through better team 

coordination. 

(7) Briefing. An effective briefing should be interesting and thorough and 

establish a “team concept” environment that will encourage open/interactive 

communications. Briefings should: 

(a) Be interactive and emphasize the importance of questions, critique, 

and the offering of information by all team members, 

(b) Establish a team concept encouraging all to participate and help with 

the flight, 

(c) Cover pertinent safety and security issues, 

(d) Identify potential problems such as weather, delays, and abnormal 

system operations, 

(e) Provide guidelines for crew actions centered on standard operating 

procedures (SOP), 

(f) Set expectations for handling deviations from the SOPs, and 

(g) Specify duties and responsibilities of all team members. 

(8) Debriefing. This would relate to the effectiveness of the group and/or 

individual performance on the mission. Debriefings deal with positive as well as 

negative aspects of performance. Debriefings should be: 

(a) Specific, 

(b) Objective, 

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9/22/05 AC 00-64 

(c) Usable, 

(d) Constructively given, and 

(e) Involve the whole crew interactively. 

d. Decision Making. Decision making training should include, but is not limited to: 

(1) Judgement. Judgement plays an important part in all phases of the operation. 

Knowing the goals, each team member involved should be trained to ensure that they are 

capable of making the best, most-informed decisions possible to ensure the mission is 

completed safely. 

(2) Situational Awareness. Many common problems can be linked to 

situational awareness failures, which could include: 

 

(a) Situational awareness for aviation crewmembers includes experience 

and training, physical flying skills, team work (CRM), spatial orientation, and health and 

attitude. 

(b) Operational clues to loss of situational awareness include incomplete 

communications, ambiguity, unresolved discrepancies, use of undocumented procedures, 

preoccupation or fixation, no one flying, no one looking, confusion, deviations form

SOPs or briefings, violations of limits and regulations, and failure to meet targets/goals. 

(3) Risk Management. Establishment of a System Safety Risk Management 

Assessment Program optimizes safety by identifying operational hazards and related risk, 

then eliminating or mitigating them to a safe state by using established policies and 

procedures. The operator’s procedures manual should contain clearly defined procedures 

for maintaining operational control during all phases of the EMS operation with total 

support from upper management. There is no “one size fits all” tool for developing a risk 

assessment program and operators should consider their own operational and 

environmental needs in developing its risk assessment tools and plan. 

(4) Aeronautical Decision Making (ADM). ADM is a systemic approach to the 

mental process used by aircraft pilots to consistently determine the best course of action 

in response to a given set of circumstances. 

(5) Standard Operating Procedures (SOP). To achieve consistent safe flight 

operations, SOPs must be clear, comprehensive, available, and understood by flight 

crewmembers. When flight crewmembers understand the underlying reasons for an SOP, 

they are better prepared to conduct a safe operation and provide feedback for 

improvements. 

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AC 00-64 9/22/05 

(6) Evaluation of Options. This training should focus on how to deal with last 

minute changes or conditions from the norm. Such changes could include a change in 

aircraft (backup ship), turning the mission over to another operation closer to the patient 

because of marginal weather conditions at your location, change of crewmember, or 

patient status change. Developing a Risk Assessment Matrix is one means for reducing 

crew anxiety. 

(7) Weather. All regulations put forth in the federal aviation regulations must be 

met at all times, recognizing that available weather reporting and actual conditions 

encountered during flight may be quite different. The safety of the air medical crew 

members, passengers, and patients must never be compromised. Training should include 

at least the minimum weather conditions permitted for departure, where to access current 

weather reports, how to make a sound decision (go/no-go--whether to continue or not), 

and how to ensure the aircraft configuration is adequate for the intended flight (i.e., IFR 

vs. VFR). 

(8) Instrument Meteorological Conditions (IMC). In addition to requirements 

in 14 CFR part 61, training for IMC should include instruction on the Instrument Flight 

Rules (IFR) regulatory requirements, IFR approaches, enroute procedures, go-around 

procedures, flight planning, flight following, and emergency procedures, as examples. In 

addition, training should be provided for inadvertent IMC penetration to prevent 

Controlled Flight Into Terrain (CFIT), which has been a major contributor to accidents, 

especially as associated with low light and marginal visibility conditions. 

e. Human Factors. Human Factors training should include, but should not be limited 

to: 

(1) Stress. While stress is normal and healthy, excessive stress may lead to 

“distress,” a condition of command pressure experienced when a person perceives that 

demands exceed the personal and social resources the individual is able to mobilize. 

There are many proven skills we can use to manage stress and help us to remain calm and 

effective in high pressure situations. These include action-oriented skills to confront the 

problem causing the stress, emotionally oriented skills, which we do not have the power 

to change the situation but manage the stress by changing the interpretation of the 

situation and the way you feel about it. In the EMS environment, it’s important that the 

dispatch of the aircraft should be examined as an air transportation decision free from the 

emotion of the “life-saver” decision. The development of acceptance-oriented skills 

where something happens over which we have no power and no emotional control, and 

where focus must be on surviving the stress, is essential in stress management. 

(2) Critical Incident Stress Management. Critical incident stress management 

is the personal analysis of the various kinds of stress experienced by team members in air 

medical operations. The two types of stress related environments that exist while flying 

complex, time critical medical missions, and performing other crewmember duties, are 

the air transportation operation and the lifesaver environment. 

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(3) Fatigue Countermeasures. The term “fatigue” has been used to describe 

many different experiences: sleepiness, physical tiredness, inability to focus mentally, 

time on duty, types and number of missions, prolonged stress, and other factors. The 

effects of fatigue, which concern the operational community, are those that affect 

crewmember alertness and performance. This type of fatigue stems primarily from sleep 

loss, circadian rhythm disruption, lack of fitness, inadequate food and fluid intake, and 

the interaction of these physiological variables. 

(4) Flight Physiology. An understanding of flight physiology is crucial in 

aviation safety. Flight physiology involves the definitive effects on the human mind and 

body when exposed to the flight environment. Preventive measures must be used in 

order for flight crewmembers to cope with this environment and to understand the unique 

effects that can erode performance. Examples of physical effects on the crew are spatial 

disorientation, head position caused by looking out or down, and sitting sideways. The 

use of over-the-counter medications, caffeine, alcohol, drugs, etc., can also bring on 

detrimental effects. 

(5) Flight Psychology. Flight psychology is the application of psychological 

principles to the unique environment of all aircrew members in order to enhance training, 

flight safety, and mission accomplishment. This has to be a cooperative effort between a 

clinical psychologist and the air medical services. The primary focus of the flight 

psychology program is stress management. 

(6) Operational Implications of Stress. Operational implications for stress, 

which affect human performance, could include fixation, increased reaction time, reduced 

effective field of view, deterioration in cognitive performance and spatial processing, 

logical reasoning decrements, negative effects on attention and concentration, increased 

workload, etc. 

(7) Preparation/Planning/Vigilance. These behaviors relate to crews’ 

anticipating contingencies and the various actions that may be required to address a 

changing operational environment. Excellent crews are always “ahead of the curve” and 

generally relaxed. They devote appropriate attention to required tasks and respond 

without undue delay to new developments. Examples of good behavioral markers are 

sharing what is happening with all team members, sharing all relevant information, 

watching for performance degradation in other crewmembers, demonstrating awareness 

of the plan, including team members in planning, and ensuring all crew members are 

aware of any changes in the plan. 

(8) Workload Distributed/Distractions Avoided. These behaviors relate to time

and workload management. They reflect how well the crew manages to prioritize tasks, 

share the workload, and avoid being distracted from essential activities. Examples of 

workload behavioral markers could include crewmembers’ speaking up when they 

recognize work overload, clear communication of task distribution and task priorities, 

and anticipation of potential distractions so that appropriate actions are taken. 

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(9) Understanding of Basic Personality Types. The type of personality defines 

“what” is important to an individual and significantly influences the way one makes a 

decision. 

(10) Understanding of Group Dynamics. The “group” may have its own way 

of making decisions. The group should be aware that perhaps their “informal” structure 

does in fact work in a formal organization. 

f. Follow Up. AMRM Training should include, but is not limited to: 

(1) Initial, 

(2) Indoctrination, 

(3) Awareness, 

(4) Recurrent Practice, 

(5) Feedback, and 

(6) Continuing Reinforcement and Evaluation. 

8. FUNDAMENTALS OF AMRM TRAINING IMPLEMENTATION. AMRM 

training should be customized to accurately and consistently reflect the operating 

philosophies, polices, practices, and procedures of the organization. Managers need to 

ensure that these elements are clearly defined and consistently implemented in 

procedures, training, and operational practices. Research findings and air medical 

operational experience suggests that the greatest benefits are achieved by adhering to the 

following practices: 

a. Assess/Evaluate the Status of the Organization Before Implementation. It is 

important to know how widely AMRM concepts are understood and practiced before 

designing specific training. Surveys of air medical team members’ experience and 

capabilities can provide essential guidance for program development. 

b. Commitment from All Managers, Starting with Senior Management. Air 

medical team members accept AMRM programs more positively when senior 

management, flight operations managers, and hospital management staff conspicuously 

support the basic concepts and provide necessary resources for training. Operations 

manuals should embrace AMRM training by providing necessary policy and procedures 

guidance. 

c. Customization of the Training to Reflect Nature and Needs of the 

Organization. Using knowledge of the state of the organization, priorities should be 

established for topics to be covered including but not limited to special issues, such as the 

effects of mergers, introduction of advanced technology aircraft, medical equipment, 

aircraft equipment, communications equipment, and new team members. 

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d. Define the Scope of the Program. Implement special AMRM training for key 

personnel at each program, including developers/facilitators and supervisors. These 

individuals can be any member of each air medical flight program. Focus should be on 

their ability to instruct, facilitate, and teach the core elements of the program. It is also

helpful to develop long-term strategies for program implementation. 

e. Communicate the Nature and Scope of the Program before Implementation. 

Air ambulance medical programs should be provided with a preview of the training, 

including the Train the Trainer Course, with plans for initial and continuing training. 

9. COMPONENTS OF AMRM TRAINING. Achieving success and safety in any 

field doesn’t just happen. They require careful and detailed planning for implementation 

and are accomplished by providing quality training. To achieve the highest level of 

success and safety, a successful AMRM training program is comprised of four elements: 

a. Presentation Skills Profile--“Train-the-Trainer Course.” To acquire a cadre of 

instructors, a Train-the-Trainer Course is the initial component of training for AMRM 

and provides an adequate number of qualified instructors as a resource for ongoing/continuing training needs. It consists of classroom instruction on basic 

presentation skills and how to facilitate and instruct AMRM core components. Areas of 

inclusion for instructor training should be, but not limited to: 

(1) What is your objective? Upon completion of this training, the student 

should be able to: Recognize and identify human factors elements by learning to: 

(a) Understand human error and recognize contributing causes, 

(b) Identify the chain of events that led up to an accident, 

(c) Learn to develop safety nets, 

(d) Be aware of individual’s differences and behavioral styles, 

(e) Be aware of how written communication can reduce human error, and 

(f) Learn to develop effective communication skills. 

(2) Who is your audience? Remember, each individual in the classroom has a 

different job function to perform. Even though their job functions are different in nature, 

they are all inter-related in some fashion, for accomplishing a successful and safe air 

medical transport mission. All audiences are different and instructors must be aware of

the different personality types or behavioral styles, individual differences, and how they 

affect the way people perceive information and communicate with one another. 

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(3) How will you structure your presentation? Presentation material should be 

structured so each individual gains knowledge from the training. It has been found that 

individual learners have three sensory preferences for learning that must be considered 

when developing instructional material. Various personality types require different 

communication skills. These are: 

(a) Visual learners prefer to see and observe, 

(b) Auditory learners prefer to hear and listen, and, 

(c) Kinesthetic learners prefer to do rather than see or listen. 

(4) How will you create impact? Adults want training that focuses on real-life 

problems and tasks rather than academic material only. They should be given an 

opportunity for active participation in an instructional setting that is safe, welcoming, 

comfortable, and where they are permitted to be a contributor. 

(5) How will you design and display visual aids? Course media, used as aids in 

understanding the material, provides impact and must be relevant to the course content 

and the learning objectives that are to be achieved. Since media interacts directly with

instructional methods, all instructional modules should include some type of live 

instructor/trainee interaction. Audio-visual aids help keep attention/focus. 

(6) How will you stage your presentation? The physical environment is 

important and should provide for a relaxed and comfortable setting that promotes 

interactivity. 

b. Initial Indoctrination/Awareness.

(1) The initial indoctrination/awareness component of AMRM training consists 

of classroom presentations that focus on interpersonal relations, including team building 

and communication skills, and the coordination involved in the decision making process. 

Emphasis on learning to assert oneself and maintaining the situation should also be

included. It further provides a common terminology and conceptual framework for 

identifying coordination problems. Initial indoctrination may be accomplished by a 

combination of methods including lectures, group discussions, interactive play, videos, 

and role-playing exercises. It is advantageous to have interactive participation of all air 

medical team members and any other members operating in their environment. 

(2) Indoctrination/awareness training modules for experienced air medical team

members are not the only way AMRM training components can be provided. AMRM 

concepts should be addressed in air medical team member’s initial qualification training 

for new team members (new hires).

(3) Curriculum development should continuously address AMRM skills that have 

been demonstrated to influence air medical team member performance. 

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c. Recurrent Practice and Feedback. AMRM training should be included as a 

regular part of recurrent training. Recurrent AMRM training should include refresher 

practice and feedback exercises. Advanced AMRM components may be introduced as 

the air medical team grows and develops comprehensive use of AMRM principles. 

Recurrent training allows participants to practice newly improved skills in 

communication and interpersonal relationships and to receive feedback on their 

effectiveness. Feedback has its greatest impact when it comes by way of self-critique and 

peer review. Feedback in a debriefing environment should focus on “the action” not “the 

individual.” Guidance from a facilitator with special training in assessment and 

debriefing techniques completes an effective practice/feedback process. 

d. Continuing Reinforcement. AMRM concepts should be carried into every other 

type of training including technical and interdepartmental training so that those concepts 

are reinforced continuously. Dissimilar groups should all be brought together for joint 

AMRM training. The objective is to improve the effectiveness and safety of the entire 

operations team (cross-pollination) as a working system. This is accomplished through: 

(1) Technical Training (e.g., initial and recurrent training) which includes: 

(a) Simulation. Simulation training provides all team members a better 

opportunity to understand other team member’s responsibilities and job function. 

Simulations that could be used for training could include a mock air medical flight to 

emergency room staff and dispatchers or providing training on the helicopter emergency 

systems and procedures to the medical flight crewmembers. This could be something as 

simple as how to turn off the battery or operate the radios in cases where the pilot was 

incapacitated and could not perform these functions. Pilots could receive training on the 

procedures for deactivating the medical equipment installed on board. 

(b) Case Studies. Most medical personnel receive training on lessons 

learned from previous medical cases. For air ambulance crewmember accident training, 

accident reports from the National Transportation Safety Board (NTSB), Aviation Safety 

Reporting System (ASRS), and the National Aviation Safety Data Analysis Center 

(NASDAC) are great training aids to be used for determining how and why an accident

happened and how to prevent a reoccurrence of the accident. 

(2) Interdepartmental Training (e.g., symposiums and seminars). 

(a) Problem Solving. A problem solving method that could be used for 

resolution consists of four basic steps. First, find out what the problem is and determine 

if you have seen a similar problem before. Second, determine what strategies are 

available then choose one that seems as if it will work. Third, solve it by using the 

strategy you selected and work the problem. Fourth, look back and reread the question, 

did you answer the question, is your solution correct, and does it seem reasonable. 

(b) Stress Awareness. Stress is individual, variable, and cumulative. When 

stress exceeds our capacity to resist or cope, there is likely to be a collapse. Identifying 

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the causes of stress is of the utmost importance. Causes could include, lifestyle stressors, 

mind stressors, body stressors, work stressors, and change stressors. 

(c) Role Reversal. In order to better understand the other team member’s 

position, their real needs must be understood. This can easily be accomplished by 

understanding: 

(1) What is the value or sense of the other position? 

(2) What might the other team member want or need?

(3) How are our needs/interests the same? 

(4) What can I do to focus on our areas of agreement?

(5) What can I do to meet their needs?

(d) Inquiry/Advocacy/Assertion. Training in the potential benefits of 

team members’ advocating the course of action that they feel is best, even though it may 

involve conflict with others. This can be accomplished by confronting complex and 

diverse issues by stimulating reflective thinking and increased awareness. There is a 

need to tap the insights of others to motivate fresh thinking by empowering others. 

Sticking with a topic longer could lead to a broader understanding of underlying 

problems by evoking more questions with a deeper meaning. 

(e) Conflict Resolution. Conflict is healthy when effectively managed and 

viewed as an opportunity for discussion and managing problems, which are inevitable in 

human relations. Quality of decision making can be improved by allowing all points of

view to be examined. Steps to managing team conflict are: 

(1) Clarify the issues, 

(2) Set goals for resolution, 

(3) Consider options, 

(4) Remove barriers, 

(5) Make agreements, and 

(6) Acknowledge the solutions. 

NOTE: Effective AMRM skills are not gained by passively listening 

to classroom lectures but by active participation and recurrent 

practice. 

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10. THE CRITICAL ROLE OF THE DEVELOPER/FACILITATOR. The 

effectiveness of any training curriculum is directly related to the expertise of the 

developers and facilitators. Ideally, developers and facilitators should be current, 

qualified members of the air medical team who have additional training in the following 

AMRM topics: 

a. Listening and communicating. 

b. Role-playing, simulations, and group discussions. 

c. Team building. 

d. Debriefing and feedback. 

11. ASSESMENT IN AMRM TRAINING PROGRAMS. AMRM is a dynamic 

process that works most effectively when it is continually assessed to determine if the 

training is achieving its goals. Each organization should have a systematic assessment 

process that tracks the effects of the training program so that critical topics for recurrent 

training may be identified and continuous improvements may be made in all other 

respects. Experience has shown that AMRM training works most effectively if it is 

continually refreshed by subject matter that is timely, relevant, and usable. Assessment 

of the training program should include observation and feedback by program

administrators and self-reports by participants using standard survey methods. 

Developers/facilitators should use every available opportunity to highlight the importance 

of AMRM skills and techniques. One of the best learning opportunities occurs when air 

medical team members examine their own behavior and performance with the assistance 

of a trained facilitator. The facilitator points out both positive and negative aspects of 

AMRM performance. Whenever highly effective performance is observed, it is vital that 

the underlying behaviors are discussed and reinforced. 

 

a. The emphasis in this assessment process should be on all team members’ 

performance. The essential areas of AMRM-related assessment include communications, 

decision-making, team building and maintenance, workload management, and situational 

awareness, always in balance with traditional technical proficiency. An additional 

assessment is to determine the impact of the AMRM training on organization-wide trends 

in team member performance. 

b. For optimal assessment, data on team members’ attitudes and behavior should 

be collected before AMRM indoctrination and again at intervals after the last component 

of AMRM training, to determine both initial and enduring effects of the program. The 

goal should be to obtain an accurate picture of the organization’s significant corporate 

personality traits before formal adoption of AMRM training and to continue to monitor 

those traits after implementation. 

c. Reinforcement and feedback are essential to effective AMRM training. Team

members must receive continual reinforcement to sustain AMRM concepts. Effective 

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reinforcement depends upon usable feedback to crew members on their AMRM practices 

and on their job function performance. 

d. Usable feedback requires constant assessment. Team members and those 

involved in training and evaluation should be able to recognize effective and ineffective 

AMRM behaviors. AMRM concepts should be critiqued during the briefing and 

debriefing phases of all training and checking events. 

e. Summarizing the assessment process should include measurement and tracking 

of the organization’s corporate culture as it is reflected in attitudes and operational norms, 

identifying topics needing emphasis within the AMRM program, and ensuring that all 

team members are well prepared and standardized. 

12. SUMMARY. More and more operators in the air medical community are 

discovering the value of extending resource management training across organizational 

lines of business. Effective AMRM begins with training the trainers. It is implemented 

through initial training and strengthened by recurrent practice and feedback. Each and 

every person on the air medical team is a resource to the air medical community. All 

operators and programs engaged in the provision of air medical services are encouraged 

to include all middle and upper-level managers as well as all support staff in their 

training. It is sustained by annual continuous reinforcement that is part of the corporate 

culture and embedded in every element of the air medical team’s training. Their 

objective is to improve the effectiveness of all the groups within the operator’s team. 

ORIGINAL SIGNED BY

James J. Ballough 

Director, Flight Standards Service 

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