Transcript Document

US Civil Helicopter
Emergency Medical
Services Accident
Analysis
Federal Aviation
Administration
Presentation to:
International Helicopter Safety
Symposium
Name: Matthew Rigsby
Date: September 26 –29, 2005
International Helicopter Safety Symposium
September 26-29, 2005
Federal Aviation
Administration
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FAA Aviation Safety (AVS)
Rotorcraft Directorate Standards Staff,
Safety Management Group - ASW112, Southwest Region
• We are part of the service arm of the FAA family involved in the
certification of new helicopters, modifications to and continued
operational safety of existing helicopters.
• Our mission is to provide the safest, most efficient aerospace system
in the world.
• Our vision is to continually improve the safety and efficiency of
aviation, while being responsive to our customers and accountable to
the public.
• Our values are based on a passion for Safety, Quality, Integrity, and
People.
International Helicopter Safety Symposium
September 26-29, 2005
Federal Aviation
Administration
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FAA EMS Task Force Preliminary Findings
• The number of Helicopter Emergency Medical Service (HEMS) accidents
have risen dramatically in recent years. In August 2004, an AVS task force
was assembled to review these accidents, to determine causal factors and
make recommendations to reduce them.
• Initial review shows that controlled flight into terrain, night operations,
inadvertent IMC, and lack of operational control are predominant factors
in the reviewed accidents.
• The majority of these accidents occurred beyond the geographic
boundaries of the Certificate Holding District Office (CHDO).
International Helicopter Safety Symposium
September 26-29, 2005
Federal Aviation
Administration
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U.S. Civil Type Certificated Rotorcraft Accidents
January 1998 – August 2005
Civil Rotorcraft Accidents:
Civil rotorcraft accidents:
Civil Fatal rotorcraft accidents:
1998
1999
2000
2001
2002
2003
2004
2005*
166
29
172
27
182
33
177
28
192
24
207
37
171
30
120
10
12
25
10
9
4
11
25
12
9
5
9
14
10
8
5
8
14
13
6
5
13
19
18
16
6
5
11
13
10
4
2
9
9
6
4
9
2
0
7
1
0
Operation Types:
External Load (Part 133):
Restricted Category (predominately Part 137):
Air Medical (Part 91/135):
Gulf of Mexico (Part 91/135):
Air Tour Operators(Part 135):
2003 - 2005 Rotorcraft Wire Strikes:
Fatal Wire Strikes
Occurred during IMC
12
25
7
3
2
11
2
0
Data Sources: FAA, NTSB, HAI, and HSAC
* 2005 Data through Aug. 31, 2005
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September 26-29, 2005
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Administration
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Estimated Flight Hours Flown by EMS Operators
350000
300000
250000
200000
150000
“The airport runway is the
Most important mainstream
In any town.”
-Norm Crabtree
100000
50000
2003
2001
1999
1997
1995
1993
1991
1989
1986
1984
1982
1980
0
Data: Steve Ludwig, CJ Systems HAI presentation AMPA Nov 2002 & Multiple Sources
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September 26-29, 2005
Federal Aviation
Administration
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US Civil Accidents Compared to HEMS Accidents
1995 -2004
US Civil Accidents vs HEMS Accidents
250
207
192
# of Accidents
200
182
152
166
157
177
172
171
144
150
Accidents
Helicopter EMS Accidents
Linear (Accidents)
100
Linear (Helicopter EMS
Accidents)
50
2
2
3
14
10
9
15
15
15
13
2003
2004
0
1995
1996
1997
1998
1999
2000
2001
2002
Year
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Administration
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US Civil Fatal Accidents Compared to Fatal HEMS Accidents
US Civil Fatal Helicopter Accidents vs Fatal HEMS Accidnets
1995 -2004
40
37
35
33
29
30
# of Accidents
28
27
24
30
24
24
25
Fatal Accidents
22
Fatal HEMS Accidents
20
Linear (Fatal Accidents)
Linear (Fatal HEMS Accidents)
15
10
5
3
0
1
3
4
4
5
6
4
1
0
1995 1996 1997
1998 1999 2000 2001
2002 2003 2004
Year
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Administration
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HEMS US Rotorcraft Accidents 98’ – 04’
Total HEMS accidents from Jan 1998 – Dec 2004
Total HEMS Fatal Accidents 98-04
Total Fatalities
85
27
74
Total Night HEMS Accidents
Total Night Fatal Accidents
45
21
HEMS Accidents Involving Part 91 Operations(18 fatal)
HEMS Accidents Involving Part 135 Operations(9 fatal)
59
26
HEMS Fatal Accidents VFR into IMC
Twins
Singles
HEMS Fatal Accidents IFR in IFR
11
7
4
1
Data source: FAA EMS Task Force Analysis
International Helicopter Safety Symposium
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2004 HEMS US Rotorcraft Accidents
• All fatal accidents in VFR only aircraft.
(3 B-407’s, 1 B-206, 1 BO-105, 1 AS-350)
• None were equipped or using enhanced vision systems or terrain
awareness warning system.
• All the HEMS fatal accidents occurred at night.
• Five of six of the fatal accidents appear to have CFIT
characteristics.
• None of the programs with fatalities are CAMTS accredited.
• VFR only programs are the largest growth segment of the HEMS
industry
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September 26-29, 2005
Federal Aviation
Administration
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International Helicopter Safety Symposium
A quote heard several times at a recent air medical conference:
“….. EMS is the only commercial carrier where the passengers,
may have no choice in whom transports them…..”
Why We are Here!!
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September 26-29, 2005
Federal Aviation
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“The airport runway is the
Most important mainstream
In any town.”
-Norm Crabtree
Pyote, TX March 2004
4 Fatal
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Evansville, IN April 2004
1 Fatal
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Newberry, SC July 2004
4 Fatal
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Battle Mt., NV 2004
5 Fatal
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Santa Rosa, FL October 2004
3 Fatal
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Apache Junction, AZ.
1 Fatal
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How the Helicopter Emergency Medical
Services (HEMS) Community has Grown
• From the mid 1990’s to present, HEMS increased +100%
• Currently, there are approximately 660 RW aircraft flying HEMS,
that number is increasing daily.
• Estimates of +300,000/hrs annually.
• Approximately 300,000 patients transported annually.
• An EMS aircraft takes off every 90 seconds in the United States.
• No formal method of tracking, hours, missions, usage.
• Single engine, non-IFR certified a/c is where HEMS is going.
• HEMS medical is changing to the “Independent Provider” model.
International Helicopter Safety Symposium
September 26-29, 2005
Federal Aviation
Administration
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September 26-29, 2005
Federal Aviation
Administration
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FAA EMS Task Force Initial Recommendations
• Industry cooperation and participation is critical to resolving the
issues.
• Joint FAA/Industry working group for accident root cause
analysis and Intervention Strategies.
• Apply System Safety Risk Management principles to HEMS
operations.
• Improve FAA oversight/knowledge.
• Approved Enhanced Vision programs.
• Investigate technology enhancements. (Aircraft & Infrastructure)
• FAA/Industry Part 135 Aviation Rulemaking Committee (ARC).
• Enhanced training and pilot pool.
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September 26-29, 2005
Federal Aviation
Administration
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FAA EMS Task Force Initial Initiatives
• Developed Helicopter Air Ambulance Accident Analysis and
Recommendations (Remains in Draft)
• Received support from Mgr Flight Standards (AFS-1) to partner
with the air medical community to resolve HEMS issues and
reduce the number of Accidents.
• Developed & Released Flight Standards Notice 8000.293;
Helicopter Emergency Medical Services operations
• Participate in Air Medical Community Working Groups.
Air Medical Transport Conference
AAMEs Safety Committee & HAI Air Medical Committee
AAME’s NVG Safety Symposium
Air Medical Safety Advisory Committee (AMSAC)
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On-going FAA EMS Task Force Activities
• Continue cooperation and development of intervention strategies
with the EMS community.
• EMS Task Force developing example Risk Assessment tools.
• AAMS NVG Symposium, FAA / Industry Participation
• Complete Air Medical Resource Management Advisory Circular.
• Completed Risk Management Notice 8000.301.
• Participate in the AMTC conference, FAA System Safety Risk Mgt.
presentations.
• Complete a review of HEMS VFR Operations Specification A021(c)
weather requirements.
• Complete a Notice for Controlled Flight Into Terrain (CFIT) accident
avoidance.
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September 26-29, 2005
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On-going FAA EMS Task Force Activities (cont’d)
• Complete a Notice for Loss of Control Accident Avoidance.
• Decision-making training
• Emergency IFR Recovery Procedures
• Qualifications/Checking
• Based on existing aircraft equipment and technology
• Complete a Notice for Part 142 Training Centers which Conduct
training for HEMS Operators.
• Risk Assessment
• CFIT Accident Avoidance
• Loss Of Control Accident Avoidance
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September 26-29, 2005
Federal Aviation
Administration
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2005 Jan - Aug HEMS Accidents
• EC-135- N135NW; Native Air/Omni Flight- Maintenance, lower right lateral
control link bolt came out in flight. Two pilots on-board, non-fatal.
• AS-350D – N350RM, Air Methods. The pilot fatal.
• EC-135 – N136LN, Air Methods, Aircraft over the Potomac River below 200ft,
impacted the water unknown circumstances. Pilot and Flight Nurse fatal,
paramedic survived.
• AS-350B3 – N351LG, PHI Air Medical, Reposition flight under NVGs
pilot became disorientated and impacted terrain. Pilot non-fatal.
• B206L-1 – N5734M, Air Evac Lifeteam, Aircraft spun on departure, impacted
terrain hard. Patient fatal.
• A119 – N403CF, Tri-State Care Flight, on approach, rapid decent witnessed,
impacted terrain hard. Pilot, paramedic, and flight nurse fatal.
* The information herein is preliminary
International Helicopter Safety Symposium
September 26-29, 2005
Federal Aviation
Administration
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2005 Jan - Aug HEMS Accidents
• BK117B-2 - N440HH; Hermann Hospital- Airframe component (door) failure.
flight. No injuries.
• AS-365N – N365S, CJ Systems, loss of “tail rotor” control, impacted heliport
rolled over. No injuries.
• BK117B-1 – N117US, CJ Systems, No. 1 engine lost power, on landing
rolled over. No injuries.
* The information herein is preliminary
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September 26-29, 2005
Federal Aviation
Administration
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Questions?
International Helicopter Safety Symposium
September 26-29, 2005
Federal Aviation
Administration
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Contact Information
[email protected]
or
Southwest Region Aircraft Certification
Helicopter Directorate Safety Management Group
[email protected]
International Helicopter Safety Symposium
September 26-29, 2005
Federal Aviation
Administration
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