6/20/91 AC 135-14A
CONTENTS Page No.
CHAPTER 1. CERTIFICATION 1
1. General 1
2. Records 5
3. Operations Specifications 6
4. Facilities 7
5. Manual 7 CHAPTER 2. TRAINING PROGRAM 11
6. General 11 CHAPTER 3. OPERATIONS 15
7. General 15 CHAPTER 4. SAFETY PROGRAM 19
8. Safety Program 19 APPENDIX 1. SAMPLE RECORD FOR FLIGHT AND DUTY TIME ENTRIES 1 APPENDIX 2. SAMPLE OPERATIONS SPECIFICATIONS (2 pages). 1 vii (and viii)
CHAPTER 1. CERTIFICATION GENERAL. Aircraft operators desiring to commence Air Ambulance or EMS/H operations as a FAR Part 135 air carrier who do not hold a FAR Part 135 air carrier certificate should refer to AC 120-49, Certification of Air Carriers, dated November 23, 1988, for methods and procedures to follow in the certification process. The FSDO located in the area where applicant desires to locate its principal business office will assist the applicant in becoming certificated. This chapter refers to added steps that may be required to obtain a FAR Part 135 certificate for EMS/H operations.
NOTE: For those operators presently conducting operations under FAR Part 135, new or revised operations specifications may be required prior to initiating EMS/H operations.
Inspections. Inspections will be conducted at the principal base of operations, and will include items such as:
(1) Maintenance facilities, equipment and records (including installation of special/medical equipment), lease agreements, and contract maintenance records.
NOTE: Lease agreements are considered proprietary documents and will be treated accordingly by FAA personnel.
(2) Manuals to ensure they contain information required by FAR Section 135.23.
(3) Recordkeeping system.
(4) Aircraft to be used in air transportation service.
Each certificate holder is responsible for the airworthiness of its aircraft (FAR Section 135.413). Operator and/or contract maintenance facilities may be inspected for compliance with appropriate FAR. This particular inspection will be accomplished to determine the adequacy of tools, spare parts, special tools, and that properly trained personnel are available.
b. Additional Equipment/General. The applicant should identify, in their initial application, any specialized equipment that may be used in EMS operations. The equipment should be installed in the aircraft in an acceptable manner (using data approved by the aircraft manufacturer, an EMS equipment manufacturer, or the FAA Administrator). The FAA may approve addon equipment installation after evidence of airborne test results are submitted from the aircraft operator, the Department of Transportation (DOT), Department of Defense, or an independent testing organization. Any equipment installed aboard the aircraft should comply with the data in AC 43.13-2A, Chap 1 Par 1 1
Acceptable Methods, Techniques, and Practices - Aircraft Alterations, Chapter 1, paragraph 2(d) and 3, and Chapter 12, paragraph 243(a), and withstand the following static loads in accordance with AC 43.13-1A, Acceptable Methods, Techniques and Practices - Aircraft Inspection and
(1) 9.0G forward, 6.6G downward, 3.0G upward, and 1.5G sideward; and tie-down, 13.5G forward, 9.9G downward, 4.5G upward, and 2.25G sideward.
(3) Supplemental Type Certificate (STC) or Field Approval. All items of additional equipment must be installed in accordance with the op die a aproval by an applicable FAR. The installation of additional equipment may require a STC or field approval by an airworthiness aviation safety inspector. It should be noted that the requirements for field approval are the same as for a STC. y should contact the hi before intele on ta initiated Maintenance Test Flight. Certificate holder should ensure that the installation of all additional equipment is compatible with all previously installed aircraft systems. Aircraft navigation and communication equipment may have to be recalibrated after installation of any additional medical equipment. Before returning the aircraft to service after the installation of additional equipment, flight tests may have to be accomplished to determine if there is radio frequency/ electromagnetic interference (RFI/EMI) with any navigation, communication, or flight control systems. The flight tests should be accomplished in visual meteorological conditions. Tests should include all installed equipment as well as items of carry-on medical equipment intended to be used for patient transport.
Results of the flight tests verifying acceptability should be entered into appropriate permanent records of the aircraft.
NOTE: Medical monitors may also be affected by the aircraft's electronic equipment; therefore, the medical monitors should be checked for accuracy by medical personnel before use with a patient.
c. Equipment Recommended for EMS/H Operations:
(1) Aircraft Approved Searchlight. A searchlight to be manipulated by the pilot, having a minimum movement of 90 degree vertical and 180 degree horizontal and capable of illuminating a landing site. The pilot should not have to remove his/her hands from the aircraft flight controls in order to operate the searchlight.
(2) Radio Capable of Air-To-Ground Communications. To ensure safe and satisfactory completion of transportation and to coordinate with emergency personnel on the scene (1.e., local or state police, fire department, etc.).
(3) Restraining Devices. To prevent patients from interfering with the flightcrew or the helicopter flight controls.
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NOTE: Child restraint seats provided must meet DOT/FAA restraint and securing criteria.
(4) Intercommunications System (ICS). An ICS should be provided for flightcrew and medical personnel to communicate with each other aboard the helicopter.
(5) Wire Strike Protection System. If type certificated for installation.
(6) Stretchers (Litters). Stretchers must be in compliance with FAR Sections 27.561 and 29.785. Restraining devices, including shoulder harnesses, must be available to ensure patient safety.
NOTE: Patient life support systems which include litters/stretchers, berths, incubators, heart pumps, etc., not normally included in the type design of the aircraft, must also be installed in accordance with the applicable FAR and FAA approved data.
d. Additional Equipment for EMS: The following additional items of equipment are recommended for EMS operations:
(1) Medical Oxygen System. A medical oxygen system including bottles, lines, gauges, regulators, and other system components which has been installed by approved data on an aircraft becomes an "appliance". If a single servicing port is installed in accordance with AC 27-1, as revised, Certification of Normal Category Rotorcraft, or AC 29-2A, as revised, Certification of Transport Category Rotorcraft, the system may be serviced by any person trained by the certificate holder. An oxygen bottle installed in a rack in the cabin area having its own regulator, hose and mask feeding directly to the patient may be removed and serviced by any person trained by the certificate holder. If servicing is accomplished by removing and replacing bottles or by disconnecting lines, regardless of the type fitting, it must be accomplished by an appropriately certified mechanic or repairman.
(2) Supplemental Lighting System. Some aircraft may require additional lighting since standard aircraft lighting may not be sufficient for adequate patient care. An emergency lighting system with a selfcontained battery pack may be incorporated to allow for continued patient care and for emergency egress from the aircraft in the event of a primary electrical failure. A means to shield the cockpit from light in the patient area should be provided for night operations.
(3) EMS Electrical Power Installation. All wiring, electrical components and installation procedures must conform to the requirements of FAR Parts 27 or 29. An electrical load analysis must be performed to preclude an overload on the aircraft generating system. The system should be designed to provide the pilot a fast means of shedding electrical load in an emergency situation.
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(4) Motor-Driven Vacuum/Air Pump. Motors and/or pumps must be installed in accordance with FAR Parts 27 and 29. Any motor-driven device should be installed in such a way as to preclude contact with any flammable fluid, gas, or foreign materials that may cause heat buildup and possibly Aircraft should be flight-tested with electrical motors running to check for RFI/EMI interference.
(5) Defibrillator. Extreme care should be taken when using a defibrillator on an aircraft. A suitable means of isolating the patient from the airframe must be incorporated to prevent inadvertent electrical shock to the flightcrew and other passengers. Defibrillator must be ground tested for proper operation before use in flight.
(6) Incubators. Incubators, balloon pumps, or other large carry-on medical equipment must be restrained in an appropriate manner to the following ultimate load factors:
(1) 3.0G upward, 6.66 downward; and
(ii) 9.0G forward, 1.5G sideward.
NOTE: If the equipment manufacturer does not provide pull test data to confirm that specific equipment can withstand the above loads, the certificate holder must demonstrate the above loads on each specific piece of equipment, or use an approved restraining device. Aircraft cargo straps or safety belts provide a satisfactory restraint in many instances.
Also, mechanical (metallic) fasteners may be used for attachment.
The incubator lid latches should withstand appropriate loads (approximately 15 pounds and any significant lid load).
The operator should ensure the unit has minimum movement when secured if straps or belts are used. If the incubator includes features requiring electrical power, operation should be evaluated to assure there is no interference with aircraft instruments and equipment that are required by the FAA airworthiness certificate. The operator should provide padding for the infant for forward and downward loads and movement. Mattresses and all padding used should be in accordance with AC 25.853-1, Flammability Requirements for Aircraft Seat Cushions, dated September 17, 1986, and FAR Sections 27.853 or 29.853.
e. Additional Equipment Installation. Some equipment is installed in the aircraft for the purpose of patient care only. This equipment should be installed, using approved data, in racks that meet the g-loading requirements of an emergency landing. The racks should be removed and replaced by a certified FAA mechanic, but the medical equipment in the racks used for patient care should be installed so that it may be removed readily to accompany the patient. Instructions for removal and replacement should be contained in the operator's manual required by FAR Part 135.
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(1) The certificate holder must ensure that the installation of all additional equipment is compatible with the aircraft systems. FAR Section 135.91(a)(1) (iv) requires that all installed equipment, including portable devices, be appropriately secured. The structure supporting the equipment must be designed to restrain all loads (up to the ultimate inertia specified in the emergency provisions/emergency landing conditions) required by FAR Parts 27 and 29. Equipment installed aboard the aircraft should meet the static and dynamic loads specified in AC 27-1 and AC 29-2, as revised.
(2) The installation of additional equipment by a STC or field approval. Normally the STC should provide instructions and operational supplements, weight and balance data, and instructions for continued airworthiness.
(3) Each installation must be evaluated at the time of its approval.
This is to determine if a mechanic is required to perform installation or if other personnel can be trained for removal or replacement of these items.
Frequent removal and replacement may constitute maintenance and require a certificated mechanic.
If the installation does not require tools and can be done in accordance with approved data and procedures in the operator's manual, any person trained by the certificate holder may be authorized to install the equipment.
2. RECORDS
a. Maintenance Records. Each certificate holder must comply with the maintenance recording requirements of FAR Sections 135.439 and/or 91.417.
When aircraft are sold, the certificate holder must comply with FAR Sections 135.441 and/or 91.419, Transfer of Maintenance Records.
b. Flight Records. Records required by FAR Section 135.63 must be kept at the certificate holder's principal business office, or at other operational locations approved by the Administrator. The following records should also be maintained at operational bases located at other than the principal business office:
(1) Flight crew member's flight time and rest records. The flight time and rest records must contain information to show compliance with the flight, duty, and rest requirements of FAR Part 135, Subpart F. (Appendix 1 contains a sample flight and duty time record). The records should indicate whether operations are being conducted in accordance with FAR Sections 135.267 or 135.271.
(2) A copy of the most recent competency and/or proficiency flight check. For each pilot assigned to that particular location, a copy of the current flight/proficiency check should be available.
(3) Current airworthiness documentation. In order for the pilot to determine the acceptability of the helicopter prior to each flight, airworthiness documentation must be available.
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(4) Flight following records. Flight following records of each flight will be maintained for a minimum of 30 days in accordance with FAR Part 135.
3. OPERATIONS SPECIFICATIONS.
a. Additional Requirements. FAR Part 135 certificate holders may use EMS procedures authorized with appropriate operations specifications. The operations specifications may contain conditional authorizations that apply to individual operators. The approving authority for the operations specifications will be either the POI, PMI, or PAI of the FAA CHDO having jurisdiction over the certificate holder. The operations specifications include the following items:
NOTE: If a FAR Part 135 operator does not provide full EMS/H services requiring medical personnel or special medical equipment but only occasionally transports body organs, that operator may not be required to comply with all provisions of the EMS/H automated operations specifications.
Bases of operation. Location of all bases of operation where EMS/H activities will be performed.
(2) Exemptions. As appropriate.
(3) Deviations. As appropriate.
(4) Area of Operation. The area of operation (local and crosscountry) for an EMS/H certificate holder will be identified on the operations specifications issued by CHDO.
(5) Special authorizations.
b. Automated Maintenance Operations Specifications. Operations specifications are indicated in AC 120-49. However, in addition the following are items that should be considered:
(1) Special/medical and navigation/communication equipment, if appropriate to the operations being conducted
(2) If the helicopter is being maintained under an Approved Aircraft of the lie on that present ente Inspection Program, the operations specifications must include the make, model, and registration number of the helicopter on that program.
weights for crewmembers, medical personnel, and patients should be developed regardless of the size of the helicopter used. This approved program will be listed in the certificate holder's operations specifications. (See appendix 2.)
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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.
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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.
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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.
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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.
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