Air Medical Service (AMS)

Is Air Medicine Unique: the role of system design in improving safety.

Sophisticated emergency care is an expectation of the public in the developed world, including the deployment of helicopter emergency medical services (HEMS). As with much in medical care, there has been limited appreciation of the effects of system design in the expected and measurable attributes of HEMS system performance, including safety. HEMS, in contrast to other aviation sectors, requires an inordinate level of public trust due to the uniqueness of the passenger, a critically ill or injured patient in a time sensitive event who is not given usually given a choice of air carrier much less carriage.

Regardless of corporate organization, safety in air medicine can be thought of as a three legged stool with clinical imperative, aeronautic reality, and financial stability in constant tension. With an increased focus on both medical error and transport accidents, aviation medicine is under renewed scrutiny as to the value of this capital intensive medical technology. Managing simultaneous clinical and transport risk within a fiscally challenging marketplace is significant operational challenge. Responsibility for the three legged triangle is generally shared among multiple managers with significantly different professional backgrounds and experience. Further complicating the equation, are 24 hour operations, often conducted with multiple remote bases with minimal direct management oversight.

High performance EMS systems have recognized that system design is the single most important determinant in long term clinical quality, operations excellence, and fiscal performance. Further, it is clear that talented and motivated people can produce good results despite poor system design, but not for extended periods of time. Alignment of decision making incentives and disincentives across the safety triangle are essential components of system design. Poor design, with imbalance in the competing pressures pulling and pushing on each leg and failure to appreciate the design equation introduces additional risk into operations, regardless of the skills and efforts of the managers and personnel involved.

This presentation examines the role of system design in improving HEMS safety and proposes management strategies and metrics to improve operations safety across the safety triangle with a focus on one accident examined in an extensive Root Cause survey conducted by a team developed by the Association of Air Medical Services (AAMS), the National EMS Pilots Association (NEMSPA), and Helicopter Association International (HAI), as well as manufacturer representatives. This particular accident, a multiple fatal crash of a medical aircraft into Casco Bay east of Portland, Maine is used to highlight the issues of design in developing and implementing air medical services.

This presentation will examine clinical as well as aviation drivers that effect safety of operations and patients and highlight a values driven design process for implementing and operating an air medical program. .

The full report of the Root Cause study is available from www.aams.org AIR MEDICAL SERVICE SAFETY SUMMIT Accident Analysis Final Report (September 24, 2001)

TABLE of CONTENTS Executive Summary ...... 1 Background ...... 3 Detailed Process ...... 4 List of Recommended Intervention Strategies ...... 6 List of Interventions Not Recommended ...... 7 Appendix A: Event Sequences Appendix B: Problem Statements Appendix C: Intervention Strategies Appendix D: Effectiveness Rating Appendix E: Feasibility Rating Appendix F: Matrix Development

Executive Summary In response to a series of Air Medical Service (AMS) helicopter accidents in 1998, 1999 and continuing into 2000, the AMS industry convened an Air Medical Summit on April 7, 2000, in Dallas, TX. In an effort to identify ways by which such accidents could be prevented in the future, the Air Medical Service Accident Analysis Team was created.

Between 1987 and 1997, there were on average four air medical helicopter accidents per year for the industry. By 1997, the accident rate for helicopter AMS operations had been reduced to 1.97 accidents per 100,000 flight hours from a high of 17.08 in 1987. In 1998, however, the number of accidents rose to a nine year high of seven, but more alarming was the rise in fatalities to fourteen, the highest number since the peak year of 1986. In 1999, the number of accidents rose even further to ten, the highest also since the peak year of 1986. Fatalities were down to ten but still higher than the average of six.

To address the issue of safety, the Association of Air Medical Service, in consult with HAI, the National EMS Pilots Association (NEMSPA), the National Flight Paramedics Association (NFPA), the Air & Surface Transport Nurses Association (ASTNA), the major air medical service operators and aircraft manufacturers, convened the Air Medical Safety Summit in Dallas, TX, on April 7, 2000, to discuss safety within the air medical service industry.

In a process very similar to that used by the FAA’s “Safer Skies” Joint Safety Analysis Teams (JSATs) in their recent study of weather and controlled flight into terrain (CFIT) accidents, the Safety Summit attempted to identify what prevalent factors existed in AMS operations that tended to degrade safety. With insufficient time at this particular meeting to conduct an in-depth cause analysis, the identification of accident causes was based primarily on opinions and speculation. However, several broad areas were identified, including: a lack of training (recurrent, CRM, weather, decision making, etc.); an administrative culture that too often does not place safety first; inadequate technologies; and other human factors (fatigue, cockpit overload, sense of mission urgency, inadequate piloting skills, etc.) Although the Summit arrived at a variety of perceived causes of air medical accidents, no comprehensive analysis of accidents had been conducted. Therefore, the Air Medical Service Accident Analysis Team was formed to conduct an in-depth analysis of air medical helicopter accidents to identify the chain of events that has led to accidents and to identify intervention strategies that would be both effective and feasible in preventing such accidents in the future. The Team’s purpose was to analyze past AMS accidents to identify the root causes of the accidents, and to identify effective and feasible interventions that would prevent future accidents.

Although some accidents may have been caused by mechanical malfunction, improper maintenance or structural failure, it was deemed that the focus of this accident analysis would be on the human factor elements involving the pilot, flight crew or others directly involved in the conduct of the accident flight. By addressing human factor accidents, the intervention strategies identified would have the broadest and most immediate effect on reducing the number of accidents and enhancing the safety of AMS operations.

The Team reviewed 20 air medical service helicopter accidents that occurred between November 1993 and November 1999. These accidents were selected for the richness in data contained in their Final NTSB Accident Reports. The process by which these accidents were analyzed was patterned after a similar process referred to as “root cause analysis” and employed by two Joint Safety Analysis Teams (JSATs) chartered by the FAA under its “Safer Skies” Initiative to study the causes of and develop interventions for accidents involving weather and Controlled Flight Into Terrain (CFIT).

Under this process, the Team reviewed each accident to develop a timeline of events to include the period of time prior to the flight, preparation for the flight, conduct of the flight and the direct events of the flight during the accident. Throughout these timelines, any and all “problems” that could have contributed to the accident were identified. After all accidents were completely analyzed and all problems identified, the “problem statements” were consolidated to combine common problems and thus eliminate duplication. A total of 56 individual problems were identified. These problems were then classified into various groupings for easier consideration: pilot performance issues (23 problems), aircraft issues (9 problems), landing zone issues (5 problems), environmental issues (6 problems), corporate and/or program management issues (4 problems), and infrastructure issues (9 problems).

The Team then reviewed each consolidated Problem Statement to identify possible interventions that might have prevented each particular problem, as well as the associated accident. At this stage of the process, an intervention’s effectiveness or feasibility was not yet directly considered. The criteria for listing interventions were based solely on whether they might have prevented the accident from occurring. After each problem was reviewed and intervention strategies identified, the interventions were consolidated to combine common ones and eliminate duplications. Sixty-five distinct interventions resulted. These interventions were grouped into several classifications depending upon their nature: Training Interventions, Equipment Interventions, Air Traffic Management Interventions, Regulatory or FAA-sponsored Interventions, National Airspace (NAS) or Infrastructure Interventions, and Miscellaneous Interventions. Within these groupings, interventions were numbered and then applied to each problem statement with which it was identified. Each intervention, therefore, can be traced back to an associated accident.

Once a consolidated list of interventions was determined, the Team then evaluated each intervention for its effectiveness. Drawing on the experience and expertise of all team members, the interventions were rated for high, moderate or low effectiveness in preventing the problems with which they were identified. If the pilot had had access to the intervention during the accident flight, would the intervention have been effective in preventing the accident? The scoring was based on 3 points for High Effectiveness, 2 points for Moderate Effectiveness, and 1 point for Low Effectiveness. The total score from the Team was assigned to each intervention, and all interventions were then ranked in order of their Effectiveness score. The aggregate score was divided into thirds to establish groupings of interventions that rated high, moderate and low effectiveness. The maximum possible score was 21, and the lowest score given was 8. Interventions ranking from 21 to 17 were classified as having High Effectiveness. Those ranking from 16 to 13 were ranked as Moderately Effective, and those interventions scoring from 12 to 8 were ranked as having Low Effectiveness.

The next step was to evaluate each Intervention for its feasibility. The Team was tasked to rank each intervention based upon four categories: Technical Feasibility, Financial Feasibility, Regulatory Feasibility, and Operational Feasibility. If an intervention was easy to implement, off-the-shelf technology, inexpensive, did not require regulatory change and would be well accepted by the industry, it was considered highly feasible. If it required some further technological development, involved some level of funding, required some level or degree of FAA review or approval, or if the intervention might meet some resistance by the AMS community, it was ranked as moderately feasible. If the intervention involved technology that was not well along in development, involved significant expenditures, required FAA rule-making or regulatory change, or would meet significant resistance within the air medical service industry, it was given a Low Feasibility rating. Within each category, high feasibility was given a score of 2; moderate feasibility was scored a 1; and low feasibility was given a score of 0. Thus, the maximum score for each intervention from each team member was 8, and the lowest score was 0. Each intervention was ranked based upon its total score. Cumulatively, the maximum score possible was 48, and the lowest score possible was 0. The scores on all sixty-five interventions ranged from 48 to 13. The aggregate score was divided into thirds to identify High, Moderate and Low Feasibility interventions. High feasibility interventions scored from 48 to 37, moderate feasibility interventions scored from 36 to 32, and low feasibility interventions scored from 31 to 13.

With all interventions ranked by effectiveness and feasibility, they were charted accordingly and compared against each factor. Some interventions ranked highly effective and highly feasible, but others were highly effective and low in feasibility. Some were highly feasible but low in effectiveness. Others, still, ranked low in both effectiveness and feasibility.

Having thus completed a thorough analysis of human factor-related AMS accidents, the Air Medical Service Accident Analysis Team has developed a list of intervention strategies that have great potential for preventing such accidents in the future. It is the recommendation of the Team that the Air Medical Safety Advisory Council (AMSAC) review these findings and focus efforts within the air medical service industry on developing implementation strategies for those interventions that are highly effective and highly feasible. AMSAC should also consider interventions that are highly effective but moderately feasible, as well as interventions that are highly feasible but moderately effective. If time and resources permit, AMSAC should also consider interventions that are moderately effective and moderately feasible, as some of these interventions may require only modest implementation but may have some impact upon the enhancement of safety. However, those interventions that are identified as low in effectiveness, low in feasibility, or both, should not be pursued.

The interventions that ranked high in both effectiveness and feasibility are:

 Enhance the training for night flying operations  Enhance the training for mountain flying operations  Equip aircraft with Terrain Avoidance Warning Systems (TAWS)  Equip aircraft with Radar Altimeters  Provide aircraft with mission essential equipment  Improve the content of weather briefings Timeline and Problem Statements 3640 hrs m/m; 345 hrs NTSB Number: BFO94FA013 Night/ IMC instr; Date: 11/19/93 1218 nite hrs TIme: Event: Problem Statement: Remarks: n/r Aircraft dispatched to pick up a burn victim in Ellsworth ME

Conditions of brief not n/r Pilot obtained FSS wx brief reported approx 1800 EST Aircraft airborne under VFR

Arrived Ellsworth, ME; picked up patient, enroute Inadequate preflight 1912 EST back to Portland, ME Departed w/ 310 lbs fuel planning

Company Operations Wx: 400ft ovr, 2 mi vis, n/r Encountered IMC Manual: winds night x/c minimums require 1200 ft/ 4 mi vis 13G19 knots

Encountered headwinds of n/r 40 60 knots

Company Operations Pilot obtained IFR Manual: for EMS clearance to PWM procedures the minimum n/r Portland, ME acceptable wx. is VFR

Pilot receives vectors to n/r Runway 11

"Low Fuel" warning may During approach, "Fuel illuminate even w/ 215 lbs. Low" caution light fuel, Assume only 10 gal. n/r illuminated remain

Pilot requested straight-in n/r approach to Runway 29

Inadequate preflight Fuel 310 lbs at t/o; burn rate planning; insufficient fuel for of 220 lbs / hr. = 1+24 hrs. to Engine loses power due to mission in existing flameout (t/o 1912 EST + 2039 EST fuel exhaustion conditions 1+24 hrs = 2036 EST) Aircraft flotation unsuitable for sea conditions / No helmets on crew, crew Pilot autorotates to water; had not had formal 2039 EST hard landing, aircraft sinks egress in water training. 3 Fatal, 1 Serious