AirMed & Rescue August / September 2018

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ISSUE 91 | AUGUST / SEPTEMBER 2018

AIRMED&RESCUE MAGAZINE

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ISSUE 91

AUGUST / SEPTEMBER 2018

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In this issue

Editor-in-chief: Ian Cameron Editor: Mandy Langfield

News Case Study Contributors

Sub-editors: Christian Northwood, Lauren Haigh, Stefan Mohamed, Sarah Watson Advertising Sales: James Miller, Kathryn Zerboni Design: Tommy Baker, Will McClelland, Katie Mitchell

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FEATURES

Web: Tom Reed Marketing: Isabel Sturgess, Kate Knowles, Kane Rich Finance: Elspeth Reid, Alex Rogers, Kirstin Reid

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Contact Information: Editorial: tel: +44 (0)117 922 6600 (Ext. 3) email: editor@airmedandrescue.com

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Advertising: tel: +44 (0)117 922 6600 (Ext. 1) email: jamesm@airmedandrescue.com

Electric avenue Electronic flight bags are changing how pilots work

Online: www.airmedandrescue.com @airmedandrescue www.airmedandrescue.com/facebook www.airmedandrescue.com/linkedin www.vimeo.com/airmedandrescue

Night riders The ever-increasing availability of night vision imaging systems onboard helicopters and the regulations surrounding them

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I, robot helicopter The latest generation of helicopters are lighter, faster and better equipped

SPECIAL REPORTS

Subscriptions: www.airmedandrescue.com/subscribe subscriptions@voyageur.co.uk

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Published on behalf of Voyageur Publishing & Events Ltd Voyageur Buildings, 19 Lower Park Row, Bristol, BS1 5BN, UK The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy.

Neither the publisher nor Voyageur Publishing & Events Ltd can accept any responsibility for any error or misinterpretation. The views expressed do not necessarily reflect those of the publisher. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or firm mentioned, is hereby excluded.

Printed by Pensord Press Limited © Voyageur Publishing & Events 2018

magazine AIRMED & RESCUE ISSUE 91 ISSN 2059-0822 (Print) ISSN 2059-0830 (Online)

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Costs of medical transport in Florida come under scrutiny

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Focus on helicopter evacuations in Nepal

AirMed&Rescue Magazine attended the 2018 annual Air Centric Personnel Recovery Course (APROC) at GilzeRijen air base, The Netherlands

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Aeromedical transport training in Bangkok

INDUSTRY VOICES Creating the right culture Bruce Webb, Airbus pilot, offers his thoughts on leadership and the culture of safety for crewmembers

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Working to the limit Fatigue management in the world of international medical repatriations

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PROFILES

Materials in this publication may not be reproduced in any form without permission.

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Capital Air Ambulance

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AIUT Alpin Dolomites

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Airbus Helicopters

NEWS

AW169 chosen by Magpas Air Ambulance UK-based Magpas Air Ambulance has selected the AW169 as its new generation helicopter. Specialist Aviation Services will customise the aircraft with an advanced medical interior and will operate the helicopter on behalf of Magpas Air Ambulance, providing pilots and maintenance services.

Daryl Brown, CEO of Magpas Air Ambulance, said: “We are delighted to be working with Leonardo and Specialist Aviation Services towards the delivery of a new AW169, to replace our current aircraft in the spring of 2019. The current Magpas Air Ambulance MD902 Explorer entered service 17 years ago and has been with Magpas Air Ambulance since June 2012. While the current model has flown to thousands of patients over the last six years and has helped the charity respond to its highest number of activations ever, in 2017; it is now coming to the end of its operational life. Following intensive research, Magpas selected the AW169 helicopter, with the most advanced aviation

technology, to become the new Magpas Air Ambulance. We recently launched a twoyear appeal to raise £1.5 million and bring this new state-of-the-art AW169 helicopter to the east of England and beyond. The new aircraft will be able to fly further, faster and allow the lifesaving service to reach an even greater number of patients.”

Henk Schaeken, Managing Director, Specialist Aviation Services (SAS), said: “Magpas Air Ambulance is a key provider of emergency medical response in the East of England and we are delighted to maintain our close working relationship with them as they launch the extra life-saving capability which the AW169 is proving it can deliver.”

SAS has placed orders for 12 AW169s and is also an Authorized Service Centre for the AW169 in the UK, providing a range of support and maintenance services to AW169 customers. SAS has also recently been appointed as an Authorised Service Centre for the AW139 to support the growing number of customers in the UK that are operating the helicopter type.

AeroStretcher MkIV granted STC

by EASA GVH Aerospace has been awarded the European Aviation Safety Agency Supplemental Type Certificate for the installation of its AeroStretcher Mk IV Modular Aeromedical System on the Airbus H135 helicopter. The AeroStretcher Mk IV system is an evolution of the previous Mk III product, which was well received by helicopter transport operators and provided them with the capability to rapidly reconfigure their aircraft to support medevac missions. The Mk IV system improves on that operational capability significantly with a broader product range and a more cost-efficient pricing model.

The AeroStretcher Mk IV system is installed directly on the aircraft seat tracks using a patent-pending multi-fit floor interface system. The system is installed and removed in minutes without the need 44

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for tools and can be quickly adapted to any aircraft with standard seat rack fittings.

The modular design of the system provides multi-role and utility operators with mix-and-match flexibility in configuring their aircraft to provide different levels of medical care capability, from simple casualty evacuation to inflight critical care. The product family includes litter stretchers, standard stretchers, stretcher bridges and oxygen bottle stowage racks.

Editor’s comment This issue of AirMed&Rescue brings you a diverse range of news, analysis, interviews and opinion pieces, all written by experts in their fields from around the world.

We’ve got a special report from the US Florida Office of Insurance Commissioner Advocate, who is considering the regulation of emergency air medical transportation providers, while in Nepal, the Chief Executive of Traveller Assist reports on his work to prevent the abuse and misuse of medical helicopters for the evacuation of climbers from Everest.

US-based helicopter pilot Bruce Webb, meanwhile, offers his thoughts on why leaders of companies have to be first in line to create a culture of safety for their pilots, empowering them to make the right decisions. In addition, Stuart Cox and Kerryn Reynolds, both experienced air medical professionals, are concerned about the level of fatigue that flight doctors and nurses are enduring, and are keen to see new regulations introduced that would ensure appropriate rest times for medical professionals doing long shifts, many of whom cross time zones in the process.

For those readers who want to dig a little deeper, our features include a report on how electronic flight bags are making life easier for pilots in different organisations, an in-depth look at night vision goggle regulations and a wideranging article on how technological innovations are shaping the helicopters of the future.

AirMed&Rescue is proud to work with a wide range of industry experts, without whom the magazine would undoubtedly not be able to bring you the level of in-depth analysis that you, our readers, enjoy so much. If you would like to be involved, contributing an article or publishing some research that you have undertaken, please do not hesitate to get in touch with us – email editor@ airmedandrescue.com.

NEWS

Saving Lives.

Anytime, Anywhere.

169 Lives depend on you.

The AW169 is ideally suited to life-saving primary and secondary EMS missions anytime, anywhere.

Easily adaptable, rapidly configurable and uniquely designed around patients’ needs; the AW169 ensures that air medical professionals can provide the best care at the most critical moments.

Inspired by the vision, curiosity and creativity of the great master inventor Leonardo is designing the technology of tomorrow.

leonardocompany.com Helicopters | Aeronautics | Electronics, Defence & Security Systems | Space

www.airmedandrescue.com

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NEWS

Survival Flight adds new jet to medical fleet Michigan Medicine’s Survival Flight has added a new Bombardier Learjet 75 fixedwing aircraft to its existing fleet of three rotor-wing aircraft to serve even more critically injured patients and improve organ procurement services. The Survival Flight team members specifically designed the jet’s interior for the acutely ill and injured patient populations they treat. “There is nothing our nurses that designed this interior haven’t thought of,” said Denise Landis, Clinical Director of Survival Flight.

The fixed-wing aircraft is mainly used for preplanned trips, including organ procurement and patients that need to be picked up from distances the rotor-wing aircraft cannot reach.

“This jet will allow our organ procurement teams to fly as far as Las Vegas and back to Ann Arbor within a 12-hour shift,” Landis commented. “Before, we would not be able to make it to such a far distance in one shift.”

The Learjet 75 will replace the program’s

Cessna Citation Encore jet, which was acquired in 2001. “Our former aircraft was a corporate interior and while it has served us well for the past 17 years, we are constantly looking toward the future and improving our ability to care for patients,” said Landis.

“This jet has been in process for over a year. It started out with a committee within the university with all of the stakeholders that fly in the aircraft coming together and deciding what is it we need to better serve our patients.”

Improved features of the jet include: • A wider door access point to the interior patient cabin to accommodate larger patient beds, isolettes and patients • A wider interior patient care cabin with the ability to care for the wide variety of patient populations Survival Flight encounters, including neonatal through geriatrics patients, complex ICU patients, ECMO patients, etc.

• The ability to carry liquid oxygen and heavy equipment on board, as well as TransMedics Organ Care System for organ procurement, Impella devices and balloon pumps • A mounting system in the interior patient care cabin for IV bags and other medical needs • A monitor in the interior patient cabin that displays time to destination, ground speed, flying altitude and cabin altitude, which is needed for some of the medical devices • The ability to carry two organ procurement teams in one flight because of additional seating • A shorter take-off and faster climb rate to a top speed of 464 knots (534 mph), with the ability to fly over poor weather conditions at a maximum operating altitude of 51,000 feet • A Garmin G5000 touchscreen avionics suite in the cockpit, dual main tires, two lead-acid batteries for electrical power and increased aerodynamic efficiency.

“The committee really looked at all of our equipment, weighed each piece and made space for it,” Landis said. “It’s a very mobile interior because we can pull things out and put them back in based on what we need for that particular patient or trip.”

The jet will accompany Survival Flight’s existing three twin-engine Eurocopter EC155B1 helicopters, with aviation services for all aircraft provided by Metro Aviation.

Air Tattoo world first for remotely piloted aircraft A remotely piloted aircraft that is to become the backbone of the future Royal Air Force safely touched down at the Royal International Air Tattoo in July. The MQ9B SkyGuardian, which is currently being developed by US-manufacturer General Atomics Aeronautical Systems, touched down on schedule at RAF Fairford after an epic 24hour, two-minute flight from North Dakota.

The aircraft will go on to form the basis of the RAF’s new Protector system, due to enter service in the early 2020s.

The flight to RAF Fairford has achieved a number of major firsts. It is the first transatlantic flight performed by a mediumaltitude remotely-piloted aircraft and the first to be entirely controlled by satellite 66

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communications in British airspace. The aircraft was controlled by pilots sitting in North Dakota taking 12 hour shifts as the aircraft flew over Canada, across the Atlantic and around southern Ireland before reaching the UK mainland in west Wales.

The SkyGuardian is the latest version of the General Atomics Aeronautical Systems MQ-9 Reaper remotely piloted air system, which the Royal Air Force (RAF) has operated successfully over Afghanistan and is currently flying on operations over Iraq and Syria.

Just hours before the SkyGuardian arrived, the Royal Air Force Chief of Air Staff, Air Chief Marshal Sir Stephen Hillier, announced in London that the first RAF unit

to operate the Protector will be 31 Squadron, which currently flies the Panavia Tornado. Air Vice Marshal Julian Young, Chief of Materiel (Air) at the Defence Equipment & Support agency said: “Protector features world-beating characteristics that we are bringing into service as the lead customer and this aircraft will be a game-changer like none other. One hundred years of experience is being applied to this world-leading capability.”

Air Tattoo Chief Executive Andy Armstrong said: “Air Tattoo has a proud history of featuring aviation firsts. It’s appropriate that on the RAF’s centenary – we present not only aircraft from the RAF’s illustrious past and present but also offer a rare glimpse of its future.”

NEWS

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Make sure your rotorcraft can operate non-stop until every life is saved — equip it with a Goodrich rescue hoist.

Learn more at goodrichhoistandwinch.com.

www.airmedandrescue.com

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NEWS

AirMed World Congress review The AirMed World Congress 2018 was held in Warsaw, Poland, in June, attended by over 350 delegates from air medical backgrounds around the world.

The conference sessions were as varied in the topics they covered as were the nationalities of the speakers themselves.

With a focus firmly on the medical education side of the industry, there were workshops on pre-hospital neurological

examination and CT scanning in stroke victims, emergency ultrasonography and pre-hospital advance airway management.

For the pilots, a session on night vision goggles allowed time for education and debate.

With a busy exhibition area and plenty of networking opportunities throughout the three-day event, the AirMed World Congress was well worth attending.

Spanish Civil Guard chooses HUTC for training Héli-Union Training Center (HUTC) has been awarded a 24-month contact by the Spanish Civil Guard, under which it will train 30 of the service’s pilots. HUTC will utilise its full-flight simulator (FFS) based at Angouleme Airport, France to train potential pilots on its corresponding Dauphin AS365 N3 helicopter simulator.

The training will include emergency procedures exercise, instrument flight rules (IFR) navigation, harsh condition flights and many others.

“We are very honoured to be given this opportunity to train 30 pilots from the Spanish Civil Guard,” said Hervé Maugis, Director of HUTC. “Here at the HUTC,

we are aiming to provide the best service through our qualified instructor, top of the range training courses, and all the required means (simulators, fleet, etc.) to ensure all our pupils are successfully qualified and well trained after finishing their courses.”

HUTC is the only company in Europe that operates a Dauphin AS365 N3 FFS. It allows for several different types of training, including ab initio and recurrent training to specific programmes covering failure procedures, instrument flight rules, offshore and rescue operations, night flight (night vision goggles), flights over mountainous regions and low altitude navigation.

CNC Technologies tapped by Michigan State Police CNC Technologies, an aviation technology and wireless communications company serving the law enforcement, military and government markets, has been selected by the Michigan State Police (MSP) to deploy a state-of-the-art mobile video network to support the department’s airborne law enforcement operations. Developed to improve the ability of MSP to share actionable aerial intelligence, the new solution will enable secure transmission of real-time video and data from the department’s airborne assets to officers and partner agencies across the region.

CNC will design, deploy and provide ongoing support for the entirely mobile video network, which will be integrated within MSP’s Mobile Command Center 88

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truck. The system will centralise live video and data streams from MSP’s Aeryon SkyRanger UAS fleet and helicopter assets, allowing officers to immediately distribute up to four simultaneous feeds to HD monitors, PCs and handheld devices via local WiFi and satellite.

To provide complete coverage across the state’s 96,000+ square miles, the system has the capacity to stream video and data over both cellular and satellite networks, leveraging cellular in metro areas and satellite in rural regions. The system is also the first from CNC to integrate both helicopter and drone video within a single platform with the drone transmission capability driven by a custom, CNCdeveloped software package.

“MSP has been at the leading edge of airborne law enforcement as one of the first agencies to integrate drones into its public safety and policing efforts,” said Ron Magocsi, Founding Partner and Chief Technology Officer at CNC Technologies.

“We are pleased to assist them on this assignment and look forward to supporting the department in its public safety mission.”

NEWS

Hungary orders 20 H145Ms The Hungarian Ministry of Defence has ordered 20 H145M military helicopters equipped with the HForce weapon management in the frame of the military modernisation programme Zrinyi 2026.

Together with the helicopters, Airbus will provide an extensive training and support package.

“We are honoured to be of service – once more – to the Hungarian Ministry of Defence whom we today welcome as a new customer for our H145M helicopters.

With this new order, we are fostering our excellent and trustful relationship with the Hungarian Armed Forces after their acquisition of two A319 military troop transporters last year. Team Airbus is grateful for the continued trust and confidence that the Hungarian government has placed in our products”, said Tom Enders, Chief Executive Officer of Airbus.

With a maximum take-off weight of 3.7 tonnes, the H145M can be used for a wide

range of tasks, including troop transport, utility, surveillance, air rescue, armed reconnaissance and medical evacuation. The Hungarian fleet will be equipped with a fast roping system, high performance camera, fire support equipment, ballistic protection as well as an electronic countermeasures system to support the most demanding operational requirements. The HForce system, developed by Airbus Helicopters, will allow Hungary to equip and operate their aircraft with a large set of ballistic or guided air-to-ground and air-to-air weapons.

The H145M is a tried-andtested light twin-engine helicopter that was first delivered in 2015 to the German Armed Forces and has since been ordered by Thailand and the Republic of Serbia. The programme’s maturity allows Airbus Helicopters to execute

orders on cost and on schedule. Mission readiness of the H145Ms already in service is above 95 percent.

Powered by two Safran Arriel 2E engines, the H145M is equipped with full authority digital engine control (FADEC). In addition, the helicopter is equipped with the Helionix digital avionics suite which includes a high-performance 4-axis autopilot, increasing safety and reducing pilot workload.

We speak your global aviation language...

AOG URGENT Dauphin parts in stock

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SPECIAL REPORT

COSTS OF MEDICAL TRANSPORT IN FLORIDA COME UNDER SCRUTINY

In 2016, Sha’Ron James, Insurance Commissioner Advocate in Florida, US, set up the Emergency Medical Transport Working Group to assess the impact of emergency medical transportation costs on local consumers of insurance, bringing industry stakeholders together in an effort, she said, ‘to gain a balanced perspective on the air and ground ambulance industry and provide solutions to protect consumers from financial distress after suffering a medical emergency’. Following an emergency medical flight, there is a risk that a patient will be ‘balance billed’ by the operator, who would not have received payment from the patient’s insurer as air and ground EMT services are considered an ‘out-of-network’ cost.

Operating costs and charges The Air Medical Services Cost Study Report, published in March 2017, found that the median annual operating cost for an air ambulance base was US$2,969,360. Looking specifically at the current air medical operations in the state, the report from the Office of the Insurance Commission considered data from independent company FAIR Health. The report states that the average bill for a fixed-wing air medical transport in Florida was $15,828. When comparing this with other US states, Georgia’s average charge was around $11,000, New York’s was $17,226, and in Texas, the figure stood at over $18,000.

Delving further, FAIR Health provided fixed-wing data on four regions in Florida. Of the four regions, Miami reported the lowest average charge for a fixed-wing transport at $5,715. The Spring Hill/ Palm Harbour area had an average charge of $12,911, and the Tallahassee/ Pensacola/Panama City area’s average charge was $24,872. Tampa’s average charge was $30,000, though the data included only one flight in the area 10 10

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during the timeframe. Using the FAIR Health data again, the average bill for a rotary-wing helicopter transport in Florida was $21,221. While Georgia had the lowest average charge for fixed-wing transport, Florida held the lowest average charge for rotary-wing transport. Georgia’s average charge for rotary-wing transport was $24,660, New York’s was $25,857, and Texas’ was $22,652.

Resolution on the horizon?

Following the findings of the Emergency Medical Transport Working Group, James has put forward several recommendations to protect consumers from surprise bills. This includes banning aeromedical balance billing.

“Stakeholders,” says the report, “must recognise the challenges consumers face when dealing with out of network aeromedical balance bills. Steps must be taken to deregulate the aeromedical industry from federal regulation, so that states may more appropriately regulate the market to address consumer needs.”

The difficultly in dealing with air ambulance rates is due to a long-standing federal law, the Airline Deregulation Act (ADA) of 1978, which prohibits states from regulating prices, routes or services of air carriers. To date, several federal courts have rejected state efforts to regulate air ambulance charges, ruling that the ADA pre-empts state regulation of air ambulances. In state legislatures, a number of different approaches are being taken in an effort to protect consumers from balance billing. Michigan, Virginia, Hawaii and Kentucky are all proposing bills that would impose transparency requirements or controls on the air ambulance company contracted by a hospital to move a patient. HB915 in Hawaii, for instance, would require healthcare facilities to request services first from an air ambulance provider contracted by the patient’s insurer. If such services are not available, the healthcare provider must notify the insurer of the intention to use a non-contracted provider.

SPECIAL REPORT

FOCUS ON HELICOPTER EVACUATIONS IN NEPAL The Ministry of Culture, Tourism and Civil Aviation in Nepal has announced the launch of an official Special Investigation Unit that will be looking into the activities of more than 500 expedition, trekking and helicopter companies in the country who are accused of corruption and price-fixing through unnecessary and fictitious helicopter rescues to defraud the travel insurance industry out of millions of dollars. Jonathan Bancroft, Managing Director of Traveller Assist Ltd, which provides medical assistance and cost containment services in Nepal, said he was proud to support the efforts of the Ministry of Culture, Tourism and Civil Aviation.

The company’s campaign to end the issue of helicopter evacuation fraud in Nepal began in August 2017, when Traveller Assist – in a joint venture with an Australia-based insurer – sent Operations Manager Forest Williams to Kathmandu to assess the level of care being provided in hospitals, and to ascertain why the 2017 spring climbing season had been the most expensive on record for medical claims, particularly for helicopter rescues and evacuations.

“We learned a lot from the 2017 high-season [Oct-Nov]. It was the busiest year on record since the 2015 Nepal earthquake. This gave us the opportunity to try and test different methods to facilitate and improve rescue and evacuation missions,” said Williams.

Last year, a record 940,000 visitors arrived in Nepal and within the last three months of 2017, Traveller Assist provided medical assistance for over 250 travellers from the UK, Australia, New Zealand, Canada, and the US – 37 of which involved a helicopter evacuation. After further investigation, it was found that 30 per cent of these evacuations were completely unnecessary.

Bancroft explained the situation to AirMed&Rescue Magazine: “A typical scenario that we have seen repeated again and again: a traveller on an expedition complains of a headache. The expedition leader calls for a helicopter. The helicopter arrives and provides an evac, with an agreement to pay the expedition company a commission. The helicopter company then flies the patient to a hospital, where in turn they are promised a commission by the hospital. The patient, who remember only complained of a headache, is then admitted for observation, and given blood tests, X-rays, and in some cases, even an MRI and EKG.” A helicopter rescue and inpatient medical bill is then presented to the travel insurance company, which at the time has no choice but to seek a medical opinion or direct care. In some cases, the bill for the helicopter evacuation and medical care can total more than $20,000. “It’s a racket that’s

tantamount to fraud, and it’s happening on a large scale throughout Nepal,” said Bancroft.

Spearheaded by the company’s Head of Assistance, Danny Kaine, the first task for Traveller Assist was to create a chart of all helicopter companies registered in the country, and then ascertain which companies actually owned helicopters, and which ones just rented them. “Stands to reason,” noted Bancroft, “that the cost to charter a helicopter from the owners is less than renting it from a company who in-turn rented it from the owners.”

The second task was to visit the senior management of every hospital in Nepal that was suspected of over treating patients in their facilities, and of paying helicopter companies a commission to receive these patients in the first place. With a letter signed by four major insurance companies – which in turn manage 27 brands and collectively insure over three million travellers worldwide – Traveller Assist was authorised to deny a claim on their behalf if fraud was suspected.

Bancroft said: “With the intelligence we had gathered, and the support we received from our clients, I reached out to request a meeting with a representative at the Department of Tourism in Nepal, where I was authorised to disclose that a major underwriter was considering the option of no longer offering travel insurance in the region due to the sheer amount of fraudulent claims, which would have a major effect on the economy of Nepal.” In what the company says is an industry first in Nepal, Traveller Assist has created an agreement and established a line of communication with helicopter companies, whereby if the operator is called on to evacuate a traveller who is covered by an insurer on its list of clients, it calls the regional operations centre in Kathmandu, whereupon the in-house doctor or nurse assesses whether the patient requires an evacuation or not. Bancroft pointed out that this strategy is already having a positive effect: “So far in 2018, we have successfully managed to capture 65 per cent of helicopter evacuation cases insured by our clients, and 40 per cent of medical assistance cases, before a service was provided – meaning that we got to assess the patient, and direct care before a single helicopter charge or medical bill was created. While these numbers will never reach 100 per cent due to various factors, we do think we can get them closer to 80 per cent based on this season’s results.”

Fast forward to the end of the 2018 spring climbing season, and Traveller Assist has provided medical assistance for over 800 cases and stopped over 100 unnecessary helicopter evacuations from happening in Nepal.

www.airmedandrescue.com

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FEATURE

Electric avenue

The development and introduction of electronic flight bags – EFBs – has taken some time, but now they are now considered to be standard operating equipment on air ambulance and rescue helicopters and fixed-wing aircraft around the world. So, what differences have they made to the pilots using them?

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ilots need to take a wealth of information into the cockpit with them, from maps to manuals to weather charts. Traditionally, this meant carrying a bag weighed down with reams of paper documents: the ‘flight bag’. These days, ‘electronic flight bags’ – portable computers loaded with specialised software – allow pilots to save not only weight, but also time.

The early days of the EFB may have involved individual pilots taking personal equipment onto their aircraft, perhaps laptops with standard office software to help with calculations. Nowadays, tailored applications are commonly paired with lightweight tablets such as Apple’s iPad. Adopting GKN Fokker Services EFBs on three of its Callenger 604 jets in 2012, Switzerland’s Rega commented that tablets (in this case, iPads) ‘reflect the most ergonomic and least room and weight demanding way of an EFB integration’.

Feature-packed The beauty of digital tech is, of course, its flexibility. A tablet can be loaded with the user’s choice of software to process and display

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information in a convenient manner, and applications can be easily added or updated as needed. As well as replacing paper documents, an EFB can provide additional functionality, such as performing fuel calculations, or receiving real-time information from the operations centre such as updated weather data. Rega’s helicopter crews have benefitted from getting mission taskings via the EFB, rather than over the radio as used to be the case.

In the US, Metro Aviation announced in August 2015 that it would introduce EFBs for its fleet of 120 aircraft. Listing some of the benefits, the air medical provider explained: “The EFBs will allow pilots to access charts, maps, company manuals and a variety of weather and flight planning resources.”

As another example, UTair Helicopter Services of Russia said in November 2017 that it had become the first Russian helicopter operator to introduce an EFB based on mobile tablets, which provide crews ‘with convenient access to all materials required for flight preparation and performance, including route and flight maps, charts of aerodromes, heliports and landing sites’.

SkyTrac

David Walley, AW169 Program Manager, and the Auckland Rescue Helicopter Trust have been using EFBs in their operation for a number of years. “AvPlan EFB gives us unrivalled situational awareness in the cockpit. It combines all the charts we need, approach plates, weather and NOTAMs all in a single package,” Walley said. “We can plan a flight quickly, brief, file it and then be airborne in minutes. We use AvPlan EFB on every flight, VFR or IFR.” Depending on the set-up, it’s possible for the EFB to interface with the plane or helicopter’s onboard electronics to provide data to the pilot or relay it to the operations centre. For example, UTC Aerospace Systems offers an EFB platform that allows the user’s tablet device to access aircraft power and avionics data during all stages of flight, such as ground speed, GPS position and aircraft heading, as well as the aircraft’s communications systems, ‘which facilitates the transmission of real-time information such as weather and flight performance tracking’.

Software provider ForeFlight combines GPS position and altitude data with global terrain and obstacle data from Jeppeson to provide terrain hazard and obstacle warnings. US-based PHI Air Medical first adopted ForeFlight in 2011. Edward Goodman, airplane flight standards manager at PHI Air Medical, managed the EFB integration programme.

He has highlighted the ‘profile view’ as a powerful feature: “You can draw a line across the map and view the highest obstacles. There’s a regulatory requirement for [visual flight rules helicopter air ambulance] operators that mandates an analysis of terrain and obstacles along the planned route, and then fly at a minimum altitude above the terrain and obstacles. The profile feature has helped our helicopter operations by allowing us to do that analysis in a simple and efficient fashion.”

EFBs can help with completing checklists as well. For example, ForeFlight suggests that using digital checklists reduces cockpit clutter, adding: “Digital checklist templates keep important safety procedures organised and easily accessible for every phase of flight, and helpful colour-coding leaves no step unchecked.”

And it’s not just aviation-related apps that can be useful. Harald Brendel, who was involved in the implementation of EFBs at DRF Luftrettung in Germany, noted that its systems included programs such as calculators, currency converters and Skype.

US-based Air Methods has equipped its fleet of aircraft with HeliEFB’s Flight Risk Assessment (FRAT) module. Prior to each flight, pilots fill out a flight risk assessment on the iPad and receive flight approval from their OCC (Operations Control Center) within seconds. In addition,

SkyTrac

FEATURE

Air Methods is in the process of adding HeliEFB’s Weight & Balance and Performance module to further expand the scope of their EFBs. “We operate a fleet of over 400 aircraft and HeliEFB’s capabilities to be centrally managed gives us full operational control over our fleetwide EFB data. We are using EFBs as a tool to enhance our business processes, operational speed and flight safety,” explained Craig Houtz, EFB manager at Air Methods.

Nigel Thomson, Flight Safety Officer for Mission Critical Services for Babcock International Group, told AirMed&Rescue that he ‘can’t imagine operating without his Airbox Aviation Command and Aircraft Navigation System (ACANS)’, as it ensures the safety of both crew and airport. He explained: “The simple fact is that by using ACANS it helps me complete our ‘life critical’ mission more effectively, especially when faced with short notice or unexpected changes, a norm when conducting HEMS operations. Be it pre-flight planning or inflight re-planning, landing site selection and potential hazard identification, information is well presented, accurate, user friendly, adaptive and intuitive in its use.”

Improvement vs paper One of the problems with paper is that an operator has to regularly spend time making sure the documents are up to date. With an electronic unit, on the other hand, you simply let it download data updates when needed. UTair Helicopter Services noted that the relative ease of keeping aeronautical information and regulatory documents up to date has helped to reduce costs.

Malcolm Humphries, managing director/chief pilot for the UK’s Capital Air Ambulance, told AirMed&Rescue: “EFBs have provided us with an excellent method of reducing cockpit paperwork and clutter. With a fleet of 11 aircraft, the old paper Jeppesen airport charts that we used to carry proved to be a major headache to keep up to date. Our operations department needed a dedicated night shift which regularly updated the reams of paper airport charts required to be kept onboard.

The new Jeppesen iPad electronic replacement service is always up to date and easy and intuitive to use.”

Goodman of PHI Air Medical commented: “EFB technology has allowed [us] to simplify the management of required publications and navigational charts, while simultaneously lowering the recurring costs of managing these subscriptions. The time required for pre-flight planning and post>>

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flight paperwork has decreased and will continue to decrease as PHI Air Medical becomes more reliant on EFBs.” In addition, with digital, there are none of the delays – or costs – associated with the need to physically print and distribute new documents. Air Alliance of Germany started using EFBs in 2014. Joachim Wirths, COO, told AirMed&Rescue that it’s a major advantage that administrators can remotely update the documentation: “It was in former times a safety issue or safety concern to launch worldwide flights correctly with always updated and valid documents as required. Different revision dates for documents, different revision procedures and the distribution of such revision hard copies to crews and aircraft was always a big challenge for an aviation company.” He added that just to keep the aircraft documentation up to date required the work of more than one member of staff: “Depending on company size, it took a lot of man hours to track all files belonging to each aircraft correctly and to implement the weekly or monthly revisions in a correct manner.”

There was also the organisational challenge of getting the proper documentation to the crew on time when an aircraft was away from its home base.

Ongoing costs are also saved through the lighter weight of an EFB, which means the aircraft consumes measurably less fuel. Wirths of Air Alliance said the weight and space savings are key: “The biggest advantage is to save weight and to generate more space available for other needs.

This is very important especially for crews flying smaller ambulance jets as available space is always an issue here. [Previously], a big flight case could weigh approximately 30 kgs and would carry all aviation charts and documentation necessary to cover a worldwide operation.”

Just how significant are the fuel savings? DRF Luftrettung said in 2012

Holders EFB tablets are often used in conjunction with after-market holders, such as those offered by Bucher Aerospace, to hold them firmly in place and also provide charging in-flight. Gustavo Romero, Director – Europe Region, said the firm began developing EFB holders in 2014, and is still customising them for different cockpit types. He said: “I would say that the most important features of an EFB holder nowadays is to be compatible with many tablet sizes, so as to be able to survive several tablet generations (i.e. between five and 10 years at least).” The second most important feature of an EFB holder, said Romero, is ease of operation, with the pilot being able to engage or remove the tablet, stow or deploy the holder with simple motions and as far as possible with one hand only.

Sources www.marketsandmarkets.com/PressReleases/commercial-electronicflight-bag.asp

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that the 600g tablets adopted for its air ambulance jets compared to 35kg for the previous paper versions. Udo Kordeuter, DRF Luftrettung fleet commander, said: “If we extrapolate this to our annual average use, the tablets will save about €7,000 per year in [fuel] costs.”

Other than costs, another advantage of EFBs is that information is easier to access. Jim Arthur, director of operations for Metro Aviation, told AirMed&Rescue: “When we introduced EFBs to our fleet, it gave our pilots access to charts, maps, company manuals and planning resources.

We effectively enhanced the pilot’s ability to access the information they need to do their job safely and effectively.” He added: “It really streamlines our process and keeps everything in one place, which is ideal when going through data.”

Evolution/future The EFBs in use with many air ambulance operators may be state-ofthe-art, but with digital technology, things rarely stand still for long. The software continues to improve, as Jan van der Heul, vice-president of sales at SkyTrac, explained: “Since last year’s launch, we’ve refined an in-flight weather application. With no additional hardware or software, the operator can also access up-to-date regional weather information off the tablet.”

Capital Air Ambulance is looking at how to get more out of its devices.

Malcolm Humphries said: “We are continuing to investigate future possibilities for the EFB, including electronic aircraft technical logs and paperless navigation logs.”

It’s not only the apps, but also the hardware that changes. Joachim Wirths of Air Alliance noted that the IT industry is one of the fastestgrowing commercial sectors worldwide. He added: “Therefore the replacement of tablets/EFBs in use must be part of the business plan.

Such replacements will most probably take place every three to four years as the hardware will become more and more unable to cover all new developments.”

Safety and security Many commentators remark on the impact that EFBs have on safety, for example citing the reduced pilot workload and the automatic data

FEATURE

revisions. On safety, Malcolm Humphries of Capital Air Ambulance told AirMed&Rescue: “We have added a tailored safety management application to our iPad EFBs which allows the flight crew to directly access the company safety system whilst airborne, together with easy reference to company operations manuals and aircraft flight manuals.

The crew are able to report any safety reports directly from the EFB during the flight and the company is notified on landing.” He added that pilots are able to review destination security briefings using the MedAire application.

One potential concern is the possibility of electronic devices being hacked, which could lead to software failure or data loss. Jan van der Heul of SkyTrac noted: “Data security is a big concern in the industry and operators need to look at the data repositories, the data in transmission and the security of the app itself. Our mobile form technology is actually hosted directly on our secure ISAT-200A onboard server on the aircraft.

The interface is pulled up only on designated tablets. We use an encrypted auto token to identify the app to our servers and the logins can be user-specific as defined by the operator.

During the submission process, data is sent over an encrypted satellite connection or WPA/ WPA2.” He added: “For our ground repositories, we have all of the security infrastructure and redundancy that you’d expect when accessing a private bank account.”

Meanwhile, Alexander Killeffer, a spokesperson at UTAS, said: “Our ADM/EFB solutions are rigorously tested both during development and on a regular basis in service to maintain system security. This is especially important as aircraft become more connected. We work closely with our customers to regularly review and implement best practices for network security.”

existing forms such as flight and crew reports so that staff don’t have to relearn processes from scratch. He added: “Flight data, engine data and timestamps can all be auto-populated directly into the Skytrac EFB in real-time. When the pilot or crew submit the form from their tablet, that information is forwarded over to the ops team and can be pushed immediately to other software programs.” This means that operators don’t need to retrain staff or revamp existing procedures from scratch.

Here to stay Considering all the advantages they bring, it’s not surprising that Wirths believes that EFBs will move from being a standard to a must: “Definitely the usage of EFBs is the future in aviation and will become mandatory in a modern cockpit and for the aviation industry. There is no way back as aviation technology and IT technologies are going to merge or pair to each other more and more.”

plan smarter, fly sooner

Making the change However beneficial the technology is, the move from paper to screen must be carefully managed. Joachim Wirths of Air Alliance commented that it’s important to spend time developing an implementation plan tailored to the individual company. He added: “An uncontrolled implementation of hardware and software will lead to huge difficulties and will delay the required civil aviation approval process accordingly.”

Jan van der Heul of SkyTrac recognised that transitioning to digital processes can be hard for operators in the air ambulance industry. He told AirMed&Rescue: “A lot of these operators have specific forms and processes already in place.

Many things may be working well except for the paper aspect. Manual data entry on paper is time consuming and information requires re-transcribing into accounting or SMS systems, which often leads to delays and errors.” An EFB provider can take steps to ease the change, said van der Heul, such as digitising the operator’s

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A CAPITAL IDEA Capital Air Ambulance is a UK-based operator with a fleet of aircraft at its disposal and team of experienced medical professionals to call on. AirMed&Rescue Magazine spoke to Managing Directors Malcolm and Lisa Humphries, along with Medical Director Dr Terry Martin, about the company’s development and capabilities

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he challenge of starting an international air charter company is not to be undertaken lightly, and one that pilot Malcolm Humphries, and his wife Lisa, overcame with aplomb. The duo founded Capital in 1991, starting with just one aircraft and working from a home office. Discussing the challenges of being a working mother, Lisa tells a story about having a (very weighty!) mobile phone back in the day, pushing the pram with one hand and doing quotes for flights with the other – nothing like multitasking to keep the mind active!

Gradually, over the years, more contracts were won and the company grew, mainly operating shuttle flights for corporate companies, and offering the aircraft to medical companies who would provide the medics to fly, VIP executive flights and cargo contracts.

In 2011, the team decided to focus directly on the air ambulance market, which was when it established a fully staffed medical department, with dedicated aircraft operating solely as air ambulances.

In 2015, Sir Peter Rigby became the major shareholder in Capital, and this investment enabled the company to become a global operator with a worldwide Air Operator Certificate with Learjets for the longer-range taskings, and King Airs for the more local European repatriations.

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Fleet details: – Three Learjet 45s – Five King Air 200s (Purchases of the third Learjet and fifth King Air should be complete by publication) Number of staff: – 50 full time permanent staff plus over 100 medical bank staff

Fleet renewal is a vital but expensive part of operating an air ambulance company. Lisa told AirMed&Rescue: “We are constantly upgrading our aircraft with engines, props and avionics to meet European Aviation Safety Agency requirements. As the types of aircraft we operate are still in production we do not find this to be an issue, as parts are easily obtained when required.”

WE ARE CONSTANTLY UPGRADING OUR AIRCRAFT WITH ENGINES, PROPS AND AVIONICS TO MEET EUROPEAN AVIATION SAFETY AGENCY REQUIREMENTS Dedicated to medical flights When Dr Martin first joined the company in January 2012, it was on a part-time basis while he continued his work as a consultant anaesthetist and intensivist in the National Health Service (NHS). In December

PROVIDER PROFILE

2013, his role progressed to full-time Medical Director at Capital while he remained part-time at the NHS. “That first year was very hard work,” he told AirMed&Rescue.

“There was so much to do in setting everything up from scratch. Everything imaginable was needed – it was like building a whole new company. I started with creating plans, business cases and project timelines, recruiting criteria, Gantt charts and business documents, and was very soon purchasing medical equipment, setting up a pharmacy, creating a medical department containing a bespoke store room, a despatch room, training facilities and the medical ops and management offices.” Next on the ‘to-do’ list was the establishment of protocols, policies and general rules for the way in which the service would be operated, along with guidelines for managing medical operations, as well as how these would interface with flight operations.

The first ‘live’ mission was postponed until June 2012 so that all the systems could be tested with some preliminary flights and, by the end of the year, 110 missions had been completed successfully with no complications or significant problems. Dr Martin said: “That was quite a feat for a new air ambulance company and it was recognised as such.

CAPITAL UNDERTAKES AROUND 1,000 AEROMEDICAL TRANSPORT MISSIONS A YEAR AND ADVISES ON MANY MORE Some new set-up services take five years to reach that target!”

Next on the list of challenges was internationally recognised accreditation of the air ambulance service. EURAMI (the European Aero Medical Institute) usually doesn’t let companies that have been operating for less than two years apply for accreditation, but made an exception in Capital’s case due to previous experience in both its aviation and medical sectors. Dr Martin commented: “The activity that followed to ensure we passed all the required standards has now become a hectic blur of

memory and there were times when I regretted trying to run before we’d even established a fast walk, but it was well worth it. We sailed through the audit inspection and won our first EURAMI accreditation outright, to the amazement of our customers and competitors alike.”

He went on to say: “Ever since then, the workload has increased, our capabilities have grown, our equipment catalogue has improved and increased to match our workload, we have met governance challenges face-on and set up reliable and robust systems for quality management, risk assessment, clinical oversight, safety in practice, medicines management and human resources (medical staffing), to name but a few.

This, of course, has been a continuous and ongoing process and long will it be so.”

Dr Martin’s medical director role has been extended to include business processes, marketing, and networking, using decades of past friendships and relationships to push the company forward and attract new customers, as well as encourage and attract new recruits. “I continue to write aeromedical scientific papers and to run my CCAT aeromedical transport courses,” he added, with the side benefit of this being that many of Capital’s current staff have actually been recruited by virtue of being one of his students.

Risk assessment At Capital, every member of the medical team (full-time and part-time) is trained to look at each aeromedical transport case in exactly the same critical way. Dr Martin teaches risk assessment and harm reduction at every stage of the training, from basic physiology, through environmental stress, to clinical considerations.

“In this way,” he explained, “all my staff, whether they are office based or flight medical crew, understand the concepts that underpin the decision-making process in terms of the logistic and clinical aspects of each case. Using policies and other guidance materials, I have provided a framework of information that accelerates the risk assessment for patients with common conditions and straightforward logistics.” By doing this, it means that staff don’t need to contact the medical director for every

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single case that comes their way, which, given the case load, would certainly end up as an onerous task. Capital undertakes around 1,000 aeromedical transport missions a year and advises on many more, and risk assessments for the majority of cases are routine and generic. These are dealt with by Flight Nurse Co-ordinators, who write each individual pre-mission briefing.

“On the other hand,” added Dr Martin, “I have defined complex cases that may be significant in terms of the patient’s clinical condition, age, the logistics of the transfer and any social, financial or any other important issues that may impact the safety, efficacy or efficiency of the transfer. My staff therefore seek my advice only when there is a dilemma that results in the case being defined as complex.”

The most serious and significant cases that are identified as ‘high risk’ will have a complete and formal risk assessment, analysis and management plan, drawn up by utilising Capital’s in-house Risk Policy.

These documents are used to establish the staffing, kitting and conduct of high-risk missions so that potential problems are identified prior to the mission, and all possible steps are taken to ameliorate, mitigate, reduce or remove the risks identified. “If nothing else, this process focuses the mind on what might potentially happen, and highlights the importance of close monitoring and ‘monitoring with intention’ to exclude latent factors that threaten the patient or, indeed, the mission,” said Dr Martin.

Operating a critical-care fixed-wing air ambulance service that caters for all age ranges and all types of patients is a very complex task that demands hour-by-hour and minute-by-minute attention to detail, almost forensic gathering of information, and the ability to pull together a 18 18

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clinical and logistical plan that properly analyses and manages known and anticipated risks, while also building in enough reserve capability to cover the latent unexpected unknowns that lay waiting to be exposed.

“This is especially true,” said Dr Martin, “when we aren’t given enough information about our patient. This can be for a number of different reasons and happens so often that I consider it to be the number one risk in itself! Indeed, an entire mission can be sabotaged simply by the reticence of one individual to tell the entire truth about a patient’s

DR MARTIN TEACHES RISK ASSESSMENT AND HARM REDUCTION AT EVERY STAGE OF THE TRAINING clinical stability, or through the inexperience, indolence or apathy of an individual or organisation in unravelling the medical history and probing when the facts don’t quite add up. This is frustrating and, at Capital, we much prefer to seek and interrogate medical reports ourselves, rather than rely on third parties.”

This is, of course, all part of the process of case handling, where clinical and logistic problems are examined, analysed and solved together, for every individual case. To help, Capital trains all of its medical staff and medical operations team about cultural, religious and geographical differences, as well as in the key differences in healthcare delivery and law in various parts of the globe. End-of-life care is an example of how

PROVIDER PROFILE

customs and laws vary dramatically between regions. For instance, DNACPR orders are not legal in some parts of the Middle East. Over the years, the company has collected information concerning pretty much every aspect of patient transport and repatriation all around the globe.

Such intelligence and corporate memory is often extremely valuable when planning patient transfer missions. There are many reasons why communication and understanding can break down during case handling conversations, and language itself is a key factor; therefore, the language capabilities of a team working in a company that carried out its missions all over the world is another key aspect of successful case management. Capital employs a diverse population of healthcare professionals from 16 countries, making it rare for there to be a need for external interpreters.

AirMed&Rescue asked Dr Martin his opinion on an industry trend that seems to be occurring more and more in the international air ambulance industry: Wing-to-wing (‘tarmac’) transfers. “These do seem to be on the rise,” he noted. “As a quality air ambulance service, we firmly believe that a bed-to-bed operation is far superior, given that the handover of patients from one team to another is well known to be the weakest point of any transfer. In our own experience, we have encountered latent dangers that have occurred after handovers that followed long hours on duty, sometimes in the middle of the night, occasionally in atrocious weather, and sometimes when there is a professional mismatch between receiving and referring teams. So much is taken for granted when passing patients between teams, and trust can only be born out of familiarity with the companies we work with.

However, this is an ongoing issue that has risen in importance as more

and more requests are received for tarmac transfers.”

On the other hand, tarmac transfers can reduce the duration of a long journey, and allow missions to be completed when logistical problems (such as lack of crew flying hours, or border control restrictions) would prevent a single aircraft/crew mission. Finances may also be an issue, but often the reason in favour of the tarmac transfer is simply to allow the patient to continue to receive uninterrupted care from a new medical team that is on peak performance while the first team retires for rest.

Ultimately, the wing-to-wing transfer usually shortens the total transfer time (and, hence the time that the patient is outside of a hospital.

Onwards and upwards In recent years, Capital has seen passed milestones including the introduction of jets to the fleet, the creation of a neonatal transfer service, establishment of ECMO, IABP and paediatric intensive care capabilities, the start of worldwide operations, level three (critical care) capability in commercial airliners, establishing partnerships with operators in other continents, and some nearby partners with larger and more long-range aircraft. It has also been through two tough EURAMI inspections and two equally complex Care Quality Commission inspections, as well as helping colleagues with CAA and ISO9001 audits. “All of these processes,” said Humphries, “are now ingrained in our management systems and frameworks to make matters much easier in years to come.”

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NIGHT RIDERS The ever-increasing availability of night vision imaging systems onboard helicopters working in the civilian emergency services spectrum means more providers are starting to fly at night. There are, however, a complex set of rules to which they must adhere in order to fly safely – Mario Pierobon details the ways in which night flights are being regulated

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LifeFlight Australia

ight vision imaging system (NVIS) technology has been around for several years, but until recently it has been limited mostly to military applications. NVIS is now developing a significant critical mass in several specialised domains of aviation, including helicopter emergency medical services (HEMS) and airborne law enforcement. “Although law enforcement and EMS are the biggest civil users of NVIS in the US, they are definitely not the only users,” said Jeff Stubbs, Senior Vice President of Operations and Systems Technology at REB Technologies. “Recently, firefighting has become more involved as well as crop sprayers – it is more economical to spray when the wind is at a minimum – airborne reporters and university flying programmes. The added safety of NVIS benefits a wide range of users.”

Yet NVIS technology alone is not enough to ensure safe NVIS operations.

Civilian operators wanting to experience the benefits enabled by the adoption of NVIS have a wealth of requirements to which they need to conform, and it is important that they be familiar with such requirements in order for NVIS technology implementation to be a smooth and fruitful experience.

The NVIS crew The first thing to be noted is that although NVIS operations are often single pilot, there is also a requirement for the minimum crew to be composed of one pilot and one NVIS technical crew member. This is always the case under European Aviation Safety Agency (EASA) when conducting operations to/from a HEMS operating site, while it is optional in certain circumstances under the Federal Aviation Administration (FAA), because in the US there is no need for an NVIS crew member when departing from or landing to an ‘improved area’.

“Many operators are approved to fly single pilot NVIS. However, they will typically be restricted to take-off and landing at improved airports or helipads,” said Adam Aldous of Night Flight Concepts. “The restrictions will be listed in the flight manual supplement for the night vision goggles (NVG) lighting supplemental type certificate (STC) as approved by the FAA. Typically, for unimproved landing sites, there is a requirement to have two trained persons wearing NVGs to assist in obstacle avoidance and increase situational awareness. This is the distinctive case of single pilot EMS operators where one of the medic crews is also wearing NVGs and has been properly trained.”

In the US, for the most part, EMS and law enforcement aircraft are single pilot. “In the EMS world, in a Bell 206/407 for instance, the aircraft will be equipped with a single pilot, a nurse and a paramedic all wearing NVGs. Generally, the nurse or paramedic simply assists the pilot, as needed, when landing in an unimproved area,” explained Stubbs: “In the law enforcement community, in many operations it will be a single pilot only, while urban area airborne law enforcement may employ a pilot and tactical officer that is working with moving maps, addresses, and communication with ground officers. EMS typically flies under Part 135, while law enforcement may fly under Part 91, Part 135 or public service depending on the mission. The authority is derived under their particular operations specifications.”

Improving visibility at night NVIS are being used for improving safety margins at night but without allowing for lowering the night visual flight rules (VFR) minima. “The use >>

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of NVGs is a significant safety feature, but should never be used to lower the minima. We find that most pilots/crews can become uncomfortable returning to unaided night flight after use of NVGs,” noted Stubbs.

NVIS operations are permitted only for night VFR. Operators must comply with the ceiling and visibility requirements of the applicable regulations and their operational approval/operations specifications and cannot change the type of weather (night VFR to IFR (instrument flight rules), as an example) they are permitted to fly in. “Under FAA regulations, Part 135 operators must comply with Part 91 but also have VFR ceiling and visibility requirements published in their operations specifications. NVGs dramatically improve situational awareness by enabling the crew to see the terrain and obstacles as well as changing weather patterns. They also reduce stress and workload due to the increased situational awareness,” pointed out Kim Harris of ASU – Aviation Specialties Unlimited.

Equipment requirements There is a specific protocol that NVIS operators need to develop before being granted an approval as the aircraft lighting must be modified for NVIS compatibility. “In new aircraft, much of the NVIS modifications can be done by the aircraft Original Equipment Manufacturer (OEM). Equipment that is added by a completion centre or the operator require modification which is done by installing an NVIS Supplementary Type Certificate (STC),” said Harris. “The NVGs to be used must be listed as approved in the NVIS STC flight manual supplement (FMS). In the past, NVGs were listed by part number and that still applies. However, new NVGs are produced under TSO C164a and so the FMS may authorise any TSO NVG to be used. This depends on the STC holder.”

NVIS implementation requires, first of all, top management buy-in, and once this is in place it is important to start discussions with the local civil aviation authority (CAA), who will provide guidance on their requirements. “From that point on, while an operator is working on finding a NVIS modifier for 2222

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the aircraft – as well as training and goggles – the operator can be working with the CAA in the background so the entire package comes to fruition at the same time,” said Stubbs. “Once discussions with the CAA have started, an operator should begin the due diligence on working with the aircraft modifiers. This requires providing detailed pictures of the instrument panel, avionics stack, overhead (anything that lights up, get a picture) and asking the modifier how it would propose to modify the aircraft.”

“Some modifiers simply add flood lights and post lights and need to rewire portions of the aircraft. Consideration should be given to how this would >>

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Training needs As a modifier might also work with an NVG school, it will probably be able to help in the training search process as specific regulatory requirements apply also with regard to flight crew training, qualification and recent experience. “Under the FAA, CFR Part 61.31(k) outlines the required ground and flight training requirements in order to act as pilot in command of an aircraft while using NVGs. In addition, CFR Part 61.195 also identifies the requirements for an individual to be issued an NVG instructor endorsement,” explained Aldous.

“Pilots have several NVIS flight training schools available, and simulators have now added NVIS capability. It is important that individual operators decide on what fits best with their organisations in terms of whether conducting training abroad, training on the operators’ own aircraft at their own

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affect the organisation’s ability to sell the aircraft in the future,” Stubbs added.

“Other modifiers internally modify all of the equipment and in this case the operator must have spares to support flight operations when the units are out for repair. We often notice that a company selects the modifier solely based on price and the solution does not match their organisational needs or expectations.”

There are specific considerations to make with regard to the lighting arrangement of NVIS aircraft depending on whether LED, traditional incandescent or infra-red (IR) lights are being contemplated. “LED aircraft lights present their own challenges and advantages,” said Harris. “LED lights emit energy in a narrow band, typically just on the edge of the spectrum that the NVGs are sensitive to. LED lights used in a searchlight are nearly useless for their intended function of illuminating terrain and obstacles at a distance that provides the flight crew time and space to see and respond to hazards. LED landing lights, skid lights, load lights all are a great asset when using NVGs because they provide great-unaided visibility when looking under and around the NVGs, but LED lights have minimal negative impact to NVG performance.” In contrast, old-fashioned incandescent searchlights very dramatically enhance the capabilities of the NVGs. “An incandescent searchlight emits a great deal of IR energy that enhances the effectiveness of NVGs. The light energy diffuses outward from the main beam of light which provides a great deal of visibility to the crew, increasing situational awareness,” he said.

According to Harris, IR searchlights should not be installed or used on civil aircraft, the exception being for law enforcement aircraft that have a requirement for covert operations. “IR searchlights are not as effective in illuminating obstacles or providing situational awareness, they do not provide visible light the crew can use when manoeuvring close to the ground and other aircraft not equipped with NVGs cannot see IR lights. Moreover, they can damage the retinas of personnel on the ground. Conversely, they require little or no training to use because they are so weak,” he says.

Once a modifier has been selected, a benefit may be derived from the fact that typically, a modifier is able to help the operator with goggle and helmet recommendations. It should be noted that after the initial implementation, the NVGs must also be recurrently inspected in accordance with the requirements in the operations specification or, under EASA rules, the approved operations manual.

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facilities or even conducting training with the OEM,” added Stubbs.

It is also vital that training be focused on NVG use in a civil airspace environment and a civil flight profile, according to ASU’s Harris. “Instruction provided by a pilot with extensive military experience but without civil NVG flight experience is incomplete,” he told AirMed&Rescue. “Military training is focused on tactical operations, preparing to operate in hostile environments where any light emitted from the aircraft makes you a target to hostile forces.

In a civil, non-hostile environment, white light is a pilot’s best friend on NVGs. The use of white light while operating NVGs is not intuitive and must be taught by an instructor who understands how to optimise NVG performance using aircraft searchlights and other lighting.”

Night vision technology certainly holds great promise for the future of emergency service provision, but it is no doubt vital that those operating the flights are current with the latest training and regulatory requirements.

CASE STUDY

PARIS

DUBAI

Mid-air emergency threatens mission

VIETNAM

HYDERABAD BANGKOK

The key to success in aeromedical missions is detailed planning and preparation, but unforeseen logistical or medical complications can potentially throw everything off course in a matter of moments. A mid-air medical emergency threatened to do just that on a recent European Air Ambulance (EAA) mission, during the repatriation of a 23-year-old from Bangkok to Paris.

Setting the scene The patient had been knocked from her motorbike by a truck in Vietnam some weeks earlier, sustaining massive soft tissue damage, liver and pulmonary contusions, and multiple rib and pelvis fractures. After transfer to a Bangkok intensive care unit, she received weeks of treatment in isolation due to drugresistant bacterial infections. But with her condition improving, the decision was taken to repatriate her to France for the next stage of her treatment; permanent wound closure.

EAA’s Mission Control Centre in Luxembourg began planning the transport, having been satisfied by information from the hospital that the patient was fit to fly. The necessary medical equipment was prepared, and the flight and medical crew set off.

The handover in Bangkok was carried out utilising EAA’s checklist-type transfer sheet. This guarantees that no pertinent issues – such as current medication, allergies, lab results, CD copies of imaging – are left behind. It also ensures that all medication required during repatriation is available and given at correct times. The Thai nurse in charge confirmed that all medications up to the time of handover were administered, including an adequate dose of low molecular weight heparin (LMWH).

The patient was then transferred via road to EAA’s dedicated air ambulance at Bangkok Don Mueang airport, where the flight to Paris commenced. Noninvasive monitoring was carried out continuously, with oxygen administered via nasal cannula, a continuous morphine infusion via syringe pump, and all other medication as required.

A sudden downturn The patient remained stable for six hours, including a fuel stop in Hyderabad, India – but suddenly developed severe shortness of breath, nausea and vomiting. These symptoms were extremely worrying and indicated either a pulmonary embolism or pneumothorax (potentially caused by her multiple rib fractures).

As standard lung auscultation is futile at cruising altitude with two engines blasting 7000 pounds of thrust, an arterial blood gas (ABG) analysis was performed immediately with the point of care analyser onboard. The ABG confirmed

severe hypoxaemia.

The oxygen supply was changed to a non-rebreathing mask and the flow was increased to the maximum of 15l/min. Thereafter, oxygen saturation levels increased from 75 per cent to 92 per cent. Fortunately, the patient remained haemodynamically stable under these conditions. However, as there was no possibility to confirm either of the two suspected diagnoses, the medical crew declared a medical emergency.

A 12 lead ECG raised concerns about some right ventricular stress. When the patient, who was awake and alert at all times, denied having received any subcutaneous injection in the morning, the medical crew suspected a pulmonary embolism caused by insufficient treatment with blood thinners. Immediately, 5,000 units of heparin were injected intravenously. Gradually things improved on board. Nevertheless, prompt hospital admission was imperative to obtain a final diagnosis of what caused the severe deterioration.

With the support of EAA’s mission control centre who secured the necessary permissions, an ambulance was summoned to the tarmac at Dubai airport – which, although 15 minutes flight time farther than Muscat, is significantly closer to hospital facilities.

The patient was admitted to the Al Quasimi Hospital, where an emergency chest X-ray showed a bilateral ventilated lung, but blood tests disclosed elevated D-Dimers and Troponin, therefore confirming the EAA medical team’s primary diagnosis of a pulmonary embolism.

Taking into account treatment times, the patient’s now-stabilised condition, the opinion of the EAA medical crew, ED doctor and the patient herself, and the fact that the best treatment options could effectively be carried out while in transit, it was decided to continue with the repatriation.

The patient remained stable for the rest of the journey to Paris, where she was taken by ground ambulance to the receiving hospital.

Dr David Sinclair, Medical Supervisor at EAA, said of the flight: “This mission presented unexpected challenges, both medical and logistical. But thanks to the quick actions of EAA’s expert team – in the air and on the ground – we were able to adapt our flight and medical plans immediately. I’m pleased to say that the mission was successfully completed, and the patient returned to her home country safely and in a stable condition.”

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INDUSTRY VOICE

CREATING THE RIGHT CULTURE Bruce Webb, Airbus pilot, offers his thoughts on leadership and the culture of safety for crewmembers

The task of changing our industry’s safety culture is, in my opinion, the most important component to improving our safety record. And of course, this means that it will be difficult to accomplish. When we discuss ‘Safety Culture’, I often feel as though we are attempting to answer a grey question with a black and white answer. Unfortunately, I fear that such an approach is doomed to failure; our accident trend (curve) remains relatively flat. This seems proof that our present approach is no longer effective.

Leading from the front I believe that leadership is the key to any culture, and safety culture is no different. Unfortunately, our society is rife with managers, but sorely lacking in leaders. Leadership and management often have opposing views about many issues, not just safety; because leadership is about people, while management is about money. And today, I believe that the vast majority of decisions are made from a management point of view.

Managers are often too concerned with short-term profitability, and the bottom line is often their sole metric. Leaders know that the cost of safety will be amortised over many years, and virtually no cost will outweigh the consequences (neither human nor economic) associated with an accident.

So perhaps safety is not tangible enough. It is certainly difficult to quantify. How do you measure the cost savings from an incident, or 26 26

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accident averted? Managers cannot assess a value to something that did not occur. Even with that said, I do not believe that managers intend to cast a blind eye towards safety. Their black and white answers are simply incongruent with the question(s). But leaders are much more adept in this world of grey. They lead using reasonableness, common sense, compassion and mercy. They do not need a profit and loss statement, or a balance sheet to tell them the importance of safety; they see the value every day in the people who depend upon them to lead. True leaders know that the cost of an incident or accident is far greater than replacement cost of an aircraft. Leaders value people, not because they are a resource within their company, but simply because they are human beings.

Influencing behaviour Daniel Kahneman won the Nobel Prize in Economics in 2002 for his studies of human behaviour. He points out that as humans, we are often blind to the obvious, and blind to our blindness. A good example in his book Thinking, Fast and Slow describes an experiment regarding priming, specifically, a priming phenomenon known as the ideomotor effect (the influencing of action by an idea). One group of students were asked to form sentences with words which we would normally associate with old age such as: Florida, retirement, wrinkle, Cadillac, and Medicare. Another group was asked to form sentences with words

INDUSTRY VOICE

associated with youth such as: California, surfing, bikini, Ferrari, and smartphone. He discovered that the students who worked with the ‘old age’ words walked slower as they departed the experiment, than those who worked with the ‘youthful’ words.

Merely forming sentences with words which subconsciously ‘primed’ them affected these peoples’ physical behaviour.

Another great example of the ideomotor effect was an experiment conducted in which a woman walks into a room with people taking an exam. The first room she enters (with students taking an exam) was ‘moneyprimed’. There were images or items placed around the room with financial meaning, like monopoly money stacked on a desk, the financial page of the Wall Street Journal opened on a table, a photograph of different world currency on the wall – all relatively subtle and seemingly benign to an observer. The second room she enters (again with students taking an exam) was not primed in any way.

Leaders need to ensure that the flight crewmembers consistently receive the message that safety is paramount The walls were beige and unadorned – nothing designed to prime the students. When the lady walked into each room she would purposely stumble and fall, causing the contents of her purse to spill out onto the floor. The students in the money-primed room were less apt to

help her recover her belongings than the students in the un-primed room. Priming changed their physical action/response. And certainly, none of the students in the money primed room were aware that their behaviour was impacted by the simple suggestion of money.

Being human You may be asking yourself, so what does this have to do with ‘Safety Culture’? I believe there is a direct corollary between the behaviour of the test subjects in these experiments and ordinary flight crewmembers.

We are all human, and thus subject to the same foibles. Pilots and mechanics – in fact, almost every person involved in flight operations today are money-primed. As much as possible, we need to remove flight personnel from information or images that link their performance to money. Leaders need to ensure that the flight crewmembers consistently receive the message that safety is paramount. Words such as: revenue, direct operating cost, overtime, bottom line, cost, loss, etc. should be forbidden around the crew. Instead, we should promote words and messages such as: ‘please err on the side of safety’, ‘safe is better than sorry’, ‘tomorrow is another day’, ‘safety is NO accident’, ‘nothing is worth an accident’, etc.

Let’s embrace the human element within our aviation operations! It is well documented that human error is responsible for the vast majority of our accidents. This is a testament to the quality of the aircraft we are flying today. It is also proof that we have underfunded/under appreciated the most complex component in any aircraft operation, the human element. We must learn to effectively use what we presently know about human behaviour, and seek to enhance our understanding as we move forward.

Commit to being a human factors leader!

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PHOTO GALLERY

APROC 2018

Where practice makes perfect AirMed&Rescue Magazine attended the 2018 annual Air Centric Personnel Recovery Course (APROC) at Gilze-Rijen air base, The Netherlands The often-hostile locations from where personnel recovery is most necessary mean that the crews responsible for such missions have to be trained to the highest possible level to deal with any scenario they may face. Seamless teamwork between crews and nations is therefore essential for the rescues and medical extraction of military and civilian personnel to be successful.

During the event, the 186 international training participants and 14 helicopters together formed three Task Forces (TF), which had a daily routine that started with a mission briefing and planning. In the afternoons, the plans were executed and each helicopter TF went to a different area. In addition to the military helicopters taking part were fighter aircraft for Close Air Support, a NATO AWACS and an Italian E-550, which were in orbit over The Netherlands with their Airborne Mission Commanders guiding and co-ordinating flights.

APROC 2019 is scheduled for Zaragoza, Spain and 2020 will be held in the UK. Reporting and photos by Peter ten Berg for AirMed&Rescue Magazine.

The flight line at Gilze Rijen Air Base showed a wide variety of APROC participants

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An Extraction Forces team enters an Italian Air Force HH-101A Caesar prior to an APROC mission

Extraction Forces return to their helicopter after evacuating two casualties on stretchers

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A Spanish Air Force AS-332B just dropped an Extraction Forces team into theatre to secure the area and retrieve a missing person

Gunner and crew of a Spanish Air Force AS-332B Super Puma are ready for the start sign of their Task Force mission

Dutch Extraction Forces give medical aid to a ‘casualty’, who is fitted to a tow-stretcher to prepare for evacuation by helicopter

Every day, the make-up of a Task Forces changed – this depicts a combined mission including the Spanish Air Force AS-332B, the Italian Air Force HH-101A and the French Navy NH-90-NFH Caiman.

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FEATURE

I, ROBOT HELICOPTER

BELL

Technology that was once only to be found in science fiction novels is fast becoming reality, as advances in avionics, composite materials and connectivity bring enhanced services and safety to the air ambulance sector

V280 Valor

It took 450 years for the fantasy helicopter imagined, described and drawn

by Leonardo da Vinci to evolve into the planet’s first practical rotorpowered flying machine. Igor Sikorsky’s VS-300 took its first untethered flight at Stratford, Connecticut in 1940, and since this time, helicopters have become vital – and ever lighter, nimbler and faster – assets not only for armed forces but also for emergency medical and rescue services.

Now, though, the industry is moving faster than ever, with better engines powering lighter aircraft, while developments in avionics mean pilots can fly more safely and patients can receive better care from medics using enhanced kit.

Structural and environmental progress The Kopter Group in Switzerland was founded in 2007 with the aim of building a new generation of turbine helicopters. Its Executive VicePresident (Technology) Michele Riccobono took AirMed&Rescue through the development of airframe design and manufacture since Sikorsky got his VS300 up in the air – progress that has resulted in the shape and performance of the medevac helicopters we see today.

“The past 30 years have seen an evolution mainly in the areas of materials which, in turn, drove design and manufacture. All helicopter airframes produced and certified in the 1970s and 1980s were manufactured using aluminum structural elements riveted together. With the availability of composite materials in more recent years, a series of structural elements started to be produced using these new materials, initially with glass fibres then honeycomb, and finally full carbon fibres.”

As is often the case with advancements in the aviation industry, what 3030

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slows down the introduction of new equipment is the lengthy certification process, explained Riccobono: “The introduction of these materials has been progressive due to the certification burden; the need to establish new certification requirements and guidelines for material qualification. Initially, secondary structures, such as doors and cowlings, started to be produced with composite materials, taking advantage of the easier modelling and

THE MAIN FLIGHT IMPROVEMENTS ARE THE INCREASED LOAD CAPACITY, SO WE CAN CARRY EXTRA FUEL, EQUIPMENT AND PEOPLE reduced complexity in serial manufacturing once the proper tooling had been developed.”

Step by step, though, the development of the material continued: “A series of hybrid structures mixing composite and metal started to appear, to switch later to a full composite structure in which different elements are either bonded or riveted together … basically using the same assembly concept of metallic structures, but producing the individual elements out of composite.

This is now being pushed further forward to develop a full composite airframe in a monococque configuration: the entire fuselage is made of a single part. But this has so far been done only with small helicopters – two seaters – due to the complexity in certification and production.”

The use of carbon fibre, added Riccobono, is also beneficial for safety.

FEATURE

“It allows us to create a structure that has a level of crashworthiness equivalent to that of a conventional metallic structure but with a much lighter weight. Carbon fibres also make it easier to model complex aerodynamic surfaces that enhance the helicopter’s performance, and we have adaptive manufacturing using 3D printers for producing even complex moulds.

Carbon fibre or composite structures also offer better damage tolerances and a very long service life, especially for primary structural elements such as helicopter rotor blades.”

Talking of progress, Honeywell in the US points to the ‘continuous improvement’ in helicopter engines over the years. “Since Honeywell

OUR TEAM HAS COMPLETE ACCESS TO THE PATIENT, HEAD-TO-TOE

Operator POV One of the best ways to determine the optimal features of a 21st Century air ambulance helicopter is to talk not only to the manufacturers, but also to the people who actually operate and fly them across all terrains and in all weathers. The Dorset & Somerset Air Ambulance Service in southern England ran 1,197 missions – that’s 23 each week – in the year ended March 2018 in a twin-county coastal region popular with hill walkers, sailors, swimmers, anglers and surfers, and bordered by busy shipping lanes. Last year, it decommissioned its Airbus Eurocopter EC135, which carried two

CONNECTIVITY IS BECOMING A NECESSITY ON BOARD; SAFETY, MAINTENANCE, AND REAL TIME DATA CAN ALL BE ENHANCED WITH CONNECTED SERVICES, AND IT CAN ALSO HELP WITH FUEL ECONOMY our team has complete access to the patient, head-to-toe. That means that they are in a much better position to help a patient if there is a problem en-route to hospital.

He continued: “Having the greater endurance allows the helicopter to cover a much wider area than before and means the aircraft can complete more tasks without the need for a re-fuel. Having fully integrated traffic collision avoidance, helicopter terrain awareness and synthetic vision systems >>

BELL BOEING

entered the aircraft propulsion market in 1953,” said Karina Larsen, VicePresident (Partnerships & Business Development), at Honeywell Aerospace, “we have overseen improvement programmes that have resulted in engines that provide more power, increased mission range, enhanced payload capabilities and a wider operating spectrum. There is,” she added, “an evergrowing need for engines that require less maintenance, have more intuitive design, and benefit from lower fuel consumption. Modern engines are certainly expected to be more fuel efficient.”

Riccobono at the Kopter Group reports that turboshaft engines are now being developed with requirements that were not, until now, rated as being of primary importance in a world that was largely unworried by climate change and aircraft noise. Times, though, are changing: “Low specific fuel consumption, reduced CO2 emissions and lower noise levels are requirements of the airplane engines that are now being imported into the helicopter market. Additionally, the reliability of engines is being increased significantly not only by their design but also by the availability of control systems – such as Full Authority Digital Engine Control – that constantly monitor the engine’s health. This enables the early detection of degradation that, if not discovered, could lead to engine failure in flight.” This enhanced reliability is bringing more choice to the industry, he added: “The use of single-engine rotorcraft is now being considered more and more for missions such as helicopter emergency medical services for which in the past only twin-engine helicopters were used. This is particularly beneficial because it reduces operating costs and, because it’s more affordable, it ultimately increases service availability.” Kopter’s own helicopter, the SH09, is being developed as a game changer, since it ‘offers the cabin space, performance and safety standards of a twin-engine helicopter for the price of a single’.

crew and two patients, and replaced it with an £8-million AW169, a twinengine, 10-seat helicopter developed and manufactured by Italy’s Leonardo Helicopters, AW’s re-branded identity.

The new machine was necessary, says the service’s CEO Bill Sivewright, because changes in the region’s hospital network meant that patients with major trauma conditions would have to be flown to centres farther away than was previously the case. “Without a major trauma centre in Dorset or Somerset, we therefore needed the ability to be able to fully treat a patient en-route to hospital. Further examination of the requirement also revealed something quite simple: if the patient was at the centre of our thinking – and on-scene the patient is at the centre of the ‘treatment zone’ – should the patient not be at the centre of the cabin of the air ambulance?

Once this logic was applied, the choice of a successor aircraft was quite straightforward. That is not to say that factors such as cost, safety, and potential for night operations were not considered, but only one platform offered us the cabin format to meet our fundamental requirement.”

The unit’s chief pilot Mario Carretta highlights the improved medical and flight capabilities of the AW169 compared with the machine it replaced.

“The main flight improvements are the increased load capacity, so we can carry extra fuel, equipment and people. The main difference clinically is that

V22 Osprey www.airmedandrescue.com

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BELL

FEATURE

A NSW Police Bell 412

What’s on the inside As ambulance helicopter airframes evolve into what are almost flying treatment rooms, attention is turning to making the most of the increased space available with interior fittings that are light, functional and easily adaptable.

In Austria, Helikopter Air Transport (HAT) has designed Kokon, a carbon fibre modular medical interior lining that has been installed in the twinengine Airbus H135 helicopters used by the company’s air ambulances. Kokon, says HAT, is a ‘superior, stylish and minimalist alternative to standard interior panels’. Manufactured in Innsbruck, its features include: • A total payload capacity of 76.5kgs/166.4lbs directly on the interior lining • Flexible and fixed mounting positions for varying loads and dedicated containers for medical equipment, which increases cabin space 3232

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BELL

increases the pilot’s situational awareness and helps to reduce the workload, particularly at night and in poor weather. The aircraft’s single-engine performance is also impressive.”

The service, which takes patients to 14 hospitals across the south-west of England, says that the AW169’s night flying capabilities mean that it can undertake full night medical missions. Pilots can fly directly to the patient without the need for any fixed or pre-established lighting, described as a ‘significant’ advantage.

The AW169 was not in fact bought by the service which, like many air ambulance units in Britain, is funded largely by charitable donations instead of the state. “It is leased,” Sivewright told AirMed&Rescue. “This was the most cost-effective way to procure such an expensive asset. If we owned the aircraft and for whatever reason it needed a major component replaced, the charity would have to meet the full cost of repair. That is a risk that we felt was not justified.”

Three other air ambulances services in England are using the AW169, and it’s been ordered by medical and rescue operators in Sweden, Switzerland and New Zealand.

Q400 Interior

• Easy and fast change of equipment configuration • Smooth cladding that makes helicopter interiors seem larger than they actually are • Availability in different colour schemes • Quickly removable to enable access to airframes • Customisable, with or without sound proofing • Cleanable with standard disinfectants and detergents.

Wolfgang Burger, the company’s Technical Director, told AirMed&Rescue: “It’s a multipurpose, carbon fibre interior liner is designed to get more medical and other equipment into smaller spaces – to maximise available space – so that the cabin area for crews is wider, and the smooth cladding makes the interior space look even larger. The design can be adapted for use in different helicopter airframes.”

At Cobham’s Aerospace Communications division in South Africa, Regional Sales Director Andrew Legg flags up an avionics problem – or challenge – for helicopters. “Cobham has always prided itself on reducing the weight and cost of satcom products. While our equipment is one of only a few accepted standards in the industry for fixed-wing airframes, rotary wing

NAVIGATION SYSTEMS ARE SPECIFICALLY BUILT TO WITHSTAND THE OFTEN HOT AND DUSTY CONDITIONS THAT ROTORCRAFT OPERATE WITHIN platforms remain a challenge for satellite communications. This is due to interference caused by the chopping of the signal by the helicopters blades, which rotate between the antenna and satellite.” The effect of this ranges greatly based on the nature of the blade composition, blade dimensions, the satcom system’s antenna location and area of operation of the rotary wing platform, explained Legg. This means that helicopter applications can work

FEATURE

either very well, moderately or with difficulty.

Integration and proof-of-concept operation testing, he said, ‘are therefore mandatory in any installation planning prior to fleet roll-out of a satcom solution. There are solutions to this problem and we continue to explore these with our partners in the industry’. “One such solution is the HDR Bearer offered by Inmarsat on its SwiftBroadband Service. While this solution works well in principle, it has a niche market in that it really serves only high throughput customers moving video off the platform. It’s not cost effective for general connectivity. We do have product working successfully on a range of platforms from the Bell 407 to the AW101.”

Honeywell’s Karina Larsen agrees that helicopters present communications and connectivity problems, but says they can be overcome. “They are a challenge because rotor blades can interrupt satellite signals to and from

rotorcraft. But with a digitised solution, such as our Aspire 200 Satellite Communications system, we see significantly enhanced capabilities for reliable, connected communications for helicopters.

“Connectivity is becoming a necessity onboard; safety, maintenance, and real-time data can all be enhanced with connected services, and it can also help with fuel economy. Consistent connectivity is very important for helicopter operators. It enables critical communication between the aircraft and the ground and allows passengers to stay connected while they are in the air. Connectivity effectively turns an aircraft into an information hub, providing a stream of data to and from the aircraft. Whatever its mission profile – air ambulance, government use, oil and gas transportation, VIP/executive transport and others – connectivity greatly enhances the modern rotorcraft.”

Honeywell also flags up developments in navigation systems. “They are specifically built,” Larsen told AirMed&Rescue, “to withstand the often hot and dusty conditions that rotorcraft operate within. With our ring laser gyro technology, we provide pilots with incredibly accurate positioning data and maximised safety even during extended periods of operation.”

The latest avionics suites available come with scalable architectures that can be tailored to a variety of helicopter designs, said Kopter Group’s Riccobono. “They collect and analyse a large volume of data in an intuitive environment, significantly reducing pilot workload. The increase in pilot situational awareness is the result of cockpit designs that prevent humanfactor related errors that are still the major cause of aviation accidents.

“Kopter is the first original equipment manufacturer to partner with Garmin for their new G3000H avionics suite, the best-in-class situational awareness system enabling a higher level of safety for every mission. The large dual landscape-oriented displays and single touchscreen controller can be configured according to customer requirements. Helicopter pilots can make the most informed decisions while operating in high workload conditions.”

Looking to the future, Kopter sees helicopter airframes getting even bigger, believes Riccobono. “They are likely to be larger, with a reduced number of parts, although switching to a full monocoque architecture is made difficult by the certification burden, especially for the reparability of impact damage.

A reduced number of parts cuts assembly costs, but as increased investment for tooling is necessary, a careful balance has to be made in the design to develop a sustainable economic model. Some recent helicopter models have airframe sections such as the canopy produced as a single part, thus reducing manufacturing and assembly costs.”

Coming soon?

In Italy, Leonardo and the Politecnico di Milano (PoliMi) are developing new technologies for helicopters as part of their expanding collaboration, launched in 2016 with the signing of Innovation Hub, a multi-year framework agreement. “In Leonardo, we invest in continuous and increasingly collaborative innovation,” noted Alessandro Profumo, Leonardo’s CEO.“[We aim] to develop increasingly effective and sustainable solutions for our customers and for Italy.” The multi-year collaboration with the Politecnico of Milan is a concrete example of this. “By putting our wealth of skills in line with those of the academic world,” added Profumo, “we can accelerate the processes of innovation and technological development, create synergy and mutual benefit to support the competitiveness of Italy.”

Through project Comfort, Leonardo and the PoliMi are developing technologies to reduce the vibration and noise of helicopters, and the reference platform for the study is the AW139 helicopter. The research activities are concentrated on three main areas: the rotor, from which the vibrations originate; the main gear box attachments, through which rotor vibrations are transmitted into the helicopter structure, thereby reducing the level of comfort, and finally on the airframe itself. The ultimate goal of the programme is to demonstrate a significant vibration and internal noise reduction, through the co-ordinated use of passive and active systems.

Elsewhere, the shape of air ambulances to come could be the pilotless Cormorant, built by Israel-based Tactical Robotics. It could be used, if and when it’s operational, for battle area medical evacuations. At a demonstration in northern Israel in 2015, the one-ton Cormorant – with a

AIRFRAMES ARE LIKELY TO BE EVEN LARGER, WITH A REDUCED NUMBER OF PARTS mission range of approximately 30 miles – carried 1,000 lbs. of cargo and a medical training mannequin at speeds exceeding 100 mph.

Powered by a single turboshaft engine of the type used in conventional helicopters – but with two smaller, contained rotors instead of one large one on top – its physical footprint is reduced, a big advantage in urban, wooded and mountainous environments. The company – which hopes the bug-shaped Cormorant will be bought by Israel’s defence force and the US military – says that it can operate in winds higher than those with which a human helicopter pilot would be comfortable. Patients – it can carry two if there’s no cargo load – would be connected via a remote monitoring system to ground staff able to check their vitals and talk with them on a twoway video link. Tactical Robotics says the carbon-fibre airframe should help it to dodge radar detection, while its exhaust system can be air-cooled to reduce its infrared signature.

Science fiction, or a reality coming to a helicopter ambulance station near you?

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PROVIDER PROFILE

Dominating the Dolomites Aiut Alpin Dolomites has a long history of performing rescues in the Italian mountains, and the collaborative environment in which the teams carry out their work saves the lives of climbers and skiers throughout the year Aiut Alpin Dolomites was officially founded in 1990, although technically, the private association – registered as a non-profit social utility organisation – has been operating since 1987. Its goal is to provide mountain rescue services in the Italian Dolomite mountains, an area that has long been popular among climbers, and more recently for winter and extreme sports enthusiasts. The helicopter rescue service was conceived and implemented by voluntary rescuers of the Ladin valleys – Gardena, Fassa and Badia – as the number of accidents in the region continued to climb. Today, Aiut Alpin Dolomites is formed of 17 different mountain rescue teams situated in the districts of Bolzano, Trento and Belluno.

The techniques used by teams of volunteers rescuing injured climbers underwent rapid evolution in the post-war period. Originally, rescuers would use normal climbing gear, ie ropes, nails and carabiners. In the 1950s, new equipment was made available that had been specially designed for rescues on large rock faces. The most important innovation was the replacement of hemp or manilla cords with thin steel cables. By joining these cables for many hundreds of meters, rescuers could descend along entire walls and perform recoveries that until then had been considered impossible. These new techniques required the commitment of more people and a better training of the team, which led to a greater unity of the group and a strong bond of solidarity and friendship between the various components. It was this spirit, 34 34

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fostered by the volunteers, which led to the use of the helicopter and the foundation of Aiut Alpin Dolomites.

Towards the end of the 1960s in Italy, the Light Aviation Army group began to operate with various Agusta Bell helicopters. A department (then called ALE-Altair) was also operational in Bolzano at the IV Corps de Armata, located at San Giacomo airport. It is thanks to this military department that helicopters were introduced into the alpine rescue service in Alto Adige in the early 1970s. Since, in peacetime, the main task of the army consists of military training, carrying out rescues in the Dolomite mountains were a great way for the pilots to practise.

In the mid-1980s, a rescue was performed in Val Gardena using a Lama helicopter, which was brought in from an outside company for the occasion.

For the first time, a rescue basket was used hanging on the barycentric hook, which brought with it new possibilities and alternatives in mountain rescue.

In the Spring of 1986, a dozen helicopters, all different, were brought in to perform 15 rescue scenarios. These included several civil and military versions from Agusta-Bell, a Lama Aerospatiale and a BK117. A few months later, the first rescue helicopter was leased, and an Alouette III soon joined the team.

The rest, as they say, is history.

Aircraft and kit When the service first began, it was very difficult to secure the necessary resources. Aiut Alpin Dolomites was initially supported by different mountain rescue teams situated in the Dolomites; but gradually, the organisation found sponsors, local associations of ski lifts and cable cars, private citizens, mountain shelters and many other commercial businesses, who helped to cover the

PROVIDER PROFILE

costs of the operation. To finance the helicopter itself, a special membership card was created, which offers insurance against the cost of a rescue mission for members.

“The local health department pays part of the cost per flight minute,” explained Adam Holzknecht, President of AIUT ALPIN Dolomites, “but we are still dependent on support. Therefore, special thanks goes to all people who supported – and still support – our activity.”

Rescue missions are co-ordinated firstly by the emergency centre – all calls for help are primarily directed there. The staff then decide which organisation will be necessary for the mission at hand. They can call on the local ambulance, fire department, police, and/or mountain rescue team, and the helicopter, if it is needed and available. All year round, the team undertakes training with other local rescue organisations and emergency teams to ensure readiness and to improve collaborative efforts to enable a seamless response when the time comes.

Adam Holzknecht has been working as a volunteer in the mountain rescue industry for many years – as a rescuer, in fact – since the organisation began. What he has learned throughout that time, he said, is one of the most important safety factors during rescue operations is to have a light helicopter. Starting as a volunteer in Alpine rescue, with a passion for mountains and climbing, his experience in effecting real rescues is key to managing the organisation currently. And there is still progress being made.

He told AirMed&Rescue: “The main challenge for the future of the Aiut Alpin Dolomites will be to train the crew on board for night flights (visual flight rules), in order to bring help to the mountaineers in difficulty on our mountains, as we have been doing for more than 30 years during the day.”

Holzknecht added: “Over the years, we have flown a Lama, Alouette III, Ecureuil B2 and Ecureuil B3. Finally, in 2003, we bought our first helicopter – a Eurocopter (Airbus) 135 T2i. The decision to buy our own helicopter was taken due to the fact that in Italy, rescue missions have to be done with twin-engine helicopters.” Since March 2015, Aiut Alpin Dolomites has been the proud owner of an H 135 T3, the first to be sold worldwide by Airbus Helicopters. The aircraft is equipped with a 90-metre-long hoist and a fixed rope attached to a double hook human cargo, vacuum mattress and winch bag.

The medical side of the operation is led by Medical Chief Executive Dr Lydia Rauch. In 2017/18 winter season, Aiut Alpin Dolomites assisted 520 people, nearly all of which were emergency calls, the only exception being secondary

transports and training exercises, which form less than 10 per cent of callouts.

In the winter season, the typical patient seen by medics are skiers who have suffered an accident on the slopes or a heart attack in their hotel.

Dr Rauch is clearly in agreement with Holznecht when it comes to thinking about the medical kit that is taken onboard the helicopter – lighter is better.

She explained: “We use a special equipment that fits our specific needs in helicopter rescue in the difficult terrain of the Dolomites: light, efficient, resistant and up to date.”

The H 135 T3 also has the latest medical equipment for resuscitation and stabilision of the patient. The following equipment and supplies are available for use by the medical staff on board: • Defibrillators • Intra-venous infusion sets (drip sets), and comprehensive resuscitation sets/kits.

• Respirator and ventilator (children and adults) also for ground use • Portable suction units • Medical kit for critical patients (adult and paediatric use) • Medical kit with additional medical equipment such as: chest drainage equipment, intubation equipment, amputation set, etc.

• Equipment for immobilising patients when using the winch and double hoist hook for rescue Special box for the disposal of used medical equipment and drugs Container for medical documents etc.

The team of people working on the helicopters has to have a great experience in out-of-hospital emergency and be specialised in anaesthesiology, said Dr Rauch.

“Above that,” she added, “they have to have a basic alpine education and have to be able to complete climbing walls as well as in steep ice and snow.” To this end, the organisation offers two specific courses every year: a winter training, which takes place over four days, and a summer training, which lasts for six days. Both courses include alpine training during the whole day and a theory part in the evening when the team shares care reports, scientific news and do professional skill-training.

By combining the skills of pilots, doctors, winch operators and mountain climbers and rescuers, Aiut Alpin Dolomites effects the rescues of hundreds of adventurers each year.

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COMPANY PROFILE

Airbus Helicopters

A

major player in the helicopter manufacturing market for many years, Airbus Helicopters has taken strides over the decades to cement its position with ongoing innovation in airframe design and manufacturing processes Airbus Helicopters (AH) has provided aircraft for helicopter emergency medical services (HEMS) operations right from their inception, when the very first dedicated HEMS operation was started by ADAC Luftrettung in Munich in November 1970, when Germany faced a very high number of deaths on national highways due to the booming economy. Authorities took the decision to launch a medical helicopter trial period with a doctor and a paramedic onboard in order to shorten the response time for accidents, pioneering the concept of taking the physician to the scene of the accident. The project was managed under the leadership and operation of the German Automobil Club (ADAC). The main challenges were: • How to finance the service • What the operating rules were, and • Who the stakeholders were.

The helicopter, medical equipment and training were the least of the problems, however, with some hiccups that occurred in the initial phases putting the project at risk of failure before it had even really started. ADAC eventually selected the light twin-engine BO105 helicopter, manufactured by AH’s 36 36

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predecessor company MBB with its – at this time – unique capabilities of two powerful engines and full system redundancies, high set main and tail rotor system, compact external dimensions with good visibility and, in particular, the unique rear loading capability via large clamshell doors. Since then, AH has been the leader in the HEMS segment with 60 per cent fleet share.

Stefan Bestle, Key Segment Manager for HEMS for AH, pointed out that these challenges that faced ADAC while the service was being introduced are still the same today in emerging markets without HEMS. Indeed, the worldwide market is very diversified. At the end of 2017, about 2,500 helicopters were dedicated to HEMS operations around the world. About 55 per cent of that fleet is light twin, 30 per cent singles and 15 per cent medium to heavy helicopters.

“In terms of geographical distribution,” commented Ralph Setz, Senior Manager Operational Marketing, “we see that 50 per cent of the overall HEMS fleet operates in North America with 53 per cent single and 47 per cent twin, mostly light twin. In Europe, about 35 per cent in operation with nearly 100 per cent twin engines (due to EASA operating rules) 81 per cent of which are light twins. There are very few EMS helicopters in the rest of the world, and many countries that have no HEMS at all.”

Bestle went on to explain that such a disparity means that the company is dealing with a variety of mature customers that have many years of experience

COMPANY PROFILE

and know exactly what they need in some areas, while on the other hand, discussions take place with HEMS beginners with whom AH needs to consult and define the right helicopter and the right equipment for them. “The success and our strong market position is due to the fact that we work very closely with our HEMS customers,” he said. “If we look back at the development of the H135, a task force was set up with many HEMS operators shaping the design of the new aircraft. We further improved key benefits such as wide rear loading, fully flat floor, protected tail rotor, medical design, layout etc.” He continued: “We are in dialogue with our HEMS customers, but also of course with our EMS suppliers for permanent improvements to our offering.” Two examples of such discussions leading to changes are that initially, there was a standard floor plus a special medical floor on top for the H135 in HEMS configuration, which resulted in weight penalties. AH developed a new design and now offers a special medical floor directly from the factory, eliminating the standard floor and providing a weight saving of up to 40kg, which allows for more payload.

Another example was the H145. “We have many EMS suppliers and we wanted to facilitate multiple new medical developments,” explained Bestle. “So, we have designed EMS fixed provisions. Those are defined together with the EMS suppliers but installed by us at the assembly line so that every customer can select his favourite EMS solution that fits easily to our airframe. By the usage of such fixed provisions/interfaces, the installation of HEMS equipment can be performed more easily and quicker. Furthermore, it improves the versatility of the helicopter.”

Worldwide market One of the most mature markets for helicopter sales, is, of course, the US. Bestle said that in North America, the size of the HEMS fleet in operations across the US has more or less doubled in the last 10 years. “HEMS is considered as a business and many commercial operators have developed so called ‘Independent Provider Models’,” he told AirMed&Rescue. “That means, the commercial operators are providing an equipped helicopter with complete crew somewhere in the country and anybody can order the service against payments. That trend increased the number of light twins. In recent years, the trend has been moving towards less expensive single engine helicopters in order to remain competitive, especially in rural areas.”

In Europe, meanwhile, the market for AH has been more in the nature of replacements, as most countries had already set up a mature HEMS network.

“Of course,” continued Bestle, “new helicopter models and increasing safety and patient quality requirements attract the market and pave the way for fleet renewal. Furthermore, the centralisation and specialisation of hospitals is driving the demand for long-range intensive care transport capabilities.

More powerful versions of H135 and H145 provided more payload and safety for complex operations such as mountain hoisting. Modern cockpits such as Helionix with its embedded four-axis autopilot system features – more on that later – and extra safety (one-line scan with blue line, recovery button, voice alarm), increase the level of safety significantly and allow for safer operations in adverse weather conditions.”

In emerging markets, AH is seeing an increasing interest in HEMS – some countries, such as Malaysia and China, have successfully started their first HEMS activities, and while such services are still being developed, initial challenges need to be overcome. Airbus Helicopters is gearing up to serve this market in a number of ways, one of which is setting up an assembly plant for the H135 in China, ground for which was

broken in 2017.

Countries such as India, Brazil, Mexico and Indonesia have also been identified as potential candidates for a strong HEMS development in the next decades.

Driving forward Stefan Bestle’s mission is to drive the Airbus Helicopters strategy for the Emergency Medical Services segment through the right understanding of the mission (regional specificities, business model mechanism, operational requirements, etc.) and customers’ needs to ensure the future Airbus solutions will cope with the customers and market expectations – a challenging role, to be sure: “The global HEMS market and its aircraft requirements are quite diverse due to different regional and geographical situations. In addition, there are different business models starting from charity, insurance based (private and/ or public) up to state-funded or even driven systems. Trying to define solutions that fit all of these aspects and requirements is a challenge but has also been one of the strengths of Airbus Helicopters. Airbus offers customer-orientated mission solutions to reach the highest efficiency for lifesaving missions.”

Digitalisation is a buzzword for any number of industries right now, including the air medical sector – customers are demanding more digitalisation of services, and Airbus must step up to the plate and meet these demands. Bestle said that when talking about digitalisation, there are two distinct parts – the helicopter operation, and the medical mission. “Airbus,” he explained, “already delivers digital services and connectivity solutions like an electronic flight bag, Fleet Keeper, real-time transmission of helicopter warnings and exceedances etc. The first aircraft are already equipped with a smart communication server.” Meanwhile, the medical market is transforming. “Digitalisation projects can be seen everywhere, whether it is telemedicine, live streaming of patient data, usage of robotics and 3D-printing, up to augmented reality. In addition to the development of innovative systems and solutions, special medical care laws have already changed or are under investigation to provide a legal basis for telemedicine applications.”

Especially for rural areas where the density of the emergency services systems might be lower than in urban areas, telemedicine applications could enhance the services.

Next to today’s standard training like ARCM (Aeromedical Crew Resource Management) the technology developments have allowed further improvement of the safety level for HEMS operations. A big step forward is the new Airbus avionics family called HELIONIX®. Exclusively developed by Airbus for helicopter usage, the objective of the avionics solution was to reduce the pilot’s

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COMPANY PROFILE

workload and provide the pilot with more time to concentrate on his mission.

This has been enabled by a new HMI concept, innovative advisory and alarm functionality, simplified indications, centralisation of vital piloting data and reducing the indicated information to the bare and essential minimum required. This HELIONIX® continuously monitors the aircraft vehicle status and anticipates if there is a negative trend regarding a certain parameter. If so, the pilot will receive a pre-information warning and will be able to anticipate in advance and act, not just to react. This reduces the pilot’s workload, which is essential for single pilot missions.

In addition to the new avionics solution, Airbus Helicopters has also designed its four-axis autopilot system, which enhances not only the mission capability, but further increases flight safety. Bestle gave more details about the system: “A button on the cyclic grip recovers the aircraft to a safe flight attitude. This can be a life saver when IMC is entered inadvertently. The autopilot also provides protection of the engine and the flight envelope.” Furthermore, new operations like low level IFR flights, LPV and point in space (PINS) approaches can be flown with a minimum pilot workload and increased situational awareness. Systems like HTAWS (Helicopter terrain awareness and warning system), SVS (Synthetic Vision System), Enhanced Moving Map and TCAS (traffic alert and collision avoidance system) can be seen as today’s standard available safety equipment.

Due to the new autopilot systems, Airbus is currently developing a truly vertical PC1 take-off and landing procedure for the H145. This, says the company, will further increase safety during take-off and landing at heliports and public interest sites surrounded by obstacles, while at the same time further reducing the pilot’s workload and hence increasing safety in case of an engine emergency.

To further improve the efficiency of the operative aircraft usage, Airbus provides, whenever possible, ‘plug and play’ designs for mission equipment. The concept comes with fixed provisions where a quick installation of mission equipment is possible without the usage of special tools. This guarantees a quick conversion to different mission scenarios whenever required.

Investment in the future Currently, there are a number of operators around the world that wish to continue their air medical and rescue operations into the hours of darkness. AH is designing its helicopter cockpits so they are ready for when more operators

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decide to fly into the night. Ralph Setz told AirMed&Rescue that while HEMS operations in North America and many countries in Europe already perform day and night-time operations, some countries and operators do not provide the service at all. The implementation of night flying services (NVG) requires availability of sufficient funding and experienced pilots as well as a national legislation allowing such operations for commercial operators. He added: “Our helicopters are of course fully night operation capable and fully NVG compatible including the medical installations. We see clearly the trend towards more night operations fully supported by our NVG cockpits and goggles, e.g. the UK and Austria often perform two pilot operations.”

Bestle added: “Our new Helionix cockpit philosophy is a step further towards more night operations due to the ease of operation and integrated safety systems such as SVS, HTWAS, TCAS, etc. AH strives continuously to provide pilots with cockpits that lower their workload and this will be further highlighted by the new Helionix software steps to come in the future. As Helionix is our design, such improvements can be rolled out regularly for the benefit of operations.”

Training is also a large part of AH’s business model, into which it has made significant investments in recent times. Nearly one year ago, the H145 Full Flight Simulator (Level D) was certified by the German Federal Aviation Office in Germany and is frequently used by customers. Indeed, AH provides complete training solutions in 23 training centres throughout the world – from ab-initio up to recurrent training for both pilots and technicians. Some of these centres have state-of-the-art full-flight simulators equipped with an OEM Sim Data Pack that provides the most true-to-life experience possible. And many of them utilise full-scale mock-ups, offering trainees an experience similar to what it would be on a real aircraft.

Furthermore, Airbus Helicopters, Thales and Helisim (a joint venture of Thales and Airbus Helicopters) are going to build a regional helicopter training centre including an H145 Full Flight Simulator in Texas. Helisim will develop and operate the simulation centre, which will include the first H145 and H175 Level D simulators in North America.

Investment in future technology, then, is high on the agenda for this company, and it certainly has plans in place to face any challenges the industry – and global economics – can come up with.

SPECIAL REPORT

Aeromedical transport training in Bangkok

Run by Dr Terry Martin and co-ordinated by Asian Assistance, the second Clinical Considerations in Aeromedical Transport (CCAT) course to be held in the region took place in June at Rangsit University in Bangkok, Thailand

The ever-increasing number of visitors to Asia has amplified the demand for aeromedical transport across the region, and courses such as the CCAT training has brought, and will bring, much benefit to the standards and quality of care available. The 10-day event started with the foundation level phase, but also included a three-day advanced component for the graduates of the 2017 course. Both phases were directed and taught by Dr Terry Martin, the founder of the CCAT training in the UK, while five local highly experienced guest speakers from South-East Asia helped to deliver the syllabus. Together, they shared their experiences on providing high-quality care in the air for complicated cases such as major trauma, critically ill patients and paediatric and neonatal transfers by both fixed-wing air ambulance and HEMS. Additional activities included visits to Medical Wings Department at Don Mueang Airport and Samitivej Srinakarin Hospital. The hospital medical transport team introduced and demonstrated the Extracorporeal Membrane Oxygenation (ECMO) transport service and patient loading/ unloading into the HEMS helicopter. Delegates also received handson practical skill demonstrations, simulated emergency procedures in flight, and received competency training on air transportable medical equipment.

Participants travelled from across Asia to attend the event, including

Thailand, Myanmar, Nepal, Singapore, Cambodia, Vietnam, Indonesia, Philippines, Malaysia and South Korea, and all received an accredited CCAT Training Certificate in partnership with Rangsit University. Dr Yin, Chief Medical Officer of Asian Assistance, stated: “The course was challenging to run but turned out to be highly successful, with a greater number of participants than last year. Feedback from the participants has been overwhelmingly positive. We are pleased to be the centre in South East Asia for organising such significant and respected educational experience.”

Dr Terra, one of the participants, stated “This CCAT course focused intensively on systematic critical thinking. The group discussion allowed us to share our knowledge and experiences in aeromedical transport under the supervision of the expert in this field. Increased knowledge on the dos and don’ts are one of the things that we carried out after the completion of the training.”

Another participant, Dr Feemuchang, noted: “The professional atmosphere and the great teaching staff made my CCAT training a big success. Not only could I develop my medical knowledge further, it also enabled me to meet interesting people from several countries.”

In his summing up on the final day of teaching, Dr Martin described the Bangkok course as a great event, congratulating the delegates for their enthusiasm and dedication to passing each stage of the training.

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INDUSTRY VOICE

WORKING TO THE LIMIT

Fatigue management in the UK: Is this being ignored by the retrieval and repatriation industry, or are there good examples in practice?

Aim Explore what fatigue is and how medical professionals working in flight differ from their aviation and hospital colleagues.

through the introduction of the Working Time Regulations (1998), which implemented the European Working Time Directive into UK law. These reduced the maximum working time to 48 hours in a week, averaged over 17 weeks, which could arguably be a step closer to the flight time limitation scheme as seen in the airline industry. However, within healthcare, and especially within the sub speciality of retrieval and repatriation medicine, there is evidence that problems with inadequate rest and fatigue continue to persist (McClelland et al, 2017). Is fatigue management being ignored by the industry and medical professionals undertaking retrieval and repatriation to the detriment of patient safety?

Introduction The fusion and learning between aviation and healthcare is apparent in air ambulance and commercial retrieval and repatriation, with healthcare learning from initiatives undertaken in aviation. There are many examples of aviation-to-healthcare translation: ground-breaking initiatives such as simulation training (Gaba, 2004); checklists for pre-theatre assessment (WHO, 2009); and Just Culture (Eurocontrol, 2012), all of which have changed healthcare for the better regarding safety and quality standards.

However, one area healthcare is slow to adopt from aviation is fatigue management, its guidelines and regulation of medical professionals (doctors and nurses) who are involved in retrieval and repatriation medicine.

There has been an attempt to regulate working time in UK healthcare

What is fatigue?

The Faculty of Intensive Care Medicine (2017) describes fatigue as ‘extreme tiredness resulting from mental or physical exertion or illness’.

Susceptibility to fatigue depends on many factors, including those directly related to the individual such as their workload, home life, colleagues, critical care unit, and hospital. Further factors such as age, changes in family life, and physical and mental health often fluctuate the effect of, and susceptibility to, fatigue. There are two types of fatigue, Acute and Chronic (The honourable company of air pilots, 2017): Acute fatigue is short term and can be experienced during a sequence of duties that may be within prescriptive limits. It is rectified by allowing a suitable period of rest for the individual member concerned.

Chronic fatigue has long-term medical consequences, and can be

Authors: Stuart Cox and Kerryn McGowran (nee Reynolds) (Royal College of Nursing, Critical Care and Flight Forum).

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bought on by irregular sleep patterns, circadian rhythm changes, eating at odd times, and a whole host of domestic and personal factors. As this disorganised time progresses, the normal pattern of life begins to break up and minor irrelevant things become very important to the affected person. Conversely, very important things become minor, so compliance with safety procedures, normal balanced speech and temper can change.

Some of the behaviours and symptoms of an affected person can include aggression, ignoring warnings, feeling very depressed, crying and laughing inappropriately, and repeatedly falling asleep. This has a direct influence on crew resource management (CRM). There are a myriad of symptoms frequently misunderstood and misdiagnosed by those with limited knowledge. If left unchecked and undiagnosed, it can take many months, even years, to correct.

Acute and chronic fatigue can affect our actions, causing deleterious effects on patient outcomes. To Err is Human stated that 98,000 patients die annually from preventable medical errors (Kohn et al, 2000). Does fatigue play a part in this, or even exaggerate the risk? Fatigue can be insidious and develop over months to years. It is very important that we look after both ourselves, and our colleagues’ welfare. It’s easy to forget in the rush to get home, that it may be safer to have some food and drink, and have a rest before travelling and putting yourself, and others at increased risk. Sleep-related vehicle accidents account for up to 20 per cent of all road traffic accidents and drowsy driving is as important a factor in accidents as drink driving. If the flight crew or medical professional commutes by car, they should be reminded that they may be driving after lengthy periods of time on duty at the end of the mission.

In addition, they may be at further risk due to crossing several time zones and their circadian rhythm for alertness may be at a low point due to travel. Medical professionals are not legally counted as flight crew, and are therefore not subject to flight time limitation schemes, thus lack overall fatigue management regulations specific to their role in flight. This is an area of concern for the authors as it allows individual companies to potentially task medical professionals to lengthy retrieval and repatriations Does fatigue management differ between the aviation industry and healthcare?

Yes, the aviation industry recognised in the 1950s that aircrew fatigue may have been a contributory factor in some aircraft accidents (CAP 371, 2004). The Bader Report (Air Navigation Order 1974) was commissioned and the Flight Time Limitation Board convened, with the object of regulating the hours worked by aircraft crew. Restrictions placed on the number of hours worked, developed over the years, have gone a long way towards ensuring that crew are sufficiently rested prior to commencing a flying duty period.

In healthcare, following the traumatic death of an anaesthetic trainee who

was returning home after a night shift, a study by McClelland et al (2017) in hospital fatigue demonstrated that fatigue is definitely prevalent among junior anaesthetists. This study found that fatigue has effects on physical health (73.6 per cent), psychological wellbeing (71.2 per cent), and personal relationships (67.9 per cent). Fifty-seven per cent (55.0-59.1) stated they had experienced an accident or near-miss when travelling home from night shifts.

The medical repatriation and retrieval environment (IATA 2018) has additional risks such as: • A hypobaric environment, hypoxia and decreased humidity • turbulence, vibration and noise • Discomfort arising from cabin layout and sustained relative immobility • Irregular lifestyle; especially with regard to sleep cycle, local time change, irregular shift patterns, family and social life • Repeated changing of team, climate, culture, work and off-duty routines • Changing time zones, disruption to circadian rhythm and jet lag.

These are exacerbated by the fact that not all medical specialists are occupationally screened for retrieval and repatriation work (unless working within helicopter emergency medical services). Medical standards for professional and private pilots have long been clearly specified in international regulations (ICAO, Annex 1, Chapter 6); however, there is generally no equivalent for medical professionals on flights. Exceptions do exist; a certain number of countries require cabin crew to be licensed to private pilot standards, but this does not apply uniformly for medical professionals. The airline may determine the appropriate pre-employment health assessment required causing potential variation in standards.

Does fatigue management differ between air ambulance and commercial repatriation and retrieval?

The view of the Civil Aviation Authority (CAA) regarding air ambulance movements is that most companies class medical professionals as ‘passengers’ and are thus not part of the flight crew. Hence, they do not have to train them in emergency safety procedures and fire and >> smoke drills. This is usually phrased in operations manuals as ‘the person responsible for patients in air ambulances’. This then removes them from a formal flight-time limitation as stated by The Air Navigation Order (2016). Conversely, this regulation does apply to the Commercial Air Transport aircraft operator. However, the following groups are currently exempt from these regulations: • Air taxi operators of aeroplanes of 19 seats or less • Emergency Medical Services (EMS) • Single-pilot operations • Helicopter operations

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The guidelines are clear for actual aviation crew. Should these be adopted by air ambulance operators and assistance companies? There could be flight-time limitations added, including all the hours the flight medical specialist works in conjunction with working time directives, for example: Fatigue of crew – operator’s responsibilities 175 (1) The operator of an aircraft to which this article applies must not cause or permit that aircraft to make a flight unless: (a) the operator has established a scheme for the regulation of flight times for every person flying in that aircraft as a member of its crew; (b) the scheme is approved by the CAA; 175 (2) The operator of an aircraft to which this article applies must not cause or permit any person to fly as a member of its crew who the operator knows or has reason to believe is suffering from or, having regard to the circumstances of the flight to be undertaken, is likely to suffer from, such fatigue as may endanger the safety of the aircraft or of its occupants.

175 (3) The operator of an aircraft to which this article applies must not cause or permit any person to fly in the aircraft as a member of its flight crew unless the operator possesses an accurate and up-to-date record for that person and for the 28 days immediately preceding the flight showing: (a) all dates and flight times; and (b) brief details of the nature of the functions performed in the course of those flight times.

Flight times – responsibilities of flight crew 177 (1) Subject to paragraphs (2) and (3), a person must not act as a member of the flight crew of an aircraft registered in the UK if, at the beginning of the flight, the aggregate of all that person’s previous flight times: (a) during the period of 28 consecutive days expiring at the end of the day on which the flight begins exceeds 100 hours; or (b) during the period of twelve months expiring at the end of the previous month exceeds 900 hours.

Journey log, crossing time barriers and options This journey log demonstrates flight routings for a medical repatriation from Australia (Perth) to London, and with aviation advances such as the Boeing Dreamliner more direct routes are now an option. This does not take into consideration the pre-hospital visit, the ambulance or taxi journey at the beginning or the end of the journey, handover to receiving care or the time taken to check in and collect luggage. This can add approximately six hours to any flight and is estimated in the working time. Consideration by the organising company needs to also include the journey from the person’s home to their end destination, which should also be included in total working time. These estimates do not account for potential flight delays that may be incurred on a long haul flight with a scheduled airline.

Origin: Perth, Australia Destination: London 42 42

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Perth – London (Direct)

Perth – Doha – London

Perth – Dubai – London

Sectors

1sector

2 sectors

2 sectors

Total flight hours

17.20

20.15

22.30

Transit time

0

1.05

2.10

Total time zones crossed

8

8

8

Total estimated working time including check in and additional travel (6 hours)

23.20

26.15

28.30

For a one-person medical specialist this is a considerable length of journey at best. It is also vital to consider the impact of travelling from London to Perth to pre-position prior to the transfer of the patient back to the UK. Some companies will add a second medical person onto flights but this is not standard or consistent.

Additional areas to take into account in terms of fatigue risk: • Rest time for the medical specialist prior to leaving the UK to travel to Perth • Impact of crossing time zones from East to West to pre-position in terms of jet lag, and resulting disruption to their circadian rhythm before the transfer even commences.

• Short period of rest (24 hours minimum) on the ground in Australia before travelling back with the patient.

• In terms of jet lag, travel across six-time zones will typically take the body between three and five days to adjust. Jet lag causes tiredness, exhaustion, poor sleep quality and concentration and memory problems (NHS choices, 2017).

• These factors, coupled with general fatigue from physically working extended hours medically supporting a patient, mean the medical specialist is at a much higher risk than their hospital and flight crew colleagues.

Conversely, there are routing options that can be considered to reduce fatigue and this is demonstrated with anticipated working times.

• In this journey log, it is clear to see that with different time zones, retrieval and repatriation operations are not always conducive to a regular sleep/ wake schedule and can affect sleep and circadian factors in two ways, which can further lead to fatigue (IATA, 2018). The first is as a result of duty periods occurring at unusual or changing times in the day/night sleep cycle and the second when there is a requirement for time zone crossings. This leads to: • Conflict between the environmental time (in the case of unusual or

INDUSTRY VOICE

changing work schedules) or local time (in the case of changing time zones) and body times.

• Circadian disruption when the body is required to adjust continuously between day and night schedules.

A further factor that can create sleep loss is a prolonged period of continuous wakefulness. So, should companies look at two sector (or more) flights with a different medical specialist to take over in transit to breakdown the risk of fatigue irrespective of cost but to add value to patient safety?

• •

• Summary The scope of the problem for fatigue management within the industry for medical professionals has not been addressed on a global scale. Some of this may be related to staffing availability, cost constraints for companies by using two professionals, and also a general lack of awareness of fatigue management.

While some companies may have a robust policy on fatigue management, this is not a legal requirement to date. The length of time medical professionals should be expected to work should be similar to that within comparable clinical roles such as hospital length shift, with adequate break facilities and in an adequate location. It is also important that longer term factors are kept in mind; sleeping habits, social life, personal fitness, alcohol, caffeine, taking regular holidays and so forth. These are all very important to pay attention to in our attempts to prevent fatigue and this should be closely considered by companies and all medical professional hours in all roles should be recorded and monitored. Individual medical professionals should also be more aware

•

• •

the same way as pilots and cabin crew, with change driven by medical professionals and regulators.

Assistance companies and medical professionals need an enhanced appreciation of fatigue management when planning a repatriation.

Medical professionals need to be empowered to say NO to retrievals or repatriations based on fatigue risk and the potential effects on patient safety. This can be achieved by heightened awareness of fatigue and its identification and management.

At home and before duty – get the best possible sleep before starting a trip. A nap can improve subsequent alertness and performance and will decrease the period of continuous wakefulness. If napping immediately before a duty period, limit the length of the nap to no more than 45 minutes. At other times, naps can be longer.

The repatriation does not end until you are in a place of rest (i.e. at home) and corporate liability needs to be undertaken to ensure this is considered and factored into logistical planning.

On a trip – try to get as much sleep in every 24 hours away as in a normal 24 period at home Trust your own physiology – if the crew member feels sleepy and circumstances permit, then they should sleep where possible, provided it is safe to do so.

References: CAP 371: Avoidance of Fatigue in Air Crews 16 January 2004.

The length of time medical professionals should be expected to work should be similar to that within comparable clinical roles such as hospital length shift of fatigue management, and take ownership and be accountable for its prevention in the planning and delivery of medical repatriations and to say ‘no’ to long retrievals or repatriations without safe rest. As Still (2014) stated, nurses who experience impairments due to fatigue, loss of sleep, and inability to recover between shifts are more likely than unimpaired nurses to report decision regret.

For future management, it is key to use resources such as ‘I’m safe’ – a checklist adapted for clinicians to assess fatigue and fitness to work. This covers key areas such as: illness, medication, stress, alcohol, fatigue, eating.

Awareness should be raised and all individual medical practitioners and assistance dispatches should ask these questions before sending staff on a repatriation, and the individual should also be empowered to risk assess themselves before the return leg of the flight.

Regulators and industry should look upon fatigue management as a crucial area to regulate and to ensure they have transparent plans for their professionals while keeping a log of hours worked in all roles. The Royal College of Nursing is to shortly release the date of its fatigue symposium looking at creating guidelines for nurses working within the aviation industry.

European Organisation for the Safety of Air Navigation (EUROCONTROL) (2012). Just Culture Policy. Online reference: http://www.eurocontrol.int/sites/default/files/publication/files/201209-just-culture-policy.pdf Flight Time Limitations Board: policy; implementation of the Bader Report; proposed amendments to Air Navigation Order 1974 and associated Requirements Document; fatigue of crew (1974).

Gaba DM (2004). The future vision of simulation in health care. British Medical Journal. Quality and Safety; 13: i2-i10.

Kohn, L.T., Corrigan, J.M., Donaldson, M.S. (2000) To Err is Human: Building a Safer Health System.

Washington (DC): National Academies Press (US).

McClelland, L., Holland., J., Lomas J.-P., Redfern, N., Plunkett, E. (2017). A national survey of the effects of fatigue on trainees in anaesthesia in the UK. Anaesthesia; 72, 1. Pages 69 –1077 doi:10.1111/anae.13965.

National Health Services Choices (2017). Jet Lag. Accessed online: https://www.nhs.uk/conditions/jet-lag/ World Health Organisation (2009). WHO guidelines for safe surgery: safe surgery saves lives.

IATA, version 11, 2018. Online reference: https://www.iata.org/publications/Documents/medical-manual.pdf

The Association of Anaesthetists of Great Britain and Ireland (AAGBI) (2018). Online reference: https://www.aagbi.org/professionals/welfare/fightfatigue

The Air Navigation Order 2016. No. 765 (chapter 5)

The Faculty of Intensive Care Medicine (2018). Online reference: https://www.ficm.ac.uk/Fatigue The honourable company of air pilots (Nov, 2017). DISCUSSION PAPER FATIGUE WORKING GROUP REPORT.

Still, K. (2014). Flight nursing: Fatigue can affect safety and performance. Kai Tiaki : Nursing New Zealand; 20,1. Page 34.

Key Points • There is no specific aviation law covering medical professionals’ fatigue management, nor flight time limitations. Companies should take action and monitor all flight staff hours, especially those working ad-hoc hours and freelance work to ensure compliance with working time regulations.

• An industry-wide approach is required, viewing medical professionals in

www.nhschoices.co.uk

Disclaimers: This article was written outside their roles, but Stuart works for CEGA group (Chares Taylor Company) Kerryn works for International SOS.

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CONTRIBUTORS

diary dates

Jonathan Bancroft Jonathan Bancroft has spent the past 32 years protecting and rescuing people. He has served as a kidnap response manager for Lloyd’s Insurance Group, a security manager for the UK Government’s Foreign and Commonwealth Office, and as a British Army intelligence officer. Now, he is the Managing Director of Traveller Assist, a medical and travel assistance company who travel insurers contract to assist travellers when they are sick, injured, lost or in trouble abroad.

Send your diary dates to: info@airmedandrescue.com

Stuart Cox Stuart Cox is a committee member for the Royal College of Nursing representing nurses at a local and a national level in critical care and flight aviation medicine. He has a passion for aviation safety, medicine and simulation training, and worked as a former senior nurse for CEGA Air Ambulance and has been deployed to Camp Bastian Critical Care unit. Stuart has recently been appointed to a critical care helicopter emergency medical service in the UK with a shared role as an advanced critical care advanced practitioner.

David Kernek David Kernek is a freelance writer and photographer who in recent years has been editor of Holiday Villas, Holiday Cottages and Go Holiday travel magazines. In an earlier life, he was the Westminster-based political correspondent of The Northern Echo and, later, editor of the Bath Chronicle, the York Evening Press and The Northern Echo.

Mario Pierobon Mario Pierobon is a safety management consultant and content producer. He writes extensively about aviation safety and has in-depth knowledge of European aviation safety regulations on both fixed and rotary wing operations. His rotary wing expertise is concerned primarily with specialised operations and the operations requiring specific approval, such as HEMS, hoist operations and performance-based navigation.

Kerryn McGowran Kerryn McGowran (nee Reynolds) is Director of Nursing – Assistance at International SOS London. Her background is primarily medical assistance and emergency medicine with a special interest in tropical and travel medicine. Kerryn is an elected member on the steering committee for the Royal College of Nursing Critical care and Flight nursing forum.

Dr David Sinclair David Sinclair MD graduated from medical school in 1998 after studying at the University of Tübingen (Germany), Dartmouth Medical School (US) and University of California, San Diego (US). He specialised in anaesthesiology, critical care medicine, emergency medicine and travel medicine. He is board certified in Germany, France and Luxembourg and works as an anaesthetist in a hospital setting, as EMS physician for the city of Luxembourg and as a flight physician for European Air Ambulance. He was appointed Medical Supervisor for European Air Ambulance in 2007.

Peter Ten Berg Peter Ten Bergy grew up in the neighborhood of Soesterberg AB, The Netherlands, witnessing the USAF F-4 E aircraft action from nearby, which was where his passion for aviation began. He works as a freelance contributor for various international aviation magazines, focusing on military aviation, as well as civil HEMS operations. This combination of work results in interesting reporting assignments like visits to operational aircraft carriers at sea and joining flights for aerial photography.

James Paul Wallis Previously editor of AirMed&Rescue Magazine from launch up until issue 87, James Paul Wallis continues to write on air medical matters. He also contributes to AMR sister publication the International Travel & Health Insurance Journal.

Bruce Webb Bruce Webb is the Director of Aviation Education and Community Outreach for Airbus Helicopters. He believes that the key to improving aviation safety is through a better understanding of human behaviour. He joined Airbus (Eurocopter) in 1999 as a pilot and quickly was promoted to Chief Pilot, a position he held for 16 years. He stepped down in 2016 to begin his new challenge of promoting safety from a lectern, not a cockpit.

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AIRMED&RESCUE

7-9 September SAREX 2018 El Dorado, California, US

19-20 September The Emergency Services Show 2018 Birmingham, UK

1-4 October American College of Emergency Physicians Annual Meeting San Diego, California, US

16-19 October Helitech International 2018 Amsterdam, The Netherlands

19-20 October The Pittman Course: Flight & Critical Care Paramedic Review Phoenix, Arizona, US

22-24 October Air Medical Transport Conference Phoenix, Arizona, US

29 October EMS World Expo Nashville, Tennessee, US

29 October-1 November International Travel & Health Insurance Conference with Air Ambulance Forum Geneva, Switzerland

1-3 November International Technical Rescue Symposium Portland, Oregon, US

12 November Association of Air Ambulances Air Ambulance Conference London, UK

Medic’Air International

Ace Air & Ambulance (Pvt) Ltd. 2 Mount Road, Avondale, Harare, ZIMBABWE

+263 (4) 302 141

AMREF Flying Doctors Dr Bettina Vadera Medical Director

Wilson Airport, Langata Road, PO Box 18617, Nairobi, KENYA tel: +254

20 6000 090 fax: +254 20 344 170

email: emergency@flydoc.org website: www.flydoc.org

medic-air.com

+212 5 24 38 13 88

Asia Air Ambulance Asia Air Ambulance Co. Ltd., Bangkok599/59 Ratchadaphisek Road, Jatujak, Bangkok 10900, THAILAND

+668 9896 9000

asiaairambulance.com

EDS AVIATION PTE LTD 33 Ubi Avenue, #08-13, Vertex Tower B, SINGAPORE, 408868

+65 9836 3265

eds-aviation.com

+65 6483 5412

flyingdoctorsasia.com

Flying Doctors Asia A’Posh Bizhub, 1 Yishun Industrial St 1, #08-03, SINGAPORE, 768160

LifeFlight

Awesome Air Evac Hanger 104C, Gate C, Lanseria Airport, Lanseria, SOUTH AFRICA

Dar El Bacha - Tizougarine 5, 40000 Marrakech Medina, MOROCCO

ace-ambulance.com

(ASIA-PACIFIC)

AIR AMBULANCE (AFRICA)

SERVICE DIRECTORY

+27 11 430 1777

awesomeairevac.com

+61 7 5553 5955

LifeFlight.org.au

Medic’Air International 每递安国际

ER24 Cambridge Manor Office Park, Manor 1, Stone Haven Road, C/o Witkoppen & Stone Haven Roads, Sandton, Paulshof, SOUTH AFRICA

PO Box 15166, City East, QLD 4002, AUSTRALIA

+27 (0) 10 205 3100 er24.co.za

885 Renmin Road, Huaihai China Building, Room 808, 200010 Shanghai, CHINA

+86 2163 558289

medic-air.com

www.airmedandrescue.com

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>>

Medical Wings 222 Don Mueang International Airport Office Building 3rd Floor, Vibhavadi Rangsit Road, Sanambin, Don Mueang, Bangkok 10210, THAILAND

+662 247 3392

medicalwings.com

Air Alliance Medflight GmbH SIEGERLAND AIRPORT, Werfthalle G1, 57299 Burbach, GERMANY

+49 170 366 4933

air-alliance.de

AIRLEC Air Espace Zone Aviation Générale, 33700 Mérignac Cidex 05 FRANCE

+335 56 34 02 14

AIR AMBULANCE (EUROPE)

AIR AMBULANCE (EUROPE) (APAC)

SERVICE DIRECTORY

airlecairespace.com

quickair.de

+49 2203 955 700

Hangar 3, Cologne Airport, 51147 Cologne, GERMANY

Rescue Wings Malta +356 2703 4129

186 Ix Xatt Santa Maria Estate Mellieha MLH 2771, MALTA

Swiss Air-Rescue (Rega) Rega-Center, PO Box 1414, CH-8058 Zurich, SWITZERLAND

Capital Air Ambulance

+41 44 654 33 11

rega.ch

Tyrol Air Ambulance capitalairambulance.co.uk

DRF Luftrettung / German Air Rescue +49 7007 3010

drf-luftrettung.de/air-ambulance

EURO LINK GmbH +49 89 6137 2103

Allgemeine Luftfahrt, D -85356 München Flughafen, GERMANY

FlyEuroLink.de

European Air Ambulance Luxembourg Airport, B.P.24, L-5201, Sandweiler, LUXEMBOURG

+352 26 26 00

air-ambulance.com

FAI – rent-a-jet AG

taa.at

+43 512 22422 100

Fuerstenweg 180, A-6026 Innsbruck-Airport, AUSTRIA

AIR AMBULANCE (NORTH AMERICA)

+44 845 055 2828

Airport House, Exeter International Airport, EX5 2BD, UK

Rita-Maiburg-Str. 2, D-70794 Filderstadt, GERMANY

Quick Air Jet Charter GmbH

Aeromedevac Air Ambulance Gillespie Field Airport, 681 Kenney Street, El Cajon, CA 92020,USA

+(800) 462 0911 eromedevac.com

AirEvac International 8001 South InterPort Blvd., Suite 150, Englewood, CO 80112, USA

aeiamericas.com

+1 619 754-6755

AMR Air Ambulance 001 South InterPort Blvd., Suite 150, Englewood, CO 80112, USA

+1 720 875 9182

AMRAirAmbulance.com

Global Jetcare, Inc.

Flughafenstasse. 124; 90411 Nuremberg; GERMANY

+49 911 36009 31

fai.ag

GlobalMed International

+1 352 799 7771

globaljetcare.com

Helidosa Aviation Group +212 5 24 38 13 88

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

15421 Technology Dr. Brooksville, FL 34604, USA

Karla Viñas

medic-air.com

Air Ambulance Account Executive

Jet Executive International Charter Mündelheimer Weg 50, D-40472, Düsseldorf, GERMANY

+49 211 602 7775

jetexecutive.com

Malteser Service Center Malteser Service Center Kalker Hauptstr.

22-2, 51103 Köln, GERMANY

tel: +1

+49 221 98 22 333

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AIRMED&RESCUE

email: k.vinas@helidosa.com website: helidosa.com

JET ICU +33 141 72 1414

medic-air.com

2561 Rescue Way, Brooksville, FL 34604, USA

+1 352 796 2540

jeticu.com

Jet-Rescue Air Ambulance

North Flying a/s North Flying Terminal, Aalborg Airport, DK-9400, Nørresundby, DENMARK

(829) 345-7219

malteser-service-center.de

Medic’Air International 35 rue Jules Ferry, 93170 Bagnolet, Paris, FRANCE

Hangar 1 10 & 14 La Isabela Airport Santo Domingo Dominican Republic

+45 9632 2900

northflying.com

Suite 100, 7777 Glades Road, Boca Raton, Florida 33434, USA

+1 786 619 1268

medjetsUSA.com

REVA Inc 2101 W. Commercial Blvd., Suite 1500, Fort Lauderdale, Florida 33309, USA

flyreva.com

+1 954 730 9300

Skyservice Air Ambulance Montreal/PE Trudeau Int Airport, 9785 Avenue Ryan, MONTREAL (Quebec), H9P 1A2, CANADA

+1 514 497 7000

skyserviceairambulance.com

AAMS 909 N. Washington Street, Suite 410, Alexandria, VA 22314, USA

tel: +(703) fax: +(703)

836-8732 836-8920

website: www.aams.org

IAFCCP Monica Newman Executive Director

MEDICAL ESCORT ON COMMERCIAL AIRLINES

ASSOCIATIONS

AIR AMB. (N. AMERICA)

SERVICE DIRECTORY

AMREF Flying Doctors Dr Bettina Vadera Medical Director

Wilson Airport, Langata Road, PO Box 18617, Nairobi, KENYA tel: +254 fax: +254

20 6000 090 20 344 170

email: emergency@flydoc.org website: www.flydoc.org

European Air Ambulance Luxembourg Airport, B.P.24, L-5201, Sandweiler, LUXEMBOURG

website: www.iafccp.org

GROUND TRANSPORT - MEDICAL

fax: +770-979-6500

600 Pennsylvania Ave SE, Washington DC, 20003, USA

+1-202-499-2294

globalmed-international.com

LIFESUPPORT Patient Transport Graham Williamson CEO

VANCOUVER – TORONTO – HONOLULU tel: +1

250 947 9641 877 288 2908

email: graham.williamson@LifeSupportTransport.com

website: www.LifeSupportTransport.com

Medical Wings gateway-ems.com

LifeMed Worldwide 990 Biscayne Blvd. Suite 502 Miami, FL 33132, USA

+49 6742 897 425

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

fax: +1

Gateway International EMS

air-ambulance.com

GlobalMed International

4835 Riveredge Cove, Snellville, GA 30039, USA tel: +770-979-6372

+352 26 26 00

222 Don Mueang International Airport Office Building 3rd Floor, Vibhavadi Rangsit Road, Sanambin, Don Mueang, Bangkok 10210, THAILAND

+662 247 3392

medicalwings.com

Prime Nursing Care, Inc. +1-305-501-2009 lifemedworldwide.com

1918 Harrison Street, Suite 215, Hollywood, Florida, 33020, USA

+1 754 999 0460

primenursingcare.com

One Call Medical Transport 24hr Worldwide Ground Transports 3815 E Main St., Suite C St. Charles, IL 60174, USA tel: +1 fax: +1

630 444 2100 630 823 2900

To have your company listed in our service directory contact the sales department now: sales@airmedandrescue.com +44 (0)117 925 51 51 (opt.1)

email: ops@ocmt.com website: www.ocmt.com

www.airmedandrescue.com

47 47

ADVERT LEFT

ADVANCED MEDEVAC When time and distance are matters of life, Gulfstream aircraft are uniquely equipped for medevac. High-speed, long-range flight speeds arrival. Payload capabilities allow for an array of critical-care equipment that sustains multiple patients during transport.

GULFSTREAM.COM/SPECIALMISSIONS

TROY MILLER | +1 703 841 7443 | troy.miller@gulfstream.com