FACILITTES. The facilities include the business office required by FAR Section 135.27, maintenance area, and operational area. Items to be checked during FAA inspections should include the manual as required by FAR Section 135.21, as well as the operator's use of business names, aircraft, advertising, area of operations.
a. Maintenance. Maintenance facilities should be large enough to house the largest type of helicopter used by the certificate holder, adequately lighted, and equipped to perform required maintenance. Additional specialized equipment may be required for the EMS equipment installed in the aircraft. Contract maintenance will be performed in accordance with the procedures outlined in the operator's manual.
b. Operations. The operations facilities should have an area for flight planning, scheduling, flight following, training, and recordkeeping.
c. Flightcrew Place of Rest. In accordance with FAR Section 135.271, an adequate place of rest will be provided for flight crewmembers assigned EMS/H duty at or in close proximity to the hospital at which the HEMES assignment is being performed. The place of rest should be in an area away from the general flow of vehicle and pedestrian traffic allowing a quiet, restful atmosphere. The place of rest should provide adequate facilities including but not limited to, a shower, a closet, a bed with sheets, and the space environmentally controlled for comfort. The place of rest should be available on a continuous basis for flight crewmembers.
d. EMS/H and HEMES Heliports. FAR Part 135 EMS/H heliports, other than medical emergency sites, should meet the criteria established in AC 150/5390-2, Heliport Design. This heliport criteria has been established to ensure the highest level of safety for established heliports.
5. MANUAL. It is recommended each certificate holder conducting EMS/H operations should prepare a manual for such operations. The manual should be available in each helicopter and at each dispatch location. The following items are suggested for inclusion in the operations manual as well as items identified in FAR Section 135.23:
NOTE: This list does not relieve a certificate holder from including other items in their operations manual as required by FAR Part 135.
a. Names of all EMS/H management personnel that have authority to act for the certificate holder. The aeromedical director will not exercise control over EMS air ambulance missions unless he/she is listed in the manual required by FAR Section 135.21 as a person authorized by the certificate holder in accordance with FAR Section 135.77.
b. The front page of the certificate holder's appropriate operations and maintenance operations specifications.
Accident and incident notification procedures to include the local FAA, National Transportation Safety Board, and FAA CHDO telephone numbers.
Chap 1 Par 4 7
d. Refueling procedures with the engine(s) running (hot refueling) or shutdown.
NOTE: Refueling with the engine(s) running, rotor turning, and/or passengers on board is not recommended. However, situations of this type can arise during an EMS/H operation. Specific and rigid procedures should be developed by the operator in accordance with the POI to handle these occurrences. (See ACOB 9-90-1.) Such ®hot refueling" procedures will be covered in the operator's training program.
e. Type of medical oxygen system installed including bottles, lines, gauges, regulators, other system components, and the approved method of servicing.
f. Instructions for the removal and replacement of equipment installed for the purpose of patient care only. This equipment should be installed in racks by approved data that meet the g-loading requirements in an emergency.
The racks that hold the equipment should be removed and replaced by a certificated FAA mechanic, but the medical equipment used in patient care should be installed for easy removal by medical personnel if it is needed to go with the patient and the medical personnel should be trained accordingly.
NOTE: Patient life support systems which are not normally included in the type design of the aircraft, such as stretchers/litters, berths, incubators, heart pumps, etc., must be installed in accordance with approved data. This approved data normally include installation and removal instructions and should contain operational supplements, weight and balance data, and instructions for continued airworthiness.
Removal and replacement of these items may be repeated on a frequent basis and may or may not constitute maintenance. Each installation must be evaluated at the time of its approval to determine who is authorized to complete the installation. If the installation is simple, does not require tools, and can be done in accordance with approved data and procedures contained in the operator's manual, any person trained by the certificate holder may be authorized to install FAR Section 135.91(a)(1) (iv) requires that all equipment installed, including portable devices, must be appropriately secured. The supporting structure to which the equipment is to be attached must be designed to restrain all loads up to the ultimate inertia specified in the emergency provisions/emergency landing conditions required by the FAR.
Chap 1 8 Par 5
g. Flight release and flight following procedures.
h. In-flight emergency and emergency evacuation duties for EMS/H crewmembers and medical personnel.
NOTE: Items listed in (a) through (h) above do not preclude a certificate holder from including other items in the operator's manual required by FAR Part 135.
Chap 1 Par 5 9 (and 10)
CHAPTER 2. TRAINING PROGRAM
6. GENERAL. This chapter outlines recommended training for all EMS personnel including flight crewmembers and medical personnel.
a. Flight Crewmember. The unusual requirements of the EMS/H mission means that aircraft may be dispatched in less than ideal weather conditions;
i.e., night, low ceiling and/or low visibility, and into remote areas.
Because of these adverse conditions, the pilot should be trained in the basic instrument flying skills to recover from inadvertent Instrument Meteorological Conditions (IMC).
NOTE: This training does not authorize or condone operating an aircraft in IMC without proper Air Traffic Control (ATC) clearance.
Its purpose is to provide pilots with an additional margin of safety when conducting life saving missions. An operator's training program should include night operations into similar or like conditions that are normally encountered in EMS operations.
b. Medical Personnel. Medical personnel assigned duty during flight should be trained in the use of aviation terminology. Medical personnel should use aviation terminology to avoid confusion or misunderstandings of instruction from the flightcrew during the EMS mission.
(1) Medical personnel should be trained to properly use, remove, replace, and store medical equipment installed on the aircraft.
(2) Medical personnel should also be trained in physiological aspects of flight prior to being assigned flight duty.
(3) Medical personnel should be trained in aircraft evacuation and patient loading and unloading.
NOTE: The training program should consider the particular aircraft being used, and its safety features. A practice evacuation using emergency exits should be accomplished.
NOTE: If the certificate holder desires to use medical personnel to help advise the pilot of wires, obstructions, and other traffic during takeoffs and landings at EMS/H sites, those duties should be assigned by the certificate holder. Personnel assigned those duties should receive appropriate formal training.
Ground crew and other ground personnel (i.e., nurses, paramedics, etc. 2. EMS operations require stringent safety around the aircraft especially during arrivals, departures, loading, and unloading. The FAA Chap 2 Par 6 11
recommends that each certificate holder and hospital develop a training program that encompasses, in addition to their normal training program, the following:
(1) Personal safety in and around the helicopter for all ground personnel, including FAA rules and regulations and safety measures for each aircraft used.
(2) Loading and unloading the helicopter with the rotors and/or engine running.
(3) Loading and unloading with the helicopter shut down.
(4) Use of visual cues for positioning and parking the helicopter
(i.e., standard hand signals, communications, etc.).
(5) A program coordinated with local authorities (i.e., fire and police departments) to deal with fuel leaks on the heliport, helicopter fires, and other situations requiring emergency responses.
(6) In-flight emergency and emergency landing procedures (securing equipment, body position, etc.).
(7) Aircraft evacuation procedures.
(8) Fire suppression (ground and in-flight).
(9) Procedures for day/night operations into and out of an unprepared landing site for the recovery of a patient.
(10) The safe handling of oxygen equipment by all involved personnel. All personnel authorized to refill oxygen should be trained in the use of the recommended cascade system. If liquid oxygen (LOX) is used, the specific nature of LOX should be addressed.
NOTE: The FAA recommends that this program involve a licensed airframe and power plant mechanic to teach the correct procedures for handling oxygen equipment.
d. Maintenance Personnel. In addition to meeting the requirements of FAR Part 65, Certification: Airmen Other Than Flight Crewmembers, maintenance personnel should be trained by the manufacturers of aircraft modification equipment, or in other maintenance training programs approved by the Administrator.
(1) Inspection of installation, as well as the removal and reinstallation of special medical equipment, should be a part of this training.
(2) Supplemental Training. Training on servicing and maintenance of medical oxygen systems, along with characteristics of medical oxygen versus aviator breathing oxygen, should be included in the training program.
12 Chap 2 Par: 6
NOTE: Recurrent training is recommended for all maintenance personnel.
e. Cockpit Resource Management (CRM). Regardless of the type of operations conducted (Instrument Flight Rules (IFR) or Visual Flight Rules (VFR), a training program should be established for CRM and the use of checklists. CRM procedures should include the utilization of all flightcrew resources, including medical personnel assigned duties, for all operations, including emergencies. Pilots should be trained in "challenge and response" method of checklist usage. First officers, when assigned, should be trained to assist the pilot as directed. when two pilots are assigned to a particular EMS transport, cockpit procedures should be developed for emergency situations where one pilot is designated to fly the aircraft while the second pilot tends to the emergency.
f. Judgement and Decisions. The decisionmaking process should have input from all elements involved in an EMS operation. Aeromedical directors, helicopter operators, flightcrew, medical personnel, and ground crew contribute to this process. The degree of input from each of these elements will depend upon the type and complexity of each mission.
should be familiar with appropriate FAR and FAA guidelines related to safe operations. Management personnel should participate in the certificate holder's training program to gain knowledge concerning EMS/H operations.
(2) An essential element in flight operations is the timely decision to conduct a particular flight or continue a flight as planned. To familiar with helicopter operations pertaining to the mission being planned.
(3) All personnel assigned to EMS/H should be trained in the operational aspects of each type of helicopter being used. Training should include, but is not limited to, the range of each helicopter versus number of crewmembers/passengers carried, equipment installed versus carry-on equipment, weather capabilities, safety around helicopters, and safety in landing areas.
(4) The certificate holder should be thoroughly familiar with the operational characteristics of each helicopter and the qualifications of each flight crewmember.
(5) Pilot judgement may be defined as: The mental process by which the pilot recognizes, analyzes, and evaluates information regarding himself/herself, the aircraft, and the external environment. Good pilot judgement can be developed as part of a flightcrew training program.
Pamphlet DOT/FAA/PM-86-45, Aeronautical Decision Making for Helicopter Pilots, is recommended to improve aeronautical decisionmaking. The pamphlet covers the concepts of judgement and decisionmaking and is designed to be reviewed under the supervision of a flight instructor.
Chap 2 par 13
(6) A decision whether or not to conduct a flight, or to continue a flight as planned, is required by regulation to be made by the pilot in command. This decision should be based on the information received from other elements involved and on his/her judgment as an experienced pilot. The decision should not be based solely on the condition of the patient.
(7) The final step is the decision to conduct the flight in a safe and timely manner.
Chap 2 14 Par 6
CHAPTER 3. OPERATIONS
7. GENERAL. This chapter outlines recommendations regarding the conduct of FAR Part 135 EMS operations with helicopters.
a. EMS/H Flight Following. In order to ensure a safe, orderly execution of an EMS/H mission, each operating site should have a flight following system. Several factors including the potential 24-hour demands of EMS/H missions, surrounding terrain, and variable weather conditions, affect the safety of EMS flight operations. The following is provided to help ensure safe mission accomplishment:
(1) The certificate holder should have flight following procedures to include the notification of the communications center of specific aircraft departure times and estimated time of arrival.
(2) Flight following and/or communications should be maintained with the helicopter during each mission. These intervals should not exceed 15 minutes in flight and 45 minutes while on the ground.
(3) A communications system is established to ensure that medical personnel and crewmembers can communicate with the hospital and ground personnel at the patient transport site.
(4) A qualified, trained individual is designated as a communications specialist to receive and coordinate flight requests for EMS/H operations.
(5) An intercommunications system is available for communications between medical personnel and the flightcrew.
b. Weather Minimums. Each EMS/H flight following location should establish a local flying area and a cross-country flying area. VFR weather minimums should be specified for day and night local, and day and night cross country. VFR minimums should be no less than in table 1 which follows.
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Table 1. Uncontrolled Airspace
CONDITIONS CEILING VISIBILITY Day local 500 ft 1 mile Day cross country 1000 ft 1 mile Night local 800 ft 2 mile Night cross country 1000 ft 3 mile NOTE: For operations in controlled airspace, refer to FAR Sections
91.155 and 91.157.
(1) Each EMS/H certificate holder should develop a system of obtaining weather information prior to releasing any flight.
c. Landing Sites.
(1) Criteria should be established to ensure each airport/approved helicopter landing site has been evaluated by qualified personnel and the heliport or landing site meets the guidance contained in AC 150/5390-2, Heliport Design. The site evaluation should include the following:
(i) Identification and/or removal of obstructions.
(ii) Assessment of area lighting.
(iii) Notation of helicopter ingress/egress limitations.
A system should be established to familiarize pilots with all heliports serviced by the hospital/certificate holder. A method considered acceptable would be photographs, drawings, and other descriptive means to identify the helistop or heliport and any obstructions.
d. Flight controls. The flight controls of a helicopter should not be left unattended by crewmembers while the rotor is turning.
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Flight Time and Rest Requirements. Each operator will maintain a record that distinctly shows the difference of flight time, rest time, and off-duty or unassigned time, in accordance with FAR Part 135. It should be noted that in addition to FAR Section 135.263, there are two basic flight and duty time FAR sections applicable to EMS operations.
(1) FAR Section 135.267, Flight time limitations and rest requirements: Unscheduled one-and two-pilot crews, allows the flight crewmember to conduct any flight or other duties as assigned such as training, testing, routine transport missions, etc., while on duty/assignment. For an assignment conducted under this section, flight crewmembers must receive rest in accordance with FAR Section 135.267 (at least 10 consecutive hours of rest during the 24-hour period that precedes the planned completion of the assignment).
NOTE: FAR Sections 135.267 or 135.271 should be identified in the company training program and operations specifications and specify which FAR the operator has chosen to comply with for his/her particular operation.
from the requirements of flights conducted under FAR Section 135.267. During operations in accordance with FAR Section 135.271, provisions must be made for 8 consecutive hours of rest during any 24 consecutive hour period. If the flight crewmember does not receive the required rest period, that pilot must be relieved of the assignment. The certificate holder should establish a recordkeeping mechanism to show that only bona fide emergency flights are conducted during these FAR Section 135.271 assignments. While a flight crewmember is assigned to HEMES under FAR Section 135.271, he/she may not be assigned to any other duties.
(3) For programs providing 24-hour consecutive EMS/H coverage, it is recommended that no less than four pilots per aircraft be assigned. EMS/H programs with high activity levels or those with unusual circumstances may require higher pilot-to-aircraft ratio. Sufficient staffing levels should be established to promote operational safety standards.
(4) Each certificate holder should provide relief for each person performing maintenance from duty for a period of at least 24 consecutive hours during any 7 consecutive days, or the equivalent thereof, within any 1 calendar month. The requirement of the certificate holder should be the same for contractor/vendor maintenance.
f. Weight and Balance. Each operator should develop a control system for weight and balance that shows the aircraft will be properly loaded and will not exceed limitations during flight. A control system may include the following:
(1) A loading schedule, composed of graphs and tables based on pertinent data for use in loading that particular aircraft in a rapid manner for EMS/H operations, should be prepared.
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An index type weight and balance program using average load weights may be established in accordance with AC 120-27A, as revised.
index-type weight and balance is used, the manual should contain the procedures for using, managing, and updating.
(3) These programs should include assorted aircraft occupant and equipment configurations (1.e., one or two pilots, two medical personnel, two patients, large carry-on equipment, balloon pumps, fuel in the most critical center of gravity location, etc.).
g. Procedures for Flight Into Instrument Meteorological Conditions (IMC). An operational procedure for inadvertent flight into IMC should be developed for inclusion in the certificate holder's operations manual. The procedures should address the applicable FAR pertaining to IFR including operations in an ATC radar environment as well as inadvertent IMC in isolated areas or a non-radar environment.
NOTE: This procedure should in no way be construed as authorizing or condoning actual IFR flights without meeting all IFR requirements.
The FAR Part 135 certificate holder/operator might choose to request the use of a discreet transponder code from the local ATC facility for use when conducting EMS/H operations in that area. This would provide positive identification during an EMS/H operation at all times. This procedure may be established with a Letter of Agreement between the operator and its local ATC facility.
h. Night Experience. The pilot in command must meet the requirements of FAR Part 61 and should complete a company night training program before conducting any night operations. Procedures for maintaining night currency in EMS/H operations should be developed and specified in the company training program. Such night training should be tailored to the operations of a certificate holder considering the experience level of EMS pilots, the area of operations and the management and safety policy for that operator.
1. EMS/H Heliports. Because of the operating environment (night, weather, and emergencies), EMS operations require a high degree of safety.
FAR Part 135 EMS/H operations should only be conducted from heliports that meet the criteria established in AC 150/5390-2. For operations over congested areas, ingress/egress routes to EMS/H heliports may have to be identified for compliance with FAR Section 91.119.
Chap 3 18 Par 1
CHAPTER 4. SAFETY
8. GENERAL. The commitment to safety must start at the top of an organization. The single most important element of a successful safety program is the commitment of senior management. Safety cannot be dictated - it must be practiced. Managers must display a prudent safe attitude by being involved in safety training. The following safety program recommendations are unique to EMS/H operations:
a. Safety Program. The safety program should be developed considering coordination, when necessary, with organizations that may be essential to the safe completion of an EMS/H mission. The operator may coordinate with one or more of the following organizations: ATC, hospitals, police and fire departments, and search and rescue organizations. An operator might hold briefing sessions with another organization prior to undertaking a specific EMS mission addressing topics concerning the aircraft operations.
b. The certificate holder should designate a safety officer. This individual should be familiar with each aspect of an EMS/H operation with particular emphasis on the safety requirements involved in the operation of helicopters. This individual should plan, organize, and disseminate information about the safety program to all involved persons.
c. The program should encompass at least the following areas: Safety in and around helicopters, site evaluation/preparation, weather analysis, communication equipment and procedures, facilities, and other areas deemed appropriate by the certificate holder and local FSDO.
Chap 4 Par 8 19 (and 20)