AirRescue Magazine 4/2012

HEMS OFFSHORE

Airrescue InternatIonal aIr rescue & aIr ambul ance

M A g A zine

Interview

The new CEO of ADAC Air Rescue

Medical Care

HEMS response to the Utøya island shooting

Technology

Bell 429 in European HEMS

ISSUE 4 | Vol. 2 | 2012

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KARL STORZ GmbH & Co. KG, Mittelstraße 8, 78532 Tuttlingen/Germany, Phone: +49 (0)7461 708-0, Fax: +49 (0)7461 708-105, E-Mail: info@karlstorz.de KARL STORZ Endoscopy America, Inc, 2151 E. Grand Avenue, El Segundo, CA 90245-5017, USA, Phone: +1 424 218-8100, Fax: +1 800 321-1304, E-Mail: info@ksea.com KARL STORZ Endoscopia Latino-America, 815 N. W. 57 Av., Suite No. 480, Miami, FL 33126-2042, USA, Phone: +1 305 262-8980, Fax: +1 305 262-89 86, E-Mail: info@ksela.com KARL STORZ Endoscopy Canada Ltd., 7171 Millcreek Drive, Mississauga, ON L5N 3R3, Phone: +1 905 816-4500, Fax: +1 905 858-4599, E-Mail: info@karlstorz.ca www.karlstorz.com

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e dI torI a l Dear Readers, You are holding in your hands the final issue of our magazine for this year. I’m addressing you again after a break, as my close colleague, Denise Eikelenboom, authored the editorial in the last issue. Before we look back on 2012, I would like to share with you a summary of the Strategic Planning Meeting, which took place in the Dutch town of Lelystad in the second half of September.

We talked about the Air Safety Report project, a system for reporting events that happen during operations. We want to make this system more widespread among EHAC members, the plan being to create a central database.

Other topics we discussed were the ongoing EASA Rulemaking Tasks in relation to our operations, more specifically, relating to Flight Times and Duty Limitations for EMS OPS, CRM and HEMS Performance, and Mountain OPS. In each of these processes EHAC has its own representative, namely Urs Nagel from Rega, and Bernd Lang and Hubert Becksteiner from ÖAMTC Air Rescue.

As regards our relationship with EASA, EHAC will soon be applying to join the Safety Standard Consultative Committee. If we are accepted, we will get direct and timely access to important expert information.

Another topic discussed was the preparations for the AIRMED 2014 conference. Intensive work on the Scientific Programme is currently underway, and two meetings have already been held. I am confident that the participants of the conference in Rome will have something to look forward to. Members of the Board and the Board’s working groups also took home two assignments from the meeting.

Their tasks were to draw up proposals, firstly, for developing EHAC Principles and, secondly, in relation to possible changes to the EHAC Statutes, Electoral Rules and Internal Regulations. In this context, I would like to ask you, the

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readers – that is, members of EHAC – for your comments regarding our organization’s key documents. Please send them to the Managing Director, Stefan Becker, by the end of this year.

We also dealt with the issue of relations with the New EHA and expect that you will soon be informed of significant progress. On a final note, I’d like to inform you that on 22nd and 23rd of May 2013 the first EHAC Symposium in conjunction with the Annual General Membership Meeting will be held in Warsaw. And it looks like an excellent keynote speaker will be speaking on the topic of Just Culture.

I must say that I’m looking forward to reading this issue of AirRescue Magazine. I will focus primarily on the interview with the new top representative of ADAC Air Rescue, Frédéric Bruder. The interview with Patrick Moulay about the Bell 429 in Europe will also be an interesting read for me. I would like to thank the team at AirRescue Magazine for including a very engaging theme in this issue – HEMS in offshore wind farms. I am also glad to see the Hungarian HEMS Profile and Case Report by my friend Péter Temesvári.

I will see many of you personally at the EASA Symposium in Cologne. And to those of you I will not see, I wish you and your families a joyful Merry Christmas and all the best for the New Year.

Pavel Müller President of the European HEMS and Air Ambulance Committee

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Airrescue InternatIonal aIr rescue & aIr ambulance

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ISSN: 2192-3167 Publisher: L. Kossendey Verlagsgesellschaft Stumpf & Kossendey mbH Rathausstraße 1 26188 Edewecht | Germany service@skverlag.de Tel.: +49 (0)4405 9181-0 Fax: +49 (0)4405 9181-33 www.airrescue-magazine.eu Medical Advisor: Dr Erwin Stolpe Medical Director EHAC

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Key component of the rescue chain: HEMS for trauma patients in offshore wind parks N. Weinrich, D. Dethleff, C. Friebe, et. al.

Editor-in-chief: Dr Peter Poguntke Tel.: +49 (0) 711 4687470 Fax: +49 (0) 711 4687469 E-Mail: poguntke@airrescue-magazine.eu Editors: Tobias Bader Tel.: +49 (0)4405 9181-22 E-Mail: bader@skverlag.de Klaus von Frieling Tel.: +49 (0)4405 9181-21 E-Mail: frieling@skverlag.de Christoph Kossendey Tel.: +49 (0)4405 9181-14 E-Mail: cko@skverlag.de Marketing · Advertising · Subscription Ch. Niemann Tel.: +49 (0) 4405 9181-16 Fax: +49 (0) 4405 9181-33 E-Mail: sales@airrescue-magazine.eu Subscription Rate: Europe: (Shipping included) World: Price per Issue: (Shipping not included)

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Interview with D. Bernitz on HEMS offshore: “Eurocopter is an integral part of the survival chain”

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Through rough winds: HEMS missions at offshore wind parks K. Graf

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Bank Account: Postbank Hannover BLZ 250 100 30 Kto.-Nr. 2837300 IBAN: DE08 2501 0030 0002 8373 00 BIC: PBNKDEFF Production and Design: Bürger Verlag GmbH & Co. KG Frank Lemkemeyer Rathausstraße 1 26188 Edewecht | Germany

AirRescue ist the offical publication of the European HEMS & Air Ambulance Committee (EHAC)

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Case report: Road traffic collision of a 40-year-old male motorcyclist with a small van P. Temesvári

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Oslo government district bombing and Utøya island shooting: The immediate EMS response S. Sollid, R. Rimstad, M. Rehn, et al.

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“Bell Helicopter is back in Europe”: Interview with P. Moulay of Bell Helicopter

SAFETY News Interview with F. Bruder, new CEO of ADAC Air Rescue: “Highest medical quality for people in distress”

OFFSHORE

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HEMS in offshore wind turbines: Promising highline rescue procedure Editorial Team

IN PROFILE

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CHC SAR: One of the world’s largest networks of SAR services Editorial Team

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Helicopter crash in Morbegno: EMS-helicopter hits high voltage cable F. Martorana

SAFETY

Hungarian Air Ambulance and NAS: cooperation for a countrywide HEMS P. Temesvári

MEDICAL CARE

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HEMS response to major incidents: Lessons from the Sierre bus accident R. Lyon, J. Sanders

SAFETY

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Documentation of air rescue missions in Germany: Analysis of air rescue data set K. Reinhardt

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Helicopter safety: Everybody’s concern J. Stevens Cover Image: A. Pecchi/Eurocopter

6 | neWs “Paperless” fixed-wing cockpit at DRF Luftrettung Recently DRF Luftrettung (Germany) has begun to successfully use tablet PCs in the cockpits of its air ambulance jets. These digital devices facilitate the work of crew members on their flights to repatriate patients and at the same time save time, weight and costs. DRF Luftrettung has procured a total of seven Electronic Flight Bags (EFB) for its three ambulance aircraft. The tablet PCs contain all route, approach and departure charts, documents and the flight manual. Around 35 kgs of paper therefore are replaced by just a single tablet PC (of 600 grams). “If we extrapolate this to our annual average use of kerosene, the tablets will save about 7,000 Euros per year in kerosene costs”, says Udo Kordeuter, DRF Luftrettung Fleet Commander.

In addition, the EFBs facilitate the work of the crew: “We update all the relevant data prior to every flight. This is done automatically via Internet and takes about 30 minutes”, Norbert Fleischmann, captain and head of aircraft standardization at DRF Luftrettung, explains. This eliminates the previously necessary revision of the charts, on which a pilot used to work up to four hours every two weeks. Moreover, EFBs are easier to handle than paper documents and thus increase flight safety.

For more information, visit: ››› www.drf-luftrettung.de

Czech state honours awarded to HEMS doctor Rudolf Zvolánek An important event took place in the Czech Republic recently: On 28 October, Václav Klaus, the President of the Czech Republic, personally gave Dr Rudolf Zvolánek, a close colleague and friend of Alfa-Helicopter from Brno, a state decoration.

He was awarded the Medal of Heroism for his courage, resourcefulness and professionalism in saving the life of a severely injured young man. According to Czech news reports, it was “thanks to his courage, presence of mind and professionalism” that Zvolánek saved the life of this seriously-injured man “who had been sucked through a narrow opening in a machine for mixing plastics. The man was subsequently operated on.”

Rudolf Zvolánek was the doctor from the HEMS crew that was sent to the aid of the victim whose arm was caught in the factory machine.

Politicians, cultural figures and church dignitaries gathered in the Vladislav Hall at Prague Castle on that day to celebrate the 94th anniver-

K. Šulová

sary of the birth of independent Czechoslovakia.

On the occasion, President Klaus presented high state distinctions to veterans, scientists, cultural figures and sportspeople as well. It was the last time that Václav Klaus awarded state honours as president.

For more information, visit: ››› http://bit.ly/Zvolanek & http://bit.ly/VKlaus

Aerosuisse Award 2012 for Rega’s chief pilot Rega’s Chief Helicopter Pilot, Heinz Leibundgut, was presented with this year’s Aerosuisse Award in recognition of his outstanding achievements.

With this prize, Aerosuisse – the umbrella association of the Swiss aviation and aerospace industry – pays tribute to Leibundgut’s untiring efforts to increase flight safety and develop new technologies.

For many years, Heinz Leibundgut has been actively involved in improving helicopter flight safety and reliability, particularly in the sphere of air rescue. Among other things, he worked closely with other partners to launch the highly successful “Remove” project, a free service aimed at dismantling redundant air navigation obstacles that pose a hazard to helicopter pilots. Leibundgut has also been responsible for developing the concept of all-weather GPS approach flights to hospital helipads, which is currently in its introduction phase. Heinz Leibundgut has held the position of Chief Pilot of Rega’s helicopter fleet since 2000, and has over 30 years’ experience in the field of helicopter flying. In 2011, Rega flew a total number of 14,240 missions out of which

Aerosuisse

10,797 missions were by helicopter and 1,052 by ambulance jet. Rega operates from 13 bases and employs more than 300 people (full and part time, in 2010).

For more information, visit: ››› www.rega.ch

AAA-Conference (UK) a real success

DRF

Almost 300 people attended the Association of Air Ambulances’ annual conference which was held on 19 and 20 November in Telford near Birmingham. The conference was divided into three thematic fields: “Charity and Communications”, “Air Ambulance Operations” and “Clinical Excellence”.The conference was opened by the Chair of the AAA, Dr Anthony C. Marsh, who is also the CEO of West Midlands Ambulance Service. The AAA has been established as a representative body for the Air Ambulance Services in the UK

that advocates for Air Ambulances as an integral part of the healthcare provision. The success of the Air Ambulance Services in providing a rapid response to life-threatening situations has clearly been established. Clive Dickin, National Director of the AAA, also said that this conference “showed the vital impact the air ambulance community has on healthcare provision in the UK.” For more information, visit: ››› www.associationofairambulances.co.uk

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neWs | 7 HMC to expand air ambulance services

Latitude and Navicom with distribution deal

2012 Cormorant Trophy for Helicopter Rescue

The Hamad Medical Corporation (HMC) from Doha is planning to add more helicopters to its air ambulance service (LifeFlight) next year, in collaboration with the Qatar Emiri Air Force. The service currently receives and responds to an average of 80 to 85 calls each month (an increase of 25 to 30%) or about three calls a day. The vast majority of cases are trauma emergencies like road traffic accidents and industrial accidents. Since the service began in 2007, it had grown from being a daylight hours service to an 18-hour service, enabling the crew to respond to emergencies from 6 a.m. until midnight.

Latitude Technologies (Canada) announced that it has put in place a multi-faceted distribution arrangement with Navicom Aviation, a leading avionics solutions reseller in Japan. Under the terms of the distribution deal, Latitude will be providing Navicom with a custom version of the WebSentinel® flight following system (with all on-screen and user information presented in Kanji/Japanese writing). In addition, Latitude will broaden its partnership with Navicom for the supply of Latitude’s SkyNode® data and voice satcom solutions, and will be supporting Navicom in the EMS helicopter tracking project of the Japan Aerospace Exploration Agency. “Latitude has had a long-standing, solid, and mutually respectful business relationship with Navicom” commented Latitude President, Mark Insley. “I am very pleased to see our relationship going to the next level where we will now work together to deliver more comprehensive flight data solutions to Navicom’s customers.”

Navicom Aviation is a leading avionics systems and flight-following solution provider to the Japanese market. Navicom’s moving map system, NMS-01S, is a Japanese-oriented map system with approval from the Civil Aviation Bureau.

AgustaWestland announced the winner of the 2012 Cormorant Trophy for Helicopter Rescue.

The recipients of this year’s award are Captain Aaron Noble (aircraft commander), Captain Dean Vey (co-pilot), Sergeant Brad Hiscock (flight engineer), Sergeant Daniel Villeneuve (SAR Tech team lead), Master Corporal Shawn Bretschneider (SAR Tech team member) from 103 SAR Squadron at Canadian Forces Base Gander, Newfoundland.

They had rescued two walrus hunters who were stranded on an ice flow in the Arctic sea near Igloolik, Nunavut. During the mission, Canadian Forces SAR Tech Sergeant Janick Gilbert died, after he had jumped into the water from an accompanying CC-130 Hercules in order to assist the hunters. This year’s awarding shall serve as a “reminder of danger and selfless dedication of SAR crews every day in Canada”. Jeremy Tracy, AgustaWestland’s Head of Region for Canada, also said: “Despite the tragic loss of life, this rescue is being recognized because of the extreme circumstances of distance, location, weather conditions and the rescue of two hunters, two SAR Techs from another squadron and the recovery of their companion.”

For more information, visit: ››› www. www.hmc.org.qa

For more information, visit: ››› www.latitudetech.com

For more information, visit: ››› www.agustawestland.com

HMC

8 | neWs New board elected at EURAMI

EHAC on the “Road to Rome” 2014 EHAC‘s Scientific Faculty met for a one-day meeting in Amsterdam on 19 September 2012 in order to plan and prepare the scientific programme of the next Airmed World Congress to be held in Rome in 2014. The EHAC meeting of European professionals (HEMS doctors, pilots, technical and medical directors, flight ops managers, directors from the air medical field) was hosted by Stefan Becker (right), Switzerland, Managing Director EHAC, and Dr Matthias Ruppert, Director Medical Operations, ADAC Air Rescue. Divided into three sub teams, participants discussed topics to be covered at the AIRMED 2014. Identified as being relevant for discussions were, among others, “building a mission”, “crew composition”, “communication and crew training” as well as “regulation issues”. Another sub team also identified “risk management”, “patient safety” and “mass casualty response” as burning issues. The third group added, among other things, “finance and sustainability”, “mission equipment” as well as “inter-organizational cooperation” to the list.

ARM

According to an official statement by the EURAMI board (posted 9 November 2012), the elections of the board „have been one of the most interesting since EURAMI’s inception in 1986.“ The interim board is said to have ensured „the continuity of the association“ with „diligence and courage“.

The following five members were elected to the board: Laurent Taymans, MD (Aeromedicale), Bettina Vadera MD (AMREF Flying Doctors), Mark Jones (Air Ambulance Worldwide), Terry Martin MD (CCAT course, Capital Air Ambulance) and Pascaline Wolfermann (FrontierMEDEX). Andrew Wither, who has previously worked for EURAMI as the office manager, has agreed to stay on to ensure continuity. Being the new EURAMI president, Laurent Taymans will be stepping down as EURAMI auditor with immediate effect and for the entire period of his tenure. A short biography of all five board members will be posted on the EURAMI website in due course.

The first board meeting was held immediately after the elections and members have found an agreement on their future work. A draft shall be published before the end of this year. The statement (signed by Laurent Taymans) ends with the words: „Change is a process; to achieve success depends on our perseverance and the support we hope to receive from you, the members.“

For more information, visit: ››› www.eurami-academy.com

FinnHEMS with new base in Tampere Thursday, 8 November 2012, saw the official opening of the HEMS base in Tampere, Finland, a city situated around 180 km north-west of the capital, Helsinki. The event was attended by countless guests from the world of politics and business, as well as figures from the air rescue community itself. Following a welcome speech by CEO Jyri Örri, various speakers took to the stand to talk about the success of the work that has already been done, and the challenges that lie ahead for FinnHEMS. Finland now has a total of six HEMS bases in place. The Tampere base is situated right at the Tampere-Pirkkala airport (and military base). There’s a Eurocopter EC135 helicopter that provides emergency medical care in the first instance – only in more serious cases will the patient be flown directly to the trauma centre at the hospital. Its crew consists of one pilot, one

HEMS doctor and one HEMS crew member. Night flights using Night Vision Goggles (NVG) are also common, especially given the limited number of daylight hours in winter.

FinnHEMS, a non-profit company, has been responsible for organising air rescue in Finland since 2011, with an annual budget of just over 23 million euros at their disposal. FinnHEMS is funded by Finland’s Ministry of Social Affairs and Health. State funding and administration of the HEMS system via FinnHEMS became possible thanks to new legislation which came into force in May 2011. You will be able to read more about FinnHEMS in the next issue of the AirRescue Magazine.

For more information, visit: ››› www.finnhems.fi

All experts agreed that cross-professional competencies and cross-professional trainings are of major importance in the future and this should also be taken into account while planning for the AIRMED 2014. A wide range of major target groups was identified at the Amsterdam-meeting as well. These included flight ops staff (HEMS/ AEMS), “environmental stakeholders” (such as governments and rule-making agencies), researchers, dispatchers and support services (e.g., technicians, logisticians) as well as mission partners such as police, fire brigade, mountain and maritime rescue, ground EMS staff and hospitals.

The next AIRMED pre-conference, scheduled for September 2013, will have to face the challenging task to narrow down the scope.

For more information, visit: ››› www.ehac.eu

AgustaWestland ARM

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neWs | 9 ADAC Air Rescue and Wiking in offshore wind farms

ADAC

ADAC Air Rescue and Wiking Helikopter Service have recently agreed to pool their resources and work together on rescue missions in German offshore wind farms. The assignment will see the partners providing an ‘in-house rescue service’ on behalf of a number of wind farm construction companies and operators.

Setting up and operating offshore wind farms in the North Sea and the Baltic represents a major challenge when it comes to emergency rescue and the provision of emergency medical care to

staff. Over the coming years, thousands of staff will be carrying out highly dangerous work in difficult conditions, so in order to be prepared in the event of an emergency, it was essential to draw up plans and measures in advance so that staff can receive emergency medical care by professionals should they fall ill or injure themselves (a topic also focused on elsewhere in this edition).

Wiking Helikopter Service, which has 37 years of experience in offshore and winch operations at sea (equating to 43,000 manoeuvres by winch), is providing a suitable helicopter, flight crew and winch operator. ADAC Air Rescue is supplying the medical crew and equipment, and offering up their rescue expertise of course – particularly in relation to rescue using a winch and emergency medical care in difficult conditions.

Avincis

East Anglian Air Ambulance heralds “new era”

to Aberdeen, where they were installed into the gearboxes of the affected aircraft. The aircraft were then thoroughly tested and returned to service in the North Sea. All aircraft are being flown in accordance with the EASA Emergency Airworthiness Directive 2012-0225-E. Newly appointed Bond Offshore Helicopters Managing Director, Luke Farajallah, said that “there is no doubt that recent weeks have been challenging for the industry, but I am pleased that Bond Offshore Helicopters has been able to help its customers by returning our AS332 L2 fleet back to service. Our attention is now focused on the EC225’s, where we are actively participating in the industry meetings and we look forward to further developments.” Safety of the passengers and crew would always come first, Mr Farajallah added.

The East Anglian Air Ambulance’s (EAAA) most recent addition to its fleet is a new EC135 T2e which was equipped in Gloucestershire at Bond Helicopters HQ to the precise specification of the air ambulance. The aircraft will enable EAAA to attend missions at night. Tim Page, Chief Executive of EAAA, said: “Our move into night flying means that during the winter months when people drive to and from work in the dark, should an accident or medical emergency happen, we will be there, bringing the hospital emergency room to them, wherever they are in East Anglia.” Andrew Egerton Smith, Chairman and founder of EAAA said: “My vision for this vital service is that everything we do is of the highest standard and our mission is to deliver exactly what people need, when they need it. We need to constantly innovate and initiate new ideas and, more than anything, we must provide value for money. We are the very first air ambulance in the country to be cleared to fly at night and our brand new helicopter has been fitted with state of the art technology to allow night flying.

Peter Rosenvinge, Director of Fundraising at EAAA, said: “I was inspired to join this charity by the passion and energy of the incredible volunteers, supporters and donors. It’s the people of East Anglia who keep us flying and mean that we can reach people in their hour of need. Their efforts on our behalf continue to inspire me. Indeed it is their generosity that has made it possible for us to extend our service into the hours of darkness.” The crews will now undergo extensive training and it is expected that life-saving missions by helicopter during the hours of darkness will begin by the end of the year.

For more information, visit: ››› www.bondaviationgroup.com

For more information, visit: ››› www.eaaa.org.uk

For more information, visit: ››› www.adac.de/luftrettung ››› www.wiking-helikopter.de

Bond returns all AS332 L2 to service Bond recently announced that it has returned six of its nine helicopters (comprising of four crew change helicopters and two SAR helicopters) back to service. Last week Eurocopter dispatched four technicians and four unaffected rotors shafts

EAAA

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For more information email ENQUIRIES@UTECSOLUTIONS.COM or visit WWW.UTECSOLUTIONS.COM

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10 | neWs ADAC Air Rescue to renew its helicopter fleet ADAC Air Rescue recently signed an order in a framework acquisition agreement with Eurocopter for the purchase of 14 EC145 T2 and three EC135 P2e helicopters, which are to be delivered between 2013 and 2017. The contract concluded at the ILA Berlin Air Show was for an EC145 T2, which is part of the renewal strategy for ADAC Air Rescue’s current BK117 inventory.

“We are very pleased that ADAC Air Rescue has once again chosen Eurocopter, marking a continuation of the more than 40 years in our close and successful cooperation,” Wolfgang Schoder, Eurocopter Executive Vice President – Programs, said. “With the EC145 T2, ADAC Air Rescue will be operating the newest aircraft in the light twin-engine helicopter category. The EC145 T2 was developed in close consultation with air rescue organizations with the specific aim of further satisfying operators’ exacting safety and performance requirements.”

GNAAS with automated chest compression device Great North Air Ambulance Service (GNAAS) has equipped its aircrafts with the automated, portable chest compression device AutoPulse® that will be used on all cardiac arrest patients. The GNAAS is the first air ambulance service in the North of England to use this device, which delivers consistent, uninterrupted, high-quality chest compressions. The AutoPulse’s easy-to-use, loaddistributing LifeBand® squeezes the entire chest, improving blood flow to the heart and brain during sudden cardiac arrest.

The device is especially useful when patients are being transferred from the ground to the stretcher, from the stretcher into the helicopter, and during flight to hospital. Blood flow can be continued throughout the rescue and rescuers freed up to focus on other potentially life-saving tasks. Jane Peacock, deputy director of operations at GNAAS, said: “I don’t normally get excited about medical equipment but this device is amazing. We have used this device a couple of times

now and we are seeing great results.” The GNAAS is a charity operating a fleet of air ambulances across an area of 8,000 square miles, from the Scottish Borders to North Yorkshire, from East Coast to West. On board are specialist trauma doctors and paramedics, bringing accident and emergency expertise to the scene.

For more information, visit: ››› www.greatnorthairambulance.co.uk

GNAAS

Bond joins forces in “jigsaw puzzle”

ADAC

With an existing fleet of 49 helicopters, ADAC Air Rescue is one of Eurocopter’s largest European customers in the emergency medical services market segment. The new EC135 P2e and EC145 T2 helicopters acquired by ADAC Air Rescue will be fitted with medical equipment and the communication tools needed for rescue operations.

Sporting ADAC’s classic yellow livery, they will be deployed as air ambulances for transporting intensive-care patients from one hospital to another, as well as in rescue missions – using a rescue hoist when necessary.

Bond’s offshore SAR operation comprises two dedicated and specially-modified Super Puma AS332L Mark II helicopters, made available under a long-term contract with BP to provide 24/7 airborne SAR and medical evacuation for its workforce in a North Sea system known as Jigsaw. One of the high-specification, twin-engine aircraft is based at Sumburgh Airport, Shetland, the other on the Miller platform, in the central North Sea. Joint exercises of the crews of Bond and of Lerwick harbour pilot boats take place once or twice a week, day and night, with the location – depending on weather – to the north or south of the harbour and often outside port limits. Scenarios practiced regularly with the dummies include winching a stretcher case from the deck of

the pilot boat, winching from a multi-seat liferaft and recovery from the sea. They involve either the authority’s pilot boat/tug boat or Kebister (harbour boat), each with a crew of three who are responsible for deploying a life raft and dummies, depending on the scenario. With increasingly large vessels using the deep-water harbour, the pilot boat crews undertook more than 1,200 ship movements last year, a rise of 15.5% on 2010. Jigsaw operations were launched in March 2006 and there have been around 60 winchings to date, as well as medevacs and downmannings.

For more information, visit: ››› www.bondaviationgroup.com

For more information, visit: ››› www.adac.de/luftrettung

Make your ad space reservation for the upcoming

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Bond

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neWs | 11 Mountain Rescue organizations equipped with AED HeartStart

certificate from Transport Canada for helicopter operations. Through the approval process, FAA officials vetted aviation documentation, including policy and training manuals, procedures, and certificates of airworthiness, and determined Ornge to be in compliance with its regulations.

During the application process, Ornge PC-12NG airplanes continued to transport patients to and from the U.S.

Philips Electronics announced it donates the onemillionth HeartStart AED manufactured to Everett Mountain Rescue Unit (EMRU) of Snohomish,. EMRU is a volunteer SAR organization serving Snohomish County in the state of Washington, USA, which is also the location of Philips’ HeartStart headquarters. The one-millionth AED marks a major milestone in Philips’ more than 50-year history of cardiac resuscitation. Philips also announced that it will make AED donations to nine other local rescue organizations, including Snohomish County Volunteer Search and Rescue (SCVSAR) and eight groups associated with the Washington Mountain Rescue Association (WMRA).

Philips says it wants to drive early defibrillation program best practices, and has helped to establish defibrillation programs at U.S. hospitals and airlines. The introduction of the ForeRunner AED (formerly manufactured by Heartstream, acquired by Philips in 2001) in 1996 helped to raise awareness and to improve public access to AEDs which eventually resulted in legislations to improve public access to AEDs in the U.S. and in many other countries as well.

For more information, visit: ››› www.ornge.ca

For more information, visit: ››› www.everettmountainrescue.org

Ornge

Ornge air ambulance allowed in U.S. air space Ontario’s air ambulance service, Ornge, got U.S. Federal Aviation Administration (FAA) approval to fly its helicopters in U.S. airspace. The fleet can now transport patients to or from any U.S. destination. Windsor Regional Hospital CEO David Musyj said the decision also makes it easier for Ontario residents injured or ill in the U.S. to return home once stabilized: “It strips a level of bureaucracy from the process”, because EMS staff from the U.S. are no longer needed in the transfer process.

Ornge submitted its foreign air carrier application to the FAA after it was granted an air operator

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4 · 2012 I Vol. 2 I AirRescue I 215

12 | neWs Avincis Group with global headquarter in London

Children’s Air Ambulance (UK) as “national” service?

The Avincis Group with operations in the UK, Spain, Italy, France, Portugal, Ireland, Norway, Australia, Chile and Peru provides safe transport for mission critical people and assets for public services. Avincis’ operating companies deliver across the service areas “Life and Rescue” (including SAR and air ambulance); “Safety and Environment” (including fire-fighting, fisheries and marine protection as well as border patrol, disaster response, civil protection and marine pilotage) and finally “Energy Support” ( that includes the transport of assets to remote locations such as oil and gas rigs and wind turbines).

Screenshot

Air ambulance charities across the UK are warning that the launch of a new air ambulance operation could lead to a reduction in air ambulance provision and cause public confusion. The concerns were raised prior to the launch of a “national” Children’s Air Ambulance (CAA) based in the Midlands.

The Association of Air Ambulances (AAA), which represents the majority of air ambulance charities and ambulance services throughout the UK, says the service is a retrieval service based on the current Paediatric Retrieval Service provided by the NHS. It is not an emergency service unlike all other air ambulance operations. AAA Director, Clive Dickin, said: “There is currently no clinical evidence to support the provision of an enhanced service above the one already provided through public funding. Whilst the current service

does very occasionally request a patient to be airlifted, it always uses the established network of air ambulances, military aircraft or private air ambulances.”

The CAA says it will initially transport specialist paediatric medical staff. From next year it will be used to fly patients to ICUs. The operator emphasises that the helicopter will not be used for emergency pick-ups. The pre-advertising of this service as a “national” one has led to confusion amongst members of the public. The Association of Air Ambulances forecasts a drop in fundraising for all charities and criticizes that to date, actually no clinical need for this new service has been identified.

For more information, visit: ››› www.associationofairambulances.co.uk

Pub_E

Polycon waterproof SAR radio system now NVG compatible

Avincis

It operates around 350 rotary and 50 fixed-wing aircraft, from 295 bases in ten countries. Avincis employs almost 3,000 people worldwide and, at end of 2011, had an annualised turnover of 521 million euros (421 million UK-pounds). The Group is headquartered in London. The brands include Inaer, Bond, Australian Helicopters and Norsk Helikopterservice. In 2011, its companies flew in excess of 126,000 hours, conducted more than 3,900 SAR missions over seas and mountains, more than 36,000 air ambulance missions, rescued more than 7,000 people from lifethreatening situations, flew more than 8,800 fire fighting missions and flew over 180,000 people over the North Sea.

Axnes Aviation of Norway, the manufacturer of the Polycon waterproof intercom extension system for SAR helicopters, recently announced that it has developed an NVG compatible version of the system. This is in response to the SAR market upgrading to NVG compatible modern helicopter platforms and the increasing use of NVG systems in civil rotorcraft to increase operational safety.

The upgrade includes the fitment of NVG compatible LED indicator lamps and NVG filters over the unit display windows on both the aircraft installed base station and the MP20 transceiver. The dual band MP20 transceiver is also available as an NVG compatible version. All the NVG compatible units have been tested and are in compliance with MILSTD-3009 NVIS radiance levels for Class B compatibility.

The Polycon communications system provides the capability to rotary and fixed-wing operators to have wireless audio communications

between on and off aircraft crew members, as well as ground crews as if thy were hard wired to the intercom system.

The Polycon wireless intercom extension system has been designed for the typical needs for operations in SAR as well as in EMS. In addition, it also allows the operators to improve efficiency in other areas, for example when mechanics work with running engines, in “pre-flight ground check”, while on and offloading personnel, when ground personnel uses sling loads, during inter operations with ships, boats, ground personnel, interoperations with ground rescue teams, when mechanics on ground conduct short test flights, and also for loadmasters on larger helicopter and aircraft.

E

E

For more information, visit: ››› www.axnes.com

For more information, visit: ››› www.avincisgroup.com ››› www.brunswickgroup.com

4 · 2012 I Vol. 2 I AirRescue I 216 Axnes

Max at 53

neWs | 13 KSE: rope work covering offshore The special unit of climbers (KSE) headed by Manuel Marburger specialises in work at higher altitudes – including offshore rescue. It is fair to say that this offshore service is also provided by other operators in this field, but what makes KSE different is how they provide their service. All the employees in the KSE unit are experienced altitude climbers and/or rescue workers with paramedic training, so they can provide professional assistance at the scene. The ‘standby’ nature of KSE in the wind farm itself, meaning they can be at the scene as quickly as possible, is further evidence of the special position the unit is in.

Manuel Marburger and his ‘rope team’ have many years of altitude rescue experience to draw

KSE

on, which they can also successfully utilise in offshore missions. Their high level of skills and expertise is paying off: KSE is market leader in Germany for (work and industry-related) altitude

rescue and a pioneer when it comes to offshore rescue at altitude. Major companies in Germany, such as RWE and E.ON (electric utilities and service companies), rely on KSE’s know-how to ‘get the job done’. More than 50 employees ensure that a broad range of missions are covered.

What’s more, Marburger has also founded a government-accredited vocational climbing school to ensure that the next generation of climbers can be given expert training. The unit also has its own specialist shop to supply the teams with high-quality equipment.

For more information, visit: ››› www.kletter-spezial-einheit.de

Cega Air Ambulance expands fleet Cega Air Ambulance, based at Bournemouth International Airport (UK), has extended its international reach with the purchase of a Learjet 45, to supplement its existing fleet of King Air 200’s.

“This significant investment has been made to meet the growing demand for longer distance critical care transfers, particularly from emerging and remote destinations back to Europe,” says Graham Ponsford, Cega Group Chief Executive.

Aside from its speed and range, the new jet is expected to benefit clients through its capacity to carry not just patients and medical crews, but also an accompanying relative or employer.

Its generous interior also makes it suitable for the most complex critical care cases, whilst its auxiliary power unit provides a climate controlled cabin, even on the ground. Cega’s investment in the Learjet45 supports its recent launch of a

global private repatriation division. ICU equipment is supplied as standard on all flights, with additional specialist equipment where needed. Cega has been established almost 40 years ago, it has EURAMI accreditation and is CQC-registered. It operates 24/7, 365 days a year.

For more information, visit: ››› www.cega-air-ambulance.com

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14 | eHac

Fig. 1: “In future, we will raise general awareness about the benefits of air rescue to the national economy.” (Photographs: ADAC Air Rescue)

“Highest flight safety standards and medical quality for people in distress” Frédéric Bruder took over as CEO of Munich-based ADAC Air Rescue on 3 September this year, having previously worked as Corporate Director of Strategy and International Business Development at Inaer. Editor-in-chief Dr Peter Poguntke interviewed Mr Bruder for AirRescue Magazine (ARM) and asked him what challenges he faced in his new position.

ARM: Mr Bruder, as someone starting a new job, we inevitably have to ask you – what was it in particular that attracted you to your new role?

Frédéric Bruder: The fascinating nature of air rescue is what attracted me first and foremost. The field involves a unique variety of tasks, both in a business management sense and in terms of operational aspects. The opportunity to control and shape these areas within such a professional and ground-breaking organisation as ADAC Air Rescue is incredibly exciting. It was pretty much a no-brainer for me.

ARM: In your new role, you’re also inheriting the responsibility for a great legacy – the ADAC organisation’s air rescue operations in Germany began in 1970. How do you view this legacy?

Frédéric Bruder: ADAC Air Rescue is renowned worldwide for its achievements – not only as one of the pioneers of air rescue many decades ago, but also as an organisation that remains at the cutting edge of technol-

ogy even today, using the latest flying procedures, as well as the latest air-based emergency medical services. It is a real honour to be preserving and continuing the success story that ADAC Air Rescue has written so far.

ARM: What areas are you likely to focus on in the future?

Frédéric Bruder: Our main priorities will be flight safety and the quality of the medical care we provide. After all, these are the existential pillars of our activities. Although we’ve already achieved great things, we need to keep working to make continuous improvements and pursue all necessary avenues to do justice to these priorities.

Training, maintenance, procedures, but also openness to technological developments, will play a vital role here.

Of course, we will also need to create the financial conditions necessary to maintain our safety standards and quality levels in the future. Compromises in those areas will not be an option.

ARM: In the future, what will be the greatest challenges for air rescue at a national level?

4 · 2012 I Vol. 2 I AirRescue I 218

Frédéric Bruder: Air rescue in Germany will face a multitude of challenges. Economic conditions will have a big part to play, as will the legal framework governing aviation. Costs are rising rapidly, and these are not simply ‘inflation-related’ increases such as investments, maintenance, staffing, kerosene and so on – some increases are systemic, caused by changes in legislation and new rules and regulations. Even though the cost of air rescue in Germany is just the tip of the iceberg in relation to the cost of emergency rescue as a whole, we are still noticing the extreme cost pressure felt by our contracting bodies. In the future, it will be increasingly important to raise awareness about the benefits of a ‘well-oiled’ air-rescue system for the national economy, in addition to the medical benefits and other undisputed advantages brought by air rescue, such as the ‘First Golden Hour’ principle.

ARM: The most important air rescue rules and regulations are, of course, pan-European. That said, do you have any specific requests you’d like to put to the German government?

Frédéric Bruder: We see two aspects as being particularly important here: pragmatism and constructive dialogue with large organisations and operators. We need to find ways of doing things so that safety is the main focus, but which are also practicable in the day-to-day business. When drawing up, commentating on and implementing rules and regulations, it definitely helps to refer back to the extensive pool of knowledge and experience that operators have. However, we should point out here that the German government is definitely moving in the right direction, although we also believe they could still work more closely with the European bodies. One current example which urgently requires a long-term solution is the planned enforcement of ‘Rule 60’, which will ground rescue pilots aged 60 and over in a single cockpit operating environment. From a present-day perspective, this rule makes no sense whatsoever. It is our understanding that no scientific research exists to back this up and therefore any proof of an increased risk among pilots aged between 60 and 65 is lacking.

Let’s not forget that our pilots undergo specialized medical screening regularly to confirm they are fit to fly – at the end of the day, we as operators are the ones with highest interest in having the best flight safety possible.

ARM: If you had to sum up ADAC Air Rescue’s vision in a few words, what would it be?

Frédéric Bruder: To rescue people in emergency by air, while adhering to the highest flight safety standards, and to provide these people with the highest level of medical care.

ARM: Mr Bruder, many thanks for talking to us.

4 · 2012 I Vol. 2 I AirRescue I 219



Image depicts actual rescue Broken legs | Darkness | Hypothermia | Pilot wearing nvg’s | Man lives and sells skis on ebay |

16 | oFFsHore

Fig. 1: Offshore workplaces are challenging in terms of medical emergency response because of their remoteness from medical care as well as the likelihood that poor weather may delay evacuation (Photograph: AREVA Wind/ Jan Oelker)

Authors: Nils Weinrich Dirk Dethleff Caroline Friebe Markus Stuhr Klaus Seide Christian J眉rgens Berufsgenossenschaftliches Unfallkrankenhaus Trauma Hospital Hamburg Germany

Key component of the rescue chain: HEMS for trauma patients in offshore wind parks Helicopter Emergency Medical Service (HEMS) has become a key component of the rescue chain for offshore wind industry, especially during construction and maintenance of the wind turbines. Besides issues of pre-hospital care and transport to and from the scene, accessibility of the turbines due to marine conditions is an important factor for a sufficient and successful Emergency Medical Service (EMS) for offshore workers. This article will review current findings about HEMS for trauma patients and highlight some issues that are relevant for the offshore wind sector. This work is part of an ongoing research project to develop a rescue chain concept for critically ill and injured patients in offshore wind parks in order to provide recommendations for the future development and implementation of a rescue chain.

HEMS plays an important role to provide pre-hospital medical support to trauma patients at the accident scene as well as rapid and safe transport from the scene to an appropriate care facility in an environment, where travelling times may be excessive by surface vehicles or where

remote communities might be deprived of the required level of healthcare service. In general, offshore workplaces are challenging because of their remoteness from medical care as well as the likelihood that poor weather may delay evacuation (1).

4 路 2012 I Vol. 2 I AirRescue I 220

oFFsHore | 17 In contrast to the workplaces in the offshore oil and gas industry, where the work area is more compact and the establishment and maintenance of an appropriate level of EMS is easier to manage, offshore wind parks cover large areas as a certain distance between the turbines is needed to avoid or minimise the wake effects (2).

The offshore wind park “Meerwind Süd/Ost” for example, located in the German Bight in the North Sea 23 km north off the island of Helgoland, will consist of 80 wind turbines and covers an area of about 42 km², which is equivalent to the terrain of a city like the small port town Wismar on the Baltic Sea Coast.

Levels of MER offshore (OGP)*

Level 1

Basic first aid

Level 2

Advanced first aid

Level 3

Trained medic, paramedic or emergency medical technician

Level 4

Doctor or nurse working in a primary care facility

Level 5

Specialist doctor working in a secondary or tertiary care facility *See also Ref. (1).

Medical emergency response (MER) in the offshore oil and gas industry is often divided into tiers or levels. A scheme (see also boxed text above) is recommended by the International Association of Oil & Gas producers (OGP) (3) and many companies follow a similar system to organise MERs (1). For offshore wind parks this scheme may be applicable during construction in the presence of jackup-vessels but will be inapplicable during maintenance of individual wind turbines due to limited personal and organisational resources.

A main aspect for EMS in offshore wind parks will be patient safety. According to the International Classification for Patient Safety of the WHO (4), safety “is the reduction of risk of unnecessary harm to an acceptable minimum” in which an “acceptable minimum refers to the collective notions of given current knowledge, resources available and the context in which care was delivered weighed against the risk of non-treatment or other treatment”. But what are the collective notions of “given current knowledge”, the “resources” that are “available” or have to be installed and the risk of non-treatment or other treatment in view of EMS for offshore wind parks?

Looking onshore, a recently published retrospective cohort study involving 223,475 patients older than 15 years admitted to a top-level trauma center draw attention as the study found that helicopter transport supports trauma patient survival compared to ground transport (5).

Analysing more than 1.8 million patient recordings listed in the 2007-2009 version of the American College of Surgeons (ACS) National Trauma Data Bank (NTDB) from more than 900 centers in the United States the result was a 1.5% increase in survival rate for patients transported by helicopter as compared to ground emergency transportation to level I trauma centers, and an absolute survival advantage of 1.4% for those patients transported

4 · 2012 I Vol. 2 I AirRescue I 221

to level II trauma centers by helicopter compared with ground transported. The authors concluded that for patients transferred to level I trauma centers this percentage means that 65 patients need to be transported by helicopter to save one life. For patients transported to level II trauma centers, the number of patients is 69.

Before, Butler et al. (6) already investigated the evidence comparing helicopter and ground transfer of trauma patients from the scene of injury in a systematic literature review. The authors concluded that it remains challenging to reliably identify the effect of helicopter EMS on the mortality of trauma patients transported from the scene, and that an efficient helicopter EMS will finally depend on effective operating procedures and tasking protocols as well as clinical governance and auditing of the helicopter EMS activities. Already in 2004, Biewener et al. (7) compared in a study including 403 patients the mortality of four typical and complete pathways of polytrauma patients (Injury Severity Score [ISS] > 16) and found that primary transfer by HEMS into a Level I trauma center reduces mortality significantly. In this context, it needs to be mentioned that new German regulations for inhospital treatment in emergency situations will come into effect on 1st January 2013 (8). A new aspect is the

Fig. 2: Intensive care helicopter “Christoph Hansa” for onshore flights run by ADAC Air Rescue (Photograph: Fotoabteilung BUKH)

Fig. 3: Even under ideal conditions, most offshore rescue missions for trauma patients will take many hours to be completed successfully (Photograph: Fotoabteilung BUKH)

18 | oFFsHore

Fig. 4: Hoisting an emergency physician on board a SAR Sea King helicopter of the German Navy over the German North Sea (Photograph: M. Stuhr)

explicit designation of a third care level: Besides the levels of primary and secondary care, this new third level defines a level of maximum care in the framework of severe injury type procedure.

Another working group recently demonstrated the lack of uniformity in the use of dispatch criteria for trauma assistance, both on national and international level (9).

Furthermore, the group found that HEMS is not only depending on dispatch criteria protocols, but is also influenced by organisational factors like education of the dispatcher, training of the EMS personnel, familiarity with the dispatch criteria and the responses of bystanders (9).

But compared to onshore (H)EMS, we have to consider some additional issues in offshore wind park (H)EMS which mainly arise from the environmental parameters in offshore wind parks, the distance to the scene and the constructional conditions in wind turbines.

Constructional conditions in offshore wind parks Constructional conditions of the wind turbine are determining factors for an effective EMS. Space in – as well as access to – the wind turbine is limited. Therefore, an adaptive strategy that considers the limited space in terms of medical and technical rescue at the scene as well as the large area with the spatial distribution of workplaces in the parks, is needed in order to provide professional and efficient EMS in offshore wind parks.

Looking onshore again, Cassone et al. (10) recently highlighted both the differences and similarities between urban/suburban (“traditional”) EMS and backcountry EMS responses, and also outlined the differences in protocols.

They defined a backcountry situation “as any context in which there’s little to no communication with medical centers, a limited number of available resources, susceptibility to severe environmental conditions and the possibility for prolonged evacuations”, and emphasise that these factors can present many logistical and patient care dilemmas and often require significant modifications to

traditional urban EMS standards. The authors concluded that EMS in wilderness requires special considerations (10): “Patient care and the extended-care principles associated with outdoor medicine present an important break from standard EMS practice. Patient rescue, assessment and evacuation will often be complicated due to the variability of terrain, environmental conditions and limited resources in the backcountry. Wilderness rescuers must be respectful of their environment, safety conscious, resourceful and able to apply a modified scope of practice from traditional EMS to ensure success in outdoor medical emergencies.”

Warden et al. (11) currently mentioned that some of the operational emergency medical services (EMS) programs which provide pre-hospital emergency care to patients in austere and resource-limited settings “are additionally considered to be wilderness EMS programs, a specialised type of operational EMS program, as they primarily function in a wilderness setting (e.g. wilderness search and rescue, ski patrols, water rescue, beach patrols and cave rescue). Other operational EMS programs include urban search and rescue, air medical support and tactical law enforcement response” (11). They concluded that the operational EMS medical director should be as qualified as possible for the specific team that is being supervised and should train and operate with the team frequently to be effective. Furthermore, an adequate provision for compensation, liability and equipment needs to be addressed for an optimal relationship between the medical director and the team.

With respect to the role of the medical doctor in mountain rescue service, Putzke concluded that the development of obligatory standard operating procedures should be the major goal of medical associations and societies (12). Schmid et al. (13) recently mentioned that there are little data on the current availability of airway management equipment on HEMS helicopters in central Europe.

In a previous study, the same group found a wide variation in the advanced airway management equipment that was carried routinely on UK air ambulances (14). On the other hand it seems to be clear that – besides skilled personnel – adequate equipment is a key prerequisite for an advanced out-of-hospital airway management.

Nevertheless, currently presented and practised rescue concepts for offshore wind parks vary, from a less equipped transport helicopter with portable EMS equipment to a fully equipped rescue helicopter (as known from onshore EMS). Besides technical and economical aspects, the discussion should also consider aspects of the constructional conditions in the parks and the time necessary to provide appropriate care to a patient. Transportation of equipment and limited space for medical interventions at the accident scene have also to be taken into account. In view of the entire offshore wind industry and the multitude of indications, the implementation of both concepts seems to be favourable.

Distance and time Distance to offshore wind parks is one of the most important factors for providing rapid rescue and medi-

4 · 2012 I Vol. 2 I AirRescue I 222

oFFsHore | 19 cal care to the rescue scene and for rapid transport of trauma patients to a medical facility, and hence for an effective HEMS mission. Offshore wind parks are planned to be installed at locations of up to 200 km away from the coast (especially in the German Exclusive Economic Zone) (15).

Even under ideal conditions, most offshore rescue missions for trauma patients will take many hours to be completed successfully. As mentioned by Cassone et al.

(10), such long ordeals can lead to stress and emotional responses from both the patient and the rescue team.

From this point of view it is important for rescuers to remain calm and collected and to give the patient a positive outlook without making inconclusive promises, the authors stated. Furthermore, rescuers must pace themselves and prepare for lengthy patient monitoring.

Time for bringing rescue and medical care to the rescue scene represents the total of activation time, flight time and access time to the patient. With respect to medical considerations in the use of helicopters in mountain rescue, Tomazin et al. (16) noted that activation time should be as short as possible. Activation of a helicopter for a mountain rescue should primarily include indication and assessment of flight and safety conditions, but no other mediators or delaying factors should be permitted.

The main safety criteria are appropriate mountain rescue and flight training, competence of air and ground crews, radio communication between the air and ground crews, and mission briefing before the rescue (16). Flight time depends on the geographic distance and therefore can only be affected by choice of the helicopter and location of the HEMS base. Access time to the accident scene on site depends on constructional and environmental conditions as well as on the equipment and the training of the rescuers.

A French study recently suggested that medical prehospital management performed by mobile emergency and resuscitation service (Service Mobile d’Urgences et de Réanimation) is associated with a significant reduction in 30-day mortality in case of severe blunt trauma (17). With the help of the German Trauma Registry of the German Society for Trauma Surgery (DGU), a study published recently investigated the impact of the rescue time on hospital survival in severely injured patients (18).

It was found that within the German rescue system the length of rescue time has no relevant impact on the survival of trauma patients admitted to a clinic. The authors explained this with a higher amount of preclinical medical procedures during longer rescue times and further advocate that the necessary and suitable preclinical medical procedures be performed to stabilize the patient, even in cases that have exceeded the 60-minutes gold standard time window. They concluded that the “golden hour” concept today might be better interpreted as an individual and appropriate “golden period” of trauma.

From this point of view, the time for transport from the scene to an appropriate care facility seems to be of minor priority on land. Time for bringing rescue and medical care to the rescue scene, however, seems instead to be of crucial importance. But looking offshore, we have to

4 · 2012 I Vol. 2 I AirRescue I 223

consider that the extent of preclinical medical procedures will be limited compared to onshore settings.

Environmental parameters in offshore wind park helicopter rescue Environmental conditions (atmosphere, sea surface) are of crucial importance for accurate helicopter aviation and successful air rescue in offshore wind parks. While common weather and sea phenomena like wind, rain and surface waves are well manageable in offshore helicopter flying, harsher weather conditions like snow, hail, storm and thunderstorm may cause considerable problems in rescue operations. Sea fog, closed cloud cover as well as low cloud base and high ceiling are also restricting or even limiting factors in offshore aviation rescue, while less frequent extreme phenomena like tornadoes, freak waves and various ice scenarios could cause major problems for air rescue in offshore wind parks. The elucidation of the critical character of various atmospheric and marine environmental parameters for offshore helicopter operations in different offshore wind park rescue scenarios is currently under progress.

Conclusions The outcome of patient care can be fundamentally improved by bringing rapid rescue and medical care to the offshore scene if a sufficient amount of preclinical medical procedures are performed to stabilise the patient. A helicopter is the rescue vehicle of choice.

Helicopters must be operated and staffed by appropriate offshore aviation-, rescue- and medically trained personnel and should be integrated into the existing emergency medical system. Activation times of a helicopter for a rescue mission in offshore wind parks should be as short as possible. Further criteria for a helicopter used for rescue missions in offshore wind parks like onboard medical and rescue equipment, load capacity, adequate space and others need to be investigated in the future. It is obvious that all helicopter equipment must be safe to

Fig. 5: Super Puma helicopter of German Federal Police during operational flight over the German North Sea (Photograph: M. Stuhr)

20 | oFFsHore

Fig. 6: Air medical programs operating offshore must deal with additional regulatory requirements and develop operational procedures to ensure safety during flights (Photograph: AREVA Wind/ Jan Oelker)

the patients transported, and must not be hazardous to the aviation safety.

Using the words of Tomazin et al. (16), in principle, there are two main groups of indications for the use of a helicopter in offshore wind park rescue missions: the patient’s condition and the circumstances at the accident scene. All persons responsible for the helicopter rescue operation should be aware of specific problems in the offshore wind park environment. Finally, air medical programs operating offshore must deal with additional regulatory requirements and develop operational procedures to ensure safety during these flights.  For more information, visit: ››› http://bit.ly/O6gGj8

Acknowledgements The ongoing project work is supported by the Berufsgenossenschaft Handel und Warendistribution (BGHW). We thank our scientific advisory board and the offshore wind industry as well as authority officials for their candour and support and especially for the useful discussions and comments.

References: 1. Ponsonby W, Mika F, Irons G (2009) Offshore industry: medical emergency response in the offshore oil and gas industry. Occup Med 59 (5): 298-303 2. European Wind Energy Association (2009) Oceans of Opportunity. Harnessing Europe’s largest domestic energy resource. Available from Internet: http://www. ewea.org/fileadmin/ewea_documents/ documents/ publications/reports/Offshore_Report_2009.pdf.

Accessed 13 October 2012.

3. International Association of Oil & Gas producers (2011) Managing Health for Field Operations in Oil and Gas Activities. OGP report no 343. ICIEPA OGP, London 4. World Health Organization (2009) Conceptual Framework for the International Classification for Patient Safety – Version 1.1. Final Technical Report. Chapter 3. The International Classification for Patient Safety.

Key Concepts and Preferred Terms. Available online: www.who.int/patientsafety/ taxonomy/icps_chapter3. pdf. Accessed 24 October 2012.

5. Galvagno SM, Haut ER, Zafar SN, et al. (2012) Association between helicopter vs. ground emergency medical services and survival for adults with major trauma.

JAMA 307 (15): 1602-10 6. Butler DP, Anwar I, Willett K (2010) Is it the H or the EMS in HEMS that has an impact on trauma patient mortality? A systematic review of the evidence. Emerg Med J 27 (9): 692-701 7. Biewener A, Aschenbrenner U, Rammelt S, et al.

(2004) Impact of helicopter transport and hospital level on mortality of polytrauma patients. J Trauma 56 (1): 94-8 8. Kranig A (2012) Zukünftiges stationäres Heilverfahren – Aus Sicht der DGUV (Deutsche Gesetzliche Unfallversicherung) [Future in-hospital treatment. From the perspective of the DGUV (German statutory accident insurance)]. Trauma Berufskrankh 2012/14: 263-267 9. Wigman LD, van Lieshout EM, de Ronde G, et al.

(2011) Trauma-related dispatch criteria for Helicopter Emergency Medical Services in Europe. Injury 42 (5): 525-33 10. Cassone M, Sagalyn E, Dickinson ET (2012) Far from care: EMS in the wilderness requires special considerations. JEMS 37(4): 38-40, 42-47 11. Warden CR, Millin MG, Hawkins SC, et al. (2012) Medical direction of wilderness and other operational emergency medical services programs. Wilderness Environ Med 23 (1): 37-43 12. Putzke M (2008) Medical doctor in mountain rescue service – a profession’s perspective. [Article in German] Anasthesiol Intensivmed Notfallmed Schmerzther 43 (1): 74-7 13. Schmid M, Schüttler J, Ey K, et al. (2011) Equipment for pre-hospital airway management on Helicopter Emergency Medical System helicopters in central Europe. Acta Anaesthesiol Scand 55 (5): 583-7 14. Schmid M, Mang H, Ey K, et al. (2009) Prehospital airway management on rescue helicopters in the United Kingdom. Anaesthesia 64 (6): 625-631 15. Altmann M, Schmidt P, Weindorf W, et al. (2010) The assessment of potential and promotion of new generation of renewable technologies. – Study requested by the European Parliament’s Committee on Industry, Research and Energy (ITRE). Available online: www. europarl.europa.eu/document/activities/cont/20110 6/20110629ATT22895/20110629ATT22895EN.pdf.

Accessed 14 October 2012.

16. Tomazin I, Kovacs T (2003) International Commission for Mountain Emergency Medicine. Medical considerations in the use of helicopters in mountain rescue. High Alt Med Biol 4(4): 479-483 17. Yeguiayan JM, Garrigue D, Binquet C, et al. (2011) French Intensive Care Recorded In Severe Trauma Study Group. Medical pre-hospital management reduces mortality in severe blunt trauma: a prospective epidemiological study. Crit Care 15 (1): R34 18. Kleber C, Lefering R, Kleber AJ, et al. (2012) Rettungszeit und Überleben von Schwerverletzten in Deutschland [Rescue time and survival of severely injured patients in Germany]. Unfallchirurg [Epub ahead of print: DOI 10.1007/s00113-011-2132-5]

4 · 2012 I Vol. 2 I AirRescue I 224

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22 | oFFsHore

Fig. 1: Rotorcraft and energy production are two very complex technologies that were fused at a very early stage in the development of wind-energy generation (Photographs: Eurocopter)

Offshore wind farms: „Eurocopter is an integral part of the survival chain“ The activities of the energy companies in the field of offshore wind farms are increasing continuously. The oil platforms off the coasts are constantly tapping into new deposits of oil and gas. In addition the number of offshore platforms for the harvesting of wind energy is also growing. This trend also means that there is also a major challenge for helicopter manufacurers, because their aircraft supply these platforms with material and consumer goods, transport staff - and are ready for rapid action in the event of an emergency. On behalf of AirRescue Magazine, Dr Peter Poguntke spoke with Dennis Bernitz, Eurocopter, responsible for the market segment Offshore Wind, about the offshore activities and the role of HEMS in the survival chain.

ARM: Mr Bernitz, is offshore a market of the future and in which regions do you expect an above-average growth?

Bernitz: I can answer the first part of your question with a resounding ‘yes’. Oil and gas platforms are still being used as much as previously; the only thing is that they have to keep going further and further out to sea, where the new deposits are located. In addition, there are now more and more wind energy farms coming up. The nuclear catastrophe of Fukushima has led to a worldwide boom in the field of renewable energy. In this case, France and China, due to the topographic nature of their coasts, have

the advantage that they can always operate with platforms relatively close to the mainland. It is however in the UK and in Germany, where we see the highest growth rates in the field of wind energy.

ARM: Could you elaborate on this?

Bernitz: In the UK, 62 wind farms have been authorized and in Germany almost 30 – so far. But ultimately there will be 80 in the North Sea and 30 offshore wind farms in the Baltic Sea. The distance of these wind farms from the coast will range between 35 and 100 nautical miles.

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oFFsHore | 23 ARM: What are the present implications of this development for Eurocopter as a helicopter manufacturer?

Bernitz: First of all, did you know that the first large-scale wind energy plants, ‘Growian 1’ and ‘Monopteros’, were built in collaboration with our German Eurocopter headquarters? Since this time, Germany has had a technological lead in the field of wind energy. Ever since that time, two very complex technologies have become connected to each other: rotorcraft and wind energy harvesting.

In order to meet the technical challenges in the field of ‘offshore’, we have been working in this market for approximately the last three years. We attend all the conferences in this sector and present our products. This relatively new mission makes it necessary to transfer the knowledge gained from other helicopter missions, such as SAR, HEMS or freight transportation, to the field of ‘offshore wind’. We have this know-how. In addition, the objective is to create a structure in the wind farms, which would ensure the safe use of helicopters – mission navigation for flying through wind farms, for example.

ARM: What does the future look like in the field of HEMS services?

Bernitz: We are in a constant dialogue with HEMS services and platform operators working in this field. Centralized emergency and dispatch centres with comprehensive

facilities and services will definitely be installed on the coastline in the near future.

In addition, there are clear demands on us as manufacturers, both from the market and from the aviation safety authorities. Here is an example: During autumn and winter, an extended deployment time window for HEMS flights becomes essential, because strong winds restrict shipping in these periods. On the other hand, visibility at this time of the year is very poor, and so the helicopters have to operate under IFR-conditions. So far, there has no permission been granted and rules need to be defined clearly here. One thing is however clear: We are an integral part of the survival chain in the offshore industry.

Fig. 2: “This relatively new mission makes it necessary to transfer the knowledge gained from other helicopter missions, such as SAR, HEMS or freight transportation, to the field of ‘offshore wind’.”

ARM: Mr. Bernitz, thank you very much for the interview.

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24 | oFFsHore

Fig. 1: At present there are no regulations on minimum standards, nor are there binding definitions for HEMS operations at offshore wind farms (Photograph: H. Janssen)

Through rough winds: HEMS missions at offshore wind parks from a German perspective Author: Klaus Graf Manager, IQmed GmbH Aigenstadl 103 94078 Freyung Germany klaus@iq-med.ca

The transition to alternative sources of energy has become a topic that is keenly and extensively discussed – not only in Germany. In addition to several other projects, large wind parks, which will play a significant role in energy generation in the future, are under construction in the North Sea and the Baltic Sea. The responsibilities in case of emergency situations have not been spelt out with an equal degree of clarity. This article provides an overview of the special challenges for HEMS missions operations at offshore plants and a perspective of an effective design of this special field of emergency medical service. A glance at the configurations of the offshore EMS that are common from an international perspective – especially in the commercial oil and gas sectors – reveals the options available at present, and, in addition, also indicates the need for optimisation.

At present, 29 wind farms with over 2,000 wind turbines have been approved (1). In addition, there are four locations within the 12-mile zone of the North Sea, as well as three on the Baltic Sea. Two plants are already in operation here and several are under construction or will be commissioned in the next few months and years.

First and foremost, at present there are no regulations on minimum standards, nor are there binding definitions for HEMS operations at offshore wind farms. In addition to a wide variety of political discussion and problem areas, the questions of the day-to-day operation – organizationally as well as economically – play an important role for the operators of (wind) energy generation plants.

The German waters in the North Sea and the Baltic Sea are divided into the 12-nautical mile zone (the so-called territorial sea) and the EEZ (Exclusive Economic Zone).

The 12-nautical mile (NM) zone is German territory and is under the responsibility of the respective federal state.

Seawards of the 12-NM boundary, up to a maximum of 200 NM from the coast, lies the Exclusive Economic Zone (EEZ), which adjoins the high seas. In the North Sea and the Baltic Sea, the German EEZ is, in effect, identical to the so-called German continental shelf. This comprises of the seabed and subsoil of the submarine areas, located seawards of the 12-nautical mile zone (territorial sea) up to a distance of a maximum of 200 nautical miles (2).

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oFFsHore | 25 Concepts for Health, Safety and Environment (HSE) After completion of all the offshore wind energy parks, more than 2,000 people will (temporarily) live and work there. They will have to be transported to and from their places of work by ships and helicopters. The operators have sophisticated logistical plans for this purpose. Obviously, there are similar plans for medical care and evacuation in case of emergency situations, illness or injuries.

However, in most cases these plans were in the initial stages, based on the availability of government forces (SAR commands and civilian SAR institutions for example), such as the German Maritime Search and Rescue Service (DGzRS). According to professional assessments of the present HSE (Health, Safety and Environment) concepts, it was clear that merely the provisions covered by public funding are far from being sufficient for effective medical care in case of acute and emergency medical situations. This leads to the fact that the operators of the construction sites or wind farms would need to provide their “own”, company-run EMS. Due to the significant distances between the coast and the wind farms, HEMS has a major role to play here. While HEMS operations onshore are – to a great extent – effectively and efficiently organized and have recognized standards, there are no binding specifications for offshore HEMS at the open sea.

Consequently, their configurations currently vary widely and are not subject to adequate quality control measures.

Distances and effective ranges Offshore wind farms located closest to the coast (situated at a distance of about 40 km) can be reached within a reasonable time frame, without any problems. In the near future however, there will be construction sites of offshore wind energy plants that will be situated at distances of 150 km (and more) off the coast. This gives rise to the question of suitable helicopter types, since certain models are not suitable – due to their size and weight – to access offshore wind farms. In summary, the operation of helicopter types that are suitable for offshore rescue missions require a sufficient “endurance” capacity, but at the same time their dimensions should be suitable for safe operations (including hoisting) within the environment of offshore wind farms. In this respect it is important to note that even reasonable time windows for search flights in the vicinity of wind parks or for operations of support vessels and of a following transport to a trauma center or a suitable clinic should be possible without stopping for refuelling. In addition, there must be sufficient accommodation capacity available for the operating crew, which, as a rule, consists of five people (two flight crew members, one hoist operator, one paramedic/HEMS, one HEMS doctor and at least one patient). This clearly shows that conventional helicopter types are not really suitable for HEMS assignments.

Qualifications of flight crew and hoist operator Obviously, the companies responsible for the implementation of HEMS on the open sea must have the necessary authorisations such as Helicopter Offshore Operations

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Geodetic datum: WGS 84 · Map projection: Mercator (54°N)

(HOO), (Helicopter Hoist Operations (HHO) and HEMS. In addition, company-specific training modalities on JAROPS-regulations should ensure safe flight operations, including winch operation, under difficult HEMS conditions.

It is here that the experience level of the crew implementing the operations assumes substantial importance. In this respect the standards of the OGP (International Association of Oil and Gas Producers) can be used as guidelines.

In comparison with the companies that are internationally active in offshore HEMS/SAR operations, the following criteria can be applied as a minimum requirement for the flight crew:

Fig. 2: Map of offshore wind farms in the North Sea Borders Continental shelf /exclusive economic zone 12-mile zone/coastal waters International borders Offshore wind farms Planned Under construction Approved In operation Platforms Transformer platform, in operation Transformer platform, under construction

PIC (Pilot in Command)

Co-Pilot

ATPL/CPL

ATPL/CPL

Instrument flight license (IR)

Instrument flight license (IR)

Converter platform, under construction

Offshore-Training

Offshore-Training

Converter platform, planned

> 2,000 flying hours

> 500 flying hours

at least 100h on type

at least 50h on type

Transformer platform,, planned

Grid connections In operation Under construction

The experience of and team work among the crew plays a substantial role for hoist operations carried out on platforms of offshore wind turbines, on ships, in poor weather conditions and rough or very rough seas with high waves – even more than in case of hoist operations on land.

This is why the selection of well-versed hoist operators is as important as employing an experienced HEMS flying crew. Since such specialists, as is the case for pilots, are not available in sufficient numbers on the (civilian) job market, the majority – on an international scale – comes from the field of military services and, therefore, has sufficient experience in the implementation of such demanding tasks. Similarly, members of the medical crew must be experienced, educated and trained on the requirements of HEMS operations since in this process they must be

Approved Planned

26 | oFFsHore able to react to emergency medical situations with the same level of safety and efficiency – even under more difficult conditions.

In order to be able to carry out demanding HEMS operations in offshore wind farms that are safe for the crew and for patients likewise, appropriate attention must be accorded to effective crew resource management (CRM).

A helicopter underwater escape training (HUET-training) is mandatory for all crew members.

Helicopter types and configuration If one compares global offshore SAR/HEMS services, it is striking that in this field rather large helicopter types (such as the S92, the AS332 Super Puma, Sea King or SH60 Seahawk, etc.) are being operated. This is mainly due to the fact that priority is mostly given to a multifunctional configuration capability (including evacuation assignments). By having a closer look however, one may arrive at the conclusion that – for a pure rescue configuration – smaller and thus faster and more flexible helicopter models such as the EC155, the AS365, S-76, etc. offer more advantages which are particularly predominant in case of winching manoeuvres at offshore wind energy plants.

Classical EMS helicopter models such as the EC135 or BK117/EC145 come into the picture at wind energy plants which are located relatively near the coast, due to their low payload capacity and low range, as well as rather limited space and loading capabilities for patients. However, there are no differences in the configuration of the helicopter. The following features are considered to be the “gold standard” in this respect:

3.

4.

5.

6.

Fig. 4: Transportation times of offshore HEMS taken to get the patient from the emergency scene to a suitable hospital (trauma center) differ significantly from onshore HEMS (Photograph: H. Janssen)

1. An adequate, mission-specific range for SAR applications, depending on the distance between HEMS base, the operating area, and a hospital of maximum care. Worst-case scenarios should be envisaged here.

2. An instrument flying license is advisable since it guarantees – in combination with respective pilot qualifications – a higher level of flight safety. In Germany (and also in most other countries) it is not possible to execute IFR-landing approaches on offshore

7.

8.

wind turbines, platforms, nor on ships or hospital rooftop helipads. There is a lack of regulations and controlled air space required for this purpose. In this context one must also refute the widespread misconception that flights under IFR offer more flexible flight operation options in poor weather conditions and that they are thus ideal for HEMS applications under offshore conditions. While considering weather minima for HEMS, it becomes clear that JAR-OPS permit significantly greater leeway than IFR-regulations would.

The equipment for hoist operations is obligatory for offshore HEMS and should be available when required. It is of utmost importance to be able to hoist a patient on board the helicopter – without any intermediate landing (equipment with redundancy).

A collision warning system (Traffic Collision Avoidance System, TCAS) and AIS transponder (Automatic Identification System) raise the level of safety, when viewed against the background that in complex rescue situations, as also in everyday air traffic conditions, several helicopters are on the move between the offshore wind farms.

An autopilot system (see IFR) should also be mandatory for these missions. In addition to a significant stress reduction on the part of the crew during flight ops, the newer systems provide significant advantages in hovering. In case of a mission configuration of this type, modern helicopters should have a 4-axis-system and a control system option for the hoist operator.

Powerful searchlight, perhaps even in combination with a FLIR (Forward Looking Infrared) camera, not only offer advantages in the search for people in the water, but also in cases of night landing approaches etc.

Mission-specific communication facilities are of significant importance for a safe and effective implementation of rescue operations. In addition to the conventional VHF-radio devices, aircraft used in offshore applications require a marine radio for communication with maritime facilities. Furthermore, tactical radio devices of the BOS (security authorities and organizations in Germany) as well as digital radio (TETRA etc.) are essential for HEMS assignments in this sphere of work. In addition, the fixed installation of a satellite telephone is absolutely essential, as this is also used for the transmission of tracking information. If there are still more special communication channels to be linked – such as specific operational wireless devices of the wind farm operator –, their accommodation in the cockpit will become a real challenge, in addition to the licensing scenarios. Of no less importance is also the consideration that a surfeit of communication facilities does not impair safe execution of the missions.

Tracking systems, in addition to their functions in aspects relevant to flight safety, offer significant advantages in deployment, and are standard prerequisites today.

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oFFsHore | 27 9. Having a closer look at night missions, the use of Night Vision Goggles (NVG) needs to be considered in the near future. This would result in a significant increase in safety, in particular for low altitudes operations between the wind farms. In the meantime, the use of NVG devices has now become international standard practice in case of SAR/HEMS missions.

10.The future will reveal whether helicopter rotors deicing systems will become obligatory for use in the German EEZ as in other SAR/HEMS units in the international context. At present, there is very not enough experience from which one may draw appropriate conclusions. From the point of view of meteorological and marine technology, the issue of iced rotors has not yet been finally adjudicated upon.

Medical interior Regarding the question of what constitutes the best configuration for a mission-specific medical interior, a general distinction must be made as to the purpose for which the helicopter is being used. In case of a complex rescue operation, when (additional) medical personnel and equipment is to be transported to the scene as fast as possible, retrofittable helicopters, normally used for passenger transport, but capable to accommodate (additional) medical crew (paramedics and HEMS doctor) together with the corresponding medical equipment, are appropriate here. In case of this exceptional application, even the associated disadvantages can be acceptable.

Criteria valid for HEMS onshore should be the minimum requirements for HEMS at offshore wind farms (HEMS service contracted by the offshore wind farm operators): • DIN 13718-... RTH (HEMS) • Compliance with the German Medical Devices Act • Mounting systems and operating systems certified for medical equipment used in aviation (Supplemental Type Certificate) However, offshore HEMS differs significantly in one aspect from land-based EMS. These are the transportation times taken to get the patient from the emergency scene to a suitable hospital (trauma center). While HEMS onshore require an annual average of about 10 to 14 minutes for this purpose, transport interval in case of offshore applications is more than 40 minutes. In the case of remotely located wind farms, mere transportation time could even be more than one hour. Combined with the fact that the flight to an incident scene itself takes up a considerable amount of time, it is necessary to make provisions to enable special procedures and sufficient capacities (e.g., oxygen supply) for diagnosis and therapy of casualty patients on board, in case of relatively long distances. This can be ensured only by means of specially configured EMS helicopters.

Medical crew The question of the medical and professional qualifications of the medical crew is viewed differently in different countries – depending on the country-specific practices

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as well as legal conditions. In many other countries it is widely common that offshore SAR/HEMS services operate with paramedical staff (flight nurse, paramedics). Here again, this results in considerable disadvantages in the individual emergency medical procedural strategies.

Here too, the standards of air rescue onshore procedures established by statute and by convention of the concerned are to be adopted for offshore missions, and to “add on” mission-specific supplementary standards for offshore HEMS. Due to the demanding requirements in terms of the diagnostic and therapeutic treatment expertise of the medical crew, at least the qualification criteria of HEMS should apply. Additional qualification characteristics – in terms of advanced education and training – must also be met.

HEMS doctor The requirements in terms of qualifications of the HEMS doctor include: • Specialized medical qualifications in an ICU and a department relevant to emergency medicine • At least one year of intensive care medical practice • Active and regular participation in the medical emergency services • Experience in onshore-based air rescue missions • Access to an intensive care medical center or an advanced care hospital • Training and hands-on handling in procedures of rescue from great heights • Training and hands-on handling in procedures of water rescue • Training in hoist operations

Paramedics/HEMS crew members (HCM) The HEMS crew members should comply with the following prerequisites: • • • •

Fulfilment of the qualification requirements for HEMS Experience in onshore-based HEMS missions Training in rescuing from great heights Training and hands-on handling in procedures of water rescue • Training in hoist operations

Fig. 5: A helicopter underwater escape training (HUETtraining) is mandatory for all crew members (Photograph: Falck Nutec)

28 | oFFsHore Both members of the medical crew must be able to contribute the appropriate physical and psychological characteristics required for the fulfilment of their tasks and must, together with all the other crew members, continuously perform training exercises. Due to the international nature of the employment on the offshore wind farms, all crew members should be able to communicate bilingually.

The time factor ... emergency medical and mission-related aspects Due to the considerable distances that have to be covered in the event of an emergency in offshore work locations, the mission-related procedures represent an exceptional challenge. In addition to safety and quality, it is the time factor that plays the leading role here. It is critical to gain time for emergency patients and thereby at least to the extent possible, to comply with the time-window determined on the basis of medical evidence. In this process, improvised medical-technical facilities as well as improvised rescue procedures are to be avoided. In order to ensure the shortest possible reaction times and quick interventions, the time factor must be accorded the highest level of priority in consideration of all missionrelated aspects.

Due to the offshore-specific circumstances, such as wearing a wetsuits, preparatory time frames for medical procedures cannot be maintained, as they would be in case of land-based air rescue missions (< 3 minutes).

However, no more than 10 to 15 minutes may elapse between an emergency call and the time an offshore rescue helicopter is airborne. On an average, this also corresponds to international specifications. Obviously, this is predicated upon the whole medical crew being present at the HEMS base. Triangular flights to pick up the medical staff are as unacceptable as retrieval via the land route.

This requires a sophisticated deployment disposition in a dispatch centre that is appropriately equipped, both technically and in terms of personnel as well as helicopters configured specifically for this task, which are set up in such a manner that all possible diagnostic and therapeutic procedures can be executed both directly at the site as well as on board the helicopter.

Deployment scenarios and mission areas Experience with offshore HEMS bases that are already in operation reveals a virtually identical picture with regard to the frequency of deployment scenarios in comparison to land-based rescue services. Offshore too, emergency cases in internal medicine predominate over work-related accidents on the plants, platforms or ships. According to current surveys – there are two to four instances of HEMS deployment per week (at two offshore wind energy farms presently in operation and at three construction sites).

If this is extrapolated in proportion to the planned wind farms and the resultant increase in the staff complement, a frequency of approximately 20 deployment instances per week can be expected.

It may be assumed that the frequency of work-related accidents and the need for rescue procedures involving hoist operations during the construction phase of the wind

farms will be higher than it is in the actual operating phase. However, it is important to point out that, even in the operational phase, maintenance activity and assembly as well as dismantling of segments of the plants will result in a constant state of change, which, on an annual average, is expected to result in a high degree of continuity of rescue operations. Added to this, there will be an increase in the number of transfer trips and flights.

Rescue operations with the use of technical equipment represent challenging requirements in this connection. So on the tactical deployment planning, the fire brigade for example cannot be called on for assistance – as would be conventional on land and be on the spot in less than 10 minutes. Here, it is important to develop procedures, which ensure safe rescue in a reasonable time frame. Even this would not be possible without the flexible use of helicopters.

Therefore, a significantly higher degree of importance is to be accorded to the time factor in tactical considerations of deployment than is actually the case at present.

Existing plans are based too heavily on standards of disaster medicine. In the context of offshore rescue, we are however concerned not only with disaster medicine, but rather with emergency medicine that rather focuses on single cases. Merely the fact that greater distances have to be taken into consideration in cases of deployment does not justify any reduction in the level of emergency care or tactical standards, applicable to the country.

With regard to the locations of deployment, the present experience reveals that there is an approximately even distribution over the areas of the offshore wind energy plants’ living and working platforms and ships.

Deployment instances with persons in the water have been relatively rare in the recent past, but are becoming increasingly probable with the basic location having become “the sea”. Rescue services provided by the offshore operator, and, in particular offshore HEMS and their crews, must therefore be prepared to handle these deployment situations safely and efficiently and should be in a position to react to them quickly and safely. In this respect, it is of considerable importance that in case of water rescue deployments under offshore conditions, the HEMS crew can execute an essential intervention under their own steam, without having to take outside specialists on board. Appropriate procedures must be developed for this purpose and continuously practiced and improved.

There is an even greater probability that during rescue deployment instances at offshore wind farms components of the system for rescue from great heights will come into play. It is therefore of advantage if both members of the medical crew are trained in operations involving the specific methods for rescue from great heights and are able to safely carry out rescue measures at heights in cooperation with the workers from the offshore wind farm itself.

Hoist operations on offshore wind energy farms are a challenge to the entire team, medical and flight, of a HEMS crew. On the one hand, there are several different models of the tower foundations and the towers themselves, all of which do not have an extra hoist unit on which an easy placement is possible. In addition, there is the fact that the location of the rescue procedure obvi-

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Fig. 6: Helicopter types suitable for offshore require a sufficient “endurance” capacity, but at the same time their dimensions should be suitable for safe ops within the offshore wind farm environment (Photograph: Bond)

ously depends upon where the emergency patient to be offloaded is located. For this purpose, special procedures with rope procedures must be continuously practiced in order to ensure safe implementation.

Weather conditions Obviously, weather-related factors have a decisive influence on flight operations. In order to be able to make safe evaluation of whether a rescue mission is feasible under existing weather conditions, pilots on duty must be provided with a permanent overview of the current weather situation, both at the HEMS base as well as at possible operational sites. Reliable sources of information on the prevailing weather parameters are therefore tools of enormous importance for the fastest possible decision-making and should be accessible at any time. In addition, there are automatic weather stations available on the offshore wind energy farms, and there is recourse to various other sources for sea and flight-related weather data on the publications of international (aviation) weather services that are also globally accessible.

In addition to the usual WX-parameters, other factors – including the direction of the motion of the sea, oceanographic data such as significant wave height, water levels etc. – play an important role in HEMS offshore missions. Whether and how an instance of deployment is to be undertaken can be safely decided upon only if all weather data is at hand. In case of data that require clarification, contact with control rooms is of great importance to wind farm operators and captains of ships. Staff of the control rooms has adequate maritime experience and can exchange the information necessary with the HEMS flight crew.

The maximum wind speed at which a landing can be made on the landing deck of a ship depends on various parameters. Therefore, no generally applicable statement can be made in this connection. Here too, it is important, obviously, to land in the direction of the wind and in par-

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ticular, to take into consideration turbulences which may occur partially due to the height of the ship’s structures (3). In case of wind force >11 and correspondingly high waves, rolling of the ships would be too intense to permit a safe landing. Landings on prepared offshore platforms are possible at wind speeds of up to 60 knots, and hoist operations at speeds of up to 50 knots. Offshore HEMS may be deployed up to a cloud base of 600 ft. and visibility of up to 1,500 m. Under certain circumstances it is possible to undercut this for short periods.

HEMS and SAR Helicopter emergency medical service provided by the offshore wind park operator also means that there is a highly qualified and rapidly deployable civilian SARcomponent available. This could (as a supplement to the government’s service) cover – in collaboration with existing sub-facilities and at low cost – a variety of the usual (H)EMS tasks at sea and in coastal waters. This model of transferring (former) government SAR-assignments to already existing private resources is already common practice in many countries.

Even if many of the questions concerning standards of offshore HEMS missions in Germany are still debated at the moment, there are promising dynamics and projects, which will lead to an effective and efficient emergency medical service at offshore wind farms. 

For more information, visit: ››› www.bsh.de ››› www.havariekommando.de ››› www.offshore-windenergie.net/windparks ››› www.ogp.org.uk ››› www.uscg.mil ››› www.bondaviationgroup.com ››› www.chcsar.com ››› www.norskluftambulanse.no ››› www.offshore-rettung.org

Author‘s Declaration The author declares that he works as a consultant for companies that undertake offshore flight operations as well as for companies dedicated to emergency management.

30 | oFFsHore

Fig. 1: Injured persons can be rescued from an offshore wind turbine either from the helihoist (HH) platform or the transition piece (TP) (Photograph and figures: OffTEC Base GmbH)

HEMS in offshore wind turbines: Promising highline rescue procedure Authors: Editorial Team AirRescue Magazine

Hundreds of people are already employed on the gigantic offshore wind turbine construction projects off the North and Baltic Sea coasts. Soon there will be thousands: fitters, divers, welders, service technicians and engineers. In the workplace they will be exposed to accident hazards with potentially serious consequences. So how can they be rescued quickly and, more importantly, safely in an emergency?

The so-called highline rescue procedure seems to be very promising, and is aimed at making it easier for the HEMS crew to rescue and evacuate injured employees.

The highline rescue procedure was recently presented at the WindEnergy 2012 trade fair by the OffTEC Base company. Managing director Andreas Rauschelbach emphasises that the highline procedure is the first time that a variety of procedures, such as those used in mountain rescue and rescue from height, have been combined and adapted for offshore rescue situations.

Highline rescue procedure On an offshore wind turbine there are two points from which the injured party can be rescued: these transfer points are the helihoist (HH) platform on the roof of the nacelle, and the transition piece (TP), a balcony-line access platform for supply vessels around the bottom of the tower. Assuming the accident has occurred in the lower part of the turbine and the injured person cannot be conveyed to the roof platform, evacuation is only possible via this platform. In this case the highline rescue procedure would be as follows:

1. After the first rescue measures have been taken to evacuate the injured person from the immediate danger zone and an emergency call made to the rescue services, the injured person is treated directly at the scene of the accident. If the patient is not fit to be transported, he or she will be cared for by team colleagues in the wind turbine until the HEMS arrives (see Fig. 1).

2. The rotor and the nacelle of the offshore wind turbine have to be correctly positioned and secured in preparation for the arrival of the helicopter. The nacelle and the rotor both have to be brought into park position, to enable a safe approach of the helicopter. This so-called orientation stop is a turbine control procedure triggered by remote monitoring, a control room, or by service staff on site, to bring the offshore wind turbine into park position, and which can be achieved semi-automatically with the aid of a few commands.

3. The HEMS crew member and the emergency doctor are lowered down to the helihoist platform by winch.

The helicopter hovers in standby position, though

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should ideally temporarily land on the helideck of a transformer platform. The rescuers are lowered, care for the patient and – if he is fit to be transported – prepare him for transport (e.g. using a spine board or rescue sack) and transport him to the transition point (TP). The helicopter then approaches again.

4. There are two options for the highline procedure: Either the winch operator throws the end of the highline – weighted with a sandbag – onto the transition

point (TP), or – the preferred method – the emergency doctor, or a member of the HEMS crew, shoots the highline from the transition platform (TP) with a suitable device (similar to an air gun), whose range – depending on the projectile – is between 50 and 100 metres, into the water. For this application, the line (approximately 100 metres in length, 3-5 mm thick, and with a tensile strength of 2 kN) is furnished with a float (1) that keeps the line on the surface so that

Fig. 2: Nacelle and rotor have to be brought into park position in order to ensure that the helicopter has a safe approach Fig. 3: After the rescuers are lowered, the helicopter goes to standby position, ideally on the roof of a transformer

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+41 52 345 3605 +41 52 345 3606 +1 207-513-1921 mail@alpine.aero www.alpine.aero

32 | oFFsHore

Fig. 4: The highline is shot into the water from the transition platform using a pneumatic line thrower (range between 70 and 100 metres) Fig. 5: Once the line has been picked up by the helicopter and the winch operator has attached the winch rope to the highline, the helicopter ascends to winch height – maintaining sufficient distance to the offshore wind turbine

Footnote (1) The pneumatic line thrower used in the demonstration is made by Nautilus Marine Service GmbH. It has various projectiles for different applications. In this case the float is the appropriate solution.

the rescue line can be fished out of the water from the helicopter using an appliance similar to a grappling hook at a safe distance from the offshore wind turbine.

5. The winch operator now attaches the winch rope (50 to 90 metres) to the highline, the helicopter rises to a winching height of around 40 to 60 metres to create a diagonal connection of the winch rope

Who carries out rescues from offshore wind farms?

Although the general euphoria surrounding the expansion of offshore wind farms has dissipated somewhat – in recent weeks there have been reports in the press about cash-strapped operators, problems with stability during foundation construction, procedures when erecting wind turbines, and also failures by government – in general the expansion seems to be unstoppable.

The Offshore Stiftung expects that the completed wind farms will be the best argument in favour of the development of more farms. There are plans to erect wind turbines with a capacity of 11,000 megawatts in the North Sea alone by 2022. But who is responsible for offshore rescue and evacuation in case of an accident?

To date there is no law that is generally binding as to which organisation is responsible when a technician has an accident on a windmill offshore. Below a certain level of complexity, the wind farm operators are themselves initially responsible for the safety and rescue of employees, and have to determine who carries out the rescue within the scope of a risk assessment – possibly using a company rescue service – although as yet no standardised offshore rescue chain has been established. In serious cases rescue is by helicopter as this guarantees shorter response times. This relative timesaving should be weighed against the complexity of the operation and the difficulty of access to the person to be evacuated from the turbine.

between helicopter and the rescuers on the TP platform. The ascent of the helicopter to winch height ensures a small winch and highline connection angle of c. 20 degrees between the helicopter and the obstacles presented by the offshore wind turbine.

A special requirement for the pilots is to keep to a safety distance of c. one rotor diameter between the helicopter rotor and the WT rotor blades (which can be up to 60 metres in length), the tower and the nacelle of the wind turbine – whereby under certain circumstances the pilot does not have a direct view of all obstacles. During the ascent to winch height, the winch rope is lowered and then pulled over to the TP by the HEMS crew. After the injured person in the rescue sack is securely attached to the winch rope, he or she is supported and winched up into the helicopter – guided by the highline. Once the patient is safely in the helicopter, the winch operator releases the highline and the helicopter flies to the helihoist platform again to collect the rescuers. HEMS crew and emergency doctor go back up to the helihoist platform from where they are hoisted back up to the helicopter.

Realistic training scenarios The offshore wind farms off the German coast are new territory even for experienced doctors, pilots and rescuers from height. HEMS crews must therefore regularly practise rescue and evacuation of injured persons. OffTEC relies on realistic training scenarios on wind turbines, and offers these in collaboration with Heli Service International. Various hoisting, rescue and evacuation training exercises can be carried out on a training and test wind farm (onshore) specially set up with two Siemens SWT-3.6-120 wind turbines fully equipped for offshore application (90-metre tower and helihoist platform) and two Siemens SWT-3.0-101DD (80-metre tower, gearless turbine – a technology that will in future also be used offshore). The highline rescue procedure, for which courses will be provided from next year, will for the foreseeable future be for “offshore only”. 

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In ProFIle | 33

CHC Search & Rescue: One of the world’s largest networks of SAR services Helicopter search and rescue (SAR) is a unique service performed in the most challenging circumstances. From the biting winds of the North Sea to the perilous sea conditions of the South Atlantic and the busy coastal environments of Australia, pilots, crews and aircraft must be capable of operating in the harshest of remote and often difficult to access locations. As the largest commercial operator in the world, CHC Helicopter operates one of the biggest networks of SAR services with one of the most modern helicopter fleets. The company’s aircraft and crews work across the widest range of geographical and climatic conditions, providing services for civilian, military and industrial partners.

CHC’s SAR operations span Norway, Australia, Brazil, Tanzania, the South Atlantic and Kazakhstan.

It is contracted to the Maritime Coastguard Agency in the U.K. since 2007 and recently renewed its partnership with the Irish Coast Guard.

SAR activities are just one arm of the services the company provides. The market leader in offshore transportation for the oil and gas industry, CHC also transfers hundreds workers to and from offshore installations and ships across the world every day. Providing additional helicopter maintenance repair and overhaul services, the company operates more than 250 aircraft in about 30 countries

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around the world overall. “SAR is the really tangible part of everything we work towards in terms of safety, training and technology,” said Nick Mair, CHC’s regional vice president. “When an emergency call comes in, these individuals, who are by their nature all intelligent problem solvers, quickly come together and work as a team. Day in, day out, our people display their skills, courage and

Fig. 1: CHC’s air-crews participate in live training exercises or challenging simulator work, many also routinely augment their formal medical skills (Photographs: CHC Helicopter)

Authors: Editorial Team AirRescue Magazine

34 | In ProFIle professionalism. They don’t hesitate to safely work to the limit of their training and the aircraft’s capabilities, but they have a clear focus on achieving the aim of bringing people home, often from life-threatening situations.”

Underpinning these attributes is a rigorous training and exercise programme that keeps the crews ready to react, regardless of the challenges that may be posed.

When they’re not out on missions, air-crews participate in live training exercises or challenging simulator work.

Many also routinely augment their formal medical skills.

“Our focus today, as it always has been, is upon safety, reliability, performance and delivery,” added Mr Mair.

“This is nowhere more apparent than in our SAR fleet.

Our people routinely demonstrate skill, courage and dedication in undertaking missions in the most testing of conditions. “The right aircraft, the best people, the latest technology, the most extensive experience. Whatever it takes, we’re ready.”

Busy Irish Sea CHC has provided SAR services to the Irish Coast Guard since 2001, deploying a fleet of six Sikorsky 61N aircraft from four bases strategically placed around the country and averaging around 500 missions a year. With the renewal of their contract in 2010, CHC has embarked on a significant programme of investment to further enhance the fleet and achieve significant new levels in this vital life-saving service. The arrival of the first of five state-ofthe-art Sikorsky S92 aircraft in Shannon in January this year marked the beginning of a new generation of SAR services in the country.

The S92, which CHC also operates for the SAR in the U.K., is blazing a trail in terms of technological capabilities, possessing the speed, range and equipment to deliver a SAR service that meets modern-day needs.

The S92s are equipped with high-speed dual hoists and transformative technology, including: Fig. 2: In the U.K., HM Coastguard operates a 24-hour-a-day service covering more than 19,000 km of coastline and approx. 3.2 million km2 of sea

• • • •

Maritime Automated Identification System (AIS) Powerful searchlights Satellite communications with flight following Advanced medical equipment for paramedics

“S92 aircraft will be introduced to the other bases at Dublin, Waterford and Sligo in the coming months, replacing the existing S61s which have been a familiar sight in the skies for more than 21 years,” said Mark Kelly, managing director of CHC Ireland. “The landscape of each base showcases the diverse capabilities of S92s custom-made for SAR activities. The most northerly base in Ireland, Sligo deals with the stern challenges posed by the Atlantic Ocean and a clifftop environment along the northwest coast. “Missions often involve rescuing casualties from remote rural areas in the west of Ireland, greatly reducing the time needed to transfer patients to a hospital. The base also carries out rescues from the many islands of the west coast and also within Northern Ireland.”

Dublin’s patch includes a port which features high levels of ferry and merchant vessel activity on the busy Irish Sea. This includes the world’s largest car ferry. Another active area for the crews is within the Wicklow Mountains to the south of the city, which have the highest concentration of mountain rescue incidents. Located in the southeast, the Waterford base serves the area’s numerous popular beaches and challenging coastline. The base also covers the busy maritime areas of the Celtic Sea and the South Irish Sea with crews occasionally called upon to support operations in the west of Wales.

“The introduction of the S92s is just one of a number of improvements that Irish citizens will see in the SAR service. In February 2011 our crews were upgraded to paramedic status some 14 months ahead of schedule, said Mr Kelly. “In a remote environment, this can be the difference between life and death.”

As far as the Faroe Islands • Thermal imaging and high-definition, low-light sensors • Direction-finding equipment

In the U.K., Her Majesty’s Coastguard as part of the Maritime and Coastguard Agency operates a 24-hour-a-day service covering more than 19,000 km of coastline and approximately 3.2 million square kilometres of sea. The four coastguard helicopters operated by CHC are staffed with a captain, a co-pilot, a winchman and a winch-operator, with at least one fully qualified paramedic among them. They carry out an average of around 750 missions a year. As well as operating S92s from Stornoway and Sumburgh in Scotland, CHC has Agusta Westland 139 aircraft at two bases in the south of England, Portland and Lee-on-Solent, which it operates on behalf of the Maritime Coastguard Agency. The AW139 helicopters are fitted with high-speed dual hoists as well as: • Thermal imaging and high-definition, low-light sensors • Direction-finding equipment • Maritime Automated Identification System (AIS) • Powerful searchlights • Satellite communications with flight following • Advanced medical equipment for paramedics

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In ProFIle | 35 Ian McLuskie, the U.K. SAR business unit leader, said: “With an average of around 120 missions per year, the service frequency from the Sumburgh base in Shetland, for example, is relatively low, although the total number of flying hours is comparable with those of other bases.”

This is due, among other factors, to the long flight distances the crews cover, which range from the oil fields in the northeast of Shetland to as far as the Faroe Islands on occasion. For this reason, during missions it can be necessary to plan for refuelling stops. “To ensure we continually operate at the highest possible standards, training flights that include a wide range of tasks, including winch operations and special approaches,” said Mr McLuskie. “After every mission, we undertake a full analysis to see if there are opportunities to further improve the service.”

Australia: A mighty challenge for SAR The sheer scale of the Australian coastline presents a mighty challenge when it comes to SAR coverage. Unlike many European countries, there is no network of government-run SAR bases and aircraft to provide cover for shipping, sailors, walkers, etc., who are the traditional ”customers” of SAR crews worldwide. Instead, there are a number of contracts set-up around the coast which provide assistance on a regional/state basis. In contrast to the European approach, the SAR crews also tend to provide air ambulance services and are routinely manned by a combined crew of CHC (pilot and winch operator) and medical personnel (e.g. a paramedic and doctor team).

The medical professionals would be the ones who would go down the wire, as needed, to provide medical assistance and lead removal of injured people.

In addition to the SAR/EMS arrangements – which see AW139s employed in single-pilot, night (NVG), IFR operations –, CHC Australia also provides SAR resources to the Royal Australian Air Force. These crews commonly include two pilots and two other colleagues to provide SAR support to both fast-jet bases during at-home training and whilst deployed on exercises around Australia.

notoriously hazardous, with fast flowing tides, heavy seas and strong south-westerly winds.

The 27 ft yacht “Blu Argent” had run aground and was in a very dangerous position. Part of its keel was embedded in the bank and it was being heavily pounded by the wind, waves and tide. The four sailors on board were clinging to various parts of the vessel.

As the helicopter hovered, the “Blu Argent” took a particularly large wave, heeled over to about 70 degrees and started dragging over the bank. Debris from the yacht started appearing and its hull was becoming substantially submerged. Not only were the yacht crew in danger of being washed off at anytime, there was potential for them to be hit by parts from their own boat or tangled up in the rigging lines.

A decision was made to attempt a rescue. Helicopter crewman Simon O’Mahony was winched out and slowly manoeuvred towards one of the members of the yacht crew. The situation, with the boat moving about in an uncontrolled way, dragging broadside on the bank, and being pounded by the wind and waves, presented a very challenging task for the winch operator, Dave Peel.

Norwegian fleet CHC Norway aircraft and crews provide dedicated capability with offshore-based SAR assets. Ready to respond to emergency situations, the SAR crews can also be used for less serious medical evacuations for which more than routine offshore transit is required. They are also used in a controlled manner to shuttle oil-and-gas personnel and equipment between offshore platforms.

Sailors being rescued from 27 ft yacht SAR crews often view what they do as ”just part of the daily job,” but there are frequent examples of their commitments to teamwork and continuous improvement. In one such case, coastguard helicopter “Rescue 104” from Lee-o-Solent (south of England) was scrambled to a report of a vessel that was taking on water and had put out a Mayday call in the vicinity of the Shingles Bank, near the Isle of Wight. An area of shifting sand and shingle located before the narrow entrance to the Western Solent, it is

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Winched crewman entangled Due to the yacht’s further movement, Simon became entangled in the sheets of the yacht. He was unable to reach the intended crewman and could not make any headway in the conditions. This situation not only endangered Simon, but the aircraft as well. It was at this point that Dave considered cutting the cable, but he held his nerve and managed, using the winch, to thread Simon clear and back out of danger. One by one, the helicopter and lifeboat crews were able to remove all the sailors from the stricken vessel.

The heli soon made its way to the Isle of Wight hospital-landing site and handed the yacht’s crew over to the ambulance. The men were shocked, cold and bewildered about how it all went very wrong so quickly. Dave ‘s and Simon’s courage and professionalism were recognised when they were presented with The Billy Deacon Search and Rescue Memorial Trophy for 2011. 

Fig. 3: The situation, with the boat moving about in an uncontrolled way and being pounded by the wind and waves, presented a very challenging task for the winch operator

Fig. 1: Hungarian HEMS has seven bases around the country and employs 50 doctors, 44 paramedics and 19 pilots (Photograph: Hungarian Air Ambulance)

Author: Dr Péter Temesvári Medical Director Hungarian HEMS peter.temesvari@airambulance.hu

Hungarian Air Ambulance and NAS: cooperation for a countrywide HEMS Hungarian Air Ambulance Nonprofit Ltd. is a government-owned, not-for-profit organization covering the whole country as a sole provider of HEMS in Hungary. It has close ties to the National Ambulance Service (Országos Mento´´szolgálat). This organization (NAS) is the countrywide provider of pre-hospital care, rescue and emergency ambulance services in Hungary and is also responsible for dispatching land resources and HEMS helicopters alike. The NAS has about 7,000 employees and is the founder of Hungarian HEMS. This article gives an introduction to Hungarian HEMS, its organizational structure, its missions and history.

Hungarian HEMS has seven bases around the country, serving the population of around ten million people. Hungarian Air Ambulance operates five EC135 and two AS350 helicopters all year round in VFR conditions and got its own Part 145 organization for maintenance of the AS350 helicopters. The duty hours follow the daylight hours of Hungary, summer operations being longer with 14 hours, coming down to 7 hours in some winter months. Hungarian Air Ambulance Nonprofit Ltd. is also a member of the

European HEMS and Air Ambulance Committee (EHAC).

Hungarian HEMS employs 50 doctors, 44 paramedics and 19 pilots.

Missions The duty crew composes of a doctor, a paramedic and a pilot. All doctors and paramedics are trained HEMS crew members and pilots fly single pilot operations. The main task of HEMS in Hungary is to complement the work of the

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In ProFIle | 37 land resources of the NAS. Helicopters are mostly tasked to serious incidents where HEMS can provide a high level of medical care to patients and provide a fast and nontraumatic transport platform for seriously injured patients.

Hungarian HEMS is also called to incidents, where land resources are not available within 15 minutes due to road conditions, remoteness of the location, or in special situations like floods and heavy snowfalls. Among the more regular missions are serious trauma missions, transfers of STEMI patients to PPCI centres, cardiac arrest care and transfers of burn patients. Another use of the helicopter is major incidents, where rapid evacuation of patients can be achieved. Hungarian HEMS is also tasked to every aviation-related accident in the country.

Hungarian Air Ambulance’s seven helicopters complete around 2,500 missions per year. Most of them – around 90% – are primary missions. Geography and the road network in Hungary usually allow inter-hospital transfers to be performed by land ambulances. However, the benefit of a helicopter transfer is obvious in some time-critical conditions and helicopters are in fact used for these transfers. Certainly, helicopters and crews are ideal for primary missions. Both helicopter types are suitable to land in tight places and the skill and experience of the pilots allow doing just that. Flight safety of course will always remain the organization’s highest priority. Fortunately the number of hospital landing sites and rooftop helipads is increasing despite the unfavourable financial climate.

Medical equipment is standard on all seven helicopters with slight variations between the two types, but absolutely standard within the type. Medical equipment is up to the European standard with complex monitoring capabilities, including NIBP, etCO 2 and temperature.

There is no need of invasive blood pressure monitoring at Hungarian HEMS as there aren’t many secondary transfers. Ventilators are Draeger Oxylog® 2000 and 3000

Year

Primary Missions

Secondary Missions

Flight Hours (h:min)

Average Time per Mission (h:min)

2006

866

452

1,006:44

0:45

2007

1,655

614

1,313:24

0:34

2008

1,926

513

1,427:15

0:35

2009

2,275

507

1,742:59

0:37

2010

2,291

541

1,801:06

0:38

2011

2,046

190

1,306:24

0:35

models, the defibrillator-monitors are Argus Pro LifeCare

by Schiller and Medtronic Lifepak® 12-s. This equipment enables the HEMS crew to respond with confidence to any medical or trauma emergency for the adult and paediatric population. Hungarian HEMS is rarely involved in the care or the transfer of new-born or small babies, as Hungary has a very well organized and dedicated neonatal prehospital and transfer service. As of today, Hungarian HEMS doesn’t carry any special rescue equipment like ropes and harnesses and there is no winch capability on the helicopters.

Three of the bases are purpose-built with integrated, tempered hangars, while the other four can only be labelled as “temporary” measures, where crew and storing rooms leave much to be desired, and because of a lack of a “heated hangar”, crews are faced with technical difficulties during winter months.

Table 1: Number of missions and flight hours (2006-2011)

History HEMS in Hungary has a history of over 30 years. It was developed from a nationwide fixed-wing patient transfer service operated by the NAS since 1957. Fixed-wing types of the era included the Antonov An-2, the Czech Aero Ae-45, Super Aero and Morava, and more recently, the Pilatus PC-6 Turbo Porter. The first helicopters used from Fig. 2: Planned permanent bases of NAS in Hungary

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38 | In ProFIle

Fig. 3: HEMS in Hungary has a history of over 30 years and the first helicopters used were of a Polish make with Russian design (MI2-s) (Photograph: Hungarian Air Ambulance)

1980 onwards were of a Polish make with Russian design (MI2-s). These machines were then serving, with varying intensity and success, for the following 24 years. Since the early 1990s, three AS350 helicopters were already working in HEMS alongside the MI2-s. The AS350 (Single Squirrel) is a much better helicopter for HEMS missions and two of these machines are still in service today with an almost legendary reliability and cost-effectiveness.

Hungarian HEMS would continue to use them in the future – depending on the implementation of EASA Part OPS regulations in Hungary. There was a period when other – privately owned – companies were involved in the HEMS operations parallel to the government-run service. In early 2000, the government decided to provide a country-wide HEMS service with seven helicopters, slowly building up a network of HEMS bases.

New era in Hungarian HEMS A bigger step came in 2005, when the decision was made to withdraw the MI2-s from service and replace them with another modern western type. In 2005, a new non-profit Fig. 4: Medical equipment is up to the standard with complex monitoring capabilities, including NIBP, etCO2 and temperature (Photograph: R. Klenk-Sipos)

company was set up, responsible for HEMS in Hungary.

A ten-year operational lease agreement was signed after a tendering process with the Austrian HeliAir GmbH in 2006. With this agreement, a new era started in HEMS in Hungary. Five EC135 T2 helicopters started working alongside the AS350-s, and the MI2-s were withdrawn from service. With the Austrian connection came a development in aircraft operations, quality management and flight safety. Regular simulator training sessions for pilots were introduced in 2008, with great contribution to flight safety.

New bases were opened, and the quality of services provided for Hungarian citizens improved substantially, with shorter response times and a HEMS fleet with uniform flight and medical standards. A dedicated HEMS coordination dispatch center was set up. This desk is responsible for allocation of the seven helicopters, based on the tasking received from the NAS. Its tasks include providing GPS coordinates and other navigational backup for the helicopters as well as flight following, alerting SAR in case of an accident and helping to organize patient pathways to receiving hospitals. Having a uniform fleet with uniform procedures significantly facilitates this job.

Hungarian HEMS aims to be a pioneer organization in the field of pre-hospital medicine in Hungary. The elements of clinical governance introduced include a strict selection program for new doctors and paramedics, training and re-training in pre-hospital medicine. HEMS crew member training following JAR OPS 3 recommendations are also part of the program as well as Aeromedical Crew Resource Management (ACRM).

Memberships The later project came with Hungary’s EHAC membership. Hungary held the first ACRM course in the national language and today Hungarian HEMS is proud to have the first female ACRM-instructor within EHAC. Other clinical governance elements include the increased use of Standard Operating Procedures (SOPs) for clinical and non-clinical tasks, audits and research to improve the quality of care. Standardized pre-hospital anaesthesia (RSI) was introduced 18 months ago as a pioneer project in the history of Hungarian pre-hospital care, along with an SOP for chest trauma care involving the introduction of simple thoracostomies in a standardized manner. Hungarian Air Ambulance is proud to be a member of EHAC and the Medical Directors’ Working Group of EHAC as well as of the EUPHOREA group, a new European alliance for pre-hospital medical research. We also look forward to working closely with EHAC in preparations for the next Airmed World Congress in Rome in 2014.

Future plans Future plans include the purchase of a spare helicopter to be able to provide a better service when the AS350-s need maintenance. The need for the application of fixed rope evacuation techniques is still a point of discussion at Hungarian HEMS. Night operations for secondary transfers or for primary missions with NVGs are also a possible step in the

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In ProFIle | 39 future. Definite plans for the near future are to build new HEMS bases that will improve coverage and the quality of service by using “heated hangars” for the helicopters and more appropriate crew rooms closer to the helicopters, thus providing shorter response times. This project has already started and in the next two years Hungarian HEMS hopes to be able to build five new bases. These will replace five existing ones, but the permanent base structure (seven bases) remains unchanged. EU funds will be used to build the new bases, thus providing equal opportunities for the whole population.

Opportunities and challenges Future possibilities are vast, depending on government plans and funding. Along with night OPS and rope evacuation, we might see a development in medical equipment, for example in the form of ultrasound, blood gas analysis and new procedures like pre-hospital blood transfusions and resuscitative thoracotomies. HEMS might add response cars to its “fleet” in order to get the team to the scene in case of bad weather. There is also potential in re-establishing fixed-wing transfers for repatriation missions and international patient transfers. Future crew trainings should include cross-competence in order to improve team performance and safety. Hungarian HEMS also sees the need to establish –– basic and advanced training programs for helicopter pilots to become “specialized” HEMS pilots, as the traditional source of trained pilots, the military, is not a source anymore.

Tailor-made Medical interiors that fit your mission

Another issue to be solved in the near future is crew salaries, from pilots to paramedics and to doctors, as these are far below the European average. There is no alternative in keeping qualified personnel from leaving the country. We would also like to see a new era in European HEMS operations that would include cross-border operations and closer relations with all European HEMS services. With all these plans, we plan to work closely with EHAC, our partners in Central Europe and the whole European HEMS community. 

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Fig. 5: The AS350-s helicopters are operated by the Hungarian National Ambulance Service – alongside with the EC135 T2 helicopters (Photograph: Hungarian Air Ambulance)

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40 | medIcal care

Fig. 1: On scene, the team found a motorcyclist lying on the road, motionless, while the driver of the small van had only minor injuries (Image for illustrative purposes only.

Photograph: R. Klenk-Sipos)

Case report: Road traffic collision of a 40-year-old male motorcyclist with a small van Author: Dr Péter Temesvári Medical Director Hungarian HEMS peter.temesvari@airambulance.hu

In August 2012 the helicopter of the Budaörs base of Hungarian HEMS was dispatched to a 40-yearold male motorcyclist. No further details were initially given. On scene, the team found a road traffic collision between a motorcycle and a small van. The driver of the van had minor injuries only, while the motorcyclist was lying on the road – motionless.

An emergency ambulance of the National Ambulance Service with an Advanced Life Support (ALS) team – consisting of three members – arrived parallel to the helicopter. The patient was found responsive, with the helmet removed. The paramedic of the land ambulance applied manual in-line stabilization (MILS), the HEMS paramedic and the ambulance driver cut off the victim’s clothes and the HEMS doctor immediately performed the primary survey.

An ABCD survey revealed a patent airway, a significant tachypnea with shortness of breath and increased respirator effort. Bony crepitus of the right ribs and surgical emphysema was found on the right side of the chest, the later extending from the jaw to the groin. Circulation was found adequate to provide perfusion to end organs with a present radial pulse, but with tachycardia. Pupils were equal and reactive, and the patient was moving all limbs. Level of consciousness was altered by confusion

and anxiety. No history could be gained from the patient.

Significant bleeding, soft tissue injuries were found on the right knee and on the forehead. Instant direct pressure was applied by one of the land crew to the knee. No fracture of the long bones was suspected.

During the primary survey the HEMS paramedic – with the rest of the land crew – put on high flow oxygen via a non-rebreathing mask and monitoring of vital signs such as pulse and saturation. Non-invasive blood pressure was started. During a brief discussion, the team agreed that the indication for pre-hospital anaesthesia was present because of respiratory failure. The land crew was asked to continue MILS, monitor respiration rate and to establish two peripheral intravenous accesses.

After the primary survey, a needle decompression of the right side of the chest was attempted by the HEMS doctor because of a high suspicion of a tension pneumothorax with circulatory compromise. This procedure is

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medIcal care | 41 only performed as an interim measure to gain time for the preparation for more definite methods. A 14 G cannula was inserted into the chest through the 2nd intercostal space with no effect.

The HEMS paramedic started to prepare the equipment for Rapid Sequence Intubation (RSI) while the doctor made a quick phone call to the on-call consultant following the relevant Standard Operating Procedure (SOP).

There was agreement between the two clinicians about the indication for RSI and a subsequent instant right-sided chest decompression by a simple thoracostomy.

After the call, 1 mg of Midazolam was given to the patient to control his agitation and facilitate pre-oxygenation and packaging. The land crew helped with putting a pelvic splint on while packaging the patient on a plastic scoop stretcher. He was not insulated in bubble wrap because of a high ambient temperature of around 30°C. Meanwhile, the preparation of the equipment (kit dump) by the HEMS paramedic was finished, so the patient was moved to the site of the RSI. He was positioned on the trolley of the land crew for optimal height for intubation and 360 degrees easy access. Because the incident happened at around noon on a summer day, shade for intubation could only be provided by the fire service using a thick blanket. RSI using a half dose Etomidate (10 mg) and 2 mg/kg of suxamethonium (200 mg) was uneventful. Intubation was facilitated by a bougie that is routinely used by the service for every procedure. Tube placement was confirmed by capnography and auscultation. Ventilation was set to maintain normocapnia.

After Betadine® disinfection of the skin using sterile gloves, an instant right-sided thoracostomy was performed. After reaching the pleural cavity with his finger, the HEMS doctor has found a collapsed lung and a rush of air was felt from the thoracostomy hole. The initially collapsed lung expanded quickly with positive pressure ventilation. A good effect of the procedure was confirmed by the saturation rising from the initial 79% to 99% within 2 minutes. As the unilateral procedure was effective, a decision was made not to perform thoracostomy on the

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other side despite the fact that the patient’s circulation slowly deteriorated. Non-invasive blood pressure monitoring failed, so circulation was monitored with palpation of the radial pulse. No fluid was given, because an intrathoracic or intra-abdominal haemorrhage was suspected.

External bleeds were controlled by a dressing on the knee and a suture on the forehead. The relatively long on scene time of 50 minutes was identified as a learning point for the team.

Anaesthesia was maintained using rocuronuim (90 mg), fentanyl and midazolam. The patient was mechanically ventilated in the helicopter. Vital parameters were kept normal during air transfer to a major trauma centre where a hemothorax was diagnosed. No injury to the left side of the chest or to the brain was identified in hospital.

The non-invasive blood pressure (NIBP) monitor fault was later identified with a leak in the multiple-use cuff of the monitor. 

Fig. 2: In the actual case discussed, the motorcyclist was positioned on the trolley of the land crew for optimal height for intubation and easy access (Image for illustrative purposes only. Photograph: R. Klenk-Sipos)

0 | medIcal care

Fig. 1: A national government-funded air ambulance system, operated

by Norsk Luftambulanse, has provided rapid access to advanced life support by specially trained anaesthesiologists (Image for illustrative purposes only, it does not depict the actual event.

Photograph: Norwegian Air Ambulance)

Authors: Stephen J M Sollid Oslo University Hospital stephen.sollid@ norskluftambulanse.no Rune Rimstad Oslo University Hospital Marius Rehn Norwegian Air Ambulance Foundation Anders R Nakstad Oslo University Hospital Ann-Elin Tomlinson Vestre Viken Health Enterprise Terje Strand Hans J Heimdal Jan E Nilsen Mårten Sandberg Oslo University Hospital

Oslo government district bombing and Utøya island shooting: The immediate prehospital emergency medical service response On July 22, 2011, Norway was struck by two terrorist attacks. A single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. In the first attack, a car bomb exploded in the Oslo government district. The bomb comprised an ammonium nitrate/fuel oil (ANFO) mixture or “fertiliser bomb”. Eight people were killed in the explosion. Two hours later, a lone gunman attacked a political youth camp on Utøya island, approximately 40 kilometres from Oslo, and killed 69 civilians.

The scale of the attacks and the resulting emergency medical service (EMS) response was unprecedented in Norway. The massive EMS response crossed jurisdictional lines and involved responders from multiple agencies throughout the region. This paper describes the immediate prehospital EMS response to the attacks.

The Norwegian EMS The backbone of the Norwegian EMS is provided by oncall general practitioners (GPs) and ground ambulances (1). According to national regulations, all ambulance units must be staffed by at least one certified emergency medical technician, EMT (2). However, most units are staffed by two EMTs, and in most urban systems, at least one EMT is a trained paramedic. The ambulance service is government-funded and organised under local health enterprises. In Oslo, a physician-manned ambulance is

operational during the daytime on weekdays and is staffed by certified or in-training anaesthesiologists.

Since 1988, a national government-funded air ambulance system has provided rapid access to advanced life support by specially trained anaesthesiologists (3, 4).

This service consists of 11 helicopter EMS (HEMS) bases and seven fixed-wing EMS bases, all operating 24 hours a day (5). All HEMS units are staffed by an anaesthesiologist and a HEMS paramedic. Six search-and-rescue (SAR) helicopter bases operated by the Royal Norwegian

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medIcal care | 43 Air Force under the jurisdiction of the Ministry of Justice and the Police are also an integral part of the national air ambulance system (1). These helicopters are also staffed by an anaesthesiologist and a rescue-man (5). As backup during non-flying weather conditions or for incidents close to the helicopter base, all civilian and some SAR helicopter bases use rapid response cars (6).

Twenty emergency medical communication centres (EMCC) coordinate EMS resources and on-call GPs in their region. Nurses who answer public emergency calls through the national toll-free medical emergency number (“113”) staff the EMCCs together with EMT-trained operators who coordinate the EMS and HEMS resources in the region.

The Norwegian trauma care system Norway has a three-tiered system of local, central and university hospitals. The catchment areas for the local and central hospitals range from 13,000 to 400,000 people. University hospitals serve as trauma referral centres and provide definitive care for populations ranging from 460,000 to 2.5 million (7).

EMS major incident preparedness A standard for major incident triage does not exist in Norway; most triage systems are confined to local systems (8). However, a framework for the management, organisation and coordination of major incident scenes has been established (9). According to this framework, incident command is managed by a police officer. Other branches involved are represented by their respective branch scene commanders, and the most central are those from the fire and rescue and EMS. An ambulance scene commander (ASC) is responsible for coordinating all on-scene EMS resources, and a medical scene commander (MSC) is the leading medical person on scene, who is responsible for triage and on-scene medical treatment. In addition, the scene is organised with parking and loading points for EMS vehicles and casualty-clearing stations.

Scene descriptions and EMS resources The Oslo government district is located in the business district of Oslo and consists of several buildings, housing most of the ministries. Traditionally, the area has been open to the public, and all nearby streets have been accessible to civilian vehicles.

The road transport time from the bombsite to Oslo University Hospital (OUH) takes five to ten minutes. OUH is the major health institution in Oslo and consists of three university hospital campuses: Rikshospitalet, Ullevål and Aker (see Fig. 3). OUH-Ullevål (OUH-U) is a combined primary and regional referral trauma centre that serves almost half the Norwegian population. The ambulance department of OUH has 15 ambulance stations and 43 ambulance units (25 units on-call day and night) in Oslo and the surrounding municipalities. In addition, an ambulance commander is on duty day and night in a separate vehicle and acts as the ASC in incidents involving multiple units.

The air ambulance base of OUH with two HEMS units is located in Lørenskog, which is just outside the city limits

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of Oslo. The EMCC of Oslo and Akershus coordinate the activity of all the EMS resources of OUH. Utøya island is 39 kilometres from central Oslo and lies in the Tyrifjorden lake (see Fig. 6). The 0.12 square kilometre island is owned by the youth organisation of the Norwegian Labour Party and is known for its annual summer camp. The island can only be reached by boat from the mainland. A small ferry that can accommodate one car is the only organised transport route to the island.

The shortest distance from Utøya to the mainland is approximately 630 metres.

The Vestre Viken Health Enterprise (VVE) is responsible for the specialist health services and the EMS in the region. The regional hospital resources are depicted in Fig. 2. The ambulance service in VVE has 17 ambulance stations with 24 ambulances operating day and night and an additional 5 daytime ambulances. The HEMS base at Ål covers the VVE region together with the HEMS units from OUH. The EMCC of Buskerud coordinates the activity of all EMS resources of VVE.

Environmental conditions July 22, 2011 was a Friday during the Norwegian general staff vacation period. In Oslo, the midday weather was overcast with some light rain and a moderate northnortheast breeze. The air temperature was between 15°C and 17°C. The weather conditions in the Utøya island area were similar, with light rain throughout the afternoon.

The air temperature was between 14°C and 15°C in the area, and the water temperature in the Tyrifjorden lake was 14°C.

Study design This is a retrospective observational study of available and relevant anonymous data on (H)EMS activity during the first 24 hours following the attacks of July 22, 2011. The CONsensus Guidelines on Reports of Field Interventions in Disasters and Emergencies (CONFIDE) was used in the drafting of this epidemiological assessment (11). The

Fig. 2: The bomb in the Oslo government district detonated at 15.25 p.m., within one minute, the Oslo EMCC received the first call (Photograph: N. Andersen)

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10 km Ringerike hospital (local hospital)

1 - OUH-Rikshospitalet

- Ambulance base

2 - Diakonhjemmet (local hospital)

- Air ambulance base - Hospital

3 - Lovisenberg hospital (local hospital) 4 - OUH-Aker Sundvollen hotel

Utøya island OUH-Ullevål (trauma centre)

Akershus university hospital (regional hospital)

1 2

Asker og Bærum hospital (local hospital)

4

3

Drammen hospital (regional hospital)

Fig. 3: Map of the greater Oslo area, including Utøya, depicting all (H)EMS bases in the area, the hospitals and main roads

Fig. 4: Map of the Oslo government district depicting the organisation of the EMS response and evacuation routes for ambulances

heads of the involved prehospital services, the research directors of both institutions (OUH and VVE) and the Data Protection Official approved the data collection from relevant sources within OUH and VVE. Because the Data Protection Official and the research directors approved the study as a quality improvement project, formal approval from the Regional Committee for Medical and Health Research Ethics was considered to be unnecessary.

Blocked during incident

IN Blocked during incident

2

Blocked during incident

IN

1 3 Blocked during incident

5

OUT

C2

C1

4

OUT

Blocked during incident C1 C2 1 2 3 4 5

Casualty clearing station 1 Casualty clearing station 2 and ambulance parking point Forward EMS personell with medical equipment and stretchers Incident control point Ambulance evacuation point Ambulance control point Ambulance control point

Triage and evacuation in the Oslo government district & Utøya island Oslo government district  The bomb in the Oslo government district detonated at 15.25 p.m. Within one minute, the Oslo EMCC received the first call from the public regarding the explosion. Twelve ambulance units in the area were dispatched and arrived on scene within minutes. Among the first arriving units was the ambulance commander, who assumed the role of ASC, and the physician-manned ambulance, where the on-board anaesthesiologist assumed the role of MSC. The OUH-HEMS was dispatched 25 minutes after the bomb detonated. The anaesthesiologists and the HEMS paramedics of both OUH-HEMS crews went to the scene via rapid response cars, whereas the pilots shuttled several units of LESS (light emergency stretcher system) stretcher bags (10) from the HEMS base to the scene by car. Additional personnel from OUH-HEMS were also called in and participated in the on-scene work. Two neighbouring HEMS units (Arendal and Ål) were also dispatched for the incident in Oslo.

A total of 41 ambulance units and four HEMS units were involved in the EMS activities following the Oslo government district bombing. The EMCC of Oslo dispatched and controlled all the prehospital medical services throughout the mission and coordinated the allocation of health assets, in close corporation with the ASC on site.

The casualty clinic in Oslo received 64 victims from the government district bombing site in the first two hours following the attack. Only one of the victims treated at the casualty clinic was admitted to hospital. In total, 12 trauma victims were transported directly to hospitals in Oslo from the bombing site, and ten of them were transported to OUH-U. All of the seriously injured victims were transported by ambulance. Casualties suffering from minor injuries were also transported to the casualty clinic by other vehicles, such as police cars, fire department vehicles and a bus requisitioned by the EMS at the bombsite.

At 5.00 p.m. the situation was considered to be under control, and a decommissioning of ambulance resources from Oslo was initiated. A heightened preparedness was maintained, however, in case additional victims were found and as a stand-by for the rescue personnel involved.

Utøya island  The first calls from victims at Utøya island to the EMCC of Buskerud regarding the shooting were received at 5.24 p.m. The first ambulance units were dispatched immediately but were held back when they reached the Utøya area because the police had not secured the area. The landside ferry quay of the Utøya ferry (Utvika quay) was briefly declared secure a half hour later, but the arriving ambulance units were soon pulled back again when bullet impacts were observed in the water nearby. The hotel at Sundvollen was temporarily chosen as the next clearing station for victims arriving from Utøya island.

The first HEMS unit reached at Utøya island at 6.05 p.m., but could not land on the island because of the

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medIcal care | 45 ongoing shooting. The other HEMS units were routed to a deployment site on the main road south of Utøya island.

Because of a low cloud base and fog in the Utøya island area, one HEMS unit was deployed by rapid response car directly from the Oslo scene. Their helicopter was used to ferry four additional HEMS physicians from OUH to the deployment site south of Utøya island. In total, three intact HEMS units, six additional HEMS physicians, two nurses and one paramedic from OUH-HEMS and a number of ambulance units were standing by at this deployment site. Two additional HEMS units and two SAR helicopters were still en route to the area. Several local ambulances were already in the area, and more than 20 ambulances and two ambulance buses had been released from OUH. The EMCC of Buskerud dispatched and controlled all the prehospital medical services throughout the Utøya island mission and coordinated the allocation of health assets, in close corporation with the ASCs on site.

Soon after the shooting started, some of the victims with no injuries or minor injures escaped the attacker at Utøya island by swimming towards the mainland. The first victims to reach the shore arrived scattered over a large area and were attended to by civilians in nearby houses as well as by ambulance personnel and a local GP who by this time were located just above the Utvika quay.

The first organised casualty-clearing station was established at Utvika quay when police again declared the area secure. Seven HEMS physicians, two nurses, two local GPs and one anaesthesiologist deployed from VVE engaged in triage on the shores of the Utvika quay area together with ambulance personnel from multiple EMS systems. A local EMT acted as the ASC at this site. Local police secured the area, and local fire and rescue personnel assisted in patient care and rescue. Victims from Utøya island were evacuated on small private boats ferried by local civilians and tourists from a nearby camping site.

Most of these victims were physically unhurt but some of them were mildly hypothermic from swimming in the cold waters of Tyrifjorden lake. An estimated number of 10 to 15 of the victims who arrived on these boats in the initial phase had suffered trauma from one or more gunshots.

Notably, several of the injured had received crucial first aid from other victims, ferryboat personnel and the police before and during the transport across the lake. Apart from triage for transport, the medical treatment was limited to intravascular access and analgesia during the primary survey. Two critically injured victims were intubated, and one also received thoracic drainage en route to the hospital. All injured victims assessed at Utvika quay were transported directly to the nearest helicopter evacuation point or hospital as soon as possible. In two cases, physicians from the casualty-clearing station accompanied the patient in the ambulance to continue treatment en route to the helicopter evacuation point.

The location of the first casualty-clearing station was close to the scene at Utøya island, but this location proved to be ineffective for the further evacuation of patients. The area was too small and narrow for helicopters to land, and only a small, steep and narrow gravel road connected it to the main road. Ambulances had to drive backwards down

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the gravel road to pick up patients, and in some cases, patients were carried up to the main road to the waiting ambulances. The main road, a narrow county road, was heavily congested with ambulances, rescue vehicles and private vehicles and made further evacuation difficult. A secondary casualty-clearing station was therefore set up at the bridgehead to Storøya island (Fig. 6). This site was chosen because it was a safe distance from the gunshots on Utøya island, which was still unsecured, and because it could accommodate a number of helicopters.

One of the OUH-HEMS physicians who arrived at this site with a patient from the Utvika quay acted as the MSC, and this physician worked with the ASC from the local ambulance service to organise triage, primary care and

Fig. 5: In total, three intact HEMS units, six additional HEMS physicians, two nurses and one paramedic from OUH-HEMS and a number of ambulance units were standing by at this deployment site, two additional HEMS units and two SAR helicopters were still en route to the area

Fig. 6: Map of the Utøya island scene depicting the organisation of the EMS response and evacuation routes

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Fig. 7: Patient flow from both scenes to hospitals and institutions that received victims

transport for victims arriving directly from Utøya island by boats and from the primary casualty-clearing station at Utvika quay. Seven teams were organised with at least one anaesthesiologist and one assistant in each team.

Six HEMS units, two SAR helicopters and 42 ambulances were available for transport. Fig. 7 illustrates the patient evacuation routes from Utøya island and from the Oslo government scene.

Approximately 60 flight movements were registered during the Utøya island mission, with a peak of 30 in one hour. Because of bad weather conditions, several flights occurred under Instrument Flight Rules and used the GPS-based instrument approach for the OUH-U helipad.

The primary casualty-clearing station at the Utvika quay area was evacuated again after less than one hour of operation when the car of the perpetrator was discovered in the area. Because the police could not rule out the presence of explosives in the car, all inbound victims were redirected to the secondary casualty-clearing station, and victims already at the first casualty-clearing station were evacuated. By this time, a team of one HEMS physician and three paramedics had set course for Utøya island to establish an advanced casualty-clearing station. The team was initially denied access to the island by the police on the island, but later, they were allowed ashore and were followed by a second team of three HEMS physicians, one physician from VVE, one nurse and two paramedics.

The team on the island remained under police protection throughout the evening. Most of the victims passing through this casualty-clearing station were physically unhurt, but four victims with gunshot wounds were managed by the EMS group on Utøya island before evacuation.

The team was gradually reduced during the evening to

VVE

Utøya island scene

43 pts.

(1 RW)

5 pts.

12 pts.

(10 RW)

Casualty clinic

1 pat.

80 pts.

Government district scene

Ringerike 35 pts.

Asker og Bærum 7 pts.

Drammen 1 pat.

9 pts.

(3 RW)

Ullevål Aker

OUH

31 pts.

1 pat.

10 pts.

2 pts.

Diakonhjemmet

two HEMS physicians and three paramedics. This team participated in a final search for survivors under police protection after midnight, but no survivors were identified.

The team remained on the island until 1.30 a.m., when an ambulance crew replaced them.

The HEMS units were gradually released from the secondary casualty-clearing station after the last patient was delivered at OUH-U. However, both OUH-HEMS were dispatched for transferring patients from the local hospitals to OUH-U during the night. The next day, four more victims from the Utøya island shooting were transferred by air to other hospitals in Norway: two by helicopter and two by fixed-wing air ambulance.

The secondary casualty-clearing station was closed between 10.30 p.m. and 11.00 p.m. but remained the base for SAR personnel in the search for deceased victims in the lake and the surrounding area through the night.

All seriously injured victims who were treated and transported from the casualty-clearing stations were alive upon arrival at the hospital. One victim subsequently succumbed to the injuries. Numerous uninjured victims, their relatives and the relatives and friends of the casualties were treated by local physicians and community health care employees who were gathered in the hotel at Sundvolden. This service remained operative for several days.

The prehospital challenges of July 22, 2011 Geography and EMS systems  The scenes of the attacks of July 22, 2011 differed substantially from other terrorist attacks – e.g. in Istanbul in 2003 (13), Madrid in 2004 (14) and London in 2005 – in terms of geography, infrastructure, EMS system and distance to specialised health institutions. The attacks occurred within the catchment areas of two different EMS systems and hospital enterprises. Only the Utøya island scene occurred in an area of overlap between the HEMS of OUH and VVE, and OUH-U is the only hospital that covers both scenes as the regional trauma centre of Southeast Norway.

Triage and evacuation  There is no standard for prehospital triage in Norway (8), and to our knowledge, no single system was used for triage in any of the scenes on July 22, 2011. All victims attended to by the HEMS and EMS were assessed using the implemented principles for primary survey adopted from Advanced Trauma Life Support (17) and Prehospital Trauma Life Support (18).

The tagging of victims was not performed because immediate transport was possible as soon as the victims were evacuated to the nearest casualty-clearing station.

During the initial hours of both incidents, large numbers of victims were anticipated. Triage and evacuation plans were formed with large numbers in mind.

Patient flow and communication  Similarly to most incidents of this magnitude, the victims quickly spread over a large area. In the Oslo incident, the rapid control of victims in the outdoor areas was achieved. The greatest challenge was determining how many victims were still in the buildings and how to evacuate them. The new encrypted digital radio system helped to ensure stable

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Fig. 8: The light HEMS helicopters were chosen as the primary means of patient transport by air because of their greater efficiency in operations (Photograph: Norwegian Air Ambulance)

radio communication between resources and contributed to maintaining the control of patient flow.

In the Utøya island incident, a large number of victims evacuated themselves to the mainland in the first hour. Local health personnel were spread out in this initial phase, and although a meeting point had been designated at a hotel at Sundvollen, no organised casualty-clearing station was established until approximately 80 minutes after the shooting started. Therefore, complete control of all victims was impossible to obtain in the first phase. The limited coverage and performance of the old analogue emergency radio system in the area contributed to some confusion about the location of the casualty-clearing station and evacuation point at the bridgehead to Storøya island. In total, seven victims with severe gunshot injuries arrived at Ringerike Hospital and were successfully received and stabilised.

HEMS operations  None of the EMS helicopters were involved in the police operation at any of the scenes, and the police did not request support from the civilian HEMS aviation assets. The light HEMS helicopters were chosen as the primary means of patient transport by air because of their greater efficiency in operation, whereas the larger SAR helicopters were held in stand-by for the transport of large numbers of spontaneously breathing patients if the patient load exceeded the capacity of the six HEMS units.

The greatest challenge in the HEMS operation proved to be coordinating the helicopter activity in poor weather conditions, uncontrolled airspace and an unsettled security setting. In addition to the six HEMS helicopters and two SAR helicopters, three additional helicopters from the Royal Norwegian Air Force, one police helicopter and two press helicopters were in the area at different times.

Despite these challenges, all HEMS and SAR helicopters were able to communicate and organise adequate impro-

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vised landing sites and patterns for landing and take-off near the casualty-clearing station.

Conclusion The terrorist attacks in Norway on July 22 in 2011 elicited a massive prehospital response involving units from eight different health enterprises. Despite the occurrence of two scenes within a short time span and with a significant geographical distance between them, a large number of EMS and HEMS resources from different systems could be activated and utilised. The time to treatment was delayed for many victims at the Utøya island because of safety concerns and geographical challenges. However, we believe that the EMS response was successful under the given conditions. The lack of a robust radio communication system at the Utøya island scene and the breakdown of the communications log (AMIS) are issues that need to be addressed. We also believe that the experiences warrant a “common language” in the management of major incidents, perhaps in the form of a national standard major incident triage.

Acknowledgements and Funding We thank Professor David Lockey for his valuable input in the process of drafting this manuscript, Lars Andresen at the Norwegian Meteorological Institute for providing weather data from the day of the incidents and Lena Gran for her valuable assistance with designing the figures. We also thank the members of the Collaborating group for their valuable help: Finn Johansen, Håvard Larsen, Colin Pool, Roy Smedhaugen, Bjørn Sveen, Marius Tjessem and Joar Tolpinrud. 

For references, please see:

››› www.airrescue-magazine.eu/bibliography

Competing interests The authors declare that they have no competing interests.

The original version of this article appeared in Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20: 3 (doi: 10.1186/1757-7241-20-3).

We thank the authors for permission to reprint it in a slightly shortened and edited version.

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Fig. 1: The number of aeromedical resources, helicopters from both Rega and the military, enabled injured children to receive advanced medical care at the scene (Photograph: Rega)

Authors: Dr Richard M Lyon MBChB (Hons) MD MRCP DipIMC (RCS Ed) Registrar in Emergency Medicine and Pre-hospital Care Kent, Surrey, Sussex Air Ambulance Jon Sanders PGCert MCPara HEMS Critical Care Paramedic Kent, Surrey, Sussex Air Ambulance

HEMS response to major incidents: Lessons from the Sierre bus accident on 13th March 2012 Road traffic accidents are a common pre-hospital cause of mortality and major injury. On 13 March 2012, shortly after 21.00 local time near Sierre, a Swiss town close to the Italian border, a tragic road traffic accident occurred. A coach carrying 52 passengers, mainly children aged around 12, was returning to Belgium following a school skiing trip to Val d’Anniviers in the Swiss Alps. For reasons as yet unknown, the coach collided head-on with a concrete motorway tunnel wall. This resulted in one of the most serious road traffic accidents in Swiss and European history.

The accident could have occurred on any motorway, anywhere in Europe. Rescue teams worked on-scene for eight hours to extricate, treat and transport trapped passengers. In total, 28 people, including 22 children, were killed and 24 injured, many critically (1). No other vehicle was involved in the accident, which had the highest casualty rate in recent European history. Such an incident can occur at any time, on any motorway, with the potential to cause a mass casualty incident.

Details of the response to the incident were widely publicised in both national and international media. Aside from mass media interest, sharing of detailed emergency

medical services information allows other services to analyse and exercise their own systems, to improve the response – should a similar incident occur in their region.

In recent times, there have been detailed publications describing mass casualty incidents following the London and Madrid bombings or the Norwegian bombing and shooting (2-4).

Major incident reporting As yet, no formal template or debriefing structure exists for formally disseminating information after mass casualty incidents. The emergency medical services community

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eagerly awaits the formal findings of the Swiss investigation and more detailed information on the emergency medical response to the incident, but valuable lessons can already be learned. Although all major incidents are unique in nature, they all have common elements and valuable lessons can be learned from sharing detailed information. Pre-hospital services across Europe should draw on lessons learned from this incident to aid preparation â&#x20AC;&#x201C; should such an accident occur in their own region.

Emergency medical services response Media reports have comprehensively reported on the emergency medical services reaction to the incident. Following the accident, the first emergency medical services arrived on-scene within 20 minutes. Having declared a major incident, an impressive number of resources were mobilised to the scene, despite the accident occurring during the hours of darkness. In total, eight rescue helicopters, 15 doctors, 30 police, 60 fire fighters, 100 paramedics and three psychologists attended the accident scene. Triage was performed on-scene and the injured casualties transported to several hospitals. Of note is that the number of aeromedical resources, helicopters from both the Swiss air rescue service (Rega) and the military, enabled injured children to receive advanced medical care at scene, including pre-hospital anaesthesia, and flown directly to specialist paediatric trauma centers in Lausanne and Berne. This specialist centers were several hundred kilometres from the accident scene. Ambulances transported other patients to hospitals in Sion, Visp, Lausanne and Berne. In total, more than 200 people were involved in the rescue operation (1).

Major road traffic collisions Major road traffic accidents are not uncommon. The majority involve private cars, resulting in small numbers of patients for each individual incident. Road traffic accidents involving buses can result in multiple casualties requiring a multi-agency response, sometimes in the form of a major incident. Road traffic accidents that result in trapped patients require specialist input from fire and rescue services with provision of hydraulic cutting and rescue equipment to extricate trapped casualties. Such equipment may need to be transported to the scene over some distance.

Major road traffic accidents can result in significant traffic congestion around the incident, causing delay to emergency services arriving on-scene and taking patients to hospital. The use of helicopters can facilitate rapid delivery of medical teams to the scene, as well as rapid transport of patients to specialist hospitals.

Lessons for the (H)EMS community Several key lessons can already be learned from the Swiss bus tragedy. The presence of experienced pre-hospital doctors at the scene allowed medical incident command, allowed advanced interventions such as pre-hospital anaesthesia and facilitated appropriate triage of the injured children. In some European countries (e.g. UK) the tasking of pre-hospital doctors, even to a major incident, is not

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The only thing

you canâ&#x20AC;&#x2122;t see

is how you ever got along without them.

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Fig. 3: The use of NVG has already been implemented in some European countries (e.g.

Scandinavia), but is not yet routine in others (Photograph: ADAC Air Rescue)

Fig. 4: The Swiss EMS are to be commended for their ability to provide a rapid, medically advanced response to such a tragic incident – despite significant challenges (Photograph: Rega)

yet formalised and relies on voluntary schemes. These doctors have varying clinical governance structures and involve doctors with varying degrees of experience and knowledge. Ideally, doctors responding to mass casualty incidents should have received formal training in major incident management and should be fully integrated into the local emergency medical services system.

The accident happened during the hours of darkness.

In many European countries, civilian helicopter emergency medical services (HEMS) are currently restricted to daylight hours, with only military aircraft able to undertake night time landings in the dark. The use of night vision goggles (NVG) has already been implemented in some European countries (e.g. Scandinavia) but is not yet routine in others (e.g. UK). Not all European HEMS services have a doctor/paramedic team as standard. Mobilising eight separate helicopters with doctor-paramedic

HEMS teams on-board was impressive and allowed several children to receive early, advanced intervention and then flown directly to specialist centres. The main Swiss HEMS service, Rega, operates 24-hours a day, every day of the year. From 13 helicopter bases, Rega operates 17 helicopters and can reach most areas of Switzerland within 15 minutes. Without a night HEMS service, treatment and transport of these critically injured children would have been significantly delayed. Some European countries (Scandinavia) have integrated HEMS services supported by statutory Government funding, whilst others (UK, Germany) have services – fully or sometimes partly – reliant on charitable donations. A fully integrated, night-capable HEMS service would undoubtedly improve the emergency medical response to major incidents across Europe.

Incidents involving major paediatric trauma are challenging. Accidents involving children are usually emotive and are not routinely dealt with by emergency medical services. Pre-hospital paediatric triage is more complex than adult triage (5). Critically injured children require highly specialist care in the form of paediatric anaesthesia, surgery and intensive care. These services may only be available in tertiary centres at considerable distance from the incident site. Experienced HEMS teams may be invaluable in responding to paediatric major trauma, especially when multiple children are involved.

Conclusion The Swiss emergency medical services are to be commended for their ability to provide a rapid, medically advanced response to such a tragic incident, despite significant challenges. Emergency medical services across Europe can learn important lessons from this incident and should question whether a similar medical response would occur in their country. The role of HEMS in major incidents needs to be clearly defined and integrated into national emergency medical services planning, ideally supported on a national, governmental level.  References: 1. BBC News (2011) At least 28 Belgian tourists die in Swiss bus crash. www.bbc.co.uk/news/worldeurope-17363369. Accessed 1/5/2011.

2. de Ceballos JP, Turégano-Fuentes F, Perez-Diaz D, et al. (2005) 11 March 2004: The terrorist bomb explosions in Madrid, Spain – an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care 9/1: 104-111 3. Lockey DJ, Mackenzie R, Redhead J, et al. (2005) London bombings July 2005: the immediate prehospital medical response. Resuscitation 66/2: ix-xii 4. Sollid SJM, Rimstad R, Rehn M (2012) Oslo government district bombing and Utoya island shooting July 22, 2011: the immediate pre-hospital emergency medical service response. Scand J Trauma Resusc Emerg Med 20: 3 5. Carron PN, Taffe P, Ribordy V, et al. (2011) Accuracy of prehospital triage of trauma patients by emergency physicians: a retrospective study in western Switzerland. Eur J Emerg Med 18/2: 86-93

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“Bell Helicopter is back in Europe” An interview with Patrick Moulay of Bell Helicopter Textron Inc., Managing Director Europe and Russia The Bell 429 in EMS and rescue operations is gaining momentum in Europe: Swiss operator Air Zermatt has taken delivery of the first Bell 429 to be registered in Western Europe. And Scandinavian Air Ambulance has been awarded a new contract starting 1 April 2014 with a Bell 429 to be based in Visby on the island of Gotland (Sweden). In HEMS configuration the Bell 429 includes a 204 ft³ cabin that provides unobstructed full body patient access. There is space to install various medical equipment. The deck height is designed for one man loading litter system without back strain. The Bell 429 is regarded as one of the most advanced light twin IFR helicopters. Patrick Moulay of Bell Helicopter spoke to AirRescue Magazine about the delivery of the Bell 429 to Air Zermatt and Bell Helicopter’s future expectations.

ARM: Mr Moulay, what is the major target market for the Bell 429?

Patrick Moulay: The Bell 429 is a versatile aircraft, efficiently configured for corporate, emergency medical services, oil and gas, police or fire fighting missions.

It is in service today with customers around the world, including North America, Europe, the Middle East and Asia Pacific – across all market segments.

ARM: What significance do you see in Air Zermatt, being the first Bell 429 customer in Europe?

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Patrick Moulay: Air Zermatt marked the entry of the Bell 429 into the HEMS segment in Europe. The aircraft has already received many successes over the last 12 months in all other regions and we knew it would soon make an entry into the European market. Since that first delivery, Bell Helicopter has continued to receive a lot of interest and success from the European HEMS community, in Northern Europe in particular.

ARM: One of the driving forces for developing the Bell 429 came primarily from the EMS industry. What would you consider to be the arguments in favour of the Bell 429 in its EMS configuration?

Fig. 1: “Air Zermatt marked the entry of the Bell 429 into the HEMS segment in Europe” (Photographs: Victorinox/H. Schomo)

52 | tecHnoloGY Patrick Moulay: HEMS missions are all about providing the best care possible for the patient. The Bell 429’s 204 ft³ main and aft cabin enables unobstructed full body access to the patient. It’s the only light twin-engine helicopter on the market that offers true two-litter capability with enough room for two medical attendants plus two flight crew members, with enough space left over for all of the required vital medical equipments.

In addition, with a cruise speed of 150 kts the Bell 429 allows air critical care providers to be on the scene quickly, when each minute counts.

ARM: Patient loading into the Bell 429 differs from loading patients into other EMS helicopters. What are the advantages here – including the side sliding door, combined with an optional set of rear clamshell doors under tail booms?

Fig. 2: The Bell 429’s additional features include a glass cockpit with the BasiX-Pro Integrated Avionics System, featuring two or three multi-function displays

Patrick Moulay: The two main advantages of the Bell 429 compared to its competitors is the innovative deck height design that enables one person to load a litter without back strain, and the 60 inch wide side-loading doors that make loading and unloading easier. In addition, Bell Helicopter currently offers our European Bell 429 customers two different interior options fully certified by the EASA. One of them is developed by Air Methods in the United States and the other one is designed

by Aerolite in Europe. Both suppliers have been extremely supportive of all Bell Helicopter requirements in Europe and have been very receptive to all specific requests made by Bell Helicopter’s European customers. Whatever the requirements, Bell Helicopter is confident that it can meet the needs of its HEMS customers with advanced medical interiors and exceptional flight performance with the Bell 429.

ARM: From your point of view – what are the other technological features of the Bell 429 worth emphasizing?

Patrick Moulay: Pilots love the comfortable seating, operational flexibility and performance that the Bell 429 brings. Operators praise the fact that they can observe and work on the entire patient and describe the machine as roomier, quieter, smoother and faster than other helicopters. The Bell 429’s additional features include a glass cockpit with the BasiX-Pro Integrated Avionics System, featuring two or three multi-function displays, dual digital 3-axis autopilot and an integrated electronic data recorder for enhanced situational awareness and post flight analysis. Furthermore, certified single and dual pilot IFR operations with Wide Area Augmentation System – WAAS – capabilities enable point-in-space approaches in as low as 250 ft ceilings. Its exceptional flight performance with 155 kt (287 kph, ed. note) speed, over 400 nm (754 km, ed. note) range, and HOGE over 11,000 ft (3,438 m, ed. note) is also something very impressive, the spacious cabin with 204 ft³ offers seating for 7 passengers and 1 crew member. Safety of flight features include a collective mounted throttle, damage tolerant hub and rotor system as well as energy attenuating seats and an outstanding OEI performance. It is also the first helicopter certified through the MSG-3 process, resulting in reduced maintenance costs for operators.

ARM: Which particular features of the Bell 429 as well as additional aspects of the EMS configuration were of major importance to Air Zermatt, for example searchlight, infrared aviation system, NVG or rescue hoist?

Patrick Moulay: Air Zermatt’s Bell 429 is fully configured with all of the rescue equipment necessary for their extremely challenging missions in high altitudes. In particular, the Human External Cargo hook, also called ‘double hook’, was a key element for them. Performance was the most important feature that lead Air Zermatt to the select the Bell 429. They need to carry out rescue missions in extreme temperatures and sometimes at

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tecHnoloGY | 53

Fig. 3: Bell Helicopter currently offers to its European Bell 429 customers two different interior options (fully certified by the EASA); one of them is developed by Air Methods and the other one is designed by Aerolite

15,000 ft. The Bell 429 was the best option to fulfill Air Zermatt’s requirements.

ARM: Could you give us some details on the optional 4-axis autopilot?

Patrick Moulay: This is one of the features Bell Helicopter is most proud of. The newly developed 4-axis autopilot makes the Bell 429 the first helicopter equipped with a WAAS (Wide Area Augmentation System). This feature enables Point in Space LPV approaches and offers operators enhanced capability for IFR operations without the large infrastructure footprint and associated cost of ILS ground-based equipments. These new autopilot capabilities offer Bell Helicopter customers not only better safety and control, but also allow greater operation readiness in bad weather conditions.

ARM: Could you tell us which other customers, besides Air Zermatt, are most probably going to opt for the Bell 429? Which operators showed interest in buying?

Patrick Moulay: The Bell 429 EMS demonstrator has been on tour in Europe for the last 3 months and has received tremendous interest from potential customers in every corner of Europe. The Bell 429 was designed with European HEMS operators and will surely become the new standard in the European HEMS segment. So, soon you will see more EMS 429 flying in the European skies.

ARM: India for example has approved the increased maximum gross weight based on Transport Canada’s certification to 7,500 lbs (from 7,000 lb). What about the approval in other countries?

Patrick Moulay: The number of countries around the world who have approved the new weight for the 429

4 · 2012 I Vol. 2 I AirRescue I 257

continues to grow. This list now includes Argentina, Australia, Brazil, Canada, China, Ecuador, India, Malaysia, Mexico, New Zealand, Thailand and Vietnam. Bell Helicopter is continuing to work with the FAA, EASA and other airworthiness authorities and remains optimistic the increased gross weight will continue to grow globally in the coming months.

ARM: Regarding training and simulation: Has the Bell facility in Prague already been equipped with a simulator? Are trainings being offered in Prague?

Patrick Moulay: Bell Helicopter currently offers a Bell 429 simulation solution at its training academy in Texas.

All devices and training courses have been fully certified

by EASA. For European customers, a Bell Helicopter flight instructor is based in Prague full time, ready to discuss all training requirements with customers.

ARM: Are you happy with the current developments in Europe? Have your expectations been met regarding the market-demand for the Bell 429?

Patrick Moulay: Absolutely. Bell Helicopter is back in Europe with a fantastic product adapted to the European market – the Bell 429 –, a new team of European leaders as well as a footprint in Prague and Amsterdam to support our customers’ needs from Europe.

Among others, we signed a contract with the Turkish National Police for the purchase of 15 Bell 429s with deliveries to begin in May 2013 – this contract underscores our increased traction in Europe. Beyond this order, we are seeing increased demand from many police forces in Europe, as well as in the oil & gas and HEMS industries.

We also have the opportunity to replace existing aircraft dedicated to search and rescue over time.

ARM: Mr Moulay, we thank you for the interview.



54 | saFetY

Fig. 1: The main aim of analysing the air rescue data set is to provide the participating German Federal States with relevant information in order to assist them in their decisions for further planning of the air rescue subsystem (Photograph: B. Freese)

Documentation of air rescue missions in Germany: Annual analysis of air rescue data set Author: Karsten Reinhardt Geogr.

Managing Director, RUN Rettungswesen und Notfallmedizin GmbH Schulstr. 10 D-35037 Marburg Germany reinhardt@run-gmbh.de

The annual gathering of data on and analysis of all air rescue missions in Germany is one of the outcomes of the â&#x20AC;&#x153;Weiterentwicklung der Luftrettung in Deutschlandâ&#x20AC;? [Advancement of the air rescue system in Germany] project carried out between 1999 and 2004 as a result of looming structural changes and discernible developments in the framework conditions of the rescue service at the end of the 1990s. As the highest-ranking local authorities, the German Federal States felt that, given the situation, the entire rescue service needed to be assessed, and that the tasks and objectives of the air rescue service, which seemed extremely expensive, may need to be redefined.

As a result, the Federal States set up a comprehensive air rescue investigation as a basis for proper development based on requirements. In the initial project stage, as part of a comprehensive inspection and analysis of all relevant legal and technical aspects, and with the participation of the Federal States, the National Associations of Statutory Health Insurance Funds, the main air rescue medical service providers, as well as RUN (Rettungswesen und Notfallmedizin GmbH) as a scientific advisor, new principles were developed for advancing the air rescue system in Germany (1).

In 2002, with the ongoing involvement of all those involved to date, the second stage of the investigation began, which, for the first time in 30 years, focused on gathering information on air rescue structures and operational services in Germany, analysing them and evaluating the results (2).

The conclusions, drawn from the 2004 project outcomes, highlighted, among other things, the need to introduce national standardised documentation across all air rescue bases and the need to regularly collate and analyse the resulting data. Until that point, no comparable and reliable field data on air rescue in Germany had ever been available.

As a result of this, in 2004, RUN and the primary air rescue medical service providers (ADAC and DRF) developed the standardised, national air rescue data set in consultation with the Federal States. Following a decision by the relevant expert panel of the Federal States, the Rescue Service Committee, the states, in their capacity as the air rescue authorities or highest-ranking rescue service authorities, dictated that the data set should be documented across all air rescue bases in Germany from 1 January 2005 onwards.

4 ¡ 2012 I Vol. 2 I AirRescue I 258

saFetY | 55 Objectives

Implementation The introduction of a national standardised data set for documenting air rescue missions, decided upon by the Rescue Service Committee, is a prerequisite for identical data capture processes at all air rescue sites. It is based on agreed definitions, irrespective of the station operator or the software systems used for capturing the operational services. As well as describing the criteria to be documented, the national standardised air rescue data set includes documentation notes, field descriptions and definitions for capturing air rescue missions. The corresponding information is available to all medical service providers and all air rescue sites. In order to achieve as realistic a data set as possible, Germany’s main air rescue organisations were included in the development of the data set. Together with its interim additions, the data set approved in 2004 forms the basis for the annual air rescue services census. The air rescue data set currently consists of 24 characteristic fields, which focus on tactical deployment details, in particular information with spatial and temporal relevance.

All helicopter bases that are used in air rescue missions in Germany are included in the data capture.

As well as air rescue bases in Germany, air rescue bases in other neighbouring countries are also included, provided that they carry out missions in Germany. These bases are in Luxemburg, the Netherlands, Austria and Switzerland.

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1.200 1.000

Missions

800 600

1.134

1.023

400

779

200 117

0

Austria

Luxembourg

Netherlands

Switzerland

(14 bases)

(1 base)

(1 base)

(4 bases)

The air rescue data set deployment information is sent by the air rescue organisations or the Federal States directly to RUN, where information from over 100 air rescue bases is compiled. Once it has all been analysed, the results are made available to each Federal State in an annual report. The annual analysis of the air rescue data set is the only comprehensive and impartial air rescue performance report in Germany.

Fig. 2: Missions carried out in Germany from non-German air rescue bases in 2011

2011 results Information from a total of 104 air rescue bases was used to analyse air rescue operational services in 2011.

84 of the bases were in Germany and 20 in neighbouring countries.

With 103,827 air rescue missions, 2011 had the highest level of deployment since analyses began. All of these missions took place in Germany. The use of German helicopters in countries bordering Germany is not included in this analysis. After a temporary decline in use in 2010, the trend towards increasing usage of air rescue services has been bolstered in rescue service deployment. This trend has, so far, been caused primarily by primary missions (see Fig. 3).

Use of air rescue services varies tremendously from region to region. On the one hand, it is heavily determined by structural framework conditions, but also by the extent to which it is incorporated by the control centres into the basic dispatching of emergency missions. If air rescue usage is referenced in terms of population figures, in Germany in 2011, 127 air rescue missions were carried

Fig. 3: Trend development of total air rescue deployment in Germany and deployment by category

100.000 98.871

80.000 80.227

83.615

88.591

60.000

63.083 53.568

55.454

12.929

13.478

13.930

2002

2005

2006

101.193

103.827 98.704

93.117

71.252

Missions

The main aim of analysing the national air rescue data set is to provide the participating states with information for assisting them in their decisions for further planning of the air rescue subsystem both at national level and for a systematic comparison between states. The analogous analysis methodology of air rescue deployment for 2002 and 2005–2011 allows comprehensible comparisons of respective developments to be made. Ongoing annual monitoring of air rescue deployment is becoming increasingly important for the Federal States because the causal framework conditions for the organisation of rescue services by and large – and in particular those of the air service subsystem – are subject to constant changes.

The resulting effects on the deployment of rescue services have intensified over the last few years.

The aim of regularly monitoring air rescue field data is to use it to support and form the basis of planning and political processes by identifying development trends.

The focus is on systematically making information available by documenting changes and development models.

The real value of the analyses lies in the cursory evaluation rhythm, an example of which is the analysis trend graphs of the development in the deployment, for example, of total, primary and secondary missions or distance between the base and arriving on scene in the case of primary missions. Regional developments are thereby measured against the national trend and displayed as such. It is then possible to compare and rank the states involved in the investigation based on the various aspects of the analysis.

73.779

72.904

14.964

13.978

2009

2010

77.420

66.263

40.000

20.000

0

14.286

15.066

2007

2008

Total Missions

Primary Missions

15.128

2011 Interhospital Transfer

56 | saFetY

Fig. 4: Spatial distribution of total air rescue missions in the German states of Rhineland-Palatinate and Saarland

out per 100,000 inhabitants. The extremes range from 65 missions per 100,000 inhabitants in North RhineWestphalia to 306 missions per 100,000 inhabitants in the Federal State of Brandenburg.

As well as national trend developments, the analyses also focus on trend developments in the individual Federal States. State results are, among other things, considered in terms of population figures and in relation to national results. Fig. 4. (see below) for example shows the distribution of air rescue missions for the Federal States of Rhineland-Palatinate and Saarland.

As well as examining usage figures and rates, the annual analyses also extend to individual subsegments of operations, resulting in information or additional records for the specific regional situations of rescue service organisations. Among other things, the development of distances between the base and arriving on scene in primary missions is analysed in this context.

For Rhineland-Palatinate, the trend development for average distances between the base and arriving on scene in primary missions in 2011 showed that the figures had increased for the bases “Christoph 23” and “Christoph 10”, which were also above the corresponding national average. In particular, the context surrounding the figure

Analysis of the “Datensatz Luftrettung” 2011

Districts German Federal States

Christoph 5, Ludwigshafen

”RTH“ helicopter base (primary missions)

Christoph 10, Wittlich

”ITH“ or ”RTH/ITH“ helicopter base (secondary or prim./sec. missions)

Christoph 16, Saarbrücken Christoph 23, Koblenz Christoph 77, Mainz

Neighbouring Countries

Helicopter bases in neighbouring federal states Helicopter bases in neighbouring countries

Total Missions: 500 an more 250 – < 500 100 – < 250 50 – < 100 less than 50

for the average distance between the base and arriving on scene for “Christoph 10”, which dramatically increased, is that there were problems with the permanent manning of ground-based emergency medical systems in the area that it serves which is rural and sparsely populated.

At the heart of annual air rescue data set analyses are, above all, analyses of spatial questions on missions.

The following levels are used for benchmarking purposes: National level, Federal State level and County/urban municipality level. For these administrative units, the use of air rescue services is calculated as an absolute value and as an inhabitant-related value taking population data into consideration. The cartographic results show actual air rescue service usage in the Federal States, irrespective of the air rescue base providing the service. Therefore, in the analyses for the relevant Federal State, it is not only the bases situated in the Federal State that are taken into account but all bases which have performed services in the Federal State in question.

As well as spatial/temporal analyses, as part of the annual evaluation work, individual questions on patient structures and questions with medical relevance are also taken into consideration.

The results presented are examples of air rescue data set analyses and therefore represent only an abridged version of the full analyses. For Federal States responsible for planning and organising air rescue, it is important on principle to have access to current and reliable data on air rescue usage and development for them to be able to make their own organisational decisions, for example as part of discussions on rescue service problems.

By compiling the field data of all relevant air rescue bases (transcending Federal States or national borders) from various data sources, the Federal States have detailed analyses on air rescue missions with annually expanding time series results for their field. Given that parameters are identified at both Federal State and national level, and a systematic comparison between Federal States and the country as a whole is shown in the results, the Federal States have access to important tools assist them in their decisions. These can be used for further planning for the air rescue subsystem and integrating it into the rescue service’s basic planning. It should be assumed that analogous data analyses involving all national air rescue bases and additionally taking relevant foreign air rescue bases in other countries into consideration are carried out only seldom (if ever).  References: 1. Ausschuss Rettungswesen (2000): Grundsätze für die Weiterentwicklung der Luftrettung in Deutschland.

Abschlussbericht zur Phase I. Mendel-Verlag, Witten [Rescue Service Committee (2000): Principles for the further development of air rescue in Germany. Final report for stage I. Mendel publishing house, Witten] 2. Ausschuss Rettungswesen (2004): Weiterentwicklung der Luftrettung in Deutschland. Abschlussbericht zur Phase II. Wolfsfellner Medizin Verlag, München [Rescue Service Committee (2004): Further development of air rescue in Germany. Final report for stage II. Wolfsfellner Medizin publishing house, Munich]

4 · 2012 I Vol. 2 I AirRescue I 260

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Helicopter crash in Morbegno: EMS-helicopter hits high voltage cable Author: Fabio Martorana HEMS doctor “AREU 118” Emergency Health Service Lombardia Base Bergamo Ospedali Riuniti Bergamo fabiomartorana@hotmail.com

Fabio Martorana was the HEMS doctor on duty when the Bergamo-based EMS-helicopter crashed just after 6 p.m. in Morbegno, outside Sondrio, in a forest in the Orobie Alps (Lombardy, Italy). The helicopter hit a high voltage cable with the tail rotor, the rotor severed the cable and the helicopter became uncontrollable. This is his brief report of the incident.

“I read some of the articles that came out in the aftermath of the crash and many of the things reported are incorrect. Upon completion of a previous mission for the same dispatch center in Sondrio, we were sent on a second mission to Morbegno, involving a motorcyclist who had fallen down a slope for several meters. Based on clinical data reported by the HEMS doctor on site, it was very likely that the motorcyclist had suffered a spine injury.

Considering that Sondrio has a neurosurgical service in Sondalo (quite distant from the site of the incident) and the potential risks and delays involved in ground transportation, they wanted us to check on the patient and fly him to Sondalo.

I communicated the request to my pilot with whom we agreed on the following plan of action: Since we were low on fuel, he wanted to take us to the crash site and – while we attended to the patient – he was supposed to fly to Colico (our helicopter contractor has its headquarters in Colico, in the province of Lecco, Lombardy, a short flight from Morbegno) to fill up and subsequently come back for us.

The nurse, alpine rescuer and I got off with a hovering manoeuvre (the helicopter touches the ground and personnel disembark without turning off the engines), unloaded our equipment and moved away from the helicopter.

4 · 2012 I Vol. 2 I AirRescue I 262

saFetY | 59 Fig. 1: “We watched – only a few meters up in the air – as the helicopter hit a high voltage cable with the tail rotor.” (Photographs: P. Sonzogni & Q. Stefani)

Fig. 2: “The rotor severed the cable and the helicopter became uncontrollable, swirling for no longer then a minute or two before crashing into the backyard of a primary school.”

Fehler! Verweisquelle konnte nicht gefunden werden.

We met the first medical team with the motorcyclist at the edge of the field and, while the alpine rescuer was busy cutting a fence so that we could get to the patient, the nurse and I turned around and watched the helicopter take off again towards Colico.

We watched as – only a few meters up in the air – the helicopter hit a high voltage cable with the tail rotor; the rotor severed the cable and the helicopter became uncontrollable, swirling for no longer than a minute or two before crashing into the backyard of a primary school.

While calling our dispatch center in Bergamo to report the incident, the alpine rescuer and I ran to the helicopter; we still heard noise coming from one of the engines that was still running, as was the main rotor, even though all the blades were missing.

While we evaluated how to approach the wreckage to check on the pilot and mechanic (the only crew members that were left on board after the hovering manoeuvre), we were joined by a firefighting squad (they had been called to help with the motorcycle accident and were therefore close at hand). We watched one of the firefighters who helped the crew members out of what remained of the helicopter; they were able to walk and apparently unscathed, except for a few minor contusions and bruises.

Nurse, alpine rescuer and I attended to our crew while the firefighters managed to turn off the running engine.

4 · 2012 I Vol. 2 I AirRescue I 263

We were then met and supported by the first medical team that had been sent for the motorcyclist. After a number of frantic phone calls, we were informed that a second helicopter from Como was on its way and that, after having flown the motorcyclist to Sondalo, it was supposed to pick us up and take us home.

While waiting, the colleague on duty at the dispatch center in Sondrio suggested to transfer the two injured crew members to the hospital in Morbegno in order to run a few tests to better ascertain their condition. We agreed on his suggestion and learn that, as expected, no major injuries had occurred. We were subsequently moved to a helipad nearby, where the second helicopter was waiting to fly us back to Bergamo.” 

Fig. 3: “We still heard noise coming from one of the engines that was still running, as was the main rotor, even though the blades were missing.”

60 | saFetY

Helicopter safety: Everybody’s concern Author: Jos Stevens Senior Scientist National Aerospace Laboratory (NLR) EHEST member EHSIT ST Technology Team Leader

The long-term helicopter accident rates on a worldwide basis have remained unacceptably high and trends have not shown significant improvement during the last 20 years. In late 2005, the International Helicopter Safety Team (IHST) was launched as a government and industry cooperative effort with the goal to reduce the worldwide civil helicopter accident rates by 80% in the year 2016 (1). According to an extensive IHST analysis, groups most likely to have helicopter accidents are general aviation pilots, trainees and small operators. Their accident rate is higher than the rate for more prominent mission types such as emergency medical services, law enforcement and tour operators.

The basic principle adopted by IHST is to improve helicopter safety by complementing regulatory actions by voluntarily encouraging and committing to cost-effective safety enhancements. The process is directly linked to the analysis results of real accident data, which results are used as a basis to develop safety-enhancing material addressing the highest rating safety issues. In Europe, the

Fig. 1: “Dangerous operations”: The long-term helicopter accident rates on a worldwide basis have remained unacceptably high and trends have not shown significant improvement (Photograph: S. Burigana/ Elilombarda)

European Helicopter Safety Team (EHEST) has adopted the IHST objective.

EHEST: a safety improvement partnership The European Helicopter Safety Team took off in 2006 as the helicopter component of the European Strategic Safety Initiative, ESSI (2), and as the European branch of

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saFetY | 61 the International Helicopter Safety Team, IHST. EHEST is committed to the IHST objective with emphasis on improving European safety.

EHEST brings together European helicopter manufacturers, operators, authorities, helicopter and pilots associations, research institutes, universities, accident investigation boards and some military operators (totalling around 130 participants from 50 organisations). EHEST addresses the broad spectrum of European helicopter operations, from Commercial Air Transport to General Aviation, and also includes flight training activities.

EHEST itself is the strategic and decision-making body and within its structure, two main working groups have been created to deal with different steps in the process: • The European Helicopter Safety Analysis Team (EHSAT) analyses helicopter accident investigation reports and identifies suggestions for safety enhancements, called Intervention Recommendations (IRs); EHSAT will also be involved in the measuring of results and effectiveness of safety improvements developed within the initiative; • The European Helicopter Safety Implementation Team (EHSIT) uses the results from the EHSAT accident analyses and their IRs to develop safety enhancement strategies and action plans.

Communication is also an important part of the safety initiative, as this can raise awareness and can contribute to improve safety by making available and sharing good practices. The EHEST-wide Communication Working Group has defined a process to efficiently communicate with the helicopter community, especially General Aviation and small operators. The Group addresses the global helicopter community through publications in professional journals and linking to international forums such as the Forum of the American Helicopter Society (AHS) and the European Rotorcraft Forum (ERF).

EHSAT: analysing helicopter accidents The EHSAT accident analysis aims at identifying all factors, causal or contributory, that played a role in the accident. In order to tackle the variety of languages in the accident reports and account for regional characteristics, regional teams have been formed in various countries like France, Germany, United Kingdom, Italy, Spain, Switzerland, Norway, Sweden, Finland, Ireland, Hungary and the Netherlands. The countries covered by the regional teams account for more than 90% of the helicopters registered in Europe. In order not to interfere with ongoing accident investigations and to ensure the data analysed are to the same ICAO Annex 13 standard, only those accidents where a final investigation report is available, are analysed.

The first step is the collection of factual information on the accident, such as occurrence date, state of occurrence, helicopter registration, helicopter make and model, type of operation, phase of flight, meteorological conditions, the flight crew’s flight experience as well as damage and injury level. Next, the team identifies all the factors

4 · 2012 I Vol. 2 I AirRescue I 265

that played a role in the accident, using standardised taxonomies to ease accident aggregation and statistical analysis. Two complementary taxonomies are used, the Standard Problem Statements (SPS) and Human Factors Analysis and Classification System (HFACS) by Wiegmann and Shappell (3).

Standard Problem Statement The Standard Problem Statements (SPS) taxonomy has over 400 codes in a three-level structure. The first level features the following 14 categories: • • • • • • • • • • • • • •

Ground Duties Safety Management Maintenance Infrastructure Pilot Judgement and Actions Communications Pilot Situation Awareness Part/system Failure Mission Risk Post-crash Survival Data Issues Ground Personnel Regulatory and Aircraft Design

The second and third levels go into more detail. A single causal factor identified in the accident can be coded using multiple SPSs. E.g. when one of the causal factors was a pilot lacking proficiency for a certain type of operation, this can be coded as “inadequate pilot experience” and additionally as “inadequate supervision”; and maybe even as “customer/company pressure”, depending on the narrative in the accident report.

Fig. 2: The EHEST-wide Communication Working Group has defined a process to efficiently communicate with the helicopter community, especially General Aviation and small operators (Photograph: J.P. Brasseler/ Eurocopter)

62 | saFetY al coding system adapted for maintenance. The system features the following main categories: Maintainer acts, Maintainer conditions, Working conditions, and Management conditions.

Organisational Influences

Facilitate identification of the underlying causes

Unsafe Supervision

Preconditions for Unsafe Acts

Unsafe Acts

Merely symptoms

Fig. 3: HFACS Model Structure (5)

Human Factors Analysis and Classification System In order to address human factors in a structured manner, EHSAT also uses the Human Factors Analysis and Classification System (HFACS). HFACS allows describing and analysing human errors in four levels (Fig. 3): 1.

2.

3.

4.

Fig. 4: Standard Problem Statement (SPS) Analysis Results: Percentage of accidents where SPS has been identified at least once in the accident dataset 2000-2005, based on Van Hijum M et al. (2010)

Organisational Influences Unsafe Supervision Preconditions for unsafe Acts and Unsafe Acts of Operators (e.g. flight crew, maintainers, air traffic controllers etc.)

Only focusing on unsafe acts (the “lower” levels) would be like focusing on merely symptoms without looking at the disease that caused them (the “higher” levels). HFACS divides each level into a series of causal factors. HFACS contains over 170 codes in the four main areas. In addition to providing more detail on human factors, it also encourages the analysis to not only identify the human error at an operator level, but also to search for underlying management and organisational factors.

For maintenance related human factors, the HFACS Maintenance Extension (HFACS ME) was introduced. Developed by the US Naval Safety Center, this is an addition-

Pilot judgment & actions Safety Culture & Management Ground Duties Data issues Pilot situation awareness Mission Risk Regulatory Part/system failure Post-crash survival Aircraft Design Maintenance Infrastructure Fatal accidents

Communications

Accident Analysis Result Analysis results for the timeframe 2000-2005 were published in October 2010 in the Final Report – “EHEST Analysis of 2000-2005 European Helicopter Accidents” (4), available on the EHEST website. Results are based on the analysis of 311 European helicopter accidents. The scope of the data set is accidents that occurred within an EASA Members State where a final investigation report from the Accident Investigation Board (AIB) had been issued. Of the accidents analysed, 140 accidents (45%) involve General Aviation operations; 103 accidents (33%) involve Aerial Work operations; 59 (19%) were Commercial Air Transport operations; and 9 (3%) involved State Flights. Most accidents analysed by the EHSAT occurred during the en-route phase of flight.

For the accidents in the dataset more than 1,800 Standard Problem Statements have been recorded, with the top three SPS categories at level 1 being (Fig. 4): • “Pilot judgement and actions”, identified in almost 70% of the accidents; this includes issues like pilot decision making, unsafe flight profile, and procedure implementation; • “Safety culture and management” identified in more than 50% of the accidents; with issues like Safety Management System, training and pilot experience; • “Ground duties”, identified in 40% of the accidents, including mission planning and helicopter pre- and post- flight duties.

The lower SPS levels provided insight into why “pilot judgement and actions” figures were the highest amongst the top three accident factors. E.g. when a helicopter is being used for aerial work, this can result in pushing the helicopter and pilot towards the limits of their capabilities, and operating close to terrain or obstacles. Therefore, aerial work is highly prone to accidents related to the mentioned category. The use of the HFACS taxonomy provided a complementary perspective on human factors. In most accidents, unsafe acts or preconditions of unsafe acts were identified. In fewer accidents supervisory or organisational influences were found. For the SPS as well as for the HFACS taxonomies, different patterns were observed for various types of operation (see Table 1). These patterns provide an understanding of a ‘typical’ accident scenario.

The accident analysis teams were also tasked to develop suggestions for safety enhancements, the socalled Intervention Recommendations (IRs), for all identified safety issues. Most recommendations fall into the following categories:

Non Fatal accidents

Ground personnel 0

10

20

30

40

50

Percentage of accidents %

60

70

80

• Flight Operations and Safety Management/Culture • Training/Instructional and • Regulatory/Standards/Guidelines

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saFetY | 63 EHSIT: developing safety-enhancing products The EHSIT defined a process to aggregate, consolidate, and prioritise the intervention recommendations produced by the EHSAT and to develop suitable and effective safety enhancement action plans. To address the top IR-categories identified by the EHSAT, the EHSIT has launched Specialist Teams (STs) focussing on specific topics: • ST Operations and SMS, focussing on risk management, Safety Management System (SMS) and Standard Operating Procedures (SOPs); • ST Training, developing safety leaflets and videos; • ST Regulation, identifying potential areas for rulemaking; • ST Maintenance, developing a maintenance toolkit (in co-operation with IHST); • ST Technology, developing a tool linking the results of the EHSAT analysis to technological developments.

All safety products developed by the teams are selected because of their potential to resolve the identified top safety issues, thereby also taking into account economic and other considerations. The following products have been developed or are under development, all of which are published on the EHEST website.

Standard Operating Procedures Standard Operating Procedures (SOPs) are being prepared for Helicopter Emergency Medical Service (HEMS) operations. Several more SOPs are being considered.

Safety Leaflets Four training leaflets have been published, regarding • Safety Considerations (addressing important subjects such as Vortex Ring State, Loss of Tail-Rotor Effectiveness, dynamic and static rollover and loss of visual references) • Helicopter Airmanship • Off Airfield Landing Site Operations and • (Single Pilot) Decision Making Other leaflets regarding Risk Assessment in Training and Autorotation, Weather Anticipation and Passenger Management are under development.

Videos Videos on Flying in the Degraded Visual Environment (DVE) and on Helicopter Passengers Management have been published. A video on Helicopter Mission Preparation Including Off-Airfield Landing is under development.

Guides Development of a Helicopter Flight Instructor Guide that addresses Threat and Error Management is planned for 2013.

Tools and toolkits A Helicopter Maintenance Toolkit has been published. This toolkit enables operators to assess their existing main-

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Type of operation

Top issues SPS

Top issues HFACS

Commercial Air Transport

- Pilot decision making

- Inattention

- Pilot in command, self-induced pressure

- Decision-making during operation

- Inadequate oversight by the Authority

- Channelized attention

- Mission involving flying near hazards, obstacles, wires

- Risk assessment during operation

- Mission requires low/slow flight

- Mission planning

Aerial Work

- Channelized attention

- Pilot decision making General Aviation

- Pilot decision making - Mission planning - Pilot misjudged own limitations/capabilities

- Risk assessment during operation - Overconfidence - Mission planning

tenance activities against guidelines for maintenance procedures, quality assurance, training and competence assurance, record keeping, HUMS, maintenance support equipment and fuel systems. The toolkit shows best practices used by many operators throughout the world.

A Pre-flight Risk Assessment Tool has recently been published, and the same team also published a Safety Management Manual (SMM) and toolkit. The manual was developed to comply with the Annex III to the future EU regulation on Air Operations, to be published end of 2012.

It aims at assisting ‘complex operators’ (a regulatory concept defined in the AMC) with little experience of running an SMS. Technology matrix The ST Technology has been created to assess the potential of technologies to mitigate safety issues. Technology is not high on the list of highest-ranking SPSs, as it is merely the lack of technology that may have led to an

Table 1: Top safety issues (at the lowest taxonomy level) per type of operation

Fig. 5: Various training (safety) leaflets published by EHEST

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For more information, visit: ››› http://easa.europa.eu/ essi/ehest/

Fig. 7: The EHSIT aggregates, consolidates, and prioritises the EHSAT suggestions for safety enhancements and defines safety strategies and action plans (Photograph: A. Pecchi/ Eurocopter)

accident. Technology however provides a variety of solutions that can (directly or indirectly) address the identified safety issues and that can contribute to prevent different types of accidents or to increase survivability. Technology can be a powerful means to improve safety, as it can bring solutions to known safety problems, including those of operational nature.

Rotorcraft technological developments have not been as fast as, for instance, fixed wing jet fighter developments. Current technologies are focussing on 3rd generation rotorcraft versus 5th generation fighter aircraft.

Technologies that may have been in use on fixed wing aircraft for many years, are transferred to rotorcraft at a (much) later date. And only few technologies have been developed specifically for rotorcraft. Fig. 6 shows a miniature Voice/Flight Data Recorder (standard “Coke” can size).

The ST Technology consists of a range of stakeholders, with various expertise and backgrounds. The main goal of the team is to list technologies and link them with incident/accident causes and contributing factors. The team developed a tool that contains a listing of technological developments (technology database) and a technologysafety matrix providing rows with technologies and col-

umns with the top 20 (level 2) SPS items as revealed by the EHSAT analysis of more than 300 accidents.

The process consists of two steps: • The technology database is filled with relevant technologies for the period 2006 till present; the basic selection criteria for the technologies are: new (emerging) technologies, existing technologies not yet used on helicopters and existing technologies used on large helicopters, but not yet on small helicopters; • The listed technologies are scored against each of the SPS items; this process involves two rating elements, the results of which are automatically summed and colour-coded: impact (how well can the technology mitigate the specific SPS) and usability (can the technology be utilised for a specific SPS and against what relative cost), each on a scale from 0 to 5.

The results can be used in three ways: • Which technology best addresses a specific safety problem. By scanning the coloured cells, one can

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saFetY | 65 easily identify those technologies that are rated highest, that are the specific technologies with the highest potential in mitigating certain safety issues.

These technologies can then be promoted to make them more widely available.

• Where can (additional) safety benefits be expected from a technology. New technologies are predominantly aimed at a specific goal. By rating this technology against the top SPS items, it can become clear that the technology also can be used to mitigate other safety issues. For instance, a certain sensor that aims at mitigating visibility/weatherrelated problems may turn out also to be useful to mitigate unsafe flight profiles or to aid landing procedures.

• Which safety problems are not (sufficiently) addressed by technology. Safety issues lacking (sufficiently promising) technological mitigation means, stand out as a result of the colours used. Manufacturers, research organisations and alike can address these specific safety issues, thereby creating new incentives and justification to perform research and to develop technologies.

Based on the limited number of technologies that have been listed and scored so far, a few promising technologies stand out already: • Predictive ground collision avoidance using digital terrain referenced navigation, bringing improved situational awareness to the pilot and reducing the workload; • Flight data monitoring for light helicopters (Helicopter Operations Monitoring Program, HOMP); during flight, predefined events are recorded, thereby helping to set priorities on training and maximising awareness of potential dangers; • Synthetic vision system (vision augmentation); the system will bring improved situational awareness to the pilot through a 3D-terrain with obstacles rendering on a head-up or helmet-mounted display.

Concluding Remarks The European Helicopter Safety Team (EHEST) started its work in 2006 as the helicopter component of the European Strategic Safety Initiative (ESSI) and the European branch of the International Helicopter Safety Team (IHST).

The team is committed to the IHST objective to reduce the helicopter accident rate by 80 percent by 2016 worldwide, with emphasis on improving European safety. Within EHEST, the European Helicopter Safety Analysis Team (EHSAT) analyses accident investigation reports. The analysis aims at identifying all factors, causal or contributory, that played a role in the accident, and identifying suggestions for safety enhancements. The European Helicopter Safety Implementation Team (EHSIT) aggregates, consolidates, and prioritises the EHSAT suggestions for safety enhancements and defines safety strategies and action plans.

For this, the EHSIT has launched Specialist Teams that develop various safety products. All products are selected

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Fig. 6: Miniature Voice/Flight Data Recorder (Photograph: Cassidian)

because of their potential to resolve the identified top safety issues and are published on the EHEST website.

Helicopter safety cannot be improved by developing tools and disseminating information alone. In the end, it will be up to the various individuals and organisations to apply those solutions for the benefit of the helicopter community. 

NLR The National Aerospace Laboratory (NLR) is the main knowledge enterprise for aerospace technology in the Netherlands. NLR carries out commissions for government and corporations, both nationally and internationally, and for civil and military aviation.

The overarching objective is to render aviation safer and more sustainable and efficient. In this way, NLR has been making essential contributions to the competitive and innovative capacities of Dutch government and industry for more than 90 years.

References: 1. http://www.ihst.org/ 2. http://easa.europa.eu/essi/ 3. Shappell SA, Wiegmann DA (2000) The Human Facotrs Analaysis and Classification System (HFACS). DOT/ FAA/AM-00.

4. Van Hijum M and coll (2010) Final Report – EHEST Analysis of 2000-2005 European Helicopter Accidents.

EASA, Cologne 5. Masson M et al. (2009) Human Factors in helicopter accidents results from the analysis performed by the European Helicopter Safety Analysis Team within IHST. Presented at the AHS Annual Forum and Technology Display. Texas

Acknowledgement This article has been made possible with contributions from various people within EHEST, especially the reviewers who contributed towards the refinement and improvement of the overall quality of the article.

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Mountain Rescue with a BK117 C2, Inaer, former Helitalia-DRF D-HECE and D-HDNO, based at Pavullo nel Frignano (Italy).

For more information, visit: www.saer.org Photograph by Domenico Marchi, flight photographer www.domenicomarchi.it 4 路 2012 I Vol. 2 I AirRescue I 270

( THINK MEDICAL ASSISTANCE ) A Eurocopter helicopter is a flying life support system for paramedics and rescue services.

Always on call to reach casualties of accidents and disasters or evacuate critical care patients.

Prescribe an EC135.

Thinking without limits

EC-EMS135-AD-MASTER-210x297.indd 1

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