National 

Transportation

Safety Board

Washington, D.C.

National Transportation

Safety Board

Washington, D.C. 20594

OFFICIAL BUSINESS

Penalty for Private Use, $300

PRSRT STD

Postage & Fees Paid

NTSB

Permit No. G-200
AVIATION SPECIAL INVESTIGATION REPORT 

NTSB/SIR-06/01 (PB2006-917001) 

Special Investigation Report on 

Emergency Medical Services Operations 

• Page number 50 in Appendix E has been added. (March 6,2006)

The page was originally missing from the report. 

THE CORRECTION BELOW IS INCLUDED

IN THIS VERSION OF THE PUBLISHED REPORT
Aviation Special 

Investigation Report

Special Investigation Report on

Emergency Medical Services Operations

NTSB/SIR-06/01

PB2006-917001 National Transportation Safety Board

Notation 4402E 490 L’Enfant Plaza, S.W.

Adopted January 25, 2006 Washington, D.C. 20594
National Transportation Safety Board. 2006. Special Investigation Report on Emergency Medical 

Services Operations. Special Investigation Report NTSB/SIR-06/01. Washington, DC.

Abstract: This report discusses safety issues identified during the Safety Board’s special investigation of 

55 emergency medical services (EMS) aircraft accidents that occurred in the United States between 

January 2002 and January 2005. Safety issues discussed in this report focus on less stringent requirements 

for EMS operations conducted without patients on board, a lack of aviation flight risk evaluation programs 

for EMS operations, a lack of consistent, comprehensive flight dispatch procedures for EMS operations, 

and no requirements to use technologies such as terrain awareness and warning systems to enhance EMS 

flight safety.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, 

railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by 

Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the 

probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the 

safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions 

and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and 

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about 

available publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical 

Information Service. To purchase this publication, order report number PB2006-917001 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000
iii Special Investigation Report

Contents

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Requirements for EMS Operations Conducted Without Patients On Board . . . 1

Aviation Flight Risk Evaluation Programs for EMS Operations . . . . . . . . . . . . . 4

Flight Dispatch Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Use of Technology to Assist in EMS Flight Operations . . . . . . . . . . . . . . . . . . . . 11

Terrain Awareness and Warning Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Night Vision Imaging Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Board Member Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Appendixes

A: Accident Synopses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

B: EMS Accidents: January 10, 2002 to January 30, 2005 . . . . . . . . . . . . . . . . . . . . . 26

C: Table of Potentially Preventable EMS Accidents and Safety 

Issues Discussed in This Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

D: FAA Notice N8000.293: Helicopter Emergency Medical 

Services Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

E: FAA Notice N8000.301: Operational Risk Assessment 

Programs for Helicopter Emergency Medical Services . . . . . . . . . . . . . . . . . . . . . . 37

F: FAA Notice N8000.307: Special Emphasis Inspection 

Program for Helicopter Emergency Medical Services. . . . . . . . . . . . . . . . . . . . . . . 56

G: Previous EMS Helicopter Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . 63

v Aircraft Accident Report

Figures

1. N601RX Wreckage Near Salt Lake City, Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

2. N25RX Wreckage Near Redwood Valley, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

3. N777KU Wreckage Near Dodge City, Kansas.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

4. N502MT Wreckage Near Pyote, Texas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

5. N503MT Wreckage Near Newberry, South Carolina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

6. N2YN Wreckage near Battle Mountain, Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

7. N41WE Wreckage Near Rawlins, Wyoming. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
vi Special Investigation Report

Abbreviations

AC advisory circular 

AMPA Air Medical Physician Association 

ATC air traffic control 

CFR Code of Federal Regulations 

CFIT controlled flight into terrain 

SIGMET Convective Significant Meteorological Information 

CRM crew resource management 

EMS emergency medical services 

FAA Federal Aviation Administration 

FAR Federal Aviation Regulations

IMC instrument meteorological conditions 

IHC Intermountain Health Care 

MFS Mountain Flight Service, Inc. 

NVG night vision goggles 

NVIS night vision imaging systems 

NOTAM notices to airmen 

POI principal operations inspector 

TAWS terrain awareness and warning system

VFR visual flight rules

VMC visual meteorological conditions 
vii Special Investigation Report

Executive Summary

Emergency medical services (EMS) aviation operations (conducted with either 

helicopters or fixed-wing aircraft) provide an important service to the public by transporting 

seriously ill patients or donor organs to emergency care facilities. The pressure to safely and 

quickly conduct these operations in various environmental conditions (for example, 

inclement weather, at night, and unfamiliar landing sites for helicopter operations) makes 

EMS operations inherently dangerous, and the hazards associated with EMS operations are 

resulting in an increasing number of accidents. This special investigation report of EMS 

operations and accidents is not intended to burden operators with undue requirements or to 

handicap this vital function in any way; rather the purpose of the report is to identify and 

recommend operational strategies and technologies that will help ensure that these vital 

EMS flights arrive safely and continue to provide a valuable service to the public.

Between January 2002 and January 2005, 55 EMS aircraft accidents occurred in 

the United States1 (this number of EMS accidents had not been seen since the 1980s);2

these accidents resulted in 54 fatalities and 18 serious injuries (see appendix B for more 

information). Although the number of flight hours flown by EMS helicopter operations 

has increased from about 162,000 in 1991 to an estimated 300,000 in 2005,3 the average 

accident rate has also increased from 3.53 accidents per 100,000 flight hours between 

1992 and 2001 to 4.56 accidents per 100,000 flight hours between 1997 and 2001.4 As a 

result, the National Transportation Safety Board initiated a special investigation of these 

55 accidents and identified the following recurring safety issues:

• less stringent requirements for EMS operations conducted without patients on 

board,

• a lack of aviation flight risk evaluation programs for EMS operations,

• a lack of consistent, comprehensive flight dispatch procedures for EMS 

operations, and

• no requirements to use technologies such as terrain awareness and warning 

systems (TAWS) to enhance EMS flight safety.

1 Of these 55 EMS aircraft accidents, 41 were helicopter EMS accidents, 16 of which were fatal, 

resulting in a total of 39 fatalities and 13 serious injuries; 14 were airplane EMS accidents, 5 of which were 

fatal, resulting in 15 fatalities and 6 serious injuries. Since the initiation of this special investigation in 

January 2005, 9 additional EMS aircraft accidents have occurred, resulting in 8 fatalities.

2 Comprehensive activity data regarding EMS operations (for example, exposure rates and missions 

flown) are limited because the sources for these data are generally poor. On May 12, 2005, the Safety Board 

issued Safety Recommendations A-05-11 through -13 to the Federal Aviation Administration to address the 

integrity of general aviation flight activity data. Information about these safety recommendations can be 

found at the Board’s Web site at <http://www.ntsb.gov>.

3 “Improving Safety in Helicopter Emergency Medical Services (HEMS) Operations,” Helicopter 

Association International (Alexandria, VA: August 2005).

4 Ira J. Blumen, “A Safety Review and Risk Assessment in Air Medical Transport,” Supplement to the 

Air Medical Physician Handbook, (November 2002): 35.
Executive Summary viii Special Investigation Report

Of the 55 accidents that occurred between January 2002 and January 2005, the 

following seven were considered to provide the best examples of the safety issues 

involved:

• Salt Lake City, Utah (FTW03FA082). On January 10, 2003, an EMS 

helicopter crashed into terrain while maneuvering in dense fog on an aborted 

mission to pick up a patient. The pilot and flight paramedic were killed, and the 

flight nurse was seriously injured.

• Redwood Valley, California (LAX04FA076). On December 23, 2003, an 

EMS helicopter was en route to pick up a patient when it collided with 

mountainous terrain while operating in high winds and heavy rain. The pilot, 

flight nurse, and paramedic were killed.

• Dodge City, Kansas (CHI04FA066). On February 17, 2004, an EMS airplane 

crashed about 5 miles beyond Dodge City Regional Airport while on a 

repositioning flight. The pilot, flight paramedic, and flight nurse, who were at 

the end of a 14-hour duty day, were killed.

• Pyote, Texas (FTW04FA097). On March 21, 2004, an EMS helicopter 

crashed into terrain while maneuvering in reduced visibility conditions while 

transporting a patient. The pilot, flight paramedic, patient, and patient’s mother 

were killed, and the flight nurse was seriously injured.

• Newberry, South Carolina (CHI04MA182). On July 13, 2004, an EMS 

helicopter collided with trees shortly after picking up a patient from an 

accident site on an interstate. The pilot, flight nurse, flight paramedic, and 

patient were killed.

• Battle Mountain, Nevada (SEA04MA167). On August 21, 2004, an EMS 

helicopter crashed into mountainous terrain at night and in deteriorating 

weather conditions while transporting a patient along a direct route through 

mountainous terrain rather than taking an indirect route around the high terrain. 

The pilot, two medical crewmembers, patient, and patient’s mother were 

killed.

• Rawlins, Wyoming (DEN05FA051). On January 11, 2005, an EMS airplane 

that was operating in icing conditions crashed when it impacted terrain while 

en route to pick up a patient. The pilot and two medical crewmembers were 

killed, and a third medical crewmember sustained serious injuries.

These seven accidents have been specifically cited, where applicable, in this report’s 

discussion of each safety issue. More detailed flight histories, as well as probable cause 

statements for these accidents, are provided in appendix A.

The Safety Board examined similar safety issues after the occurrence of 59 EMS 

accidents between May 1978 and December 1986 and concluded in a 1988 safety study5 that 

5 National Transportation Safety Board, Commercial Emergency Medical Service Helicopter 

Operations, Safety Study NTSB/SS-88-01 (Washington, DC: NTSB, 1988).
Executive Summary ix Special Investigation Report

many areas of EMS operations needed improvement, including weather forecasting, 

operations during instrument meteorological conditions (IMC), personnel training 

requirements, design standards, crashworthiness, and EMS operations management. As a 

result of its findings, the Board issued 19 safety recommendations to the Federal Aviation 

Administration (FAA) and others, which have since been closed (see appendix G information 

about these recommendations and their classifications). Most of the recommendations to the 

FAA were closed as a result of the June 20, 1991, issuance of Advisory Circular 

(AC) 135-14A, “Emergency Medical Services/Helicopter (EMS/H),” which addressed 

equipment, training, crew resource management (CRM), decision-making, flight-following 

procedures, weather minimums, and the development of safety programs for EMS helicopter 

flights operating under 14 Code of Federal Regulations (CFR) Part 135. Although the Safety 

Board expressed concern at the time that the FAA chose to issue an AC instead of regulations, 

the number of EMS accidents was decreasing, thus the recommendations were closed.6

Despite the guidance provided in AC 135-14A and AC 135-15, EMS aircraft accidents have 

continued to occur in significant numbers, as shown in table 1 for the 15-year period from 

1990 to 2005.

Table 1. EMS Accidents From 1990 to 2005

Total Injuries

Year

Number of 

accidents

Number of fatal 

accidents Fatal Serious Minor

1990 1 0 0 0 0

1991 1 1 4 0 0

1992 3 2 3 4 0

1993 3 2 5 3 3

1994 4 2 6 0 3

1995 5 1 3 0 2

1996 5 3 9 1 0

1997 3 1 4 0 0

1998 11 2 8 5 5

1999 6 0 0 6 0

2000 6 2 7 0 4

2001 13 1 1 2 2

6 On November 19, 1990, the FAA issued AC 135-15, “Emergency Medical Services/Airplane,” which 

contained guidance information similar to AC 135-14A. However, the recommendations from the 1988 

study focused on EMS helicopter operations, so the closure of these recommendations was based on the 

issuance of AC 135-14A.
Total Injuries

Year

Number of 

accidents

Number of fatal 

accidents Fatal Serious Minor

2002 13 6 14 8 4

2003 19 3 3 2 16

2004 19 9 29 7 3

2005 13 6 13 5 5

Executive Summary x Special Investigation Report

Recent industry publications regarding the safety of EMS aviation operations are 

consistent with the Safety Board’s findings. For example, after an extensive 2-year safety 

review and risk assessment of helicopter EMS accidents, the Air Medical Physician 

Association (AMPA) reported in November 2002 that the time of day that flights occur 

could contribute to accidents.7 The report indicated that even though 38 percent of all 

helicopter EMS flights occur at night, 49 percent of accidents during a 20-year period 

occurred during nighttime hours. The report also cited controlled flight into terrain 

(CFIT), in particular during the takeoff or landing sequence, as a common problem, as 

well as collision with objects (wires were the most common obstacles for EMS 

helicopters); inaccurate weather forecasts (about 26 percent of helicopter EMS accidents 

were weather-related, with most occurring because of reduced visibility and IMC while 

the helicopter was en route); and communications problems with air traffic control (ATC) 

or a lack of communications due to remote locations and high terrain.

AMPA’s report also cited time pressures related to the patient’s condition, rapid 

mission preparation, flight to the patient pick-up location, and low fuel as frequent issues 

in EMS aircraft accidents. According to a query of the National Aeronautics and Space 

Administration’s Aviation Safety Reporting System, patient condition was cited in 

44 percent of the EMS accidents or incidents reports as a contributor to time pressure 

leading to inaccurate or hurried preflight planning. In addition, the AMPA report stated 

that accidents occurred more often when flight crews were en route to pick up a patient 

than at any other time during flight. A white paper8 published by Helicopter Association 

International in August 2005 examined many of the same issues as AMPA.

This special investigation report is not intended to represent a comprehensive 

statistical analysis of EMS accidents. Because 14 CFR Part 135 operators are not required 

to maintain flight activity data, such an analysis is not possible. The purpose of this report 

is to discuss the safety issues identified during the Safety Board’s investigation and 

7 Ira J. Blumen, MD, and the UCAN Safety Committee, “A Safety Review and Risk Assessment in Air 

Medical Transport.” Supplement to the Air Medical Physician Handbook, (November 2002): 2.

8 “Improving Safety in Helicopter Emergency Medical Services (HEMS) Operations,” Helicopter 

Association International (Alexandria, VA: August 2005). The Safety Board has reviewed this white paper 

and determined that this special investigation report further amplifies many of the issues mentioned in the 

white paper.
Executive Summary xi Special Investigation Report

suggest recommendations that, if implemented, could address these issues. (See appendix 

C for a list of accidents that were examined during the Board’s investigation that might 

have been prevented by the corrective actions proposed in this report.) The Safety Board 

also recognizes that the use of EMS aircraft operations involves aspects of public policy 

(for example, the decision to use EMS aircraft instead of ground transportation, the 

reimbursement structure of vital services, and the economic competition among EMS 

operators) that will not be the focus of this report.

The Safety Board notes that the FAA has recently taken positive steps to improve 

the safety of EMS operations. For example, in August 2004, the FAA convened a 

Helicopter Air Ambulance Accident Task Force to make recommendations to reduce 

helicopter EMS accidents; to date the task force has not issued any recommendations or 

rule changes. On January 28, 2005, the FAA released Notice N8000.293, “Helicopter 

Emergency Medical Services Operations,” which contained information that FAA 

inspectors could provide to helicopter EMS operators “for a review of pilot and mechanic 

decision-making skills, procedural adherence, and crew resource management” (see 

appendix D). On August 1, 2005, the FAA released Notice N8000.301, “Operational Risk 

Assessment Programs for Helicopter Emergency Medical Services,” which identified 

possible risks and dangers to flight crews and patients and encouraged aircraft EMS 

operators to promote the use of risk assessment models (see appendix E). The FAA issued 

similar (although less detailed) guidance in AC 135-14A; however, the recommended 

practice of risk assessment and decision-making had not been incorporated in a formalized 

manner into the EMS operations that were investigated as part of this special investigation.9

Finally, on September 27, 2005, the FAA released Notice N8000.307, “Special Emphasis 

Inspection Program for Helicopter Emergency Medical Services,” which provided 

guidance to aviation safety inspectors for the examination of operational factors that were 

identified as causal to EMS accidents from 1999 to 2004, such as operational control, 

safety culture development, and access to and use of weather information by flight crews, 

management, and in-flight communications specialists (see appendix F).

Despite these positive steps to improve EMS operation safety, the FAA has not yet 

imposed any requirements for all aircraft EMS operators regarding flights without patients 

on board, risk management, flight dispatch, or the use of technologies. The FAA’s recently 

published notices are simply information for principal operations inspectors (POI) to 

convey to their operators and encourage them to incorporate into their operations. Because 

the guidance provided in ACs 135-14A and 135-15 was not widely adopted by EMS 

operators, the Safety Board does not anticipate that the guidance provided in the FAA’s 

notices will be widely implemented. The Board is concerned that, without requirements, 

some EMS operators will continue to operate in an unsafe manner, which could lead to 

further accidents. Although the Board recognizes that the nature of EMS operations 

involves some risks, operators should be required to provide the best available tools to 

minimize those risks and help medical personnel, flight crews, and patients arrive at their 

destinations safely.

9 See “Aviation Flight Risk Evaluation Programs for EMS Operations” in this report for more 

information.

1 Special Investigation Report

Requirements for EMS Operations 

Conducted Without Patients On Board

While carrying patients or organs for transplant, EMS flights are required to be 

conducted in accordance with the operator’s 14 CFR Part 135 regulations.10 However, 

when flights are conducted without patients aboard (positioning flights), they are 

permitted to operate under the provisions of 14 CFR Part 91,11 which are less stringent 

than the provisions of Part 135. Positioning flights often carry medical personnel who, 

although classified as “crew members,” are primarily responsible for helping the patient 

and not operating the flight. The Safety Board notes that 35 of the 55 EMS accidents 

studied during this investigation, including the accidents in Salt Lake City, Redwood 

Valley, Dodge City, and Rawlins, occurred with medical crewmembers but no patient on 

board and were conducted under Part 91. As noted previously, the AMPA study found that 

more EMS accidents occurred when a patient was not on board the flight than at any other 

time during flight.

Requirements regarding weather/visibility minimums differ significantly between 

Part 135 and Part 91. Section 91.155, “Basic VFR [visual flight rules] Weather 

Minimums,” stipulates only that helicopters must remain “clear of clouds” when operating 

below 1,200 feet above the surface under VFR. In contrast, Safety Board staff’s review of 

the Part 135 operations specifications for several EMS helicopter operators revealed that 

the specifications require weather/visibility minimums of at least 1,000-foot ceilings and 

3 miles visibility. 

The circumstances of some of the accidents discussed in this report demonstrate 

that adverse weather conditions are often key factors in these accidents. For example, the 

Salt Lake City accident flight was conducted at night as a Part 91 positioning flight in 

weather conditions below Part 135 VFR minimums. The helicopter eventually crashed in 

an area where visibility was reported at 1/16 of a mile with fog and vertical visibility was 

200 feet.12 EMS positioning flights are often conducted in accordance with Part 91 

minimums; thus, the flights may operate in weather/visibility conditions that are below 

Part 135 minimums because they are not required to meet the more stringent Part 135 

requirements.

Part 135 and Part 91 also differ regarding crew rest requirements. The provisions 

of Part 135 require that the flight crew obtain adequate rest before conducting an EMS 

10 Title 14 CFR Part 135 prescribes rules governing commuter or commercial on-demand operations.

11 Title 14 CFR Part 91 prescribes rules governing the operation of aircraft within the United States, 

including the waters within 3 nautical miles of the U.S. coast.

12 Vertical visibility is the distance that can be seen upward into a surface-based obscuration (for 

example, fog), or the maximum height from which a pilot in flight can recognize the ground through a 

surface-based obscuration.
Requirements for EMS Operations

Conducted Without Patients On Board 2 Special Investigation Report

flight with a patient on board, calling for a maximum duty time of 14 hours. In contrast, 

Part 91 has no duty time restrictions. Fatigue has been shown to impair performance and 

diminish alertness,13 both of which are critical to safe flight operations. If a pilot has 

delivered a patient and has worked the maximum duty time under Part 135 requirements 

but returns the helicopter to departure base (a Part 91 flight), the hours flown for the Part 

91 flight with no patient on board currently do not count toward his duty time 

restrictions.14 This situation could result in a pilot flying in a fatigued condition during the 

Part 91 leg of the flight or not getting adequate rest during his time off, leaving him 

fatigued when he returns to duty the following day. If the return flight were conducted 

under Part 135 requirements, the pilot could request that his duty hours be extended to 

reposition the flight, but a longer rest period before returning to duty would be required. 

Further, the hours that a pilot flies under Part 91 do not count toward the total duty time 

the pilot is permitted to fly under Part 135 requirements. If a pilot were to conduct lengthy 

flight operations under Part 91, this flight time would not be indicated in his duty record 

and his eligibility to fly Part 135 flights would not be affected.

The Safety Board also notes that when pilots are permitted to proceed under Part 

91 requirements in minimal weather conditions or near the end of their duty time (if their 

Part 91 and Part 135 duty hours were combined) to pick up a patient, the patient’s critical 

condition might significantly influence pilots to complete the mission and transport the 

patient to a hospital even though the flight would not be permissible under Part 135 

requirements. It is critical that EMS aircraft arrive safely at patient pick-up or drop-off 

locations. If the flight is unable to operate safely under Part 135 requirements, then the 

mission should not be attempted. Transporting a patient to the hospital is of utmost 

importance; however, if a flight is unable to safely reach the patient, the safety of the 

entire operation is compromised, and it may be to the patient’s benefit to be transported by 

some other means, such as ground transportation. Of the 55 accidents investigated from 

January 2002 to January 2005, 10 flights were operating under the less stringent 

requirements of Part 91 and would not have met authorized weather minimums if they had 

been required to operate under Part 135 (see appendix C).

The Safety Board does not believe that EMS operations should be permitted to 

continue to operate under the less strict requirements of Part 91 simply because a patient is 

not on board. An EMS positioning flight does not fit the traditional definition of a 

13 National Transportation Safety Board, Evaluation of U.S. Department of Transportation Efforts in the 

1990s to Address Fatigue, Safety Report NTSB/SR-99/01 (Washington, DC: NTSB, 1999).

14 The Safety Board issued Safety Recommendation A-94-194, which asked the FAA to revise the 

regulations contained in 14 CFR Part 135 to require that pilot flight time accumulated in all company flying 

conducted after revenue operations—such as training and check flights, ferry flights, and repositioning 

flights—be included in the crewmember’s total flight time accrued during revenue operations. The 

recommendation is currently classified “Open—Unacceptable Response” because of the FAA’s inaction. 

The Board also issued Safety Recommendation A-95-113 to the FAA to finalize the review of current flight 

and duty time regulations and revise the regulations, as necessary, within 1 year to ensure that flight and 

duty time limitations take into consideration research findings in fatigue and sleep issues. This 

recommendation also asked that the new regulations prohibit air carriers from assigning flight crews to flight 

conducted under 14 CFR Part 91 unless the flight crews meet the flight and duty time limitations of 14 CFR 

Part 121 or other appropriate regulations. The recommendation is also classified “Open—Unacceptable 

Response.” These recommendations are on the Safety Board’s Most Wanted List of Safety Improvements. 
Requirements for EMS Operations

Conducted Without Patients On Board 3 Special Investigation Report

positioning flight, which involves flying an empty aircraft from one location to another for 

future operations. Rather, a positioning flight in EMS operations is a critical part of 

transporting medical personnel to a patient’s location or returning from a patient drop-off; 

therefore, the positioning legs of flights should not be separated from the 

patient-transportation leg. All three of these flight functions comprise the EMS mission 

and should not be differentiated. Because Part 135 requirements impose additional safety 

controls that are not present under Part 91 requirements, the Safety Board concludes that 

the safety of EMS operations would be improved if the entire EMS flight plan operated 

under Part 135 operations specifications; 35 of the 55 accidents in this special 

investigation occurred with crewmembers on board but no patients on board.

Further, the Safety Board is aware that some certificate holders may train medical 

personnel to perform duties that loosely relate to the operation of the aircraft, such as 

looking outside the aircraft for possible obstructions or evaluating a landing site, so that 

these personnel are classified as flight crewmembers, which permits positioning flights to 

be operated under Part 91.15 The Board does not consider the assignment of limited 

operational duties to medical personnel to provide a sufficient basis for operating under 

the less rigorous requirements of Part 91, which provides inadequate safety controls for 

the transport of these medical personnel passengers. Without specific flight training 

(which medical personnel generally do not receive),16 medical personnel cannot be 

expected to meaningfully participate in the decision-making process to enhance flight 

safety or to significantly contribute to operational control of the flight; therefore, 

regardless of any operational duties medical personnel may be assigned, they should be 

considered passengers on all EMS flights. The Safety Board concludes that the minimal 

contribution of medical personnel to the safe operation of EMS flights is not sufficient to 

justify operating EMS positioning flights under the less stringent Part 91 requirements.

The Safety Board notes that, because all EMS operators already fly under Part 135 

operations specifications when patients are on board, little change would be required 

regarding the way they operate flights under Part 135 operations specifications when only 

medical personnel are on board. Because of the frequency with which EMS aviation 

accidents continue to occur while operating under Part 91 provisions, the Safety Board 

believes that the FAA should require all EMS operators to comply with Part 135 

operations specifications during the conduct of all flights with medical personnel on 

board.

15 According to FAA Order 8400.10, “Air Transportation Operations Inspector’s Handbook,” volume 4, 

chapter 5, medical personnel may or may not be considered crewmembers at the operator’s discretion. The 

order states, in part, “if the operator desires to consider the medical personnel crewmembers, the medical 

personnel must complete initial and recurrent crewmember training programs [and]...must perform some 

duty in an aircraft that relates to the operation of that aircraft.” A note in the order states, “when only 

crewmembers are on board the aircraft, the flight may be conducted under FAR [Federal Aviation 

Regulations] Part 91. When a patient or passenger is on board the aircraft, the flight must be conducted 

under FAR Part 135.”

16 According to AC 135-14A, “Emergency Medical Services/Helicopter (EMS/H),” medical personnel 

need only to be trained in the use of aviation terminology, physiological aspects of flight, aircraft evacuation, 

and patient loading and unloading.
4 Special Investigation Report

Aviation Flight Risk Evaluation Programs for 

EMS Operations

Much of the EMS mission has associated risks. Pressure to take or complete a 

mission, weather, nighttime flight, spatial disorientation resulting from lack of visual 

cues, and pilot training and experience were all identified as risk factors in the Safety 

Board’s 1988 safety study of commercial EMS helicopter operations. The 2002 AMPA 

study cited additional risks, such as unprepared landing sites, complacency, and 

situational stress. Safely operating in such a high-risk environment calls for the 

systematic evaluation and management of these risks. According to AMPA’s study, an 

effective flight risk evaluation program acknowledges and identifies threats, evaluates 

and prioritizes the risks, considers the probability that a risk will materialize, and 

mitigates loss. The Safety Board’s investigation determined that, in the EMS 

environment, conducting a flight risk evaluation would require the pilot and possibly 

another person (a manager, a flight dispatcher, or another flight crewmember) to assess 

the situation without being influenced by the sense of urgency that can accompany the 

initial call requesting services. The Board’s investigation of recent EMS accidents found 

that all of the operators involved did not have an established aviation flight risk 

evaluation program that would assist pilots in making an objective determination of the 

risks that would be present.

For example, an aviation flight risk evaluation program did not exist at 

Intermountain Health Care (IHC) Health Services, Inc., when the accident occurred in 

Salt Lake City in January 2003. If an aviation flight risk evaluation program had been in 

place, the pilot would likely have been required to complete a standardized flight risk 

evaluation matrix before the flight, including assessing weather minimums and the route 

of flight. The poor nighttime weather conditions would have raised the risk rating for 

the mission, requiring further consideration of the flight risks. As noted in the accident 

description in appendix A, a previous pilot who aborted his attempt at the mission 

informed the accident pilot of the weather conditions, but the accident pilot decided to 

take the flight anyway. A systematic evaluation of the flight risks might have prevented 

the flight.

The Safety Board has learned that IHC Health Services implemented a risk 

management program after the January 2003 accident; the program includes a risk matrix 

form that pilots begin filling out when their shift begins. When an EMS call is received, 

the pilot completes the remainder of the form and calculates the flight risk. Depending on 

the calculated risk, the flight is categorized as low risk, mid-risk (which requires approval 

of a senior pilot before the mission can be attempted), or high risk (which requires 

approval of the director of operations, lead pilot, or chief pilot to accept the mission). The 

risk matrix also contains standardized flight procedures that require a flight dispatcher’s 

agreement so that the pilot is alleviated of the sole responsibility for deciding whether to 

attempt a mission. In addition, IHC Health Services developed a safety awareness 
Aviation Flight Risk Evaluation

Programs for EMS Operations 5 Special Investigation Report

program for its EMS operations and, along with other EMS operators in Salt Lake City, 

developed and instituted a policy letter concerning communications between operators 

during adverse weather and hazardous conditions.

If the operator involved in the Battle Mountain accident had an established flight 

risk evaluation program, a different route may have been chosen before the accident 

flight. The pilot chose to take a direct route over a remote area of rugged mountainous 

terrain with little lighting instead of a slightly longer route that followed an interstate 

highway and avoided the highest terrain. The pilot might have felt additional pressure to 

take the direct route because the patient was an infant. If a risk management program 

had been in place, the dark night conditions and the mountainous route of flight might 

have raised the risk rating for the mission, which might have led the pilot to make an 

alternative decision regarding the flight (such as taking a less mountainous route) to 

lower the risk. The investigations of the Pyote and Rawlins accidents also revealed that 

neither operator had risk assessment programs in place at the time of the accidents. Both 

accidents occurred in hazardous weather conditions at night, indicating that the decisions to 

perform the flights in these conditions were flawed. As shown in appendix C, 13 of the 

55 accidents studied during this investigation might not have occurred if flight risk 

evaluation programs had been in place because the flights might have been rejected or 

the risks might have been mitigated.17

The Safety Board is aware that Notice N8000.301, “Operational Risk Assessment 

Programs for Helicopter Emergency Medical Services,” recommends that company 

procedures manuals contain procedures for maintaining operational control and 

conducting risk assessment and management. The notice indicates that although a pilot 

has ultimate responsibility and authority to determine risk, the company should promote 

the pilot’s use of information from mechanics, communications specialists, ground and 

flight medical personnel, managers, and other support personnel involved in flight 

operation. The notice states that typical risk variables include weather, airworthiness, 

technologies to aid in managing risk, performance margins, flight crew performance, 

operating environment, and the organizational environment. 

The Safety Board is pleased that Notice N8000.301, which was issued in 2005, is 

more detailed than AC 135-14A, which was issued in 1991 and had similarly addressed 

the need to consider judgment and decision-making in the development of safety 

programs for EMS operation. However, the Board is not confident that the new guidance 

will be any more widely adopted by EMS operators than the previous guidance because 

most operators examined during this investigation did not have a decision-making or a 

risk evaluation program in place (as suggested in the 1991 guidance) when accidents 

involving their aircraft occurred. Because aviation risk evaluation programs include 

training and procedural requirements that promote the risk evaluation of each flight in a 

systematic manner and consultation with others trained in EMS flight operations if the 

risks reach a predefined level, the Safety Board concludes that the implementation of 

17 Safety Board investigators analyzed the facts, conditions, and circumstances of all 55 accidents and 

applied the general criteria described in FAA Notice N8000.301, “Operational Risk Assessment Programs 

for Helicopter Emergency Medical Services,” to reach this determination.
Aviation Flight Risk Evaluation

Programs for EMS Operations 6 Special Investigation Report

flight risk evaluation before each mission would enhance the safety of EMS operations. 

Therefore, the Safety Board believes that the FAA should require all EMS operators to 

develop and implement flight risk evaluation programs that include training all employees 

involved in the operation, procedures that support the systematic evaluation of flight risks, 

and consultation with others trained in EMS flight operations if the risks reach a 

predefined level.
7 Special Investigation Report

Flight Dispatch Procedures

The Safety Board’s investigations revealed that many EMS operators lack a 

consistent, comprehensive flight dispatch procedure, which—as part of a flight risk 

evaluation program—would help EMS pilots determine whether it is safe to accept or 

continue a mission. In commercial, passenger-carrying (Part 121) operations, flight 

dispatchers are responsible for authorizing the release of a flight based on, among other 

factors, the airworthiness of the aircraft, weather conditions, and the satisfactory operation 

of communication and navigation facilities along the route of flight, such as expected 

route, landing information, and notices to airmen (NOTAM). Flight dispatchers for 

Part 121 operations are also responsible for providing flight-following and updated 

information the pilot may not otherwise have access to during the flight, such as weather 

and routing.

Currently, most Part 135 EMS operations specifications permit the pilot to be 

notified of an assignment by the local 911 dispatch system or emergency hospital staff, yet 

911 dispatch or hospital staff do not have expertise in or an understanding of the 

requirements of flight or landing procedures, particularly at night or in adverse conditions. 

When a pilot is dispatched by someone other than a flight dispatcher18 and accepts the 

flight, the pilot would typically check19 the most accessible source of weather information 

available (usually via computer, using sources that are not necessarily specific to 

aviation)20 and begin the flight. The pilot would then have limited access to updated 

information. Safety Board staff found that, in many instances, 911 dispatchers or 

emergency hospital staff did not provide, nor were they expected to provide, EMS 

operators or pilots with more than minimal information concerning expected route, 

landing information, weather updates, or NOTAMs before or during a flight. For several 

accidents, the missing information was critical and could have helped avoid the accident.

As shown in appendix C, formalized flight dispatch procedures may have 

mitigated the results of 11 of the 55 accidents examined during the Safety Board’s 

18 The Safety Board makes the distinction between a 911 or hospital dispatcher, who generally works 

for the local government or hospital and dispatches all emergency services, and a flight dispatcher, who 

generally works for or under contract to an aviation operator and has specific aviation knowledge, including 

the effects of weather, mechanical reliability, and operational needs of the flight.

19 For Part 91 flights, 14 CFR 91.103, “Preflight action,” states the following, “each pilot in command 

shall, before beginning a flight, become familiar with all available information concerning that flight. This 

information must include - (a) For a flight under [instrument flight rules] or a flight not in the vicinity of an 

airport, weather reports and forecasts.” For Part 135 flights, 14 CFR 135.213, “Weather/reports and 

forecasts,” states in part, “Whenever a person operating an aircraft under this part is required to use a 

weather report or forecast, that person shall use that of the U.S. National Weather Service, a source approved 

by the U.S. National Weather Service, or a source approved by the Administrator. However, for operations 

under VFR, the pilot in command may, if such a report is not available, use weather information based on 

the pilot’s own observations or on those of other persons competent to supply appropriate observations.”

20 Nonaviation-specific weather sources do not contain or analyze information that is important to flight 

safety, such as visibility, winds, and temperature/dew point spread.
Flight Dispatch Procedures 8 Special Investigation Report

assessment.21 For example, in the Pyote, Texas, accident, the pilot contacted the hospital 

dispatcher at the destination hospital only after he had departed Alpine, Texas, with the 

patient on board. He did not obtain a weather briefing before departure as he should have. 

If he had obtained a briefing, he would have been informed of expected thunderstorm 

activity in the area. A Convective Significant Meteorological Information (SIGMET) 

bulletin issued about 0154 (22 minutes before the accident) indicated an area of 

thunderstorms predicted for the accident site. Other weather information obtained from 

satellites and the National Weather Service also indicated thunderstorm activity 

surrounding the accident site at the time of the accident. Although the pilot took off about 

15 minutes before the SIGMET was issued, he might not have continued the flight if he 

had been in contact with a flight dispatcher with knowledge of and access to this weather 

information.

For the Salt Lake City accident, the 911 and company dispatchers might not have 

been aware of the kind of information that is critical to flight safety when dispatching a 

flight. A transcript of the conversation between the IHC Health Services pilot and his 

company’s flight dispatch center suggested that the pilot was frustrated with the 911 

dispatcher’s request to fly the mission, even though the 911 dispatcher knew that another 

company had aborted its flight because of low visibility. Despite this apparent frustration, 

the pilot and his company’s flight dispatch center operator accepted the flight. The 

transcript showed that his company’s dispatcher provided little support other than 

encouraging the pilot to accept the flight. The pilot was primarily responsible for 

obtaining weather, coordinating with the on-scene rescue personnel, and maintaining 

visual flight. Based on reports from the company that had just aborted its flight, it should 

have been clear that the IHC flight should not have been attempted. A flight dispatcher 

with specific knowledge of flight requirements would likely have been able to more fully 

comprehend the importance of the other company’s aborted flight, independently gather 

pertinent weather information from all available sources, recognize that the available 

weather information was severe enough to not even attempt the mission, and provide 

sound advice to the mission pilot. Similarly, in the Rawlins, Wyoming, accident, 

St. Anthony’s Hospital in Denver, Colorado, provided hospital dispatch for the accident 

flight by notifying the EMS operator, Mountain Flight Service, Inc. (MFS), only of the 

mission. The MFS pilot decided to launch into adverse weather conditions without 

obtaining additional information (other than a standard FAA flight service 

station briefing) related to the flight, such as the route of flight and the changing weather 

conditions near the destination.

An effective dispatch combined with a flight risk evaluation program (as discussed 

in the previous section) enhances the safety of these often-difficult missions and, for 

example, might have prevented the Newberry, South Carolina, accident. Three EMS flight 

crews had declined this mission because of weather conditions that were not conducive to 

safe flight. During postaccident interviews, the first pilot stated that he took off from 

Columbia, South Carolina, for the flight but canceled because of developing fog 

21 Safety Board investigators analyzed the facts, conditions, and circumstances of all 55 accidents and 

applied the procedures used by Part 121 flight dispatchers as outlined in the FARs to reach this 

determination.
Flight Dispatch Procedures 9 Special Investigation Report

conditions. The second pilot, who was located in Greenville, South Carolina, indicated 

that based on his experience and observation of the fog conditions and lack of a 

temperature/dew point spread, he classified the weather conditions as “red.”22 The third 

pilot, located in Columbia, declined the mission once he learned that the first pilot 

returned to the airport due to fog conditions. The accident pilot, located in Spartanburg, 

South Carolina, was not informed by the Spartanburg County 911 dispatcher that the first 

pilot had attempted but had not completed the mission or that the other two pilots had 

refused it. If a flight dispatcher who understood the weather risks based on the other 

pilots’ refusals to take the mission were involved and relayed these risks to the accident 

pilot, or if a flight risk evaluation program had been in place, the accident pilot might also 

have rejected the mission. 

Dispatch can also track flights to provide updated weather and terrain information 

or, if necessary, provide flight-locating services. In the Battle Mountain accident, the lack 

of a comprehensive flight dispatch and flight-following system resulted in the helicopter 

not being reported overdue until about 4 hours after its departure for a 1 hour 20 minute 

flight. The EMS operator used local county 911 dispatch systems for flight-following. As 

the flight crossed from one county into another, flight-following responsibility moved 

from one 911 dispatch center to another. However, the 911 dispatch centers did not 

directly communicate with one another about the progress of a flight; instead, the pilot 

was responsible for initiating these communications when changing county dispatch 

centers. When the accident pilot failed to make his required 15-minute position report 

after departing Battle Mountain, the Battle Mountain 911 dispatcher took no action, likely 

because she was not expecting another report from this pilot as he traveled into the next 

county. The helicopter was not reported overdue until personnel at the hospital in Reno, 

Nevada, became concerned when the patient did not arrive. Although this accident was not 

survivable, in other situations, flight-following and immediate notification would result in 

more timely search and rescue operations, which could have potentially life-saving

benefits. 

The Safety Board is aware that some EMS operators have company-trained 

dispatchers on staff who communicate with hospital emergency personnel or on-scene 

emergency services and notify the EMS pilot of flight assignments. These flight 

dispatchers obtain weather information for a pilot before a flight and, after a flight begins, 

they obtain updated weather information if requested by a pilot. These flight dispatchers 

also file a company flight plan and monitor the flight so that it can be quickly located if it 

is involved in an accident. This function is an important aspect of safe flight operations, 

and the safety of EMS operations would be enhanced if formalized dispatch procedures 

were used. 

Formalized dispatch procedures would include a person knowledgeable in flight 

operations, weather, maintenance, and flight-following who would be able to evaluate all 

flight risks and advise a pilot about whether to accept or continue a mission in changing 

weather situations. Because the flight dispatcher would be detached from the emergency 

22 A “red” classification is a designation used by the pilot’s company indicating that the pilot would not 

take off until the weather conditions improved.
Flight Dispatch Procedures 10 Special Investigation Report

itself (the flight dispatcher would not be the 911 or hospital dispatcher), the flight 

dispatcher would be less susceptible to making flight decisions based on the urgency of 

the situation and would be able to obtain an overall perspective of the mission’s safety. 

The Safety Board concludes that formalized dispatch and flight-following procedures, 

including a dedicated dispatcher with aviation-specific knowledge and experience, would 

enhance the safety of EMS flight operations by providing the pilot with consistent and 

critical weather information, assisting in go/no go decisions, and monitoring the flight’s 

position. Therefore, the Safety Board believes that the FAA should require EMS operators 

to use formalized dispatch and flight-following procedures that include up-to-date weather 

information and assistance in flight risk assessment decisions.
11 Special Investigation Report

Use of Technology to Assist in

EMS Flight Operations

Terrain Awareness and Warning Systems

The study by AMPA found that CFIT is a common factor in helicopter EMS 

accidents, in particular during the takeoff or landing sequence.23 During low flight over 

terrain or flight over variable terrain, the use of TAWS could provide valuable information 

to pilots who are trained in instrument flight but do not completely or properly use all of 

their instruments, as well as those pilots who are not instrument-trained.24 TAWS can 

substantially reduce pilot workload and improve the margin of safety during limited 

visibility conditions, which are often encountered during EMS operations. The FAA has 

already recognized the benefit of TAWS by requiring these systems on turbine-powered 

airplanes with six or more passenger seats. Requiring TAWS for EMS aircraft would 

extend this benefit to the patients and medical personnel traveling on EMS flights. One 

system specifically manufactured for helicopters operates in multiple modes that provide 

ample warnings to the flight crew when dangerous flight profiles are encountered. These 

modes allow for six different flight regimes from takeoff to landing and include warnings 

for altitude deviation and excessive sink rate.

The use of TAWS might have helped the pilot in the Battle Mountain accident 

avoid the terrain. According to data supplied by a U.S. manufacturer of TAWS equipment, 

the reconstructed flight profile of the accident helicopter indicated that, if the helicopter 

had been equipped with a TAWS, a “caution terrain” aural message would have sounded 

30 seconds before impact, and a “warning terrain” aural message would have sounded 

25 seconds before impact and continued to the end of the flight. These warnings would 

have provided adequate time to allow the pilot to take appropriate action to avoid impact 

with the terrain. The investigations of the Pyote and Dodge City accidents revealed that, if 

a TAWS had been installed on the aircraft involved and had been appropriately set to a 

minimum altitude setting, the pilots would have received ample warning during their 

respective aircraft’s gradual descent into terrain, thus preventing the accidents. Further, for 

17 of the 55 accidents, TAWS might have helped the pilots avoid terrain. (See 

appendix C.)

23 Blumen, MD, and the UCAN Safety Committee (2002): 8.

24 Although similar in purpose, TAWS functionality is different from that of a radio altimeter, which 

uses the reflection of radio waves from the ground to determine the height of an aircraft above the surface. 

On October 7, 2002, the Safety Board issued Safety Recommendation A-02-35, asking the FAA to require 

the installation of radar altimeters in all helicopters conducting commercial, passenger-carrying operations 

in areas where flat light or whiteout conditions routinely occur. In a September 6, 2005, response, the FAA 

indicated that an aviation rulemaking committee has discussed requiring “radio altimeters in helicopters and 

will recommend the installation in aeromedical operations.” The FAA also stated that it would solicit 

comments on whether radio altimeters should be installed in all helicopters conducting commercial 

passenger-carrying operations when it publishes a notice of proposed rulemaking.
Use of Technology to Assist in

EMS Flight Operations 12 Special Investigation Report

The Safety Board concludes that the use of TAWS would enhance the safety of 

EMS flight operations by helping to prevent CFIT accidents that occur at night or during 

adverse weather conditions. Although FAA Notice 8000.293 encourages operators to 

consider installing TAWSs for nighttime operations (see appendix D), merely encouraging 

the use of a technology is not sufficient; operators should be required to incorporate 

systems and practices that will improve the safety of their operations. Additionally, as 

TAWS become more widely used, its cost will continue to decrease.25 Therefore, the 

Safety Board believes that the FAA should require EMS operators to install TAWS on 

their aircraft and to provide adequate training to ensure that flight crews are capable of 

using the systems to safely conduct EMS operations.

Night Vision Imaging Systems

Safety Board staff found that some EMS operators use night vision imaging 

systems (NVIS),26 which enhance a pilot’s ability to see and avoid obstructions at night. 

However, most EMS operators do not use such equipment because of its relatively recent 

introduction into the nonmilitary community; the expense of the system, training, and 

aircraft modifications; and the fact that the equipment cannot be used in locations that 

have ambient light, such as populated areas. An FAA study found that “[w]hen properly 

used, NVGs [night vision goggles] can increase safety, enhance situational awareness, and 

reduce pilot workload and stress that are typically associated with night operations.”27 The 

study by AMPA found that collision with objects poses a problem for EMS helicopters 

and that wires are the most common obstacles (NVGs can help pilots see wires). The study 

also noted that although 38 percent of all helicopter EMS flights were at night, 49 percent 

of accidents occurred during nighttime hours.28

The FAA allows Part 135 operators to use NVIS to aid in night flight during visual 

meteorological conditions (VMC), but they are not to be used during IMC; therefore, VFR 

weather minimums must be complied with during a flight. The FAA’s Technical Standard 

Order-C164 describes the minimum performance standards NVGs must meet for design 

approval. The FAA also issued Flight Standards Handbook Bulletin for Air Transportation 

04-02, “Night Vision Imaging Systems,” which guides POIs in the evaluation of 

operations, training, currency, and equipment after an operator’s request to use NVIS.

The use of NVIS might have helped the pilots involved in the Battle Mountain and 

Redwood Valley accidents. If the Battle Mountain pilot had been using NVIS, he would 

likely have seen the ridgeline and been able to avoid the impact. In the Redwood Valley 

25 Current market cost for TAWS installation is about $30,000.

26 The term NVIS most commonly refers to night vision goggles but can also include technology such 

as thermal imaging equipment, night vision cameras, and heads-up displays. NVIS can enhance vision in 

dark conditions by amplifying available light several hundred times.

27 W.T. Sampson, G.B. Simpson, and D.L. Green. Night vision goggles in Emergency Medical Services 

(EMS) Helicopter, FAA report DOT/FAA/RD-94/21 (1994): Federal Aviation Administration.

28 Blumen, MD, and the UCAN Safety Committee (2002): II.
Use of Technology to Assist in

EMS Flight Operations 13 Special Investigation Report

accident, the pilot was flying at night in a narrow canyon and would not have been able to 

see any outside cues about his location in relation to the terrain around him as he tried to 

reverse course to return to his departure base. If this pilot had been using NVIS, he would 

likely have been able to identify the walls of the canyon, negotiate the terrain, and avoid 

the accident. The Safety Board notes that, among other improvements to its operations, the 

EMS operator involved in the Salt Lake City accident expedited the implementation of an 

NVG program after the accident.

As shown in appendix C, for 13 of the 55 accidents, NVIS might have helped the 

pilots more clearly observe obstacles and take evasive action to avoid the accidents. The 

Safety Board concludes that if used properly, NVIS could help EMS pilots identify and 

avoid hazards during nighttime operations. The Safety Board is pleased that the FAA has 

encouraged the use of NVIS in EMS operations and hopes that this technology will be 

more widely used. Currently, the Safety Board is not recommending that NVIS be 

required for all EMS operators because NVIS are not feasible in some situations, such as 

populated areas with ambient light and numerous streetlights. The required use of NVIS 

needs to be made on an individual operator basis. However, the Safety Board will monitor 

the effectiveness of the FAA’s recommendation that operators use NVIS to determine 

whether this recommendation is sufficient to implement NVIS use on a more widespread 

basis or if a requirement is necessary.
14 Special Investigation Report

Conclusions

Findings

1. The safety of emergency medical services (EMS) operations would be improved if 

the entire EMS flight plan operated under 14 Code of Federal Regulations Part 135 

operations specifications; 35 of the 55 accidents in this special investigation occurred 

with crewmembers on board but no patients on board.

2. The minimal contribution of medical personnel to the safe operation of emergency 

medical services (EMS) flights is not sufficient to justify operating EMS positioning 

flights under the less stringent 14 Code of Federal Regulations Part 91 requirements.

3. The implementation of flight risk evaluation before each mission would enhance the 

safety of emergency medical services operations.

4. Formalized dispatch and flight-following procedures, including a dedicated 

dispatcher with aviation-specific knowledge and experience, would enhance the 

safety of emergency medical services flight operations by providing the pilot with 

consistent and critical weather information, assisting in go/no go decisions, and 

monitoring the flight’s position. 

5. The use of terrain awareness and warning systems would enhance the safety of 

emergency medical services flight operations by helping to prevent controlled flight 

into terrain accidents that occur at night or during adverse weather conditions.

6. If used properly, night vision imaging systems could help emergency medical services 

pilots identify and avoid hazards during nighttime operations. 
15 Special Investigation Report

Recommendations

To the Federal Aviation Administration:

Require all emergency medical services operators to comply with 14 Code 

of Federal Regulations Part 135 operations specifications during the 

conduct of all flights with medical personnel on board. (A-06-12)

Require all emergency medical services (EMS) operators to develop and 

implement flight risk evaluation programs that include training all 

employees involved in the operation, procedures that support the 

systematic evaluation of flight risks, and consultation with others trained in 

EMS flight operations if the risks reach a predefined level. (A-06-13)

Require emergency medical services operators to use formalized dispatch 

and flight-following procedures that include up-to-date weather 

information and assistance in flight risk assessment decisions. (A-06-14)

Require emergency medical services (EMS) operators to install terrain 

awareness and warning systems on their aircraft and to provide adequate 

training to ensure that flight crews are capable of using the systems to 

safely conduct EMS operations. (A-06-15)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER

Acting Chairman

ELLEN ENGLEMAN CONNERS

Member

DEBORAH A. P. HERSMAN

Member

KATHRYN O. HIGGINS

Member

Adopted: January 25, 2006
16 Special Investigation Report

Board Member Statement

Member Kathryn O. Higgins’ Concurring Statement

While I fully concur with all findings, conclusions and recommendations proposed 

in the Board's report, I am concerned that the report did not address a significant issue that 

impacts safety in Emergency Medical Services - the lack of good data on the EMS 

industry and on flight operations. We don't know how many operators there are, who they 

are and where they are. We don't know how many rotor and fixed wing assets are used for 

EMS flights, and how many and when flights occur. We are told that the industry has 

grown significantly over the last ten years but the rate of that growth cannot be officially 

documented. The only data that exists is gathered by the industry and they acknowledge 

that it is incomplete.

In 2003, the NTSB issued safety recommendation A-03-037 to the FAA asking 

that they require nonscheduled Part 135 operators to report activity data on an annual 

basis. This data is critical in assessing the state of aviation safety because this segment of 

aviation operations accounts for more than half of all commercial accidents each year. 

The recommendation specifically mentions collecting data for each aircraft on the 

proportion of time spent in air ambulance service. 

While A-03-037 as well as other open recommendations issued by the Safety 

Board ask the FAA to require activity reporting, the FAA has said that they will not 

mandate reporting but will conduct a survey of all nonscheduled Part 135 operators in an 

effort to obtain the desired information, and that they will specifically ask for the 

percentage of time that an aircraft is used in air ambulance service. The information on 

activity during 2005 from that survey will be available in the fall of 2006.

I am concerned that a voluntary survey will not yield the information required to 

adequately monitor and evaluate the safety record of the EMS industry. While I would 

have preferred that the Board report reiterate recommendation A-03-037, I am prepared to 

wait for the survey results. Staff has indicated that it will review the results of the 2005 

survey when it is released in the fall of 2006. Based on the results of the survey, and staff's 

analysis of those results, I reserve the right to present this issue to the Board for further 

action.

Member Hersman joined Member Higgins in this concurring statement.
17 Special Investigation Report

Appendix A

Accident Synopses

Salt Lake City, Utah

On January 10, 2003, about 2050 mountain standard time, an Agusta A-109-K2 

twin-engine helicopter, N601RX, operated by Intermountain Health Care (IHC) Health 

Services, Inc., crashed into terrain while attempting to maneuver in dense fog near Salt 

Lake City International Airport (SLC), Salt Lake City, Utah. (See figure 1) The 

instrument-rated commercial pilot and the flight paramedic were killed, the flight nurse 

was seriously injured, and the helicopter was destroyed. Night IMC prevailed for the 

14 CFR Part 91 positioning flight, which originated at LDS Hospital in Salt Lake City 

about 2032 mountain standard time and was destined for Wendover, Utah, to pick up a 

patient before the flight was aborted.

Figure 1. N601RX Wreckage Near Salt Lake City, Utah

Before the accident flight, a pilot working for another EMS helicopter operator 

located in Salt Lake City had attempted the same mission but aborted the mission because 

of deteriorating weather conditions.1 After returning to the helicopter’s departure base, he 

1 According to this EMS operator, several other flights were canceled because of extreme fog.
Appendix A 18 Special Investigation Report

learned that a pilot from IHC Health Care Services would be attempting the mission and 

radioed the IHC pilot to inform him of the deteriorating weather conditions. According to 

the pilot who aborted the mission, the IHC pilot indicated that he was going to attempt to 

“get over” the fog and complete the mission. Before attempting the mission, the IHC pilot 

checked the weather conditions via a company weather computer station and reported to 

the company dispatcher that the weather “had gotten really bad [near SLC]” but that he 

would try to fly.

After proceeding through SLC airspace, the pilot encountered increasing adverse 

weather and decided to abort the mission and return to LDS Hospital. However, the air 

traffic controller could not permit the helicopter back through SLC airspace until traffic 

arriving at SLC was cleared. The pilot stated he could hold near his position until ATC 

gave him clearance through the SLC airspace. After holding for about 10 minutes, the 

pilot declared an emergency because of an inadvertent encounter with IMC. The air traffic 

controller received no further communications from the pilot. The helicopter wreckage 

was located 1/2 mile southwest of SLC. Witnesses located near the accident site reported 

that the weather was very foggy. The Safety Board determined that the probable cause of 

this accident was the pilot’s delayed remedial action and continued flight into known 

adverse weather conditions, which resulted in his failure to maintain clearance with the 

ground. Contributing factors were the prevailing fog and the pressure to complete the 

mission induced by the pilot-in-command as a result of the emergency medical services 

operation.

Redwood Valley, California

On December 23, 2003, about 1932 Pacific standard time, an Agusta A109A, 

N25RX, operated by Mediplane, Inc., crashed into mountainous terrain near Redwood 

Valley, California, in high winds and heavy rain while en route to pick up a patient. (See 

figure 2) The instrument-rated pilot and two flight nurses were killed, and the helicopter 

was destroyed by a postimpact fire. The 14 CFR Part 91 positioning flight departed the 

Sonoma County Airport, Santa Rosa, California, about 1900 Pacific standard time and 

landed at the Ukiah Municipal Airport, Ukiah, California, about 1925, ending the 

instrument flight rules (IFR) portion of the flight. Afterward, the helicopter departed from 

Ukiah under VFR2 and was en route to a California Department of Forestry (CDF) helipad 

just south of Willits, California, to pick up a patient. 

2 Night VMC prevailed at the time of departure.
Figure 2. N25RX Wreckage Near Redwood Valley, California

Appendix A 19 Special Investigation Report

About 1930, the pilot told the CDF that the helicopter would be returning to Ukiah 

because of an inadvertent encounter with IMC. No further transmissions were received 

from the pilot. Residents and rescue personnel near the accident site stated that high winds 

and heavy rain were present at the time of the accident. Recorded data indicated that the 

pilot obtained a weather report from an aviation-specific weather reporting service before 

departing Santa Rosa.

The Safety Board determined that the probable cause of this accident was the 

pilot’s improper in-flight planning and decision to continue flight under VFR into 

deteriorating weather conditions, which resulted in an inadvertent in-flight encounter with 

IMC and a collision with rising terrain while attempting to reverse course.

Dodge City, Kansas

On February 17, 2004, about 0256 central standard time, a Beech BE-B90 twinengine airplane, N777KU, operated by Ballard Aviation, Inc., was destroyed when it 

impacted terrain about 5 nautical miles (nm) northwest of Dodge City Regional Airport 

(DDC), Dodge City, Kansas. (See figure 3) The pilot, flight nurse, and flight paramedic 

were killed. The 14 CFR Part 91 positioning flight departed Wichita Mid-Continental 

Airport (ITC), Wichita, Kansas, about 0210 and was en route to DDC. Night VMC 

prevailed. The flight was on an IFR flight plan, but the pilot cancelled the IFR flight plan 

about 37 miles east of DDC and proceeded under VFR.
Figure 3. N777KU Wreckage Near Dodge City, Kansas

Appendix A 20 Special Investigation Report

The Safety Board’s investigation revealed that the pilot had been awake for as long 

as 21 hours at the time of the accident. Additionally, the accident occurred 14.5 hours after 

his duty day began. Recorded radar data indicate that the airplane initiated a gradual, 

straight-line descent toward the airport but flew past the airport before descending into the 

ground. No communications from the airplane were made during this descent, which 

suggests that the pilot was fatigued.

The Safety Board determined that the probable cause of this accident was the 

pilot’s failure to maintain clearance with terrain due to pilot fatigue (lack of sleep).

Pyote, Texas

On March 21, 2004, about 0216 central standard time, a Bell 407 helicopter, 

N502MT, owned and operated by Med-Trans Corporation of Bismarck, North Dakota, 

crashed into terrain near Pyote, Texas, while the aircraft was maneuvering in reduced 

visibility conditions. (See figure 4) The instrument-rated commercial pilot, a flight 

paramedic, the patient, and the patient’s mother were killed, and a flight nurse was 

seriously injured. The flight was conducted under the provisions of 14 CFR Part 135. 

Night IMC prevailed throughout the area.
Figure 4. N502MT Wreckage Near Pyote, Texas

Appendix A 21 Special Investigation Report

According to company personnel, the aircraft arrived at Big Bend Regional 

Medical Center in Alpine, Texas, about 0044 to pick up the patient and passenger; they 

boarded the helicopter about 0139. The flight then departed for the University Medical 

Center in Lubbock, Texas. About 1 minute before the accident, the pilot contacted the 

dispatcher at the Medical Center Hospital and began to provide a position report when he 

stated, “hold on a [minute] dispatch.” The Safety Board’s investigation revealed that 

severe thunderstorms were moving through the area at the time of the accident and that the 

pilot had not obtained a weather briefing from the FAA flight service station. In addition, 

witnesses reported brown-out3 conditions at the time of the accident.

The Safety Board determined that the probable cause of this accident was the 

pilot’s inadvertent encounter with adverse weather, which resulted in the pilot failing to 

maintain terrain clearance. Contributing factors were the dark night conditions, the pilot’s 

inadequate preflight preparation and planning, and the pressure to complete the mission 

induced by the pilot as a result of the nature of the EMS mission.

Newberry, South Carolina

On July 13, 2004, about 0532 eastern daylight time, a Bell 407 helicopter, 

N503MT, also operated by Med-Trans Corporation, was traveling to the Spartanburg 

Regional Medical Center, Spartanburg, South Carolina, when it collided with trees shortly 

3 Brown-out conditions connote in-flight visibility restrictions due to dust or sand in the air.
Appendix A 22 Special Investigation Report

after takeoff from interstate highway 26 near Newberry, South Carolina. (See figure 5) 

The instrument-rated pilot, flight nurse, flight paramedic, and patient were killed, and the 

helicopter was destroyed by impact and postcrash fire. Night VMC (mist and light fog) 

prevailed at the time of the accident. The Safety Board’s investigation found that three 

EMS flight crews had previously turned down this mission because of weather conditions 

that were not conducive to flight. 

Figure 5. N503MT Wreckage Near Newberry, South Carolina

The flight was on a company flight plan and was receiving flight-following from 

Regional One Communications provided by Spartanburg County 911. The Med-Trans 

Spartanburg EMS operation was a VFR program only. The Bell 407 helicopter that MedTrans operated was not authorized for flight into IMC, and Med-Trans pilots were not 

required to train for flight in IMC. The accident pilot had logged about 2,133 flight hours, 

which were all in helicopters. He had flown about 104 hours in the Bell 407, including 

6.1 hours in the last 30 days. He had logged 250 hours of total night flight, including 

2.7 hours of night flight in the last 30 days. 

The Safety Board determined that the probable cause of this accident was the 

pilot’s failure to maintain terrain clearance as a result of fog conditions. A contributing 

factor was inadequate weather and dispatch information relayed to the pilot.
Appendix A 23 Special Investigation Report

Battle Mountain, Nevada

On August 21, 2004, about 2358 Pacific daylight time, a Bell 407 helicopter, 

N2YN, operated by Jeflyn Aviation, Inc., of Boise, Idaho, d.b.a. Access Air Ambulance, 

crashed into mountainous terrain during cruise flight about 27 nm southwest of Battle 

Mountain, Nevada. (See figure 6) The instrument-rated pilot, two medical crewmembers, 

a patient, and the patient’s mother were killed, and the helicopter was destroyed. Night 

VMC prevailed at the time, and the accident occurred in a sparsely populated area with 

minimal ground lights. 

Figure 6. Wreckage Near Battle Mountain, Nevada

After takeoff, the pilot reported his departure to the Lander County dispatch center 

(where the hospital was located) and stated that his estimated time en route was 1 hour 

20 minutes. No further radio communications were received from the helicopter. Radar 

data, which showed that about 4 minutes of the helicopter's flight before coverage was lost 

due to mountainous terrain, were consistent with the flight following the direct route. The 

helicopter impacted terrain about 75 feet below the top of a ridgeline at an elevation of 

about 8,600 feet along the intended course line between the departure location and the 

intended destination. Evidence indicated that the helicopter was in level flight, which is 

consistent with CFIT. Weather reports indicated clouds and light rain before and at the 

time of the accident. Although company flight-following procedures stated that an aircraft 

would be reported missing as soon as it failed to make a required 15-minute position 

report, the search for the helicopter was not initiated until about 4 hours after the accident, 
Appendix A 24 Special Investigation Report

when it had not arrived at the destination hospital. However, this accident was not 

survivable and a faster notification would not have changed the outcome.

The Safety Board determined that the probable cause of this accident was the 

pilot’s failure to maintain clearance from mountainous terrain. Contributing factors were 

the pilot’s improper decision to take the direct route over mountainous terrain, the dark 

night conditions, and the pressure to complete the mission induced by the pilot as a result 

of the nature of the EMS mission.

Rawlins, Wyoming

On January 11, 2005, about 2145 mountain standard time, a Beech E-90 twinengine airplane, N41WE, operated by Mountain Flight Service, Inc., (MFS) was destroyed 

when it impacted terrain while performing a nonprecision approach to runway 22 at the 

Rawlins Municipal Airport/Harvey Field (RWL), Rawlins, Wyoming. (See figure 7) The 

airline transport pilot and two medical crewmembers on board the airplane were killed. A 

third medical crewmember passenger sustained serious injuries. Night IMC prevailed at 

the time of the accident. The EMS flight was being conducted on an IFR flight plan under 

the provisions of 14 CFR Part 91. 

Figure 7. N41WE Wreckage Near Rawlins, Wyoming

The flight originated at Steamboat Springs, Colorado, about 2116 and was en route 

to RWL to pick up a patient for transfer to Cheyenne, Wyoming. Radar contact was lost 

about 2142. At that time, the airplane was at 9,200 feet mean sea level and midway 
Appendix A 25 Special Investigation Report

through the procedure turn inbound for the approach to runway 22. About 2140, the 

automated surface observation system at RWL reported the weather as low clouds with 

light snow and mist.

Several witnesses near the accident site reported surface weather conditions 

varying from freezing rain to heavy snow. The airplane impacted the windward side of a 

7,269-foot msl ridgeline, 2 1/2 nm from RWL in a wings-level attitude and aligned with 

runway 22. About 1 1/2 inch of clear ice was found on the leading edges of the airplane’s 

wings, the leading edge of the vertical tail, portions of the main landing gear tires and 

portions of one of the two propellers. 

The Safety Board determined that the probable cause of this accident was the 

pilot’s inadvertent flight into adverse weather [severe icing] conditions, resulting in an 

aerodynamic stall impact with rising, mountainous terrain during approach. A factor 

contributing to the accident was the pilot’s inadequate planning for the forecasted icing 

conditions.
Appendix BEMS Accidents: January 10, 2002 to January 30, 2005TOTAL:55 accidents, 21 fatal accidents (38%), 15 fatal accidents at night (27% of total accidents, 71% of fatal accidents)Injuries: F(Fatal) S(Serious) M(Minor) N(None)Mission: EMS=Patient Transport including the flight to the patient’s location and return

EMS PT=Patient on boardEMS To=Flight to pick up patientEMS Rtn=Flight returning from patient drop offPhase of Flight: TO(Take-off) C(Cruise) LDG(Landing); A/P(Airport) H(Helipad) LZ(Unimproved Landing Zone)

Helicopter

2005

Date Accident # FAR Injuries Type

Day / 

Night Mission Comments

Phase of 

Flight

< 

01/29/05 DEN05LA053 91 1N AS350B3 N EMS TO NVG, Snowstorm C 01/10/05 NYC05MA039 91 2F,1S EC135 N EMS 

RTN

Nt. Water C 

01/05/05 ATL05FA038 91 1F AS350D N EMS 

RTN

Nt. IMC TO,LZ 

2005: 3 Total, 2 Fatal 
2004 Date Accident # FAR Injuries Type Day / Night Mission Comments Phase of Flight < 

m

12/14/04 LAX05FA053 91 1F, 2S AS350B3 N EMS To LOC, Landing LDG,LZ 11/09/04 DFW05LA019 91 2M, 1N BH-206L1 N EMS RTN Bag. Door opened C 11/2/04 LAX05LA025 91 3N AS350B3 D EMS To Power loss at TO TO 10/20/04 MIA05FA008 91 3F BO-105S N EMS To Nt. IMC C 09/27/04 DEN04LA149 91 1N AS350B3 N EMS RTN LOC on t/o TO,H 08/21/04 SEA04MA167 135 5F BH-407 N EMS PT CFIT C 07/14/04 SEA04LA145 135 4N BH-222U D EMS PT Loss of rpm TO,LZ 07/13/04 CHI04MA182 135 4F BH-407 N EMS PT Wx, hit trees on t/o TO,LZ 06/26/04 LAX04LA285 91 3N AS350B3 N EMS To Hard landing LDG,LZ 05/23/04 FTW04LA133 91 3N BH-412 D EMS RTN T/r strike on t/o TO,H 04/20/04 CHI04FA107 135 1F,3S BH-206L1 N EMS PT CFIT C 03/21/04 FTW04FA097 135 4F,1S BH-407 N EMS PT CFIT C 

2004: 12 Total, 6 Fatal
2003 Date Accident # FAR Injuries Type Day / Night Mission Comments Phase of Flight < 

m

12/27/03 DEN04LA033 91 1N AS365 N-2 D EMS Rtn R strike on taxiing LDG,A/P 12/23/03 LAX04FA076 91 3F A109A N EMS To Wx, VFR into IMC C 12/20/03 NYC04CA049 91 3N BH-407 N EMS To T/r strike on ldg LDG,LZ 12/16/03 ATL04LA055 91 3M BK117A3 N EMS To VFR into IMC C 11/29/03 FTW04LA069 91 3N BK117B2 N EMS To T/r strike on ldg LDG,LZ 11/28/03 FTW04CA030 91 2M BH-206L1 N EMS To Start w/ m/r tied TO,H 11/03/03 LAX04LA035 91 4N AS350B3 D EMS PT Hyd., LOC on ldg LDG,A/P 09/20/03 CHI03LA319 135 3N BH-206L1 N EMS To Hard landing, dust LDG,LZ 09/03/03 FTW03FA211 91 2N, 1M A109E N EMS To Eng failure on t/o TO,A/P 06/20/03 NYC03LA133 91 1S, 2M BO105C D EMS To Hard ldg TO,H 06/11/03 MIA03FA120 135 1N, 3M AS355F1 D EMS PT LOC TO,H 06/07/03 DEN03FA099 91 1F,1M,1N A109K2 D EMS Rtn t/r trunnion fatigue C 03/16/03 CHI03LA084 91 1N BH-430 N EMS To T/r strike on t/r TO,LZ 03/06/04 FTW03LA104 91 3N BH-206L3 D EMS To Blanket hit t/r C 02/20/03 FTW03LA112 91 2N, 1M AS350B3 D EMS To VFR into IMC C 01/10/03 FTW03FA082 91 2F/1S A109K2 N EMS To VFR into IMC C 

2003: 16 Total, 3 Fatal 
2002 Date Accident # FAR Injuries Type Day / Night Mission Comments Phase of Flight < 

12/26/02 NYC03LA033 91 3N BK-117A4 D EMS To M/r strike on start TO,H 12/17/02 SEA03LA019 135 4N EC-135 P1 N EMS PT VFR into IMC C 11/08/02 IAD03LA015 91 1N BH-206L1 D EMS To LOC (LTE) LDG,LZ 09/09/02 CHI02FA288 135 4F BH-206L1 N EMS PT LOC, Night C 09/07/02 LAX02FA276 91 3F BH-222U N EMS To M/r separation LDG,LZ 08/31/02 MIA02FA161 91 3M, 1S S-76A+ D EMS To M/r blade strike TO,H 06/21/02 CHI02FA174 91 3F AS350B2 D EMS To Mech., LOC LDG,A/P 06/09/02 FTW02LA176 91 3N BH-206L3 N EMS To T/r strike on ldg LDG,LZ 03/21/02 LAX02FA114 91 1F, 2S AS350B D EMS Rtn CFIT, glassy water C 01/18/02 IAD02FA026 91 2F, 1S BK-117A3 N EMS To LOC, wind, hit bld TO,H 

2002: 10 Total, 5 Fatal 
Fixed Wing 2005 Date Accident # FAR Injuries Type Day / Night Mission Comments Phase of Flight < 135 min 

1/11/05 DEN05FA051 91 3F, 1S BE90 N EMS To Nt. IMC LDG,A/P Y 

2004 Date Accident # FAR Injuries Type Day / Night Mission Comments Phase of Flight < 13

mi

12/20/04 CHI05LA047 91 4N Lear 25B D EMS Rtn N gear/direct. cntrl LDG,A/P N 10/24/04 LAX05FA015 91 5F Lear 35A N EMS Rtn CFIT TO,A/P N 9/4/04 DEN04LA138 135 5N Lear 25B D EMS PT Tires blown at TO TO N 8/18/04 LAX04CA296 91 4N PC-12 N EMS To Hit an Elk on TO TO N 2/20/04 ANC04FA026 91 1S,1M,2N Lear 25B N EMS Rtn Overrun LDG,A/P N 2/17/04 CHI04FA066 91 3F BE-B90 N EMS To CFIT C N 1/31/04 LAX04FA113 91 3F C-414A N EMS To VFR into IMC C 

2004: 7 Total, 3 Fatal 2003 Date Accident # FAR Injuries Type Day / Night Mission Comments Phase of Flight < 135 min 

3/19/03 DEN03LA053 91 3M BE-90 N EMS To CFIT LDG,A/P N 
2002 Date Accident # FAR Injuries Type Day / Night Mission Comments Phase of Flight < 1

m

12/18/02 ANC03LA019 91 4N SA-226T N EMS To Struck Terrain LDG N 8/30/02 NYC02FA177 135 1F,4S,1M Lear 25C D EMS PT Overrun LDG,A/P N 6/27/02 CHI02LA173 91 4N BE-90 N EMS To Struck deer LDG,A/P N 

2002: 3 Total, 1 Fatal Date Accident # FAR Injuries Type Day / Night Mission Comments Phase of Flight < 135 min 

2/16/03 LAX03LA088 135 5N C-421C N EMS PT Truck Collision Taxiing N 1/30/03 ANC03LA030 135 5N C-208B N EMS To Pax Loading TO,A/P N 

2003: 3 Total, 0 Fatal 
32 Special Investigation Report

Appendix C

Table of Potentially Preventable EMS Accidents and Safety 

Issues Discussed in This Report

The following table identifies 29 of the 55 EMS accidents examined during the 

Safety Board’s special investigation that the Board believes could have been prevented if 

the corrective actions recommended in this report had been implemented.

Accident 

Number

Compliance

with Part 135 

Aviation 

Dispatcher 

Flight Risk 

Evaluation 

TAWS NVIS 

1. DEN05FA051 9

2. DEN05LA053 9 9 9 99

3. NYC05MA039 9

4. ATL05FA038 999

5. MIA05FA008 9 99

6. DEN04LA149 9

7. SEA04MA167 9 9

8. CHI04MA182 999 9

9. LAX04LA285 9

10. CHI04FA107 9 9

11. FTW04FA097 9 99

12. LAX04FA076 9 9 99

13. NYC04CA049 9

14. ATL04LA055 9 9 99

15. FTW04LA069 9

16. CHI03LA319 9

17. CHI03LA084 9

18. FTW03LA112 9 9 99

19. FTW03FA082 9 9 99

20. SEA03LA019 9 9 99

21. CHI02FA288 9 9 9 99

22. LAX02FA276 9

23. MIA02FA161 9

24. FTW02LA176 9 9

25. LAX02FA114 9

26. LAX05FA015 9

27. CHI04FA066 9

28. LAX04FA113 9 99

29. DEN03LA053 9

4

4 Safety Board investigators analyzed the cause and contributing factors of each of the accidents in 

appendix B and determined which accidents may have been prevented had this report’s recommendations 

been implemented and adhered to at the time of the accident. Accidents not appearing in this table likely 

could not have been prevented through the recommendations contained in this report.
33 Special Investigation Report

Appendix D

FAA Notice N8000.293: Helicopter Emergency Medical Services 

Operations

NOTICE U.S. DEPARTMENT OF TRANSPORTATION

FEDERAL AVIATION ADMINISTRATION N 8000.293

1/28/05

Cancellation

Date: 1/28/06

SUBJ: HELICOPTER EMERGENCY MEDICAL SERVICES OPERATIONS

1. PURPOSE. This notice, which was developed in close coordination with the Helicopter

Emergency medical Services (HEMS) industry, provides guidance for principal inspectors (PI) in

all specialties regarding HEMS operators for whom they have oversight responsibilities. This 

notice also contains information which PIs can provide to HEMS operators for a review of pilot 

and mechanic decisionmaking skills, procedural adherence, and crew resource management

(CRM).

2. DISTRIBUTION. Hard copy of this notice is distributed to the division level in the Flight 

Standards Service in Washington headquarters; to the branch level in the regional Flight

Standards divisions; to the Flight Standards District Offices, and to the Regulatory Standards 

Division at the Mike Monroney Aeronautical Center. This notice is also distributed electronically 

to the division level in the Flight Standards Service in Washington headquarters and to all 

regional Flight Standards divisions and district offices. This information is available to the

public at no charge at the Federal Aviation Administration’s (FAA) Web site at:

.

3. BACKGROUND. 

a. Introduction. The HEMS role is a very demanding and time critical-/mission-orientated

operation. One consistent priority that must be addressed by each individual EMS organization

is the safety of their flightcrew, medical staff, and passengers. The safety of these persons must

be a priority. Preventing accidents is the responsibility of everyone involved in HEMS 

operations. Reducing accidents takes the dedicated involvement of all the aviation and medical

professionals involved. 

b. Soft Skills. “Soft skills” often refers to proficiencies that go beyond technical knowledge

and psychomotor skills necessary to operate a helicopter. Soft skills are often the first line of

defense – and sometimes the last – against accidents caused by lapses in human performance.

Soft skills include adherence to standard operating procedures, decisionmaking, judgment, air 

medical resource management (AMRM) (similar to CRM), and professionalism. These skills are 

not easily or quickly conveyed in training programs but are developed through the continuing 

commitment of corporate managers, trainers, pilots, mechanics, and medical staff.

Distribution: A-W(FS)-2; A-X(FS)-3; A-FFS-7 (LTD); AMA-200 (80 cys) Initiated By: AFS-200

(Electronically: A-W(FS)-2; A-X(FS)-2; A-FFS-7)
N 8000.293 1/28/05

c. Preliminary Review. A preliminary review of the commercial HEMS accidents from 

January 1998 through December 2004 reveals that CONTROLLED FLIGHT INTO TERRAIN 

(CFIT), NIGHT OPERATIONS, AND INADVERTENT FLIGHT INTO INSTRUMENT 

METEOROLOGICAL CONDITIONS (IMC) are predominant factors. Of the 27 fatal HEMS 

accidents, 21 occurred during night operations. Of the 21 night accidents, 16 of the operations 

originated under visual flight rules (VFR) and inadvertently flew into IMC conditions resulting 

in CFIT. In addition, approximately 13 accidents during this timeframe were attributed to 

maintenance. See the table below. 

Total Number of HEMS Accidents (‘98-‘04) 85

Fatal HEMS Accidents (all) 27

Day Operations 06

Night Operations 21

In 16 of the 27 fatal accidents, VFR into IMC and CFIT are listed as contributing factors by the 

NTSB. 

This data derived from NTSB accident investigation reports and does not include accidents from 

the public sector. 

d. Course of Action. The FAA plans to continue surveillance and inspection oversight. In 

cooperation with air medical industry the FAA will help develop strategies, such as risk 

management tools and system safety approaches, to reduce the number of accidents. Operators 

can make an immediate difference by reviewing their human performance issues, and 

aggressively implementing measures to enhance human performance in air medical operations. 

Those measures begin with a strong corporate safety culture that carries through to flight 

operations and training. There must be an unwavering commitment of every individual 

involved.

4. INTERVENTION STRATEGIES. 

a. FAA Actions. Because of rapid growth of the HEMS industry in recent years and an 

unacceptable rise in the number of accidents, more emphasis and cooperation between the FAA 

and the HEMS industry is required. 

(1) Certificate Holding District Offices (CHDO) will meet with their assigned HEMS 

operators to determine the location of all operating bases and geographic areas of operations.

Principals will review and update Vital Information Subsystem (VIS) environmentals as 

required.

(2) If a CHDO determines that its HEMS operator has operating bases and/or 

geographical areas of operations outside its boundaries, the CHDO will notify other affected 

CHDOs of the operator’s name (to include dba), location(s) of base(s), geographical areas of 

operation, and points of contact. The CHDO should also determine if the other affected CHDOs 

have assigned geographic inspectors to the HEMS operator and determine who these inspectors 

are. These actions will be completed prior to March 18, 2005. 

Page 2 Par 3 

Appendix D 34 Special Investigation Report
1/28/05 N 8000.293

(3) Determine, with the HEMS operator, if its operations specifications are consistent 

with Order 8400.10, Air Transportation Operations Inspector’s Handbook, volume 4, chapter 5, 

paragraphs 1335, 1337,1339, and 1343.

b. Operator Initiatives. These are voluntary initiatives which PIs shall encourage HEMS

operators to undertake to help in mitigating accident risk factors. (FAA resources are listed

below. There may be industry organizations that have similar resources available to operators.) 

(1) Determine if pilot training includes inadvertent IMC and night cross-country for their 

specific area of operation (i.e., mountainous or flat areas). Operators are encouraged to develop

action plans to deal with inadvertent IMC for their local flying areas.

(2) Review FAA-H-8083-21, Rotorcraft Flying Handbook, Chapter 14, Aeronautical

Decision Making, to see if your policies, procedures, and training programs reflect the principles 

in the handbook. The handbook is available at the following Web site:

.

(3) Emphasize a safety culture within your HEMS organization that applies basic system

safety attributes and risk management techniques to your operation. Apply safety attributes or 

risk management/assessment strategies to each flight. Information on System Safety and Risk 

Management can be found at the FAA Office of System Safety Web site:

(4) Consider incorporation of realistic night flight training such as Line Oriented Flight 

Training (LOFT), provide operating experience for new crewmembers, and consider conducting 

line checks under operating conditions.

(5) Emphasize the use of a radar altimeter for night operations. 

(6) Consider using enhanced vision systems and a Terrain Awareness Warning System 

(TAWS) for night operations when conditions and mission dictate. 

(7) Consider the incorporation of an FAA-approved night vision goggle or enhanced 

vision system into your flight program. HBAT-04-02, TSO C-164 and AC29-2C Chapter 3 

Miscellaneous Guidance.

(8) Consider a review of weather minimums particularly at night for each operational

area, focusing on minimums specific to the terrain of the intended operational area. If necessary,

increase weather minimums to enhance safety. 

(9) Ensure pilots are aware of the importance of receiving a current weather briefing at 

the time of mission launch.

(10) Consider using an operations risk assessment tool to include dual decisionmaking

for authorization to accept or continue a flight assignment (i.e., two or more persons’ permission

required).

Par 4 Page 3 

Appendix D 35 Special Investigation Report
N 8000.293 1/28/05

(11) Determine that operational control (flight locating) procedures are current and 

applicable for each base of operation (see Title 14 of the Code of Federal Regulations (14 CFR) 

part 135, sections 135.23(l) and 135.79). 

(12) Make pilot compartment, to the extent possible, free of glare and reflections. 

Ambient light may have been a factor in some of the night accidents (see 14 CFR part 27, 

sections 27.773 and 29.773). 

(13) Operators should review pilot and mechanic shift schedules and fatigue 

management programs. 

5. ACTION. Principal inspectors assigned to HEMS operators should review the contents of 

this notice, take the FAA actions specified in paragraph 4, and provide a copy of this notice to 

their assigned operators. Principal inspectors should encourage the operators to distribute this 

notice to each of the operator’s bases.

6. TRACKING. Document the conveyance of the information contained in this notice for each 

HEMS operator: 

a. Use Program Tracking and Reporting Subsystem (PTRS) codes 1030, 3030, 5030, 

Convey Non-Reg. Info. 

b. Enter “N8000293” in the “National Use” field (without the quotes). 

c. Once the initial notification is completed close out the PTRS. 

7. DISPOSITION. Because a number of considerations in this notice may require regulatory 

change, this notice will not be incorporated into Order 8400.10. Questions concerning this 

notice should be directed to the Air Carrier Operations Branch, AFS-220, at (202) 267-9518.

/s/ James J. Ballough 

Director, Flight Standards Service 

Page 4 Par 4 

Appendix D 36 Special Investigation Report
37 Special Investigation Report

Appendix E

FAA Notice N8000.301: Operational Risk Assessment Programs 

for Helicopter Emergency Medical Services

NOTICE U.S. DEPARTMENT OF TRANSPORTATION 

FEDERAL AVIATION ADMINISTRATION N 8000.301 

8/1/05

Cancellation

Date: 8/1/06 

SUBJ: OPERATIONAL RISK ASSESSMENT PROGRAMS FOR HELICOPTER 

EMERGENCY MEDICAL SERVICES 

1. PURPOSE. This notice was developed with the helicopter emergency medical services 

(HEMS) community to provide for principal inspectors (PI) in all specialties guidance related to 

risk assessment programs used by HEMS operators. This notice also contains information for 

PIs to provide to HEMS operators for developing their risk assessment program. 

NOTE: This notice identifies possible risk factors and the dangers those 

risks pose to both flightcrew and patient; for this reason, all aircraft 

operators involved in air medical flight should actively promote the use of 

risk assessment models. 

2. DISTRIBUTION. This notice is distributed to the division level in the Flight Standards 

Service in Washington headquarters; to the branch level in the regional Flight Standards 

divisions; to the Flight Standards District Offices, and to the Regulatory Standards Division at 

the Mike Monroney Aeronautical Center. This notice is also distributed electronically to the 

division level in the Flight Standards Service in Washington headquarters and to all regional 

Flight Standards divisions and district offices. This information is also available on the Federal 

Aviation Administration’s (FAA) Web site at: 

http://www.faa.gov/library/manuals/examiners_inspectors/8000/media/n8000-301.doc.

NOTE: For budgetary reasons, the examples in the appendixes are 

printed in black and white. To view them in color, go to the above 

Web address. 

3. BACKGROUND. 

a. Introduction. HEMS operate in a demanding environment. They provide an invaluable 

service to the nation by providing crucial, safe, and efficient transportation of critically ill and 

injured patients to tertiary medical care facilities. While the contribution of HEMS is profound 

as a component of the nation’s medical infrastructure, from an operational standpoint, it is a 

commercial aviation activity performed by air carrier operators. It therefore must be conducted 

with the highest level of safety. To meet this requirement, risks must be identified, assessed, and 

managed to ensure that they are mitigated, deferred, or accepted according to the operator’s 

ability to do so within the regulations and standards appropriate to the operation.

Distribution: A-W(FS)-2; A-X(FS)-3; A-FFS-7 (LTD); AMA-200 (80 cys) Initiated By: AFS-820 

(Electronically: A-W(FS)-2; A-X(FS)-2; A-FFS-7) 
N 8000.301 8/1/05

b. Regulatory Requirements.

(1) Title 14 of the Code of Federal Regulations (14 CFR) part 135 operators are required 

to have management personnel identified per 14 CFR part 119, § 119.69. This section states, in 

pertinent part (emphasis added):

(a) Each certificate holder must have sufficient qualified management and technical 

personnel to ensure the safety of its operations. Except for a certificate holder using 

only one pilot in its operations, the certificate holder must have qualified personnel 

serving in the following or equivalent positions: 

(1) Director of Operations. 

(2) Chief Pilot. 

(3) Director of Maintenance. 

............................................................ 

(d) The individuals who serve in the positions required or approved under paragraph 

(a) or (b) of this section and anyone in a position to exercise control over operations 

conducted under the operating certificate must— 

(1) Be qualified through training, experience, and expertise; 

(2) To the extent of their responsibilities, have a full understanding of the 

following material with respect to the certificate holder’s operation— 

(i) Aviation safety standards and safe operating practices; 

(ii) 14 CFR Chapter I (Federal Aviation Regulations); 

(iii) The certificate holder’s operations specifications; 

(iv) All appropriate maintenance and airworthiness requirements of this 

chapter (e.g., parts 1, 21, 23, 25, 43, 45, 47, 65, 91, and 135 of this chapter); and 

(v) The manual required by § 135.21 of this chapter; and 

(3) Discharge their duties to meet applicable legal requirements and to 

maintain safe operations. 

(2) HEMS operators, which are certificated under part 135, must have adequate 

management personnel in place. These personnel, within the extent of their responsibilities, 

must have a full understanding of safe aviation operating practices. They must discharge their 

duties to meet applicable legal requirements and to maintain safe operations throughout their 

organization and locations. The use of a risk assessment and risk management program provides 

a way to ensure that these management responsibilities are met. The company’s operating 

procedures should incorporate the program’s principles throughout the flight, as portions of the 

flight may be conducted under 14 CFR part 91 (general operating rules) or part 135 (EMS 

passenger-carrying operations). 

c. Review of Recent Accident Data.

(1) A preliminary review of the commercial HEMS accidents from January 1998 through 

December 2004 revealed that CONTROLLED FLIGHT INTO TERRAIN (CFIT), 

INADVERTENT FLIGHT INTO INSTRUMENT METEOROLOGICAL CONDITIONS 

(IMC), AND LACK OF OPERATIONAL CONTROL are predominant factors, particularly at 

night and during low visibility conditions. Of the 27 fatal HEMS accidents, 21 occurred during 

night operations. Of the 21 night accidents, 16 of the operations originated under visual flight 

rules (VFR); the pilots inadvertently flew into IMC conditions, resulting in a CFIT accident.

Page 2 Par 3

Appendix E 38 Special Investigation Report
8/1/05 N 8000.301

(2) This preliminary review revealed that inadequate risk assessment and management 

deficiencies may have contributed to many recent fatal accidents in HEMS operations. Notice 

N 8000.293, Helicopter Emergency Medical Services Operations, provides a recommendation 

that HEMS operators emphasize a safety culture within their organization by applying basic 

system safety attributes and risk management techniques to operations. Operators were also 

advised to apply safety attributes or risk assessment/management strategies to each flight. As a 

reference, operators and inspectors could access information on system safety and risk 

management from http://www.asy.faa.gov/Risk/.

d. Basic Concepts Used in a System Safety Risk Management/Assessment Program.

System Safety Risk Management techniques optimize safety by identifying operational hazards 

and related risk, and eliminating or mitigating them to a safe state by using established policies 

and procedures. The company procedures manual should contain clearly defined procedures for 

maintaining operational control during all phases of aircraft operations, and those procedures 

should contain processes or procedures for risk assessment and management. The pilot has the 

ultimate responsibility and authority to determine the risks associated with a flight operation. 

However, the method of operational control should promote his/her use, as a resource, the input 

of the mechanics, communications specialists (individuals who function as a dispatcher/flight 

follower), both ground and flight medical personnel, managers, and all other related support 

personnel involved with a flight operation.

(1) Concepts. The basic concepts of risk management include: 

(a) The overriding concept is that the pilot’s authority to decline a flight assignment 

is supreme, while his/her decision to accept a flight assignment is subject to review, if certain 

risks are identified. 

1 The pilot’s decision to decline, cancel, divert, or terminate a flight overrides 

any decision of other parties to accept or continue a flight. 

2 The pilot’s decision to accept a flight assignment may be overridden by other 

personnel by use of the operational control procedures and policies of the certificate holder, 

including the use of risk assessment and management tools and techniques. 

(b) If the pilot has declined a flight assignment, NO other parties (e.g., management, 

operations, etc.) shall continue to conduct risk assessments pertaining to that flight as their input 

could not be used to override the pilot’s decision to decline the assignment. 

(c) A risk-assessment plan is a tool used by the flight management personnel and 

flightcrews to expand the parameters of decisionmaking for the pilot and flightcrew, and to assist 

in preflight planning and operational control of the aircraft. The company should have 

procedures on how to mitigate or reduce the risk to an acceptable level. 

Par 3 Page 3

Appendix E 39 Special Investigation Report
N 8000.301 8/1/05

(d) If the pilot’s initial risk assessment results in a tentative decision to accept the 

flight, but significant risks have been identified, then per the company’s integrated risk 

assessment plan, additional operational inputs are used. 

(e) As potential hazards are identified in the assessment process, a collaborative 

group of additional persons who have the experience/knowledge to assist the flightcrew in safety 

determinations are brought into the decisionmaking process. Such collaboration should never 

result in the questioning or overruling of the pilot’s determination that the risks associated with a 

flight mission or operation are too numerous or high. 

(2) Examples. Examples of risk assessment and risk management could include: 

(a) A flightcrew is aware of a maintenance discrepancy that has been repaired, or a 

component that has been overhauled. The flightcrew may be concerned with what to watch for 

on subsequent flights, i.e., higher temperatures or higher pressures (providing the instrument 

readings are within the required operating range), and seek input from maintenance 

professionals.

(b) A VFR-only pilot accepts a flight assignment in marginal VFR conditions, and 

following the company’s risk management plan receives subsequent input on the status of nearby 

airports/heliports. The pilot then uses the information to support his/her decision: to fly the 

planned flight, cancel the flight, delay the flight until weather improves, or determine that an IFR 

(instrument flight rules) certificated aircraft and flightcrew is required. In any case, the 

information is used to support the pilot’s decisionmaking process. 

(3) Variables. In the above examples, as more information is attained to assist the 

flightcrew with the go/no-go decisionmaking process, another iteration or cycle in the risk 

assessment process is begun and the determination to fly is reviewed against a new, betterdefined, standard/environment. Typical risk variables include, but are not limited to: 

(a) Weather (Current and Forecast). 

x Ceiling, visibilitiesdeparture, en route, arrival, alternate 

x Precipitationtype(s) 

x Turbulenceexisting and forecast 

x Icingtype and forecast 

x Winds/gust spreadwind direction, speed, gust spread 

x Density altitude 

x Ambient lighting 

(b) Airworthiness Status of the Helicopter.

x Proper preflight 

x Any deferred items in accordance with the Minimum Equipment List (MEL) 

x Fuel and oil serviced 

x Security of cowling(s), doors and/or equipment 

Page 4 Par 3

Appendix E 40 Special Investigation Report
8/1/05 N 8000.301

x VFR vs. IFR equipment capabilities 

x Inspection status 

x Recent maintenance actions 

x Time remaining until next inspection, overhaul, teardown, etc. 

x Required current maps, approach plates, NOTAMs 

(c) Incorporation of Technologies to Aid in Managing Risks.

x Radio/radar altimeters 

x High intensity search/landing light systems 

x Global positioning system (GPS) moving map systems 

x Airborne weather radar systems 

x Night vision goggles 

x Enhanced vision systems 

x Autopilot/stability augmentation systems 

x Terrain Avoidance Warning System (TAWS) 

x Adequacy of training on new technologies 

(d) Performance Margins. 

x Weight/center of gravity margins 

x High density altitudes 

x Fuel margins and range limitations 

(e) Pilot and Flight Crewmember Performance.

x Experience in make and model of helicopter, area of operations, and type of 

operation

x Rest, duty, and flight time impacts on human performance (additional duties 

during duty time and adequate sleep during rest period time) 

x Personal performance factors, such as personal stress (recent divorce, death, 

illness, or birth in family) 

x Influence of pilot’s knowledge of the patient’s status (pediatric, critical injury) 

x Communication between crew and all pertinent specialists 

x Continuity during shift changes 

x Currency of training 

x Inadvertent IMC training 

x Crew resource management 

x Experience of crewmembers operating together as a unit 

(f) Operating Environment. 

x Terrain/obstructions

x Ambient lighting 

x Natural and industrial weather factors 

x Availability and status of airports/heliports 

Par 3 Page 5

Appendix E 41 Special Investigation Report
N 8000.301 8/1/05

x Air traffic density 

x Knowledge that other operators in the area have declined the flight due to 

x Localized weather 

x Forecast weather 

x Recent flight(s) experiencing marginal conditions 

x Airspace requirements 

x Communications and navigation facilities 

x Availability of low-level VFR route structure 

(g) Organizational Environment. 

x Changes in required management personnel 

x Changes in air carrier management 

x Rapid expansion or growth 

x New or major program changes 

x Merger or takeover 

x Labor management relations 

x Organization accidents, incidents, or occurrences 

4. RISK ASSESSMENT PROGRAM CONFIGURATIONS. 

NOTE: Appendixes 1, 2, and 3 contain examples of risk assessment tools 

that are currently used in the HEMS operational community. There is no 

“one size fits all” tool. Each operator should consider its own operational 

and environmental needs in developing its risk assessment tool(s) and plans. 

In addition, these unique operational and environmental needs will drive the 

relative weight of each identified risk for each operation and/or location.

The operator must determine the specific weighting of risks for its particular 

operation. The examples given are for reference only; the FAA does not 

endorse the use of one tool over another. Each of the following risk 

assessment configurations is useful; however, an integrated program 

providing enhanced training in aeronautical decisionmaking, combining 

procedure-weighted, training-weighted, and other programs, may achieve 

the best results. 

a. Procedure-weighted Program. To standardize risk assessment while minimizing 

training requirements, an operator may opt to develop and implement a “procedure-weighted” 

program configuration. This configuration typically uses a checklist format tool, often with 

numerical weighting values, which trigger levels of concurrence with the pilot’s “go” decision. 

Appendix 1 includes examples of representative procedure-weighted tools.

(1) Advantages of the Procedure-weighted Configuration Include: 

(a) Minimal training is required on the principles of risk assessment and risk 

management. 

Page 6 Par 3

Appendix E 42 Special Investigation Report
8/1/05 N 8000.301

(b) Standardized assessment of risks and mitigations, especially when using a system 

that is numerically based. 

(2) Disadvantages of the Procedure-weighted Configuration Include: 

(a) Takes more time and effort to complete the assessment, and may delay departure. 

(b) May not provide visual cues to the level of risk and, therefore, may not be as 

obvious to all users. 

(c) A checklist does not address the continuing risk assessment skills necessary 

during the entire flight. Risk assessment is an ongoing process; during a single flight, multiple 

risks are monitored on different levels. 

b. Training-weighted Program. To minimize the time spent upon receiving a flight 

assignment, an operator may opt to “front load” its efforts in risk assessment and risk 

management by providing a higher level of training on the principles of risk assessment and 

developing a highly integrated risk management program. In doing so, it may be able to achieve 

an effective risk assessment and risk management program by using fairly simple (and often 

graphically based) decision tools. Appendix 2 includes representative examples of trainingweighted tools.

(1) Advantages of the Training-weighted Configuration:

(a) In practical use, minimal time is required to make the series of decisions 

necessary to assess and manage risks.

(b) The use of graphical tools provides a visual, immediately understood description 

of the risk and the required mitigations. 

(2) Disadvantages of the Training-weighted Configuration: 

(a) May require more demanding training at the initiation of the process and in 

subsequent recurrent training.

(b) May require a stronger set of “soft skills” by users of the process. 

NOTE: “Soft skills” refers to proficiencies that go beyond technical 

knowledge and psychomotor skills necessary to operate a helicopter and are 

often the first line of defenseand sometimes the lastagainst accidents 

caused by lapses in human performance. This includes adherence to 

standard operating procedures, decisionmaking, judgment, air medical 

resource management (known as AMRM; similar to crew resource 

management), and professionalism. These skills are not easily or quickly 

conveyed in training programs but are developed through the continuing 

commitment of corporate owners/executives, managers, trainers, pilots, 

Par 4 Page 7

Appendix E 43 Special Investigation Report
N 8000.301 8/1/05

crewmembers, mechanics, medical staff, and communication specialists to an 

organizational safety culture. 

c. Alternative Risk Intervention Policy. Some operators integrate “releasing authority” 

after a nonroutine event. Experience has shown that the community tends to hire “mission 

oriented” individuals who will seek ways around an obstacle to complete the mission. It may be 

beneficial to intentionally slow the go/no-go decisionmaking process, particularly at the first 

indication that an abnormal situation might be developing. Appendix 3 includes an example of 

an alternative risk management tool. 

5. ACTION. PIs assigned to HEMS operators should review the content of this notice and 

provide a copy of this notice to their assigned operators. PIs should encourage the operators to 

distribute this notice to each of the operator’s bases and sub-bases. Operators should be strongly 

encouraged to implement a risk assessment and management program, which may incorporate 

this notice as a component of the program, or otherwise identify their management processes and 

operational controls that ensure that safe operating practices are applied in flight operations and 

to maintain safe operations. 

6. TRACKING. Document the conveyance of the information contained in this notice for each 

HEMS operator: 

a. Use Program Tracking and Reporting Subsystem (PTRS) codes 1030, 3030, or 5030, as 

applicable. 

b. Enter “N8000301” in the “National Use” field (without the quotes). 

c. After the review of the certificate holder’s procedures is complete, close out the PTRS. 

7. DISPOSITION. This notice will NOT be incorporated into Order 8400.10, Air 

Transportation Operations Inspector’s Handbook, nor into Order 8700.1, General Aviation 

Operations Inspector’s Handbook. Questions concerning this notice should be directed to the Air 

Carrier Operations Branch, AFS-220, at (202) 267-9518, or the Operations and FAA Safety 

Team Support Branch, AFS-820, at (202) 267-8212. 

/s/ James J. Ballough 

Director, Flight Standards Service 

Page 8 Par 4

Appendix E 44 Special Investigation Report
8/1/05 N 8000.301

 Appendix 1

APPENDIX 1. EXAMPLES OF PROCEDURE-WEIGHTED RISK ASSESSMENT 

AND MANAGEMENT PROCESSES

EXAMPLE 1. GO/NO-GO DECISION MATRIX

STATIC RISK FACTORS SCORE

< 6 mos. on Current Job +1

< 1 yr. in EMS +1

< 200 hrs. in Type +1

> 500 hrs. in Type -1

Last Flight > 30 Days +1

Last Night Flight > 30 Days (night requests only) +1

6 mos. Since Check Ride +2

Cockpit Not Configured for Inadvertent IMC +1

Navigation or Radio Item on MEL +1

Back-up Aircraft +1

Newly-installed Equipment (i.e., satellite phone, avionics, GPS) +1

Night Vision Goggles (NVG) Equipped -1

< 3 NVG Flights in the Last 120 Days +1

Medical Crew < 1 yrs. Experience (both crewmembers) +1

IFR Program -4

VFR Program +1

External Stresses (divorce, illness, family/work issues/conflicts) +1

Total Static Score

DYNAMIC RISK FACTORS

Ceiling within 200' of Program Minimums +1

Visibility within 1 Mile of GOM Minimums +1

Precipitation with Convective Activity +1

Convective Activity with Frontal Passage +1

Deteriorating Weather Trend +1

High Wind or Gust Spread Defined by Operations Manual +2

Moderate Turbulence +2

Temperature/Dew Point < 3 Degrees F +1

Forecast Fog, Snow, or Ice +2 

Weather Reporting at Destination -1

Mountainous or Hostile Terrain +1

Class B or C Airspace +1

Ground Reference Low +1

Ground Reference High -1

Night Flight +1

90% of Usable Fuel Required (not including reserve) +1

Flight Turned Down by Other Operators Due to Weather (if known) +4

Control Measures 

Delay Flight -1

Avoid Mountainous/Hostile Terrain -1

Utilize Pre-Designated LZs for Scene Requests -1

Plan Alternate Fuel Stop -1 

Familiarization Training (self-directed) -1

Total Dynamic Score

Page 1

Appendix E 45 Special Investigation Report
N 8000.301 8/1/05

Appendix 1 

APPENDIX 1. EXAMPLES OF PROCEDURE-WEIGHTED RISK ASSESSMENT 

AND MANAGEMENT PROCESSES (Continued) 

EXAMPLE 1. GO/NO-GO DECISION MATRIX (Continued) 

Grand Total of Static and Dynamic Scores

RISK CATEGORY COLOR 

CATEGORY 

EOC ACTION TOTAL

POINTS

NORMAL GREEN Pilot Approval 0  14

FLIGHT MANAGER 

LEVEL

YELLOW Call Manager 15  18

UNACCEPTABLE RED Cancel Flight 19 or 

Greater

NOTE: This example is for reference only. Each operator should consider 

its own operational and environmental needs in developing its risk 

assessment tool(s) and plans.

Page 2 

Appendix E 46 Special Investigation Report
8/1/05 N 8000.301

 Appendix 1

APPENDIX 1. EXAMPLES OF PROCEDURE-WEIGHTED RISK ASSESSMENT 

AND MANAGEMENT PROCESSES (Continued) 

EXAMPLE 2. ASSESSMENT CHART 

1. EXPERIENCE

Less than 2 years

23 years

45 years

+10

 +5 

 +2

2. WEATHER

Less than 3,000' – 5 sm

(Anywhere on the route)

+5

3. NIGHT

(During any portion of the flight)

+5

4. NON-LOCAL 

(Applies to all flights out of defined local 

flying area)

Not local

New location

+4

+3

5. EARLY MORNING 

Flight between 2 a.m. and 5 a.m.

(If any portion of the flight to fall 

in this time window)

+1

TOTAL

Considerations

1) Have you been to this destination 

before? How recently? 

2) What are the weather conditions? 

How confident are you of the 

weather along the entire route? 

3) Is all or any part of this mission 

going to occur at night? If so, will 

you have some moonlight? 

4) Have you thought through the 

entire mission? That is, can you 

return as easily as you can get 

there? 

5) Are there any problems with the 

aircraft that may be a factor for this 

mission? 

6) How many consecutive shifts have 

you worked prior to this mission? 

How much flying have you done 

during those shifts? 

7) Do you feel fully rested and 

capable to accept this mission? 

8) Do you have any reservations at all 

with accepting this mission? 

 A TOTAL of 20 or higher requires greater operational control.

NOTE: This example is for reference only. Each operator should consider 

its own operational and environmental needs in developing its risk 

assessment tool(s) and plans.

Page 3 (and 4)

Appendix E 47 Special Investigation Report
8/1/05 N 8000.301

 Appendix 2

APPENDIX 2. EXAMPLES OF TRAINING-WEIGHTED RISK ASSESSMENT 

AND MANAGEMENT PROCESSES

EXAMPLE 1. RISK ASSESSMENT MATRIX

RISK ASSESSMENT MATRIX 

Severity 

Likelihood Negligible Marginal Critical Catastrophic

Frequent 

Probable 

Occasional 

Remote 

Improbable 

Severity Scale Definitions 

Catastrophic Results in fatalities and/or loss of the system. 

Critical Results in severe injury and/or major system damage. 

Marginal Results in minor injury and/or minor system damage. 

Results in less than minor injury and/or less than minor system 

damage. 

Negligible

Likelihood Scale Definitions 

Frequent Individual Likely to occur often. 

Fleet Continuously experienced. 

Probable Individual Will occur several times. 

Fleet Will occur often. 

Occasional Individual Likely to occur sometime. 

Fleet Will occur several times. 

Remote Individual Unlikely to occur, but possible. 

Fleet Unlikely, but can reasonably be expected to occur. 

Improbable Individual So unlikely, it can be assumed it will not occur. 

Fleet Unlikely to occur, but possible. 

Page 1

Appendix E 48 Special Investigation Report
N 8000.301 8/1/05

Appendix 2 

APPENDIX 2. EXAMPLES OF TRAINING-WEIGHTED RISK ASSESSMENT 

AND MANAGEMENT PROCESSES (Continued)

EXAMPLE 2A. RISK ASSESSMENT MATRIX: NIGHT OPERATIONS 

RISK ASSESSMENT MATRIX: NIGHT OPERATIONS 

Use this tool to assess the potential for links in the safety chain. 

Applicable Weather for Flight 

Apply Operational 

Factors

WEATHER Well 

Above Minimums 

and Stable 

CEILING 

Within 1000'

of Minimums 

VISIBILITY

Within 3 mi. 

of Minimums 

CEILING & VIS 

Within 3 mi. and 

500' of Mins. 

NIGHT

Normal ops 

AIRCRAFT 

Performance near max 

Back-up or different A/C 

MEL items

ENVIRONMENTAL

Extreme heat or cold 

High winds 

Storms in area

FATIGUE

Late in shift? 

Consecutive shifts? 

Risk Assessment Value: 

Normal Ops

Caution

Extreme Caution

Critical Safety Decision Required

NOTE: The operator will have to next determine how to manage the 

identified risk by either transferring, eliminating, accepting, or introducing a 

mitigating action. The operator may assign different values based on its 

operating environment. 

 Page 2 

Appendix E 49 Special Investigation Report
8/1/05 N 8000.301

 Appendix 2

APPENDIX 2. EXAMPLES OF TRAINING-WEIGHTED RISK ASSESSMENT 

AND MANAGEMENT PROCESSES (Continued)

EXAMPLE 2B. RISK ASSESSMENT MATRIX: DAY OPERATIONS 

RISK ASSESSMENT MATRIX: DAY OPERATIONS 

Use this tool to assess the potential for links in the safety chain.

Applicable Weather for Flight 

Apply Operational 

Factors

WEATHER Well 

Above Minimums 

and Stable 

CEILING 

Within 1000'

of Minimums 

VISIBILITY

Within 3 mi. 

of Minimums 

CEILING & VIS 

Within 3 mi. and 

500' of Mins. 

DAY

Normal ops 

AIRCRAFT 

Performance near max 

Back-up or different A/C 

MEL items

ENVIRONMENTAL

Extreme heat or cold 

High winds 

Storms in area

FATIGUE

Late in shift? 

Consecutive shifts? 

Risk Assessment Value: 

Normal Ops

Caution

Extreme Caution

Critical Safety Decision Required

NOTE: The operator will have to next determine how to manage the 

identified risk by either transferring, eliminating, accepting, or introducing a 

mitigating action. The operator may assign different values based on its 

operating environment. 

Page 3

Appendix E 50 Special Investigation Report
Page 4 

APPENDIX 2. EXAMPLES OF TRAINING-WEIGHTED RISK ASSESSMENT AND MANAGEMENT PROCESS

EXAMPLE 3A. HOSPITAL TRANSFER

No

Yes

EDGE OF 

ENVELOPE 

PWR/PERF/FU

RANGE 

VISIBILITY 

RESTRICTIO

FOG/RAIN/SN

ICE

WX NEAR/AT M

TEMP/DEW PT 

DUTY TIME LI

DIST FROM H

MINIMUM EQ

LIST ITEM

LANDING ZO

CONCERN

FLIGHTCRE

OPERATION

CONCERN

MEDICAL CR

CONCERN 

PROCEED WITH 

FLIGHT

Green = NORMAL 

OPS

Yellow = EXTRA 

CAUTION ZONE 

Red = CRITICAL 

SAFETY DECISION 

REQUIRED

CRITICAL SAFETY 

DECISION 

REQUIRED 

DETERMINE 

IF ANY OF 

THE

FOLLOWING 

EXIST

WX ABOVE 

MINS & 

STABLE

HOSP XFER SCENE SEE EXAMPLE 3B

FLIGHT REQUEST 

DAY OR 

NIGHT 

OP? WX AT MINS 

OR

UNSTABLE PROCEED

WITH EXTRA 

CAUTION 

DAY 

WX ABOVE 

MINS & 

STABLE

PROCEED

WITH

CAUTION

NIGHT 

WX AT MINS 

OR

UNSTABLE
APPENDIX 2. EXAMPLES OF TRAINING-WEIGHTED RISK ASSESSMENT AND MANAGEMENT PROCES

EXAMPLE 3B. SCENE PROCEDURES

Page 5

SCENE

HOSP XFER SEE EXAMPLE 3A

DAY OR 

NIGHT 

OP? 

DAY 

WX ABV MINS & 

STABLE

PREBRIEFED

NO INFO 

WX AT MINS OR 

UNSTABLE 

DETERMINE 

IF ANY OF 

THE

FOLLOWING 

EXIST

FLIGHT REQUEST 

PROCEED

WITH

CAUTION

PROCEED

WITH EXTRA 

CAUTION

Yes

NIGHT 

WX ABV MINS & 

STABLE

WX AT MINS OR 

UNSTABLE

No

WX NEAR/

TEMP/DEW 

EDGE 

ENVEL

PWR/PER

RAN

VISIBI

RESTRIC

FOG/RAIN

ICE

DUTY TIM

DIST FROM 

MINIMUM 

LIST IT

LANDING 

CONCE

PREBRIEFED

FLIGHT

OPERAT

NO INFO CONCE

PROCEED WITH 

FLIGHT

MEDICAL 

CONC

Green = NORMAL 

OPS

CRITICAL SAFETY 

DECISION 

RE

Yellow = EXTRA 

CAUTION ZONE 

Red = CRITICAL QUIRED

SAFETY DECISION 

REQUIRED
N 8000.301 8/1/05

Appendix 2 

APPENDIX 2. EXAMPLES OF TRAINING-WEIGHTED RISK ASSESSMENT 

AND MANAGEMENT PROCESSES (Continued)

EXAMPLE 4. MISSION ASSESSMENT 

WEATHER 

Improving Deteriorating Yes No

Starting point 

Ceiling within 500' VFR 

Wx mins 

WX at VFR Mins 

WX below VFR Mins 

En route 

Ceiling within 500' VFR 

WX mins 

WX at VFR Mins 

WX below VFR Mins 

Destination 

Ceiling within 500' VFR 

WX mins 

WX at VFR Mins 

WX below VFR Mins 

IFR

WX for IAP to be flown < 

2000-3 

Alternate airport required 

Forecast WX at alt. <800-2 

WX at or below 400-1 

MISSION PROFILE Yes No

Night 

Scene, new LZ or no IAP 

within 5 miles 

Concerns related to 

availability of fuel 

Terrain (mountainous) 

WX within 500' of mins at 

destination/alt 

Pilot not recent on IAP to be 

flown 

Flight conducted overwater 

Winds > 30 kts, gusts 

> 15 kts 

Severe WX, icing, 

thunderstorms 

Overall assessment: Can the mission be 

completed as requested? 

Totals from the Weather Chart: For any 

more than 6 shaded items checked “Yes,” 

exercise extreme caution and re-brief 

options.

If “Yes” box and adjacent “Deteriorating” 

box are checked, VFR flight is not 

recommended or flight should be rejected. 

Combined Totals from the Weather and 

Mission Profile Charts: For any more than 

6 items checked “Yes,” exercise extreme 

caution and re-brief options. 

If in excess of 10 items checked “Yes” or 

shaded, flight should be rejected.

NOTE: This example is for reference only. Each operator should consider 

its own operational and environmental needs in developing its risk 

assessment tool(s) and plans.

Page 6

Appendix E 53 Special Investigation Report
8/1/05 N 8000.301

 Appendix 3

APPENDIX 3. EXAMPLE OF ALTERNATIVE RISK INTERVENTION POLICY 

MEMORANDUM 

TO: All Pilots 

FROM: Vice President, Operations 

DATE: June 22, 2005 

RE: The “Official Time Out” Policy 

______________________________________________________________________________

 Over the past year, we have achieved some new highs and have seen some new lows in 

safety and regulatory compliance. A common thread connecting the several incidents and 

accidents is appearing. In nearly every case we have, as aircraft commanders, been required to 

take action that most of us would describe as outside the norm. Examples include bird strikes, 

engine failures, and component failures. In nearly every case we have conducted ourselves in 

the best traditions of aviation, successfully concluding these flights by doing that which we are 

trained to do. 

 It is only after the kettle is removed from the fire that we tend to make decisions that in 

retrospect seem less than optimal. We would do well to ask ourselves if making a go/no-go 

decision immediately after concluding an in-flight emergency is in anyone’s interest. It is the 

organization’s firm belief that the level of expertise at this air carrier is a standard to which most 

of the industry can only aspire. With this professionalism comes an inherent desire to complete 

the mission and consequently we permit ourselves to push on. 

 Effective immediately, it is the policy of this air carrier that if as a member of a 

flightcrew you are involved in any of the events listed at the end of this memo, you may be 

awarded an “OFFICIAL TIME OUT” (i.e., off duty for the remainder of the shift). The Official 

Time Out is as simple as saying “Nice jobtake the rest of the day off.”

The awarding of an Official Time Out is at the discretion of the Chief Pilot, but may be 

granted by the Vice President, Operations, Director of Operations, or Director of Safety in his 

absence. Any award of an Official Time Out is contingent upon notification of Headquarters and 

specific direction by the Chief Pilot or any of the above listed personnel. Site Managers have 

the Emergency Authority to award an Official Time Out if, in their judgment, waiting for 

specific direction from the Chief Pilot would compromise operational safety. The object of 

this policy is to remove you from the decisionmaking process. There are numerous pilots, 

maintenance technicians, and support personnel on this team. This is the time to use their 

knowledge and experience. The following is not an all-inclusive list and your comments are 

solicited. 

EVENTS SUBJECT TO AWARD OF AN OFFICIAL TIME OUT 

1. Any aircraft system malfunction requiring a precautionary landing. 

2. An in-flight engine failure. 

 Page 1

Appendix E 54 Special Investigation Report
N 8000.301 8/1/05

Appendix 3 

3. Any event for which an NTSB report is required. 

 a) An aircraft incident. 

 b) A flight control system malfunction. 

 c) The inability of a flight crewmember to perform his duties due to 

injury or illness. 

 d) Failure of structural components of a turbine engine excluding 

compressor and turbine blades and vanes. 

 e) In-flight fire. 

 f) Damage to property other than the aircraft in excess of $25,000. 

 g) Aircraft collision in flight. 

 h) In-flight failure of electrical systems requiring sustained use of 

emergency bus power such as a battery or auxiliary power system. 

 i) In-flight failure of hydraulic systems. 

 j) Sustained loss of engine power. 

 k) An evacuation of the aircraft in which the emergency egress 

system is used. 

4. Any time an emergency is declared. 

5. Should there be a question as to whether an event fits the criteria for an Official Time 

Out, the Site Manager’s emergency authority applies until the Chief Pilot, VP-Ops, DO, 

or DOS can be notified. 

Page 2

Appendix E 55 Special Investigation Report
56 Special Investigation Report

Appendix F

FAA Notice N8000.307: Special Emphasis Inspection Program for 

Helicopter Emergency Medical Services

NOTICE

U.S. DEPARTMENT OF TRANSPORTATION 

FEDERAL AVIATION ADMINISTRATION N 8000.307

9/27/05 

Cancellation

Date: 9/27/06 

SUBJ: SPECIAL EMPHASIS INSPECTION PROGRAM FOR HELICOPTER 

EMERGENCY MEDICAL SERVICES 

1. PURPOSE. This notice was developed to provide guidance for aviation safety inspectors 

(ASI) in all specialties on the Special Emphasis Inspection Program for Helicopter Emergency 

Medical Services (HEMS) operated under Title 14 of the Code of Federal Regulations (14 CFR) 

part 135. 

2. DISTRIBUTION. This notice is distributed to the division level in the Flight Standards 

Service in Washington headquarters; to the branch level in the regional Flight Standards 

divisions; to the Flight Standards District Offices, and to the Regulatory Standards Division at 

the Mike Monroney Aeronautical Center. This notice is also distributed electronically to the 

division level in the Flight Standards Service in Washington headquarters and to all regional 

Flight Standards divisions and district offices. This information is also available on the Federal 

Aviation Administration’s (FAA) Web site at: 

http://www.faa.gov/library/manuals/examiners_inspectors/8000/media/N8000-307.doc. 

3. BACKGROUND. 

a. Introduction. HEMS operate in a demanding environment. They provide an invaluable 

service to the public by providing crucial, safe, and efficient transportation of critically ill and 

injured patients to tertiary care medical facilities. While the contribution of HEMS is profound 

as a component of the nation’s medical infrastructure, from an operational standpoint, it is a 

commercial aviation activity performed by FAA certificated air carrier operators. HEMS, 

therefore, must be conducted with the highest level of safety. In order to support compliance 

with this standard, a special emphasis inspection program has been developed for Fiscal Year 

(FY)-06. These inspections are to be accomplished in addition to the established National 

Program Guidance (NPG) inspection program. These inspections are expected to be included in 

the FY-07 and subsequent NPG. 

b. HEMS Operational Environment. HEMS operations are conducted according to a 

variety of business models and operating configurations. Typically, a customer hospital 

contracts with an air carrier certificate holder to conduct HEMS operations in support of the 

customer’s medical program. In this business model, the HEMS flight operation is based out of 

the customer’s facility (the hospital) and is often remote from the certificate holder’s main base, 

main maintenance facilities, and management. This complicates the management and 

operational control of flight operations and maintenance activities. It also complicates FAA 

Distribution: A-W(FS)-2; A-X(FS)-3; A-FFS-7 (LTD); AMA-200 (80 CYS) Initiated by: AFS-820 

(Electronically: A-W(FS)-2; A-X(FS)-2; A-FFS-7) 
N 8000.307 2/27/05 

oversight of such operations when locations exist outside the certificate-holding district office’s 

(CHDO) geographic area of responsibility. Such configurations require significant coordination 

between the CHDO and the geographic Flight Standards District Office (FSDO). Other HEMS 

configurations include a hospital-owned certificate holder, which accomplishes the HEMS 

function for that hospital. Cooperative systems exist in which a consortium of hospitals share 

ownership of a certificate holder. While these configurations are often contained wholly within 

the CHDO’s area, operational control issues may exist between the customer (hospital) and the 

service provider (certificate holder). 

c. Each state and territory in the United States has a lead Emergency Medical Services 

(EMS) agency. These agencies are usually a part of the state health department, but in some 

states they are part of the public safety department, or are an independent state agency. A list is 

available from the National Association of State EMS Directors at 

http://www.nasemsd.org/index.php?option=content&task=view&id=72. Inspectors assigned to

surveillance activities involving HEMS operators are encouraged to contact the appropriate state 

or territory EMS agency and to coordinate efforts and to use those agencies as a resource.

NOTE: Additional background information may be found in FAA Notice 

N 8000.293, Helicopter Emergency Medical Services Operations. 

4. SPECIAL EMPHASIS AREAS FOR THIS HEMS INSPECTION PROGRAM.

a. This Special Emphasis Inspection Program focuses on areas identified as causal factors in 

a review of HEMS accidents from 1999-2004. For all specialties, the areas of special emphasis 

include: 

(1) Operational control, including policies, procedures, training, communications, and 

management. 

(2) Safety culture development, including policies, procedures, and training. 

b. Within the operations specialty, areas of special emphasis include: 

(1) Weather information access and use by flightcrews, management, and in-flight 

communications specialists. 

(2) Operator’s knowledge of terrain, obstructions, airspace, and special weather 

considerations for operating in the specific geographic area, especially at night, and in periods of 

reduced visibility.

(3) Operator’s knowledge of the certificate holder’s risk assessment and management 

procedures, including crewmember and management duties, responsibilities, and authorities as 

related to assigning, accepting, declining, and canceling flight assignments, and the continuation, 

diversion, or termination of flights once underway. 

(4) Pilot and flightcrew knowledge of all installed aircraft equipment, including 

communications, navigation, and any special equipment such as Night Vision Goggles (NVG), 

terrain awareness and warning systems (TAWS), radar altimeters, etc. 

Page 2 Par 3 

Appendix F 57 Special Investigation Report
9/27/05 N 8000.307 

(5) Safety procedures in and around the heliport and off-site landing zone, especially at 

night.

(6) Coordination with local EMS, law enforcement, and fire services for off-site landing 

zone preparation, including weather estimation, obstruction and other hazard evaluation, lighting, 

and other operational considerations. 

(7) Procedures for use of non-pilot flight crewmembers for situational awareness during 

flight operations (clearing the aircraft for obstructions, keeping a lookout for traffic, monitoring 

checklist functions), especially at night and in periods of reduced visibility. 

c. Within the airworthiness specialties (maintenance and avionics) areas of special emphasis 

include: 

(1) A review of aircraft records for helicopter airworthiness status, regulatory 

compliance (Airworthiness Directives, Bulletins, or any other required compliances), Minimum 

Equipment List (MEL) compliance, maintenance record retention procedures, and any other 

reviews deemed necessary. 

(2) A review of maintenance procedures used on-site. This could include inspection of 

special equipment, technician qualifications/experience/training, and maintenance program for 

each make/model helicopter at base. 

(3) A review of technical data such as maintenance manuals, service bulletins, 

manufacturers manuals, illustrated parts catalogs, etc., used for on-site maintenance. 

(4) Proper tools, equipment and materials for the conduct of maintenance and 

inspections. 

(5) A review of the Weight and Balance program being used at each operational site.

Many HEMS programs have special weight and balance procedures for the various 

configurations used depending on the specific type of mission (i.e., litter, isolate, additional litter, 

patient weight, etc.). 

(6) A review of the NVG maintenance program and FAA installation approval if 

applicable. 

(7) Inspection of refueling facility if located at the helicopter base of operations. 

5. ACTION. 

a. Regional Flight Standards Divisions.

(1) Identify a resource within the region’s operations and airworthiness inspector 

workforce to serve as the Regional Helicopter Emergency Medical Services Resource, and 

forward the names of the selected inspectors to AFS-820, no later than December 15, 2005. An 

operations and airworthiness candidate should be selected. The candidates should meet the 

following requirements, as appropriate: 

Par 4 Page 3

Appendix F 58 Special Investigation Report
N 8000.307 2/27/05 

(a) Operations ASIs: Hold a commercial or airline transport pilot certificate with a 

rotorcraft-helicopter rating, and have pilot experience in HEMS operations. If no candidate 

exists with HEMS operations experience, a helicopter rated operations inspector should be 

selected.

(b) Airworthiness ASIs: Have experience in the maintenance of helicopters used in 

Emergency Medical Services Operations. If no candidate exists with HEMS maintenance 

experience, an inspector with helicopter maintenance experience should be selected. 

(2) Regional HEMS resources will serve as the focal point for standardization of 

regional HEMS certification and surveillance efforts. Assigned inspectors must be able to 

participate in monthly telecons and meetings with other regional resources and headquarters 

HEMS personnel. 

b. Flight Standards District Offices. Accomplish the following inspections, with 

emphasis on the specific areas identified with each inspection and the general emphasis on the 

areas discussed in paragraph 4:

(1) Operations. 

(a) Principal operations inspectors (POI) assigned to HEMS operators should 

accomplish the following inspections on assigned certificate holders: 

1. Conduct one Training Program Inspection (PTRS Code 1626) for each 

approved training program for each HEMS operator. Emphasis should be placed on night and 

low visibility operations training and procedures, controlled flight into terrain (CFIT) avoidance, 

and recovery from inadvertent instrument meteorological conditions (IMC). 

2. Conduct one Base Inspection (PTRS Code 1616) for each HEMS base of 

operations within the CHDO’s geographic area. Emphasis should be placed on operational 

control, management, communications, crew rest areas, weather and aeronautical data collection 

and dissemination systems, maintenance control, and crew scheduling. 

3. Conduct one Flight Locating Inspection (PTRS Code 1636) for each HEMS 

flight locating system within the CHDO’s geographic area. Emphasis should be placed on 

operational control, coordination with management, communications, weather and aeronautical 

data availability and use, and risk assessment and decision making procedures. 

4. Conduct one Ramp Inspection (PTRS Code 1622) for each make and model 

of EMS helicopter operated at each HEMS base in the CHDO’s geographic area. Emphasis 

should be placed on internal and external lighting (including cockpit windshield and window 

glare at night), night flying equipment, aeronautical information (charts, airport/facility 

directories, etc.), communications and navigation equipment, attitude flight instruments, medical 

equipment installation, use of minimum equipment lists (MEL), maintenance discrepancy 

reporting, and special equipment (radio altimeters, NVGs, TAWS, etc.). 

5. Conduct one facility inspection (PTRS Code 1635) for each HEMS base 

hospital heliport within the CHDO’s geographic area. Emphasis should be placed on safety 

Page 4 Par 5 

Appendix F 59 Special Investigation Report
9/27/05 N 8000.307 

equipment, communications equipment, access to weather information, heliport security, 

marking and lighting, approach and departure paths, and obstructions. (It is recommended that 

this inspection include a night evaluation of heliport and nearby obstruction lighting.) 

NOTE: If the POI is not helicopter rated, it is recommended that he/she be 

assigned a helicopter rated ASI to assist in the inspections. For inspections of 

operations using NVGs, it is recommended that the POI consult with an NVG 

National Resource Inspector (NVG NRI). Contact AFS-820 at (202) 267-8212 

for the list of NVG national resource inspectors. 

(b) FSDOs with HEMS operations conducted by certificate holders based outside 

their area (another FSDO is the CHDO) shall ensure that the following inspections are 

accomplished by helicopter-rated Operations ASIs on certificate holder facilities located within 

the FSDO’s geographic area.

NOTE: For inspections of operations using NVGs, see the NVG NRI guidance 

above.

1. If training is conducted away from the certificate holder’s main base, 

conduct one Training Program Inspection (PTRS Code 1626) for each approved training 

program conducted in the FSDO’s geographic area, for each HEMS operator. Emphasis should 

be placed on night and low visibility operations training and procedures, CFIT avoidance and 

recovery from inadvertent IMC. 

2. Conduct one Base Inspection (PTRS Code 1616) for each HEMS base of 

operations within the FSDO’s geographic area. Emphasis should be placed on operational 

control, management, communications, crew rest areas, weather and aeronautical data collection 

and dissemination systems, maintenance control, and crew scheduling. 

3. Conduct one Flight Locating Inspection (PTRS Code 1636) for each HEMS 

flight locating system within the FSDO’s geographic area. Emphasis should be placed on 

operational control, coordination with management, communications, weather and aeronautical 

data availability and use, and risk assessment and decision making procedures. 

4. Conduct one Ramp Inspection (PTRS Code 1622) for each make and model 

of EMS helicopter operated at each HEMS base in the FSDO’s geographic area. Emphasis 

should be placed on internal and external lighting (including cockpit windshield and window 

glare at night), night flying equipment, aeronautical information (charts, airport/facility 

directories, etc.), communications and navigation equipment, attitude flight instruments, medical 

equipment installation, use of the MELs, maintenance discrepancy reporting, and special 

equipment (radio altimeters, NVGs, TAWS, etc.). 

5. Conduct one facility inspection (PTRS Code 1635) for each HEMS base 

hospital heliport within the FSDO’s geographic area. Emphasis should be placed on safety 

equipment, communications equipment, access to weather information, heliport security, 

marking and lighting, approach and departure paths, and obstructions. (It is recommended that 

this inspection include a night evaluation of heliport and nearby obstruction lighting.) 

Par 5 Page 5

Appendix F 60 Special Investigation Report
N 8000.307 2/27/05 

(2) Airworthiness. 

(a) Principal maintenance inspectors (PMI) and principal avionics inspectors (PAI) 

assigned to HEMS operators should accomplish the following inspections on assigned certificate 

holders:

1. Conduct one Training Program Inspection (PTRS Code 3306/5306) for each 

program for each HEMS helicopter make/model being operated. Emphasis should be placed on 

the type of technical training being provided for each make/model helicopter (in-house, on-thejob training (OJT), manufacturers, etc.) to the maintenance technicians for which they have 

responsibility.

2. Conduct one Base Inspection (PTRS Code 3619 or 3620, 5619, or 5620) for 

each HEMS base or subbase of operations within the CHDO’s geographic area of responsibility.

Emphasis should be placed on aircraft maintenance control procedures, controls for maintenance 

records, inspection procedures including scheduling and unscheduled procedures, technical data, 

equipment, and general operations manual procedures relating to maintenance activities. 

3. Conduct one Ramp Inspection (PTRS Code 3627/3628 or 5627/5628) for 

each make/model helicopter being operated at each base within the CHDO’s geographic area.

Emphasis should be placed on type of inspection program for aircraft, conformity approvals for 

equipment installed (Supplemental Type Certificate (STC), Field Approval, etc.), weight and 

balance program for each make/model, MEL procedures, maintenance technical data used at 

each base for adequacy and currency (applicable to each make/model maintained at base), and a 

review of the aircraft records. If NVGs are used, inspect for FAA approval (STC) for NVG 

compatible cockpit lighting and NVG Instructions for Continued Airworthiness (ICA) being 

used to maintain the goggles and cockpit lighting. Additional ASI guidance is provided in 

Order 8300.10, Volume 3, Chapter 7, Inspect Aircraft Used for Air Ambulance. 

4. Conduct one Spot Inspection (PTRS Code 3628/5628) on one helicopter at 

each base within the CHDO’s geographic area. Emphasis should be on observation and analysis 

of in-progress maintenance operations for compliance with the specific methods, techniques, and 

practices in the operator’s inspection and maintenance programs. 

(b) FSDOs with HEMS operations conducted by certificate holders based outside 

their area (another FSDO is the CHDO) shall ensure that the following inspections are 

accomplished by Airworthiness (Avionics and Maintenance) ASIs on certificate holder facilities 

located within the FSDO’s geographic area.

1. Conduct one subbase inspection (PTRS Code 3620/5620) for each HEMS 

subbase of operations within the FSDO’s geographic area of responsibility. Emphasis should be 

placed on aircraft maintenance control procedures, controls for maintenance records, inspection 

procedures including procedures for scheduled and unscheduled maintenance, technical data, 

equipment, and general operations manual procedures relating to maintenance activities and 

refueling if used at base.

2. Conduct one Ramp Inspection (PTRS Code 3627/5627) for each 

make/model EMS helicopter operated at each HEMS base in the FSDO geographic area of 

Page 6 Par 5 

Appendix F 61 Special Investigation Report
9/27/05 N 8000.307 

responsibility. Emphasis should be placed on type of inspection program for aircraft, conformity 

approvals for equipment installed (STC, Field Approval, etc), weight and balance program for 

each make/model, MEL procedures, maintenance technical data used at each base for adequacy 

and currency (applicable to each make/model maintained at base), and a review of the aircraft 

records. If NVGs are used, inspect for FAA approval for NVG compatible cockpit lighting and 

NVG ICAs being used to maintain the goggles and cockpit lighting.

NOTE: Additional ASI guidance is provided in Order 8300.10, Volume 3, 

Chapter 7, Inspect Aircraft Used for Air Ambulance. 

6. PROGRAM TRACKING AND REPORTING SUBSYSTEM (PTRS). To document 

these special emphasis inspections: 

a. Open a PTRS record, use the codes 1030, 3030, or 5030, as applicable. 

(1) Enter “N8000HEMS” in the “National Use” field (without quotes). 

(2) After the special emphasis inspections required by this notice are completed, close 

out the PTRS. 

b. For each specific inspection required by this notice, 

(1) Open a PTRS record using the code appropriate for the inspection. 

(2) Enter “N8000HEMS” in the “National Use” field (without quotes). 

(3) Close the PTRS record when the inspection is completed. 

7. DISPOSITION. This notice will not be incorporated into FAA Order 8300.10, 

Airworthiness Inspector’s Handbook; Order 8400.10, Air Transportation Operations Inspector’s 

Handbook; or Order 8700.1, General Aviation Operations Inspector’s Handbook. Questions 

concerning this notice should be directed to the Air Carrier Operations Branch, AFS-220, at 

(202) 267-9518; Aircraft Maintenance Division, AFS-300, (202) 267-3546; or the Commercial 

Operations Branch, AFS-820, at (202) 267-8212.

/s/

John M. Allen for 

James J. Ballough 

Director, Flight Standards Service 

Par 5 Page 7

Appendix F 62 Special Investigation Report
63 Special Investigation Report

Appendix G

Previous EMS Helicopter Safety Recommendations

On February 29, 1988, the Safety Board issued a safety study exploring the rapidly 

growing commercial EMS industry and its operations, focusing on the influence of 

weather, operations under instrument flight rules/visual flight rules, pilot and medical 

personnel training requirements, EMS helicopter design standards and reliability, EMS 

helicopter crashworthiness, and the influence of EMS helicopter program management on 

safety. As a result, the Safety Board issued 19 recommendations, which are summarized 

below.

The following recommendations were issued to the FAA.

A-88-1

Amend the Air Carrier Operations Inspectors Handbook to provide specific 

guidance to principal operations inspectors on review and approval of initial and 

recurrent training requirements for emergency medical service helicopter pilots. 

This guidance should include minimum levels of instruction on poor weather 

operations, meteorological conditions, and demonstrated control of the aircraft in 

simulated instrument meteorological conditions. This guidance should also 

specify the minimum training acceptable for accident scene operations, including 

takeoff and landing.

The FAA revised FAA Order 8400.10, Air Transportation Operations Inspector’s 

Handbook, which contained four chapters on air ambulance operations and addressed the 

areas in the recommendation, and distributed it in mid 1992. Even though the handbook 

did not establish minimum amounts of training in these subject areas, conversations with 

the FAA assured staff that training to a level of proficiency is appropriate. The 

recommendation was classified “Closed—Acceptable Action” on April 3, 1992.

A-88-2

Require that the material being developed for the Emergency Medical Service 

(EMS) Pilot Supplement to the Aeronautical Decision Making Manual for 

Helicopter Operators be incorporated into EMS pilot initial and recurrent 

training.

The FAA published a draft AC in October 1988 providing guidance regarding 

aeronautical decision-making for EMS pilots. While not regulatory, the Safety Board 

accepted the FAA’s action and classified the recommendation “Closed—Acceptable 

Alternate Action” on October 1, 1990.

A-88-3

Amend 14 Code of Federal Regulations 135.205 Paragraph (B), visual flight rules 

(VFR): Visibility Requirements, to restrict emergency medical service helicopters 

to a day VFR visibility minimum of 1 mile.
Appendix G 64 Special Investigation Report

The FAA issued AC 135-14A on June 20, 1991, addressing weather minimums. 

The weather minimums contained in the AC have the effect of a rule when issued on 

operation specifications, which the FAA issued for aeromedical helicopter operators on 

December 23, 1991. In its April 3, 1992, response, the Safety Board noted that 

incorporating the 1 mile visibility into operation specifications was an acceptable 

alternative to the recommended action and classified the recommendation “Closed—

Acceptable Alternate Action.”

A-88-4

Review 14 Code of Federal Regulations 135.223, Instrument Flight Rules (IFR): 

Alternate Airport Requirements, to determine the feasibility of allowing the 

helicopter pilot, without designating an alternate airport, to file IFR with a lower 

destination weather forecast than is currently specified.

Based on an FAA study of the feasibility of changing the IFR alternate 

requirement for helicopters, the FAA did not believe that the elimination of the alternate 

requirement promotes aviation safety or could be justified by any objective data. Thus, the 

Safety Board classified the recommendation “Closed—Acceptable Action” on October 1, 

1990.

A-88-5

Develop procedures for priority handling of emergency medical service pilot calls 

to flight service stations requesting weather briefings for patient transfer flights.

The FAA revised the Facility Operation and Administrative Handbook 7210.3H, 

Paragraph 1603, to establish procedures for the priority handling of EMS pilot requests, 

emphasizing the importance of cooperation with organizations providing emergency 

medical operations to ensure prompt and efficient weather briefing services. Although the 

Safety Board continued to believe that enhanced capabilities for getting weather 

information without delay was needed, the recommendation was classified “Closed—

Acceptable Action” on November 29, 1990.

A-88-6

Amend 14 Code of Federal Regulations Part 91 and 135 to require that persons 

who intend to operate helicopters for emergency medical service activities obtain 

initial approval for this purpose from the appropriate Federal Aviation 

Administration district office, and require persons seeking such approval to 

present sufficient evidence to permit the evaluation of the following: That the 

interior modification of the helicopter is based on an engineering design [that] 

ensures that medical subsystems are designed and installed to prevent hazards to 

the aircraft and crew in the event of failure and that the modifications meet the 

intent of 14 Code of Federal Regulations 27.1309 and 29.1309; that the proposed 

portable medical equipment is suitable for the helicopter environment and poses 

no hazard to the helicopter and crew; and that the interior modification does not 

compromise the helicopter’s crashworthiness.
Appendix G 65 Special Investigation Report

The FAA issued AC 135-14 providing specific guidance on the installation and 

inspection of additional equipment on Part 135 EMS operations. This AC specifically 

references 14 CFR 135.9(a)(1)(iv) and states that the supporting structure to which 

equipment is attached must be designed to restrain all loads up to the ultimate inertia 

specified by FAA standards. The Safety Board classified this recommendation “Closed—

Acceptable Action” on October 1, 1990.

A-88-7

Develop minimum emergency medical service helicopter equipment installation 

and performance standards. These standards should include guidance on interior 

design, including but not limited to: crashworthiness, oxygen system design, 

patient location and restraint, and medical system design.

Based on the input received at a public meeting held by the FAA on April 20, 

1988, the FAA determined that new standards for EMS equipment are not necessary and 

believed the recommendation could be addressed by adding information, titled 

“Emergency Medical System (EMS) Installation, Interior Arrangements and Equipment,” 

to AC 27-1, Change 2 and AC 29-2A, Change 1. Although the Safety Board remained 

concerned about the use of older nonaviation-type oxygen systems, the Board classified 

this recommendation “Closed—Acceptable Alternate Action” on May 12, 1992, because 

the FAA’s responses substantially fulfilled the intent of the recommendation.

A-88-8

Require that shoulder harnesses be installed at all medical personnel and 

passenger seats on all helicopters when they are newly modified for emergency 

medical service (EMS) operations or when an existing EMS helicopter undergoes 

major interior modification or overhaul.

The FAA issued a final rule to require installation and use of shoulder harnesses at 

all seats of rotorcraft manufactured after September 16, 1992. Because this rule did not 

include shoulder harnesses in helicopters already in EMS use, the Safety Board classified 

the recommendation “Closed—Unacceptable Action” on July 8, 1992.

A-88-9

Require that those personnel classified as required crewmembers operating 

emergency medical service helicopters wear protective clothing and equipment to 

reduce the chance of injury or death in survivable accidents. This clothing and 

equipment should include protective helmets, flame- and heat-resistant flight 

suits, and protective footwear.

In FAA Order 8400.10, Air Transportation Operations Inspector’s Handbook, the 

FAA recommended that principal operations inspectors encourage their respective 

operators to use protective clothing but did not believe that there was sufficient 

justification or data to support regulatory changes. The FAA further noted that many EMS 

helicopter operators already use protective flight gear. Although the Safety Board believed 

that the change to Order 8400.10 was beneficial, it also believed that the revision carried 
Appendix G 66 Special Investigation Report

less impact than a regulatory change and classified the recommendation “Closed—

Unacceptable Action” on October 1, 1990.

A-88-10

Develop and conduct a research program to measure the effect of Emergency 

Medical Service (EMS) pilot workload, shift lengths, and circadian rhythm 

disruptions on EMS helicopter pilot performance. This research program should 

be conducted in cooperation with the National Aeronautics and Space 

Administration [NASA], which has developed techniques to measure the 

influence of workload and fatigue on helicopter pilot performance. This research 

should include evaluation of one- and two-pilot crews. The results of this research 

should be used to evaluate the effectiveness of the current flight time/duty time 

regulation in providing EMS pilots adequate rest.

The FAA issued AC 135-14A to provide specific guidance on issues such as flight 

time and rest requirements, cockpit resource management, judgment and decision-making 

and flight operations procedures. The FAA believed that these regulations and guidelines 

were effective based on the improved safety record of EMS helicopter operations. 

Although the FAA stated that it would continue to monitor NASA’s work, it did not 

foresee additional action. Thus, the Safety Board classified the recommendation 

“Closed—Acceptable Alternate Action” on October 28, 1994.

A-88-11

Develop guidance for Emergency Medical Service (EMS) helicopter operators 

and hospitals operating EMS helicopter programs on recommended training for 

medical personnel who routinely fly on EMS helicopter missions. This guidance 

should be developed in conjunction with the American Society of Hospital-Based 

Emergency Aeromedical Services, and the Helicopter Association International. 

Topics that should be addressed include: flight crew and medical personnel 

coordination and communication including terminology to be used; helicopter 

emergency fuel and systems shutdown, landing zone safety and obstacle 

avoidance, air traffic recognition and avoidance, and radio communication; and 

emergency training on the topics listed in 14 Code of Federal Regulations

135.331, Crewmember Emergency Training.

The FAA incorporated guidance regarding coordination between EMS flight 

crewmembers and medical personnel into AC 135-14. Accordingly, the recommendation 

was classified “Closed—Acceptable Action” on October 1, 1990.

In addition to the recommendations to the FAA, the Safety Board also issued 

recommendations resulting from the study to other entities. The Safety Board 

recommended the following to the American Society of Hospital-Based Emergency 

Aeromedical Services (ASHBEAMS):

A-88-12

In coordination with the Helicopter Association International, provide specific 

guidance to each member emergency medical service (EMS) helicopter program 
Appendix G 67 Special Investigation Report

on the need for and methods to develop a safety committee composed of 

representatives from the hospital EMS program administration, the commercial 

EMS helicopter operator, the pilot and medical personnel, helicopter dispatch (if 

applicable), and local public safety/emergency response agencies. The safety 

committee should meet monthly, with management representatives from the 

operator and hospital attending frequently. One objective of the safety committee 

should be the elimination of any negative influence caused by competition 

between EMS helicopter services that operate in the same area.

A-88-13

Develop guidance for hospital emergency medical service (EMS) program 

administrators on safety issues involved in helicopter EMS operations. Topics 

addressed should include pilot-in-command authority, marginal weather 

operations, and pilot-crewmember coordination and communication.

The Association of Air Medical Services (AAMS)5 published “Minimum Quality 

Standards and Safety Guidelines” in July 1991 and also developed an accreditation 

program for air medical services. Based on this response, Safety Recommendations A-88-

12 and -13 were classified “Closed—Acceptable Action” on February 22, 1994. 

The Safety Board further recommended to ASHBEAMS:

A-88-14

Encourage members who operate emergency medical service (EMS) programs to 

provide medical personnel who routinely fly EMS helicopter missions with 

protective clothing and equipment to reduce the chance of injury or death in 

survivable accidents. This clothing and equipment should include protective 

helmets, flame- and heat-resistant flight suits, and protective footwear.

AAMS responded that it issued a mission statement encouraging members to 

consider crash survivability issues but to put a greater emphasis on accident prevention. 

The Safety Board classified this recommendation “Closed—Acceptable Action” on 

January 19, 1990.

The Safety Board also issued to ASHBEAMS:

A-88-15

Develop guidance for members who operate emergency medical service (EMS) 

programs on recommended training for medical personnel who routinely fly on 

EMS helicopter missions. This guidance should be developed in conjunction with 

the FAA, and the Helicopter Association International. Topics that should be 

addressed include: flight crew and medical personnel coordination and 

communication including terminology to be used; helicopter emergency fuel and 

systems shutdown, landing zone safety and obstacle avoidance, air traffic 

recognition and avoidance, and radio communication; and emergency training on 

5 ASHBEAMS was renamed in 1988.
Appendix G 68 Special Investigation Report

the topics listed in 14 Code of Federal Regulations 135.331, Crewmember 

Emergency Training.

AAMS responded that, in 1988, it completed the “Air Medical Crew – National 

Standard Curriculum,” which contained subjects listed in the recommendation, as well as 

other subjects pertinent to the air medical environment. Thus, the recommendation was 

classified “Closed—Acceptable Action” on January 19, 1990.

The Safety Board also issued the following recommendations to Helicopter 

Association International:

A-88-16

Encourage all members who operate commercial emergency medical service 

(EMS) helicopters to develop visual flight rules weather minimums for each EMS 

helicopter program based on local terrain and weather patterns. These weather 

minimums should be communicated to the pilots in writing, and deviation below 

the program minimums should be prohibited.

A-88-17

In coordination with the American Society of Hospital-Based Emergency 

Aeromedical Service, encourage members that operate commercial emergency 

medical service (EMS) helicopters to establish safety committees at each EMS 

program composed of representatives from the hospital EMS program 

administration, the commercial EMS helicopter operator, the pilot and medical 

personnel, helicopter dispatch (if applicable), and local public safety/emergency 

response agencies. One objective of the safety committee should be the 

elimination of any negative influence caused by competition between EMS 

helicopter services that operate in the same area.

A-88-18

Develop guidance for members who operate emergency medical service (EMS) 

programs on recommended training for medical personnel who routinely fly on 

EMS helicopter missions. This guidance should be developed in conjunction with 

the FAA and the American Society of Hospital-Based Emergency Aeromedical 

Service. Topics that should be addressed include: flight crew and medical 

personnel coordination and communication including terminology to be used; 

helicopter emergency fuel and systems shutdown, landing zone safety and 

obstacle avoidance, air traffic recognition and avoidance, and radio 

communication; and emergency training on the topics listed in 14 Code of Federal 

Regulations 135.331, Crewmember Emergency Training.

The Safety Board did not receive any correspondence from Helicopter Association 

International and classified recommendations A-88-16, -17, -18 “Closed—Unacceptable 

Action—No Response” on April 24, 2001.

Finally, as a result of the study, the Safety Board recommended that the National 

Aeronautics and Space Administration:
Appendix G 69 Special Investigation Report

A-88-19

Develop and conduct a research program in cooperation with the Federal Aviation 

Administration to measure the effect of emergency medical service (EMS) pilot 

workload, shift lengths, and circadian rhythm disruptions on EMS helicopter pilot 

performance.

In 1988, NASA had begun to gather a pilot workload database of EMS operations 

and, by 1994, had conducted research into special human performance issues in EMS 

helicopter operations. As a result of this research, a computer-based preflight risk 

assessment system was developed and disseminated to the EMS industry. In addition, the 

Aviation Safety Reporting System performed a structured callback based on EMS reports 

and an analysis of incident data. Although the Safety Board envisioned a more structured 

program addressing the particular challenges of pilot workload, shift lengths, and 

circadian rhythm disruption, the Board determined that the NASA program was an 

acceptable alternative. Thus, the Safety Board classified Safety Recommendation A-88-19 

“Closed—Acceptable Alternate Action” on March 12, 2001.