00147 82 Advisory U.S. Department of Transportation circular Federal Aviation Administration Subject: Emergency Medical Date: 6/20/91 AC No: 135-14A Services/Helicopter (EMS/H) Initiated by: AFS-250 Change:
1. PURPOSE. This Advisory Circular (AC) provides information and guidance material which may be used by Air Ambulance and Emergency Medical Service/Helicopter (EMS/H) operators. It must be emphasized that this AC diminishes neither the force nor the effect of the Federal Aviation Regulations (FAR). The regulations, of course, are always controlling. This document does not'interpret the regulations; interpretations are issued only under established national Federal Aviation Administration (FAA) procedures.
2. CANCELLATION. AC 135-14, Emergency Medical Services/Helicopter, dated October 20, 1988.
3. FOCUS. These guidelines are applicable to EMS/H operations under FAR Part 135 and are recommended for EMS/H operations conducted by public service and other operators.
4. RELATED FAR SECTIONS. FAR Parts 1, 27, 29, 43, 61, 65, 91, 135, and 157.
5. RELATED READING MATERIAL. Additional information may be found in the following AC's (as revised) and other listed publications:
a. FAA Documents:
(1) AC 27-1, as revised, Certification of Normal Category Rotorcraft.
(2) AC 29-2, as revised, Certification of Transport Category Rotorcraft.
(3) AC 91-32, as revised, Safety In and Around Helicopters.
(4) AC 91-42, as revised, Hazards of Rotating Propeller and Helicopter Rotor Blades.
(5) AC 120-27A, as revised, Aircraft Weight and Balance Control.
(6) AC 120-49, Certification of Air Carriers.
(7) AC 135-5, as revised, Maintenance Program Approval for Carry-On Oxygen Equipment for Medical Purposes.
(7) AC 135-5, as revised, Maintenance Program Approval for Carry-On Oxygen Equipment for Medical Purposes.
(8) AC 150/5390-2, Heliport Design.
NOTE: Copies of (1) through (8) may be Department of Transportation, Distribution obtained free of charge from the U.S. • Vestinetion. DC 20580.
Requirements Section, M-443.2, Washington, DC 20590.
b. Other Documents.
(1) Pamphlet - DOT/FAA/PM-86/45, Aeronautical Decision Making for Helicopter Pilots. Copies may be purchased from National Technical Information Service, 5285 Port Royal Road, Springfield, Virginia 22161.
Order number is ADA178050. Microfiche is available for purchase.
(2) Pamphlet - DOT/FAA/DS-88/7, Risk Management for Air Ambulance Helicopter Operators. Copies may be purchased from National Technical Information Service, 5285 Port Royal Road, Springfield, Virginia 22161.
(3) Pamphlet - National EMS Pilots Association, Preparing a Landing Zone. Copies may be purchased from the National EMS Pilot Association, P.O.
Box 2354, Pearland, Texas 77588.
(4) Helicopter Association International (HAI) publications - Safety 0939 Manual (revised 1990), Helicopter User's Guide (revised 1990), Aeronautical Guidelines (under revision), Fly Neighborly Guide, Heliport Development Guide, and HAI/AAMS EMS Recommended Guidelines. Copies may be purchased from HAI, 1619 Duke Street, Alexandria, VA. 22314. Telephone 703/683-4646.
(5) NFPA Publication 410-1980: Fire Protection/Aircraft. Copies may be obtained from: National Fire Protection Association (NFPA), Battery Park, Quincy, Massachusetts 02269.
(6) Air Ambulance Guidelines, DOT HS 806703 Revised May 1986, U.S.
Department of Transportation, National Highway Traffic Safety Administration.
Copies may be obtained from: U.S. Department of Transportation, Distribution Requirements Section, M-443.2, Washington, D.C. 20590.
6. BACKGROUND.
personnel from the battlefield to medical facilities for immediate care during the Korean and Vietnamese conflicts resulted in a substantial drop in the death rate of U.S. servicemen as compared to previous wars.
dramatic use of helicopters as a medical tool spread to the civil community.
Today, helicopters are a vital tool within the medical field, providing a means of transporting critically injured people in urgent need of medical assistance. The EMS/H industry continues to expand. Each year thousands of patients are transported while being attended by medical teams trained to accommodate specific needs of the patients. EMS/H aircraft are equipped with the latest state-of-the-art medical monitoring and support systems to insure İi
proper care while en route. In response to the dynamic growth of this industry, the FAA has issued this AC providing information and guidelines that will further assist EMS/H operators in their operations. This AC provides guidance to operators conducting or planning EMS/H operations.
7. DEFINITIONS. This paragraph defines terms used for the purpose of this Other definitions may be found in FAR Part 1, Definitions and Abbreviations," and the "Pilot/Controller Glossary" supplement to the Airman's Information Manual.
Aeromedical Director. A licensed physician within an air ambulance service or EMS/H operation who is ultimately responsible for patient care during transport missions. The aeromedical director is responsible for assuring that appropriate aircraft, medical personnel and equipment are provided for each patient.
b. Air Ambulance and/or EMS/H: A helicopter designated for the transportation of ambulatory patients or other patients requiring special care including, but not limited to, basic life support (BLS) or advanced life support (ALS). An air ambulance or EMS/H is equipped with the medical equipment (portable or installed) necessary to support these levels of care in flight with trained medical personnel.
Alr Ambulance Service and/or Emergency Medical Service (EMS). The use of an aircraft in transportation, for carriage of ambulatory or other patients requiring special care, including BLS or ALS, during flight, and/or transport of body organs for medical reasons. An air ambulance or EMS aircraft may be used to transport patients deemed by medical personnel to require other special service not available on regular commercial air carrier or charter flights.
NOTE: The service of providing transportation for body organs and no passengers can be considered a cargo operation.
d. Certificate Holding District Office (CHDO). The FAA Flight Standards District Office (FSDO) with responsibility for management of the air carrier's certificate and which is charged with the overall inspection and surveillance of the certificate holder's operations.
e. Flightcrew Member. A pilot, flight engineer, or flight navigator assigned to duty in an aircraft during flight time is considered a crewmember.
f. Helicopter Hospital Emergency Medical Evacuation Services (HEMES).
The operation of a helicopter, based at a hospital, to transport patients in an emergency medical evacuation service only. This type of operation may operate under FAR Sections 135.267 or 135.271; however, the specific rule should be included in the appropriate operations specifications for that operator.
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g. Levels of Medical Care.
(1) BLS. Refers to the air-medical provider offering airborne patient transports staffed by a minimum of one medical person who is experienced and qualified by training, certification, and current competency in BLS care. This medical person practices through the orders of a physician-medical director and is supported by a medically configured aircraft capable of providing BLS systems (such as oxygen, suction, electrical supply, lighting and climate control) to the patient. As used in this statement, BLS consists of a medical person capable of recognizing respiratory and cardiac arrest, starting and maintaining the proper medical procedures until the victim recovers, or the medical person stops procedures, or until ALS is available. In air-medical transports, BLS includes air-toground communications to ensure continuity of care. ("Standards for CPR and ECG, " JAMA, February 18, 1974.)
(2) ALS. Refers to the air-medical provider offering airborne patient transports staffed by a minimum of two medical personnel who are experienced and qualified by training, certification, and current competency in emergency critical care.
orders of a physician-medical director and are supported by a medically configured aircraft capable of providing life support systems (such as oxygen, suction, electrical supply, lighting, climate control, pressurization, etc.) to the patient. The following elements are recommended for ALS:
(i) BLS.
(11) Using adjunctive equipment and special techniques, such as endotracheal intubation and closed chest cardiac compression.
(iii) Cardiac monitoring for dysrhythmia recognition and treatment.
(iv) Defibrillation.
(v) Establishing and maintaining an intravenous infusion lifeline.
(vi) Employing definitive therapy, including drug administration.
(vii) Stabilization of patient's condition.
NOTE: ALS includes: (1) air-to-ground communications to ensure continuity of care, and (2) the capability of constant monitoring and life support until the patient has been delivered to a continuing care facility.
("Standards for CPR and ECG," JAMA, February 18, 1974.)
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h. Local Flying Area. An area designated by the operator in which EMS operations will be conducted. The local flying area should be defined in such a manner that is acceptable to both the operator and the Principal Operations Inspector (POI) taking into account the operating environment and geographic terrain features.
1. Medical Personnel. A person trained in air-medical environment and other duties by the certificate holder. one say sla be trained and signed to perforta J. Patient. A person under medical treatment.
k. Principal Avionics Inspector (PAI). An FAA inspector assigned by the FAA Administrator to oversee the avionics functions of the certificate holder.
1. Principal Maintenance Inspector (PMI). An FAA inspector assigned by the FAA Administrator to oversee the maintenance functions of the certificate holder.
•. POI. An FAA inspector assigned by the FAA Administrator to oversee the operations functions of the certificate holder.
n. Public Aircraft. An aircraft used only in the service of a government or political subdivision. It does not include any governmentowned aircraft engaged in carrying persons or property for commercial purposes.
NOTE: Public Law 100-223, December 30, 1987, Section 207, Public Aircraft Defined. Section 101(36) has been amended thus: For the purposes of this paragraph, 'used exclusively in the service of' means, for other than the Federal Government, an aircraft which is owned or operated by a government entity for other than commercial purposes or which is exclusively leased by such government entity for not less than 90 continuous days."
Gotten ties David R. Harrington Acting Director, Flight Standards Service v (and vi)
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.
Chap 1 4 Par 1
(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.
Chap 1 Par 1 5
(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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