Thoughts on EMS safety

May 13, 2009 by Tim McAdams

Over the past year 28 people have died in EMS (emergency medical services) aircraft crashes. The industry is experiencing one of the worst accident rates in its history. Solving this problem is a complicated issue for sure, however I have some very basic thoughts on how this problem can be fixed.

Flying an EMS helicopter was some of the most demanding flying I have done. Flying at night and landing on streets or other confined areas, having to make quick weather decisions sometimes with little information available, and having to block out the pressure to fly. Yet many EMS helicopter pilots receive the minimum amount of required training.

Conversely, when I flew a corporate helicopter it was normally airport to airport or heliport. The occasional off-airport landing was performed, however it was planned and I had plenty of time to assess the area. This was far less demanding and risky than flying an EMS helicopter. Yet, it was also where I received the best and most consistent training. We had the time and resources available to practice our skills and FlightSafety training every six months.

Corporate helicopters are not expected to make money and the person who has the authority to cut training expenses normally rides in the back. That’s a strong motivator to ensure that the pilots know what they’re doing. EMS helicopter operations by contrast need to make money and that means keeping a close eye on costs. Also, because of the competitive bid process hospitals use when selecting vendors, margins are thin. Training costs come right off the bottom line. If a vendor increases its training costs and the others do not, then that vendor is at a competitive disadvantage. Hospital-owned programs are also in business to get patients to their hospital and make money.

To level the playing field, I think two requirements are needed. The first is more frequent and comprehensive training. Not just training in maneuvers but scenario-based training that addresses issues such as crew coordination, judgment, and accident chains to name a few. Additionally, more IFR and inadvertent IMC training, even for VFR-only programs, is needed. Pilots need to be very comfortable initiating a climb and not descending if they get caught in bad weather.

This type of training can be done in simulators. Simulators are not only good for showing pilots how to do things correctly, but can also show how quickly a bad decision can degenerate into a serious problem. That’s a powerful learning tool.

Second is better equipment, such as terrain avoidance and warning systems and night vision goggles. In addition, important in adding new equipment is providing the appropriate level of training on how to use it effectively.

Another issue that should be addressed by the industry is pilot salaries. I have known many very good pilots that have left EMS for better paying jobs. This has made EMS a steppingstone for pilots to get to something better. EMS flying requires a very specific skill set and experience level. It should be the job that pilots aspire to get. Higher salaries will keep turnover down and keep experienced pilots in the industry.

I realize that all of my solutions cost money and that some operators will claim they cannot afford these programs. That is why training and equipment should be mandated for everyone who wants to operate an EMS helicopter. The difficult part is figuring out how the industry will get there.

The FAA has tried the quick and inexpensive solutions and they do not work. Case in point is the risk assessment matrix. Three years ago EMS pilots began filling out a questionnaire before each flight to determine a score that related to a risk level. The accident rate has gotten worse in the last three years.

As with most things in life, to get the best results one needs to spend the effort and money required. Cheap solutions are just that.


  • Avi Weiss


    Though I have not worked as an EMS pilot, I have a few friends who have. Each time there is an EMS helicopter accident, we have the same discussions, yielding the same analysis you came to above.

    That additional money will have to be spent on training and equipment to improve safety is a given. Unfortunately, those costs will have to be passed along to the patient. Without being too glib about it, if someone is in serious enough condition to require EMS support, the additional cost of EMS services is likely small compared to the medical services cost they will likely be receiving. I’m sure a hospital would rather bill extra for services rendered, that write a check as part of a settlement of an accident. Said another way, one accident in an EMS program will likely far offset ANY savings of money realized over the life of that program by scrimping on training and resources, to say nothing of the cost in lives.

    To avoid going to the draconian “mandated compliance” step and issuing a whole set of FARs (which would take years anyway), one quicker and more effective approach would be to create an EMS certification program (e.g. ESP – EMS Safety Program) that will bring a standardized “baseline” to each type of EMS operation, both in terms of aircraft capabilities and pilot/crew training, similar to what the tour industry did with TOPS.

    Pushing for the highest level of aircraft capabilities and pilot experience and training will meet resistance from the community who are trying to protect their financial interests, and could result in nothing being accomplished. So the certification program could be divided into levels, with each level predicated on mission type, starting from the “lower risk” operations and working up to the “high risk” operations, much in the same way ratings are used in aircraft and airman certification. Potential certification levels could be as follows: 1. Inter-facility / airfield transfers only 2. Inter-facility transfers, one or more facility helipad stop 3. Scene call – day VFR only 4. Scene call – day/night VFR only 5. Scene call – day/night, VFR/IFR.

    Each increasing level would require specific aircraft and airman training requirements be met before the operator would be “certified” to operate under “ESP” for a particular mission type. The industry would come up with the levels, operating requirements (multi-engine, SVS, dual crew), and crew training programs, and the FAA could promote it as a “highly recommended” safety program, stopping short of issuing any regulatory material to see if self-certification works like it did for TOPS.

    Having a well-publicized program sanctioned by insurance companies, the FAA, and hospitals would push operators to participate in the program, or lose business to those operators who do participate. Once the majority of operators are working at the same “cost basis”, there will be little to no competitive cost advantage to using one operator over another, and while the total costs will rise, so will the life expectancy of those flying and using EMS services.

  • http://AOPA echomike

    Well thought out solution and commentary. So few hospitals are able to rise above the budgetary meeting level in considering program costs. This is because the hospital CFO and the hospital legal team know nothing about the reqirements of safety. The aircraft provider is a service vendor and the pilot is a necessary evil in their minds. They are incapable of understanding the financial impact of a serious (is there any other kind?) accident. Safety, and recurrent training are time and money dependent but have a short term of effectivness. The checks just keep on needing to be written with no “visual benefit”.

    Write a check for a new MRI machine and the whole hospital gets news coverage, more business and they can see it everyday. Write a check for aircraft systems enhancement, safety or training programs and (assuming they work) nothing happens.

    Underbid a contract for a hospitals Lifeflight program and everybody from the hospital administrator to the janitorial staff see it as a way to save money. They simply are incapable of comparing that with the often decades long litigation chain associated with an accident. It is very easy to cause an individual hospital or even a county wide hospital system to go into bankruptcy over an accident. If the operators and the hospitals can’t or won’t develop a safe and workable system, the public and the legislators will. Costs will only go up.

    The only way to decrease the accident rate is to fund multi-pilot, day/night full IFR, GPS, NVG, SVS, FLIR, autopilot supported aircraft that have the lifting power and range to do the mission anywhere on the planet.

    Clue: Look at what it takes to safely fly the North Sea oil patch, or the Coast Guard in Alaska, 24 hours a day, 365 days a year. It takes big complex machines operated by well qualified, fairly compensated crews, that are trained, supported and monitored by professional organizations who’s interest is safe reliable operations NOT the annual budget. Safety is not cheap, but it is cheaper than the alternative.

  • http://AOPA echomike

    P.S. Echomike has over 20,000 hours, 46 years flying and has flown helicopter based medical evacuation both in combat and stateside hospital (civilian and military) programs. He presently captains large International corporate jets worldwide that are equipped per the opinion above. Love that heads Up Display and FLIR. –echomike–

  • Kevin Carbone



    We have added features to eSectionals(tm) to make it easy to
    comply with FAA A021. eSectionals(tm) now includes the FAA Obstacles
    Database and the FAA Airports DataBase and the FAA Chart Bulletins.

    First, you must know that Sectional Charts are NOT ACCURATE. If you
    attempt to comply with A021, you cannot do it or you cannot properly
    find the obstacles along your route. The reason is simple. The FAA
    marks up Sectionals in such a manner so that items do not conflict
    with other nearby items. This includes both the Airport and Obstacle
    locations. Since eSectionals, via the FAA Airport and Obstacles Database,
    displays their actual locations on the Sectional, when you draw a route,
    eSectionals finds those locations and generates the report automatically.

    The ONLY way you can use a paper Sectional to comply with A021 is to draw
    your route and then span the route about 1/2 inch either side of the route
    to find the obstacles. Do you have the time to do this while some accident
    victim waits for your service?

    We are also adding the National Elevation Database so that eSectionals
    reports the highest terrain. We have to make this addition slowly since
    the Elevation Database has to be ordered from the USGS and presently
    takes about 8 weeks. Even so, we have added parts of the Elevation
    Database for some selected HEMS bases.

    If you wish to see how eSectionals works, download our HEMS User Guide

    For more information, call Fred Stevens (VP Sales) or Kevin Carbone (CEO)
    at ED/iT Aviation Products Division, (800) 987-3282.

  • Ray Johnson

    You hit everything right on the head. Absolutely, training is the key, but the type of training has got to be good, and demanding. That is, don’t just check the boxes, but in single pilot flying, when things start stacking up, especially IIMC, the pilot must be able to cope with the situation. During training, stack the deck on the flying pilot to the point where lessons are learned and then grade him on how he/she handled the situation. Case in point, the airline that crashed last year because of icing. Poor training? Were the boxes just checked to cover all the bases, and the quality lacking? We continue to sell crew coordination, because of the pilots that crashed in the Florida everglades where they became fixated on the landing gear light and flew the aircraft into the ground. Do we grade on crew coordination? Believe me, there is nothing more stressful as flying single pilot in IIMC, in busy airspace, tuning freq. setting up the approach, making sure everything is in order before descent, auto-pilot engaged correctly, and heaven forbid you also have an aircraft emergency to boot and approach control is cutting you short on your final and you are NOT ready to begin the approach because you have not doubled checked your setup. Simulators are great for training. I know cost effectiveness is the key, but if you have experienced pilots, with decent pay and good working conditions, they will stay.
    I have been flying helicopters over 40 years, EMS since 1988 (Maryland State Police, trooper/pilot from 1990-2007), military SIP and instrument examiner since 1970, and currently flying EMS. I agree with everything you have pointed out. In the military we always say, “Train like you fight.”

  • Doodybutch

    I see the results of these flights from the medical perspective as I am a physician and I often receive patients transported by medical helicopter.

    Helicopter transportation is extremely expensive compared with ground ambulances. The typical transport I see has travelled less than 120 statute miles and the cost is $12,000 or more. Ground transportation typically costs less than 1/4 of this amount. The large majority are hospital-to-hospital transports, not from accident scenes. The cost often represents an extreme financial hardship to patients and families who are uninsured and they are seldom informed of the cost or alternatives prior to the transport.

    The presumption is that transportation by helicopter is safer because the personnel are better trained and the patient is moved quickly and efficiently. In published studies, this has been very difficult to prove and only a small proportion of typical patient transports by helicopter involve unstable patients who would demonstrably benefit from a few minutes less transportation time. Obviously, there are real concerns that any improvement in medical outcomes using helicopters may be more than offset by the crashes.

    In my opinion, most medical helicopter transports are unnecessary and they represent a poor expenditure of healthcare dollars. Most of these programs should be scaled back a lot. In large cities, for example, each hospital typically has their own helicopter or often multiple helicopters used to compete for patients. There is obviously pressure to use them all the time.

    Families and patients should be informed of less expensive alternatives unless an extreme emergency exists. I think most would choose ground transportation if they were given informed consent of the benefits, expenses, and the potential for serious accidents.

  • http://none carey westall

    I have never understood why the medivac helicopters are not required to have GPS terrain as all WAAS units provide today. My 430/530 units provide safety at night and have seen several helicoopters in the bay area(SFO) go down at night with impacts to structrues. Why not make this a requirement.

  • Snowbeard

    I’m one of those pilots who left a helicopter EMS company for a signifacantly higher paying job in aviation. As a helicopter instructor and instrument examiner, with several thousand hours of helicopter time, I was working for half the salary of the nurses in the back of my helicopter. You get what you pay for.

    Nowhere else in aviation will you find find a lone pilot “down in the dirt”, landing at isolated sites, in the middle of the night, without current weather, lead in lights, PAPI, or any other enhancements. Then you get to add in the pressure, real or imagined, to save the patient, save the programs reputation, or to out perform a competing program.

    NVG’s will greatly assist the cause of safety on those flights flown at night, less then 20%. The FAA themselves are unfimiliar with the NVG system. It seems difficult to find anyone within the FAA willing to sign their name to any NVG program. I have taken a FAA inspector on a typical day/VFR training scenario and only suceeded in scaring them. They never again offered to ride along. The inspector certainly wasn’t going to be foolish enough to risk his life again and ride at night. Until the FAA gets a few EMS veterans in their staff, and then does the unimaginable…listens to them, the carnage will continue. At present, the only entity really demanding any experience in the cockpit are the insurance companies. We have come a long way from the “two pilot, 24/365 day program”. We will kill more before it gets better.

    Hospitals need helicopters EMS programs for the advertisement, not for efficient patient care. No self respecting hospitals will ever go to a national convention without a helicopter picture on their brochure. Hospitals, including their business offices, never complain when a helicopter brings a “cash cow” patient to their site. It’s all about the money…

    In my opinion, the easiest, quickest fix is for the FAA to mandate two qualified and trained pilots on every flight. That scramble for pilots will significantly add to the pilots wages. The only way we got away from the old “two pilot’s and a helicopter” program was an FAA mandate. All the newest “gee whiz” equipment, all the big horsepower two engine systems, all the new tracking systems, etc, combined will not add as much to safety as two pilots working on the same scenario. It then takes two to make a fatal mistake.


    Thanks for the excellent perspective Tim. As a full time helicopter EMS pilot and company instructor pilot / check airman, I can second your article as an accurate reflection from the field. The industry gives a great deal of lip service to “safety” and the importance of a “safety culture” but are unwilling to spend the money for solutions that WILL SAVE LIVES. We’re not asking for much, just a few more blade hours for training and proficiency and heaven help a little newer equipment to help us do our job.

    Hey Doc (Doodybutch) you’re right about many unnecessary flights and informed consent from the patient/family. But we save lives all across the country every day. It might be a small percent, but that life counts when it’s your loved one that is critically ill or injured. Let’s be cautious about scaling back resources that may be desperately needed “when seconds count.”

  • Winfield

    A lot of great valid points about training, equipment, operationl safety margins, experience, and personal safety limits.
    However, I didn’t see anything about the state-of the -mind of an EMS pilot.
    As a retired military aviation safety officer/investigator, I also considered the psycological state of the pilot.
    Did he/she have “mission fixation”?
    EMS operations can mean the life or death of the patient, and pilots know this. Do they take more chances, exceed their personal safety limits/capabilities or try to exact more performance from their machine than it is capable of giving, all in the “heat of the moment” to accomplish what may be a herculean task.
    This WAS a problem in Vietnam because very often, in combat, the mission took precedence over common sense, the experience level of the crew, and the capabilities of the aircraft. Since, there were a great many successes, inspite of the odds, a lot of crews continued to stretch their luck until it just ran out.

    So, perhaps EMS crews need to be constantly evaluated to make sure they don’t consistantly operate beyond the previous mentioned capabilities. Thus, management can play a major role in reducing the accident rate by reading and reviewing each flight to determine whether the crew was operating reasonably.

  • Fred Stevens

    eSectionals not only includes features to assist in A021 Compliance but has just added Search And Rescue flight planning. It automatically creates routes for two aircraft flighing a back and forth search pattern. Takes only seconds and you can export the routing to DeLorme’s Topo software. Or, using the eSectionals companion software, ePilotage, you can view a moving map chart on your TabletPC in-flight. It also prints NorthUP or TrackUP TripKits or continuous FlightStrips. About 50% of the AirMed (HEMS) providers are using eSectionals US Edition.