AC 135-14B

U.S. Department of Transportation Federal Aviation Administration Advisory Circular Subject: Helicopter Air Ambulance Operations Date: 3/26/15 AC No: 135-14B Initiated by: AFS-200 Change:

Helicopters provide a means of transporting people in urgent need of medical assistance. These operations are unique due to the urgent nature of the flight. Each year thousands of patients are transported by helicopter while being attended by medical personnel trained to respond to their needs. Helicopter air ambulances (HAA) are equipped with medical monitoring and support systems to ensure proper care en route.

The HAA industry continues to expand. In response to the dynamic growth of this industry, the Federal Aviation Administration (FAA) has issued this advisory circular (AC) to provide information and guidelines to assist existing HAA operators, other Title 14 of the Code of Federal Regulations (14 CFR) part 135 operators considering becoming an HAA operator and those considering new-startup HAA operations. To address an increase in fatal HAA accidents, the FAA has implemented new operational procedures and additional equipment requirements for HAA operations. The FAA, HAA operators and medical community all play vital roles in applying these changes to ensure safety. Implementing a safety culture will benefit all aspects of HAA operations.

Part 135 subpart L addresses safety improvements for commercial helicopter operations through requirements for equipment, pilot testing, alternate airports and increased weather minimums for all General Aviation (GA) helicopter operations. Many of these requirements also address National Transportation Safety Board (NTSB) safety recommendations directed at improving HAA safety.

ORIGINAL SIGNED by /s/ John S. Duncan Director, Flight Standards Service

CONTENTS Paragraph Page CHAPTER 1. GENERAL

1-1. Purpose1

1-2. Cancellation1

1-3. Objective1

1-4. Audience1

1-5. Related 14 CFR Parts1

1-6. Definitions/Abbreviations2

1-7. Related Source Material7

1-8. Background Information9

CHAPTER 2. CERTIFICATION AND HAA SPECIFIC CONSIDERATIONS

2-1. General11

2-2. Initial Part 135 Certification with HAA Authorization11

2-3. Adding HAA Authorization to an Existing Part 135 Certificate11

2-4. Regulatory Operational Considerations11

2-5. Training Considerations12

2-6. Equipment Considerations12

2-7. Inspection and Maintenance Considerations12

2-8. Documentation and Recordkeeping Considerations13

CHAPTER 3. OPERATIONS

3-1. General15

3-2. Operational Control, Flight Locating, and Following Duties

and Responsibilities15

3-3. Visual Flight Rules (VFR)/Instrument Flight Rules (IFR) Flight Planning

and Weather Minimums17

3-4. Preflight Risk Analysis (refer to § 135.617)20

3-5. LFAs (refer to § 135.609)21

Figure 3-1. Example of Local Flying Area(s) and Where Cross-Country

Minimums Apply22

3-6. Hazards to Operations: Identification and Mitigation24

3-7. HAA Weight and Balance (W&B) Considerations24

3-8. Heliports/LZs25

3-9. Operations Under Special Conditions26

3-10. Patient/Passenger Handling/Safety29

3-11. Biohazard Control29

3-12. Flight Time, Duty Periods, and Rest Requirements30

3-13. Rapid Fuel and Oxygen Replenishment Procedures31

CHAPTER 4. TRAINING

4-1. General33

CONTENTS (Continued) Paragraph Page

4-2. HAA Pilot-in-Command (PIC)/Second-in-Command (SIC) Ground Training33

4-3. HAA PIC/SIC Flight Training34

4-4. Medical Personnel/Crewmember Briefing/Training36

4-5. OCS Training37

4-6. Communications Specialists Training38

4-7. Ground Personnel Training/Orientation39

4-8. Maintenance Personnel Training39

4-9. CRM Training40

4-10. Air Medical Resource Management (AMRM) Training40

4-11. Judgment and Decisionmaking Training40

CHAPTER 5. EQUIPMENT

5-1. The Helicopter Air Ambulance (HAA) Helicopter43

5-2. Equipment Required by Regulation for HAA Operations43

5-3. Medical Equipment for HAA Operations45

5-4. Recommended Equipment for HAA Operations47

5-5. Equipment Installation Evaluation for HAA Operations47

CHAPTER 6. OPERATIONS CONTROL CENTER (OCC)

6-1. General51

6-2. Core Concepts: OCC and Enhanced Operations Control Procedures51

6-3. OCS53

6-4. OCC Facilities and Capabilities53

CHAPTER 7. MANUALS, DOCUMENTATION AND RECORDS

7-1. General55

7-2. Manuals and Documentation55

7-3. Records56

CHAPTER 8. SAFETY

8-1. General59

8-2. Safety Considerations for HAA Operations59

8-3. Role of Company Philosophy and Executive/Senior Management59

8-4. Emergency Operations60

APPENDIX A. SAMPLE RISK ANALYSIS TOOLS (6 pages)1

APPENDIX B. SAFETY MANAGEMENT SYSTEMS (SMS) (4 pages)1

APPENDIX C. HAA OPERATOR PILOT TRAINING PROGRAM AND

CHECKING EXAMPLES (4 pages)1

Par 1-1 Page 1 CHAPTER 1. GENERAL

1-1. PURPOSE.

a. Background. This advisory circular (AC) provides information and guidance material specifically applicable to helicopter air ambulance (HAA) operations. The Federal Aviation Administration (FAA) issued a final rule in 2014: Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations. The bulk of the 2014 HAA rule package codifies requirements formerly contained in Operations Specification (OpSpec) A021, Helicopter Air Ambulance Operations, and which are now in Title 14 of the Code of Federal Regulations (14 CFR) Part 135 Subpart L, Helicopter Air Ambulance Equipment, Operations, and Training.

b. Phraseology Changes.

(1) The term Emergency Medical Service/Helicopter (EMS/H or HEMS) is obsolete. It is being replaced with HAA because, though a critical life and death medical emergency may exist, air ambulance flights are not operated as an emergency. Pilots and operator management personnel should not make flight decisions based on the condition of the patient, but rather upon the safety of the flight.

(2) Management should discourage the use of the term “mission” to describe flight assignments in operator manuals, training, and risk analysis programs. The emphasis should be on providing air transportation rather than completing a “mission.” The mission concept has been derived from military tactical or combat aviation policies that factor in “acceptable losses,” and may affect the normal commercial civil air transportation go/no-go decisionmaking process.

c. Scope. AC 135-14B supports the 2014 final rule. The information provided in this AC cites the associated regulations and other sources for easy reference. This AC is not mandatory and does not constitute a regulation. Nothing in this AC alters legal requirements for HAA operators to comply with regulations. This AC also refers to recommended practices that are not mandatory and do not reflect regulations and their requirements. When properly followed, these compiled industry best practices can enhance safety and reduce the number of HAA accidents.

1-2. CANCELLATION. AC 135-14A, Emergency Medical Services/Helicopter (EMS/H), dated June 20, 1991, is canceled.

1-3. OBJECTIVE. The primary objective of this AC is to provide information on policy and identify best practices for HAA operations based on multiple sources including the HAA rules published in 2014.

1-4. AUDIENCE. This AC is addressed to existing HAA operators and prospective part 135 certificate holders intending to conduct HAA operations, their employees, employees of associated medical services and public service.

1-5. RELATED 14 CFR PARTS. Title 14 CFR parts 1, 27, 29, 43, 61, 65, 91, 119, 120, 135 and 157.

Par 1-6 Page 2

1-6. DEFINITIONS/ABBREVIATIONS.

a. Accident/Incident Plan/Post-Accident/Incident Plan (AIP/PAIP). Includes emergency response procedures that should be used as a basis for training or for reference in the event of a mishap or other emergency.

b. Advisory Circular (AC).

c. Aeromedical Director. A licensed medical professional associated with a HAA operation, ultimately responsible for patient care during air transport. The Aeromedical Director has no operational control authority or influence over decisionmaking related to conduct of flights.

d. Air Ambulance. An aircraft used in air ambulance operations. The aircraft need not be used exclusively as an air ambulance aircraft, and the equipment need not be permanently installed.

e. Air Ambulance Operations. Air transportation of a person with a health condition that requires medical personnel as determined by a health care provider or transportation of human organs; or holding out to the public as willing to provide air transportation to a person with a health condition that requires medical personnel or transplant organs including, but not limited to, advertising, solicitation, association with a hospital or medical care provider.

f. Air Medical Resource Management (AMRM). A dynamic process including pilots, medical personnel (not limited to those participating in HAA flights), maintenance technicians, operational support personnel and management staff that optimizes human–machine interface and related interpersonal issues, with maximum focus on communication skills and team-building curricula. (Refer to the current edition of AC 00-64, Air Medical Resource Management.)

g. Autorotational Distance. The distance a rotorcraft can travel in autorotation as described by its manufacturer in the approved Rotorcraft Flight Manual (RFM). (Refer to part 135, § 135.168.)

h. Certificate-Holding District Office (CHDO). The FAA Flight Standards Service (AFS) CHDO with responsibility for management of an air carrier’s certificate, charged with the overall inspection and surveillance of that certificate holder’s operations. (Refer to part 1, § 1.2.)

i. Code of Federal Regulations (CFR).

j. Communications Specialist. An individual trained and qualified by the operator to receive and coordinate one or more of a range of activities, including but not limited to receiving flight requests for HAA operations, communications with medical, first response and other HAA organizations, communications with HAA crews and flight locating. The employment and training of communications specialists has been identified as an HAA industry best practice.

(See paragraph 3-2f in this AC.)

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k. Crew Resource Management (CRM). The use of all the available resources, information, equipment and people to achieve safe and efficient flight operations; approved CRM training is required for flightcrews in accordance with § 135.330. (Refer also to § 135.330 and the current edition of AC 120-51, Crew Resource Management Training, for more information.)

l. Datalink. A general term referring to a variety of technologies used to transmit and receive wireless electronic data between on-aircraft systems and off-aircraft systems.

m. Extended Overwater Operation. Per § 1.1, with respect to helicopters, an operation over water at a horizontal distance of more than 50 nautical miles (NM) from the nearest shoreline and more than 50 NM from the nearest offshore heliport structure.

n. Flight Following. Active contact with an aircraft throughout all of a flight (including time on the ground), either through voice radio contact with the pilot or through automated flight following systems. Considered a best practice in the HAA industry.

o. Flight Locating. The certificate holder is required by regulation to use flight locating procedures (refer to § 135.79), unless an FAA flight plan is filed and activated. Flight locating by HAA operations, even where it is not required by regulation, is recommended as an HAA industry best practice.

p. Flight Standards District Office (FSDO).

q. General Operations Manual (GOM). Required to be compiled to include, at minimum, sections mandated by regulation, including visual flight rules (VFR) flight planning procedures (§ 135.615) and an FAA approved preflight risk analysis (§ 135.617). A GOM requires acceptance by the FAA to be valid.

r. Geographic Information Systems (GIS). A collection of computer hardware, software and geographic data designed to efficiently capture, store, manage, map, analyze and display geographically referenced information.

s. Helicopter Air Ambulance (HAA). A helicopter, defined for the purposes of § 135.619, that is identified in the operator’s OpSpecs. It need not be used exclusively as an HAA. HAA-specific equipment need not be permanently installed.

t. Helicopter Air Ambulance (HAA) Operation. A flight or sequence of flights, with a patient, donor organ or human tissue, or medical personnel on board for the purpose of medical transportation, conducted by a part 135 certificate holder authorized by the Administrator to conduct HAA operations. A HAA operation also includes, but is not limited to:

(1) Flights conducted to position the helicopter at a site where medical personnel, a patient, donor organ or human tissue will be picked up;

(2) Flights conducted to reposition the helicopter after completing transportation of the medical personnel, patient or donor organ or human tissue transport; and

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(3) Flights initiated for the transport of a patient, donor organ or human tissue that are terminated due to weather or other reasons. (Refer to § 135.601.)

u. Helicopter Emergency Medical Service (HEMS). Obsolete term. The FAA and industry are moving to the term HAA for enhanced accuracy. HAA flights do not constitute an emergency flight. Replacement of the term HEMS with HAA will take place over the next several years as each relevant document is updated. The term HAA will be used exclusively throughout this document.

v. Helicopter Landing Area (also Heliport or Landing Zone (LZ)). An area of land or water or a structure used or intended to be used for the landing and takeoff of helicopters.

OpSpec A021 grants latitude to a helicopter operator for landing site selection as well as the authority to land on appropriate sites during both day and night in HAA operations. (Refer to § 1.1; the current edition of AC 150/5390-2, Heliport Design; and OpSpec A021.)

w. Helicopter Night Vision Goggle Operations (HNVGO). That portion of a flight that occurs during the time period from one hour after sunset to one hour before sunrise where the pilot maintains visual surface reference using night vision goggles (NVG) in an aircraft that is approved for such operations. (Refer to part 61, § 61.1.)

x. Helicopter Terrain Awareness and Warning System (HTAWS). A terrain and obstacle database-driven awareness and warning system configured specifically for a helicopter’s operating environment. This system correlates ship’s position, altitude, direction of flight and speed with digital obstacle and terrain maps.

y. Inadvertent Instrument Meteorological Condition (IIMC). An emergency condition when an aircraft inadvertently transitions from visual meteorological conditions (VMC) into instrument meteorological conditions (IMC).

z. Instrument Flight Rules (IFR). Operations when weather conditions are below the minimum for flight under VFR.

aa. Instrument Meteorological Conditions (IMC). Meteorological conditions expressed in terms of visibility, distance from clouds and ceiling that are less than that specified for VMC, requiring flight to be conducted under IFR.

bb. Landing Zone (LZ). See subparagraph 1-6v, Helicopter Landing Area.

cc. Local Flying Area (LFA). A geographic area of not more than 50 NM in any direction from a location designated by a HAA operator and approved by the FAA in OpSpec A021.

(Refer to § 135.609(b)(1).)

dd. Medical Crewmembers. Also referred to as medical flight personnel, as opposed to flightcrew members. A medical crewmember (medical personnel) is an individual with medical training, carried aboard a HAA during flights or flight segments. Crewmembers typically include: flight nurses, paramedics, respiratory specialists, neonatal specialist and other medically-trained specialists. (Refer to § 135.601(b)(2).)

Par 1-6 Page 5 ee. Mountainous. Designated mountainous areas as listed in 14 CFR part 95. (Refer to § 135.601.)

ff. Night Vision Goggles (NVG). A NVG is a Night Vision Imaging System (NVIS) (q.v.)

appliance worn by crewmembers that enhances the ability to maintain visual surface reference under low-light flight conditions.

gg. Night Vision Imaging System (NVIS). An approved light amplification appliance enhancing visual sensitivity in low light conditions, combined with specialized lighting systems that are type certificate (TC) approved for the type of helicopter in which it is installed and are compatible with NVGs being used in that helicopter.

hh. Non-Mountainous. Areas other than mountainous areas as listed in part 95. (Refer to § 135.601.)

ii. Operations Control Center (OCC). An OCC is a centralized, dedicated facility staffed by trained HAA Operations Control Specialist(s) (OCS) (see subparagraph 1-6jj. The OCC is described at § 135.618. OCC review includes a wide range of safety-related items detailed in § 135.619(a).

NOTE: OCCs are required for certificate holders authorized to conduct HAA operations with 10 or more HAA-capable helicopters assigned to their OpSpecs, and are strongly encouraged for all operators. (Refer to § 135.619.)

jj. Operations Control Specialist (OCS). An individual within the OCC who provides operational support for the certificate holder’s air ambulance operations and is both initially and recurrently trained as specified in § 135.619(d) and (f). An OCS interfaces with the HAA pilot(s) prior to each flight request acceptance.

kk. Operations Specification (OpSpec). Issued by FAA to specify the commercial air operations it has authorized the certificate holder to carry out. OpSpec A021 authorizes HAA service. Before OpSpec A021 can be issued, the operator must meet the regulatory requirements of part 135 subpart L.

ll. Overwater Flight. Operation of a rotorcraft beyond autorotational distance from the shoreline. (See subparagraph 1-6xx, Shoreline.)

mm. Patient. A person under medical treatment. For the purposes of this definition, human transplant organs or tissue are not patients, but are explicitly included under HAA operations, regulations and practices. They are treated in the same manner as people under medical treatment.

nn. Pilot in Command (PIC). The PIC of an aircraft is directly responsible for and is the final authority as to the operation of that aircraft.

oo. Principal Avionics Inspector (PAI). The PAI at the CHDO specifically responsible for aviation safety inspection and oversight of a HAA operator.

Par 1-6 Page 6 pp. Principal Maintenance Inspector (PMI). The PMI at the CHDO specifically responsible for aviation safety inspection and oversight of a HAA operator.

qq. Principal Operations Inspector (POI). The POI at the CHDO specifically responsible for aviation safety inspection and oversight of a HAA operator.

rr. Residual Risk. Residual risk is the safety risk that exists after all controls have been implemented or exhausted and verified (to ensure that the risk acceptance is in accordance with a pre-existing documented risk analysis procedure.)

ss. Response Scene. Unimproved ad hoc LZ sites and other off-airport and off-heliport site locations where HAA flight landings are authorized under the authority of OpSpec A021.

tt. Risk Analysis. A formal methodology for guiding HAA decisionmaking. Its procedures, principles and policies are documented and are the subject of training by HAA operators. They include multiple people with defined roles that have been documented and are the subject of training. As total risk exceeds the operator’s pre-determined threshold, approval at higher levels is required. (Refer to §§ 135.615 and 135.617(a)(5).)

uu. Risk Assessment. Risk assessment is a key element of the broader risk analysis. The two terms assessment and analysis should not be used interchangeably. Process documentation should identify risk factors the HAA operator may consider as part of risk assessment. The operator should assign to each risk factor an appropriate numerical value reflecting both the likelihood of occurrence and severity of outcome. Section 135.617 requires HAA operators to have an FAA approved and documented Risk Analysis Program that includes procedures for elevating the final post mitigation risk to a higher management level for approval when the total risk exceeds a predetermined threshold.

vv. Safety Management System (SMS). A SMS is a formal, top-down approach to managing safety risk. It is a system to manage safety, including the necessary organizational structures, accountabilities, policies and procedures. Implementing a SMS can provide useful tools to the HAA operator for complying with the requirements of § 135.617. Additional information and resources on SMS can be found in the current edition of AC 120-92, Safety Management Systems for Aviation Service Providers, and in Chapter 8 and Appendix B of this AC.

ww. Second in Command (SIC).

xx. Shoreline. Land adjacent to the water of an ocean, sea, lake, pond, river or tidal basin that is above the high-water mark at which a rotorcraft could be landed safely. This does not include land areas unsuitable for landing, such as vertical cliffs or land intermittently under water (refer to § 135.168). Additional information is available in 14 CFR part 136, § 136.1,

i.e., “suitable for landing area for helicopters.”

yy. Standard Operating Procedures (SOP). An established or prescribed method to be followed routinely for the performance of a designated operation or in a designated situation and is used to guide training to meet such contingencies.

Par 1-6 Page 7 zz. Suitable Offshore Heliport Structure. A heliport structure that can support the size and weight of the rotorcraft being operated where a safe landing can be made.

aaa. Supplemental Type Certificate (STC). A TC issued when an applicant has received approval to modify an aircraft from its original design.

bbb. Visual Flight Rules (VFR).

1-7. RELATED SOURCE MATERIAL. The following lists documents that are applicable to HAA operations.

a. ACs (current editions). ACs can be found on the FAA Web site at http://www.faa.gov/regulations_policies/advisory_circulars.

• AC 00-64, Air Medical Resource Management.

• AC 27-1, Certification of Normal Category Rotorcraft.

• AC 27-1B MG 6, Miscellaneous Guidance (MG) for Emergency Medical Service (EMS) Systems Installations.

• AC 29-2, Certification of Transport Category Rotorcraft.

• AC 91-21.1, Use of Portable Electronic Devices Aboard Aircraft.

• AC 91-32, Safety In and Around Helicopters.

• AC 120-27, Aircraft Weight and Balance Control.

• AC 120-49, Certification of Air Carriers.

• AC 120-51, Crew Resource Management Training.

• AC 120-92, Safety Management Systems (SMS).

• AC 120-96, Integration of Operation Control Centers into Helicopter Emergency Medical Services Operations.

• AC 135-5, Maintenance Program Approval for Carry-On Oxygen Equipment for Medical Purposes.

• AC 150/5390-2, Heliport Design.

• AC 150/5230-4, Aircraft Fuel Storage Handling Training and Dispensing on Airports.

b. Handbooks, Manuals, and Pamphlets (current editions). FAA handbooks can be found on the FAA Web site at http://www.faa.gov/regulations_policies/handbooks_manuals.

• FAA Order 8040.4, Safety Risk Management Policy.

• FAA-H-8083-21, Rotorcraft Flying Handbook.

• FAA-H-8261-1, Instrument Procedures Handbook.

• Airman’s Information Manual (AIM).

• DOT/FAA/PM-86/45, Aeronautical Decision Making for Helicopter Pilots.

• DOT/FAA/DS-88/7, Risk Management for Air Ambulance Helicopter Operators.

• FAA FAASTeam Library, Flying in Flat Light and White Out Conditions.

• National EMS Pilots Association (NEMSPA), Preparing a Landing Zone. NEMSPA is located in Layton, UT 84041-9128, telephone (877) 668-0430.

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c. Other:

(1) Helicopter Association International (HAI). HAI is located at 1920 Ballenger Avenue, Alexandria, VA 22314-2898, telephone (703) 683-4646. Check their Web site for other documents and links to resources, including their Fly Neighborly Guide.

(2) The National Fire Protection Association (NFPA) is located at 1 Batterymarch Park, Quincy, MA 02169-7471, telephone (617) 770-3000. They have many publications about fire protection. The 400 series may be the most helpful. For example, the current edition of NFPA 418, Standard for Heliports, has fire standards for heliports.

(3) Air Ambulance Guidelines published by both the U.S. Department of Transportation (DOT), National Highway Traffic Administration; and the American Medical Association, Commission on Emergency Medical Services.

(4) The National Association of Air Medical Communications Specialists (NAACS) is located at PO Box 19240, Topeka, KS 66619, telephone (877) 396-2227. Check their Web site for links to resources, including training courses.

(5) Special Airworthiness Information Bulletin (SAIB) SW-10-43, Non-Aviation Transmitters. (Includes, for example, 800 megahertz (MHz) radios used to communicate with hospitals.)

(6) Policy Letter (PL) ASW-2001-01, Certification Guidelines for Compliance to the Requirements for Electro-Magnetic Compatibility (EMC) Testing.

(7) DOT/FAA/AR-99/50, High-Intensity Radiated Fields (HIRF) Risk Analysis.

(8) FAA Technical Standard Order (TSO)-C194, Helicopter Terrain Awareness and Warning System (HTAWS).

(9) International Civil Aviation Organization (ICAO) Doc 9977 AN/489, Manual on Civil Aviation Jet Fuel Supply.

(10) RTCA Inc., DO-160, Environmental Conditions and Test Procedures for Airborne Equipment.

(11) RTCA Inc., DO-178B, Software Considerations in Airborne Systems and Equipment Certification.

(12) RTCA Inc., DO-254, Design Assurance Guidance for Airborne Electronic Hardware.

(13) RTCA Inc., DO-309, Minimum Operational Performance Standards (MOPS) for Helicopter Terrain Awareness and Warning System (HTAWS) Airborne Equipment.