Air Medical Journal 35 (2016) 120e125. Contents lists available at ScienceDirect. Air Medical Journal

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Air Medical Journal 35 (2016) 120e125 Contents lists available at ScienceDirect Air Medical Journal journal homepage: http://www.airmedicaljournal.

Medical Journal Safety Survey compiled industrywide information on elements of critical care helicopter safety.

Safety Board (NTSB) recommendations. This article is a quantitative representation of the survey findings for the purpose of illustrating trends; it intentionally does not interpret the findings.

1 Air Medical Journal 35 (2016) 120e125 Contents lists available at ScienceDirect Air Medical Journal journal homepage: Featured Article 2015 Air Medical Safety Survey Joe Coons, EMT-P 1, Christine Zalar, MA 2 1 LifeFlight Eagle, Kansas City, MO, USA 2 Fitch & Associates, LLC, Platte City, MO, USA The 2015 Air Medical Journal Safety Survey compiled industrywide information on elements of critical care helicopter safety. This survey sought to quantify and track trends in medical helicopter safety-related equipment and safety practices, using the FAA mandatory changes for and previous National Transportation Safety Board (NTSB) recommendations. This article is a quantitative representation of the survey findings for the purpose of illustrating trends; it intentionally does not interpret the findings. Methodology The survey instrument consisted of 59 questions (Appendix 1, available in the online article at addressing the areas of aircraft safety equipment, safety practices, medical crew configuration, safety management systems, fatigue management, crew workload, and training. The survey was conducted in November and December The survey invitation was directly ed to known air medical providers, and a link to the survey was distributed via the membership of Air and Surface Transport Nurses Association (ASTNA), Air Medical Physician Association (AMPA), Association of Air Medical Services (AAMS), International Association of Flight & Critical Care Paramedics (IAFCCP), and the National EMS Pilots Association (NEMSPA). Surveys were completed anonymously. Respondent refers to an air medical service, program, company, or governmental unit that submitted a completed survey. Only those respondents that included medical helicopter services as their model of transport were included in the results. There were 313 completed responses, representing 422 aircraft bases (Fig. 1). Although not specifically measured through the survey, the number of aircraft is estimated at 550 helicopters, based on the reporting. Responses were received from programs in the United States (305), Canada (4), Saudi Arabia (1), and other (3), all of which were included in the results. US respondents were divided into geographic zones (Fig. 2) in attempt to group programs with similar geography and weather. The data in each zone were reviewed to ensure no duplicate submissions were received. All survey results have been rounded to the closest integer for ease of reporting. address: czalar@emprize.net (C. Zalar). Survey Respondents Profile The respondents characteristics are highlighted below: Nearly all (98%) were US based: 50% were hospital departments or hospital standalone programs, 15% were shared risk/join venture, 27% standaloneeprivately held, 3% governmental, and the remaining 5% listed as other. Three-fourths offer multi-modal medical transport services: 31% have helicopter and ground critical care transport (CCT) services; 24% have helicopter, airplane, and ground CCT; 26% provide helicopter only; and 19% have fixed-wing only. Of the estimated 550 helicopters reported, 54% are singleengine aircraft and 46% are twin engine. There was nearly an equal distribution between part 135 certificate holders (49% of respondents) and those contracting with a non-related company for aviation services (51%). Transport Profile Respondents were asked to report the number of bases they operate, their average annual transport volume, single- versus twin-engine airframes, and the hours their aircraft are staffed. Thirty-seven percent of respondents reported operating 5 bases or more, and 24% reported having only 1 base (Fig. 3). The average number of patient transports per base was annually (42%), followed by flights at 22%, resulting in 64% of the bases transporting less than 500 patients per year. As the number of respondent bases increased, the average number of transports per base declined (Fig. 4). Respondents reported that 58% of the bases are staffed 24 hours with a single-engine aircraft, and 37% are staffed 24 hours with twin-engine aircraft. Twelve-hour staffing was reported 4% of the time in bases with single-engine helicopters and 9% of the bases with twin-engine aircraft. Differences arose when a respondent reported 5 or more bases. The single-engine, 24-hour staffing increased to 65%, and the twinengine, 24-hour bases dropped to 30%. Additionally, the 12-hour, single-engine average rose 8 to 5% and the 12 hour twin engine base average dropped to 2%. Fifty-eight percent of respondents have aircraft that are equipped for instrument flight rules (IFR), and 84% of pilots are current with their IFR certifications. Single-pilot IFR was reported by 66% and dual-pilot reported by 11%. Forty-seven percent of IFR X/$36.00 Copyright 2016 Published by Air Medical Journal Associates.

2 J. Coons, C. Zalar / Air Medical Journal 35 (2016) 120e Zone A Zone B Zone C Zone D Zone E Zone F Zone G Zone H Zone I Figure 1. Base Locations. programs reported that they fly 10% or less of their total flights IFR in IFR conditions (Fig. 5). Aircraft Equipment The aircraft equipment surveyed was selected to compare the fleet s status to the NTSB recommendations from 2009 as they relate to the helicopter air medical industry as well as the Helicopter Air Ambulance (HAA)-specific regulations of the Federal Aviation Administration published in February Of the estimated 550 aircraft reported, 62% have autopilot capabilities: 32% are equipped with 2-axis autopilot and 30% with 3-axis autopilot. Radar altimeters were reported for 82% of the aircraft, 66% have weather radar, 67% reported having helicopter terrain awareness and warning systems (HTAWS) installed, and 21% are capable of using automatic dependent surveillanceebroadcast (ADS-B) systems. Some subtle differences arose between with programs with 5 or more bases. Two-axis autopilot equipment increased to 34% and 3-axis systems decreased to 28%. Decreases were reported in radar altimeters to 74%, weather radar to 62%, HTAWS-equipped aircraft to 63%, and ADS-B to 17%. Sixty-three percent of respondents reported having flight data monitoring (FDM). The most common reasons selected for installation were quality assurance (80%), incident investigation, and risk identification, each at 74% respectively; 55% of the FDM equipment was installed to identify maintenance needs. Cockpit voice recorders were reported by 25% of the respondents, and their reasons included incident investigation (91%), quality assurance (47%), risk identification (45%), and identifying maintenance needs (15%). Crew Configuration The primary staffing configuration is a nurse-paramedic team (92%). Aircraft were reported as shared with specialty teams in 61% of the survey responses. Neonatal and pediatric teams are involved in 82%, 11% share aircraft with balloon pump teams, and 7% with organ procurement teams. When a specialty team is onboard a shared aircraft, 70% of the programs require 1 of their regular crewmembers to accompany the team. In multi-modal programs, 34% of the staff rotates among the various transport vehicles during a given shift. Fourteen percent of staff have non-flight duties assigned during their shifts, including staffing in the emergency department, intensive care unit, firefighting, and law enforcement. If medical crews experience a low transport rate in the helicopter, 70% use online processes and competency checklists to keep crewmembers current in their safety practices, 18% use static simulations at the aircraft, and 2% fly as an extra crewmember. Ten percent of the respondents have no process in place. Staff Member Fitness Just over half (53%) of the respondents have a fit-for-duty program. For those that do have them, 65% conduct them annually and 52% on new hires (Fig. 6). Sixty-eight percent of the programs have a weight limit. Medical crewmembers are weighed quarterly (45% of responding programs), annually (26%), monthly (23%), every shift (5%), or weekly (1%). Fatigue management information was measured as there is limited data on the efforts of the HAA industry to combat fatigue. Sixty-four percent of the programs have a fatigue management system (FMS). Each FMS addresses fatigue in 1 or more of the following: 76% are based on employee awareness of the risk associated with fatigue, 67% have a quantification system that takes the aircraft out of service once a particular fatigue score has been reached, and 26% require manager approval prior to launch when certain criteria are met. Training Air medical resource management (AMRM) was recommended by the FAA in Advisory Circular 00-64, published in September Questions pertaining to AMRM were asked to gauge industry training in this area. Eighty-four percent of the respondents hold formal AMRM training annually; 6% provide it only upon hire, 4% on an as-needed basis, and 2% provide the training every 2 years. Four percent of respondents do not provide formal AMRM training. For those that do, 34% is provided by their air operator/ part 135 certificate holder (Fig. 7). Medical crewmembers participate 100% in AMRM, and pilots are reported as participating in 93% (Fig. 8). In regards to postaccident/incident plans (PAIP), 48% of the respondents reported performing drills annually, 34% quarterly, and 3% monthly. The remaining 15% of the respondents said they do not perform PAIP drills. Preflight Briefing and Debriefing Respondents were similar in the content of their preflight shift briefs: 98% include weather and associated special operations, 96% include scheduled maintenance, 96% discuss special variances such as MEL items, 95% cover special events, and 84% have specific topics on safety. Postflight debrief is performed after every flight in 85% of respondent programs. Other circumstances for a postflight debrief include request by a medical crewmember, pilot, or communication specialist (25%) and after unique anomalies (Fig. 9). Debriefing was reported by 98% of the respondent for medical flights; 82% debrief weather aborts, and 78% debrief maintenance aborts (Fig. 10). Respondents reported that 98% of the program s pilots and medical crews participate in the debriefing process; 63% include the communications specialists, 22% involve managers/supervisors, and 21% have maintenance personnel participate. Operational control centers regularly participate in the debriefing process 12% of the time. Safety Officers Eighty-nine percent of the respondents have safety officers. Of those safety officers, 55% are flight crewmembers (pilots, medical crew) who perform their safety duties in their

3 122 J. Coons, C. Zalar / Air Medical Journal 35 (2016) 120e125 Zone A Zone B Zone C Zone D Zone E Zone F Zone G Zone H Zone I Connecticut, Delaware, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont Maryland, Virginia, District of Columbia, West Virginia, Kentucky, Tennessee, North Carolina, South Carolina Louisiana, Mississippi, Alabama, Georgia, Florida, Puerto Rico Wisconsin, Illinois, Indiana, Ohio, Michigan North Dakota, South Dakota, Nebraska, Iowa, Minnesota Kansas, Missouri, Oklahoma, Arkansas Colorado, New Mexico, Texas Washington, Oregon, Idaho, Montana, Wyoming, Guam, Alaska California, Nevada, Utah, Arizona, Hawaii Figure 2. Survey Zones. One 24% Two Three 15% 16% Four 8% Five or more 37% 0% 5% 10% 15% 20% 25% 30% 35% 40% Figure 3. Number of Helicopter Bases per Respondent. T r a n s p o r t s Bases Fewer than Over 500 Figure 4. Transports per Base. downtime, while 23% are fulltime positions with no flight duties (Fig. 11). The experience/qualifications of safety officers were reported as follows: 50% are current/former medical crewmembers and 30% are current/former pilots. The remainder are aviation safety professionals (15%) and safety professionals with a background outside aviation (5%). The safety officer s duties include safety-related education for staff (90%), safety audits (80%), risk mitigation (80%), regulatory compliance (68%), incident/accident investigation (60%), and Occupational Safety and Health Administration compliance (53%). Safety Management Systems The primary resource for a program s safety management system (SMS) is their part 135 operator s program (53%), while 35% developed their own SMS, and 12% use a commercially available SMS product.

4 J. Coons, C. Zalar / Air Medical Journal 35 (2016) 120e IFR current pilots Single pilot IFR Dual pilot IFR 10% or less of flights have IFR segment 11% -15 % of flights with IFR segment 16% - 20% of or flights with IFR segment 25% or less of flights with IFR segment More than 26% of flights with an IFR segment 11% 13% 8% 5% 2% 47% 66% 84% 0% 20% 40% 60% 80% 100% Figure 5. IFR Operational Characteristics. Annually 65% Quarterly Monthly 2% 4% Upon new hire 52% After a work comp injury or significant illness 40% After a leave of absence 28% 0% 10% 20% 30% 40% 50% 60% 70% Figure 6. Fit for Duty Testing. Program Safety Officer 26% Part 135 Safety Officer 34% Staff Pilot 18% Outside contractor 12% Medical Crew member 3% Manager/supervisor 5% CEO/president Communication Specialist.3%.3% 0% 5% 10% 15% 20% 25% 30% 35% 40% Figure 7. Who Provides AMRM Training. Multiple components are included in the SMS; to each respondent selected all applicable SMS safety components that they already have in place. Of note were executive commitment and accountability (80%), identification of key safety personnel (84%), and Just Culture (87%). The full listing is in Figure 12. Safety Survey and Independent Safety Audits Fifty-five percent of respondents reported administering a Safety Culture survey annually, while 37% do not administer the surveys at all. Of those conducting safety surveys, 4% administer them every 3 years, 4% every 2 years, and 0.32% administer in 4- and 5-year cycles. Of responding programs, 49% have their Safety Culture surveys administered by an independent online program, and 51% are done internally. Preflight Walk-Around Eighty-five percent reported that they require the pilot and all medical crew to perform a pre-flight walk-around, 10% have the pilot only perform them, and 5% have the pilot and 1 additional crewmember complete them. Night Operations Night vision goggles (NVGs) were reported to be used in 96% of responding programs. In 64%, the pilot and both crewmembers wear NVGs, 27% have the pilot and 1 crewmember wear them, and 5% have only the pilot wear NVG.

5 124 J. Coons, C. Zalar / Air Medical Journal 35 (2016) 120e125 Pilots 93% Medical crew 100% Communication specialists 63% Maintenance staff 47% President, CEO, Vice-Presidents 19% Directors, Managers, Supervisors 57% Medical Director(s) 41% Figure 8. Who Participates in AMRM Training. After a negative event 17% Every flight 85% After unique anomalies during flights Aborted flights 16% 21% After receiving a complaint 10% When requested by a pilot, medical crew member, and/or communications specialist 25% 0% 20% 40% 60% 80% 100% Figure 9. Circumstances Driving Postflight Debriefs. Medical flights 98% Repositioning 32% Maintenance 37% Public relation 55% Weather aborts 82% Maintenance aborts 78% Figure 10. Types of Flights Debriefed. Full Time flight crew, safety duties during their downtime 55% 5 hours or less per week in addition to flight duties 7% 6-12 hours per week in addition to flight duties 8% More than 12 hours/week in addition to flight duties 7% Full-time position does not staff the aircraft 23% 0% 10% 20% 30% 40% 50% 60% Figure 11. Time Ascribed for Designated Safety Officer.

6 J. Coons, C. Zalar / Air Medical Journal 35 (2016) 120e Management Commitment & Accountability Key Safety personnel Identified Emergency preparedness and response plan 80% 84% 82% Formal SMS documentation and records process 75% Competencies and training 82% Formal Communication process 77% Reactive Risk Assessment 58% Proactive Risk Assessment Hazard identification and analysis process 84% 80% Management of change process and/or policy 65% Internal Safety Audits 80% External Safety Audits 46% Just culture 87% Figure 12. SMS Components Implemented. Pilot 100% Medical crew 99% Communications specialist 58% Maintenance technician 78% Operational Control Center 66% Figure 13. Who Can Cancel a Flight. Flight Cancellation All respondents reported that the pilot can cancel the flight, 99% reported the med crews can, 75% reported the maintenance technicians can, 66% said the Operational Control Centers can, and 59% said the communication specialists can cancel a flight (Fig. 13). Forty-six percent of the respondents require a formal debriefing when a flight is cancelled, 41% require a written report with a debrief, 8% do not require any formal follow-up, and 6% require a written report only. Search and Rescue (SAR) Operations In regards to SAR, 50% of the respondents reported that they do not participate in those operations, whereas 48% perform searches only and do not rescue. Of the remaining respondents, 3% have winching capabilities and 2% perform high angle rescues. Closing This safety survey demonstrates positive trends toward a number of the initiatives set forth by the FAA, NTSB, industry associations, and air operators.

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