thinking GETTING CLOSURE

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1 24 Feature HEMS Helicopters transport around 400,000 patients annually in the US. (Photo: Airbus Helicopters) HEMS in the US has enjoyed extraordinary growth over the past decade. Over 1,000 rotary-wing aircraft now serve the market, with an estimated 850 bases established. Around ten years ago there were 750 helicopter air ambulances flying from about 600 US bases, according to the Atlas & Database of Air Medical Services (ADAMS). Approximately 57% of all air ambulance helicopters in the world are based in North America. Europe and Russia comprise the second biggest HEMS marketplace with 32%, with the rest of the world making up the remaining 11%. ADAMS data shows that between September 2013 and September 2014, some 20 US states increased the number of such bases and 23 states increased the number of EMS helicopters. Critical thinking Recent initiatives by the US FAA have placed a safety spotlight on helicopter air ambulance operations. Grant Turnbull speaks to key EMS operators about the effect of the new rules and overall state of the sector. The Association of Air Medical Services (AAMS) estimates there are around 400,000 air ambulance transports annually in the US. Helicopters play a key role in the US healthcare system, decreasing the time it takes for seriously ill patients to reach definitive care. Aircraft can transport patients between facilities, from accident scenes and also transfer organs or other vital medical supplies. GETTING CLOSURE HEMS has also taken on greater significance in rural areas, where hospital closures have reduced people s access to care. According to the North Carolina Rural Health Research Program, a total of 48 rural hospitals have closed across the US in the past five years, resulting in a shift away from the traditional hospital-based business model for HEMS providers. Clinton Burley, CEO and president of HealthNet Aeromedical Services in West Virginia, told RotorHub this issue has increased the need to be able to transport patients from communities to larger hospitals using rotary-wing aircraft. Certainly the need is increasing, he noted. Burley s company is a traditional not-for-profit provider of air ambulance services in West Virginia and neighbouring states, utilising an all-airbus Helicopters fleet, including one EC145, two EC135s and six EC130s. These nine aircraft are operated by Air Methods and stationed at eight bases, each responsible for providing service over a 280km radius. Over half of these were established in the past decade, reflecting wider industry trends. RotorHub February/March 2015 Volume 9 Number 1

2 Feature HEMS 25 CUSTOMER DEMAND Much of the growth over the past decade has been fuelled by customer demand, ie bringing bases and helicopters to rural areas, closer to the patients, explained Richard Sherlock, CEO of AAMS. We may continue to see some pockets of growth in rural areas, because rural hospitals have closed or consolidated at a rate greater than 22% over the past 23 years, but I don t expect to see the growth rates we may have seen in the past. Burley, a former flight paramedic, offered a similar assessment of the HEMS sector: I think that we will still continue to see local hospitals closing in the coming years, but I think nationally that we are reaching a saturation point in the number of aircraft that the US can support. The demand for access to healthcare in rural areas has seen a growth in community-based operations in the US HEMS sector. This model contrasts in a number of ways with a traditional hospital-based approach, the principal differentiation being that helicopters are not financially tied to one large hospital or a healthcare chain. Instead, as the name suggests, they independently serve communities in remote areas. SINGLE OR DOUBLE? A community-based operator will employ its own medical staff capable of providing critical care on board the helicopter, reducing reliance on hospital personnel. Additionally, companies will often utilise single-engine rotorcraft in order to keep costs down. Much of the growth in single-engine aircraft is in rural areas where they are able to improve patient access to healthcare, said Sherlock. And they are more economically viable in areas with low population densities. There is an even split of single- and twin-engine aircraft serving the US HEMS sector, unlike the European market where most operations require twin-engine aircraft, explained Jeanne Connor- Osborn, an air medical specialist at Bell Helicopter. Community-based models [in the US] favour single-engine aircraft for their applications so we see growth there, she continued. Another potential area for sales will be operators replacing ageing twin-engined BK 117s and EC135s. European air ambulances also often fly over densely populated cities, while rural operators in the US do not. Around 30% of HEMS aircraft in the US are manufactured by Bell, while Airbus Helicopters has the lion s share of the market at around 57%. One of the biggest community-based operators is Air Evac Lifeteam, which was established in 1985 to provide better medical access for the small city of West Plains in Missouri. It uses over 100 EMS-configured Bell 206 LongRangers across 113 bases in 15 states. European air ambulances often fly over densely populated cities, while rural US operators do not. FOR THE MONEY Community-based operations can be lucrative for HEMS operators. According to a company presentation to investors in December 2014, Air Methods one of the largest HEMS companies in the world earned $659 million in revenue from its 186 community bases, compared with just $181 million from 99 traditional hospital bases. In a community-based model, income is generated exclusively from patient transfers rather than fixed contracts with hospitals although this can carry more financial risk for companies. Traditional operators that contract only with hospitals, such as Louisiana-based Metro Aviation, have also experienced growth. Milton Geltz, managing director of the company, told RH that the company had enjoyed exceptional growth in 2013 and They were the largest growth years that I think we ve had for quite a while, he added. Metro said it has doubled in size every five to six years since its creation in the 1980s. The company currently provides pilots, mechanics and aircraft to over 30 programmes across 18 states in the US and also runs a successful completion centre, which installs aeromedical and law enforcement kits for customers. The company entered the aeromedical market in 1983 with two used Hughes 500D helicopters and now operates 124 fixed- and rotary-wing aircraft, predominantly comprising twin-engined Airbus Helicopters machines. These include: ten EC130s; six AS350s; 44 EC135s; 27 EC145s and three EC155s. The company also operates four Bell 407s, one MD 900 and ten Bö 105s. The EC145 is a popular platform for aeromedical operations. (Photo: Bond) Volume 9 Number 1 February/March 2015 RotorHub

3 26 Feature HEMS SLOWING DOWN Geltz said Metro s completion business is likely to experience a slowdown in 2015, possibly due to market saturation or companies sitting on capital. We deliver about 33 to 34 aircraft completions every year, [but] we see a tremendous downturn in that volume of business for 2015, he told RH. A number of HEMS companies have diversified in order to decrease reliance on air ambulance operations. Air Methods entered the air tourism market when it bought Sundance Helicopters in 2012, and Blue Hawaiian the following year. The company has also expanded internationally, namely in Haiti and Turkey, and invested in training simulators. Metro Aviation has also moved into the training and simulation market with its Helicopter Flight Training Center (HFTC). The company worked with FlightSafety International (FSI) and has one AS350 Level 7 flight training device at the facility. We also have a full-motion EC135 simulator we developed in cooperation with FSI [and] we re 80% complete with an EC145 full-motion simulator, Geltz added. Simulation-based training and scenario-based training is likely to be used much more in the future by air ambulance operators, Sherlock predicted. The quality and variety of simulators and training devices that are available today are amazing, especially when I compare them with the ones I used in pilot training decades ago, he said. As companies adapt business strategies to reflect broader market changes, another major influence on operations will be a raft of new FAA regulations coming into force this year, which is will be one of the biggest challenges to overcome, according to Geltz. Beginning in April, the FAA will implement new rules covering equipment and operational Many community-based HEMS providers are not based at hospitals and instead employ their own medical staff. (Photo: Metro Aviation) procedures designed to address a number of safety concerns in the HEMS industry. The first phase was supposed to take effect in April 2014, but that was delayed a year to allow industry more time to implement the changes. ACCIDENT RATES Growth in the sector has been accompanied by a worrying increase in accident rates, resulting in several patient and crew fatalities. According to the FAA, 2008 was the deadliest year on record for HEMS operations, with 13 accidents claiming 29 lives. According to the National Transportation Safety Board (NTSB), the HEMS industry experienced 85 accidents and 77 fatalities during the period between 2003 and HEMS operations are inherently dangerous, especially as crews often have to fly in unpredictable weather, at night or to unfamiliar landing sites and sometimes a combination of all three. Everyone acknowledges that air medical transport operations are in fact riskier than almost any other kind of flying, with the exception perhaps of crop dusting and flying in combat, explained William Winn, general manager at the National EMS Pilots Association (NEMSPA). The NTSB added HEMS operations to its annual Most Wanted list in 2008, a RotorHub February/March 2015 Volume 9 Number 1

4 Feature HEMS 27 document that identifies areas where safety improvements are most needed. It also held an unprecedented four-day hearing on HEMS safety in 2009, taking evidence from pilots, medical personnel, operators, manufacturers and the FAA. A total of 21 safety recommendations emerged, covering training, equipment, airspace infrastructure and reimbursement rates for operators. MEETING DEADLINES Under the new rules, operators will have two years from April 2015 to fit two pieces of safety technology: helicopter terrain awareness and warning systems (HTAWS) and radio altimeters (a device that accurately measures height above terrain). The deadline for all operators to fit this equipment is 24 April By April 2018, all air ambulances will also need to be fitted with some type of data monitoring equipment, which the FAA hopes will promote operational safety and assist investigators in case of an accident. As part of wider air traffic modernisation, all aircraft operating in US airspace including air ambulances will require Automatic Dependent HEMS operations are inherently dangerous, especially as crews often have to fly in unpredictable weather. Surveillance Broadcast (ADS-B) Out technology by An FAA spokesperson confirmed to RH there will be no more delays, and the HEMS rule will come into effect on 22 April We have gotten helpful feedback from industry through FAA/industry meetings and also in response to our posting of draft documents on the Flight Standards draft document website, said the spokesperson. There are no other planned adjustments to the implementation time lines. Some industry insiders say the FAA rules reflect safety initiatives already embarked upon by HEMS operators. The HAA [helicopter air ambulance] rule was entirely based on industry safety efforts we were well ahead of this rule on multiple levels, said Christopher Eastlee, president of the Air Medical Operators Association. We prompted the FAA to go further in the regulations and to speed up the process. This will be a major undertaking. A lot of these [rules] are already in place voluntarily, however now we have to regulate those things There are always issues with interpretation, issues with guidance and issues with advisory material that needs to be developed. We are working through those now. MAKING AN IMPACT However, for Geltz, the FAA s requirement to fit all helicopters with HTAWS is having an impact. According to the final rule, published in the Federal Register in February 2014, no person will be able to fly an air ambulance after April 2017 unless it is fitted with HTAWS. Existing equipment must also comply with the FAA s Technical Standard Order (TSO) C194 requirements. The issue that we have is that the industry has been installing terrain warning for a number of years, even before the HTAWS TSO was established, said Geltz. The FAA is going to require us to go back and, even if it s the exact same equipment installed on the helicopter from five years ago Helicopter Replacement Windows It s more than a window it s a point of view. For 45 years, Tech-Tool Plastics has focused all its efforts on manufacturing replacement windows that fit better, last longer and far exceed OEM standards. It s a philosophy that s reflected in everything we do and every window we make. Contact Tech-Tool Plastics today and see for yourself info@tech-tool.com Volume 9 Number 1 February/March 2015 RotorHub

5 28 Feature HEMS compared to today, we re having to go back and recertify those aircraft to the TSO standard, which is a huge impact. [The industry is] looking at equipping one aircraft a week through the 2018 deadline. So it s a pretty tall mountain to climb. Then we have the ADS-B requirement in As well as technology, the rules will also cover stricter flight rules and procedures. All operations with medical personnel on board will be conducted under stricter Part 135 operating rules. Previously, these were only followed during flights with patients on board. New weather minima and visibility requirements will also be introduced along with flight planning, pre-flight risk analyses and safety briefings for medical personnel. The FAA will introduce stricter regulations this year for the HEMS industry covering technology, flight rules and procedures. (Photo: Airbus Helicopters) TAKING CONTROL HEMS operators with more than ten aircraft will also have to establish an operations control centre by April 2016 to help with risk management and flight monitoring. Despite the new rules, a concern that remains for many industry groups is the lack of airspace infrastructure to facilitate safe air medical operations. A concern for many is the lack of airspace infrastructure to facilitate safe air medical operations. Airwolf TT Straps IN STOCK for: Bell 204, 205, 210, 212, UH-1 Bell 206 Jet Ranger, Long Ranger, OH-58, Enstrom (36 month) RotorHub February/March 2015 Volume 9 Number 1 Helicopters don t operate on the established airways, said Winn. We operate at much lower altitudes so we don t have as many resources as commercial aviation does. We are trying to work with the FAA to correct that. One big problem, according to Winn, is accurate weather We use Airwolf s TT Straps and are glad that someone is helping keep our Bell helicopters flying while reducing costs. Alfonso Garcia, Great Slave Helicopters. Phone: predictions for the airspace that EMS helicopters operate in. Industry groups such as NEMSPA, the AAMS and Helicopter Association International have called for the establishment of a low-altitude IFR infrastructure to include associated approach and departure procedures to facilitate a seamless transition from VFR to IFR operations. In February 2008, three people died when an AS350 air ambulance crashed in South Padre Island, Texas, while attempting to pick up a patient complaining of chest pains. Factors contributing to the accident included operating at night and the pilot s inadvertent flight into instrument meteorological conditions (IMC) and lack of instrument flying experience. The NTSB believes accidents like this can be prevented if the pilots fly in a structured lowaltitude IFR environment or have access to additional weather data from remote locations. The pilot would have been better able to cope with IMC because of the availability of an IFR return. Improving low-level infrastructure will likely reduce the pressure pilots face to maintain VFR-only flight, especially in poor weather conditions. Some of the new FAA rules have addressed this HEMS pilots in command will now have to hold an instrument rating and require handling tests in flat light, whiteout and brownout conditions, as well as demonstrating competency

6 Feature HEMS 29 in IMC recovery. The instrument rating rule for pilots comes into effect at the same time as the HTAWS and radio altimeter requirement, the FAA confirmed. LIGHTING THE NIGHT Notable for their absence in the FAA s new rules is a requirement for NVGs. Winn, who is also the safety officer for Intermountain Life Flight in Salt Lake City, said the devices are one of the most useful pieces of equipment during EMS operations, and many at NEMSPA wish the FAA had mandated their use. To get information [from HTAWS] you have to bring your head inside the cockpit and look at the display, whereas with the NVGs if you re dealing with darkness you don t even need that display because you can look out and see that hill in front of you, he said. Not only that, but if you have an engine failure and have to find a place to make an emergency landing then the HTAWS won t help you there. With NVGs you can look off to your left and your right to find the opening of the field you need to land the aircraft in. The FAA had considered allowing operators to use NVGs or other such systems as an alternative to HTAWS. However, in the final rule the FAA states they may not be appropriate for all operations and further research must be carried out to determine their benefits and limitations. It was our position, and remains our position, that NVGs should be a required piece of equipment for night flying, asserted Eastlee. While not mandating NVGs, they are strongly recommended by the FAA, which has revised the weather and visibility requirements for NVG-equipped aircraft that allows operators to fly in slightly lower weather minima. This increases the incentives for operators to equip fleets with NVG equipment, explained Winn. There has been a very large move within the industry towards the use of goggles there are not that many that aren t using them right now, he added. Geltz confirmed to RH that Metro Aviation s fleet is now fully equipped with NVGs. That was our requirement, and actually most of the hospitals had it as their requirement, he said. Meanwhile, at HealthNet Aeromedical Services Burley said his organisation was an early adopter of NVG technology. We always have all three crew members under goggles and each aircraft has four sets of goggles assigned to it, so if there is a goggle set that goes out for calibration or maintenance then we always have three sets of goggles, that s just the level of investment that we ve made. NVGs and HTAWS are just two examples of how industry is looking to technology to help increase safety for both crew and patients. However, as with other technologies such as unmanned aircraft, FAA regulations can struggle to keep up with the blistering pace of development. The FAA had considered allowing operators to use NVGs as an alternative to HTAWS. Technology will always move faster than the red tape and that s going to be our challenge for the foreseeable future, concluded Eastlee. The next five years will likely present many more challenges for the US air ambulance sector, particularly as the evolving market and new safety regulations cast a shadow over all aspects of operations. Nevertheless, air ambulances will continue to play a vital role in the modern US healthcare system, enabling shorter transit times for critically ill patients and allowing greater access to care for remote communities. RH Volume 9 Number 1 February/March 2015 RotorHub