AC 135-15

AdVISOry U.S. Department of Transportation Federal Aviation Administration Subject: Initiated by: 11/19/90 Date: AC No: 135-15

EMERGENCY MEDICAL Change:

SERVICES/AIRPLANE (EMS/A) AFS-250 PURPOSE. This Advisory Circular (AC) provides information and guidance material which may be used by Air Ambulance and Emergency Medical Service/Airplane (EMS/A) operators. It must pe emphasized that this advisory circular diminishes neither the force nor the effect of the Federal Aviation Regulations (FAR).

ine 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.

FOCUS. These guidelines are applicable to EMS/A operations under FAR Part 135 and are also recommended for EMS operations conducted by public service and other operators.

3 . RELATED FAR SECTIONS. FAR Parts 1, 23, 25, 43, 61, 65, 91, 135, and 157.

4 • RELATED READING MATERIAL. Additional information may be found in the following AC's (as revised) and other listed publications.

a. FAA Documents:

(1) AC 91-42, as revised, Hazards of Rotating Propellers and Helicopter Rotor Blades.

(2) AC 120-27, as revised, Aircraft Weight and Balance.

(3) AC 120-49, Certification of Air Carriers.

(4) AC 135-5, as revised, Maintenance program Approval for Carry-on Oxygen Equipment for Medical Purposes.

NOTE: Copies of (1) through (4) may be obtained free from the U.S. Department of Transportation, Distribution Requirements Section, M-443.2, Washington, DC 20590

(5) 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.

(6) Airman's Information Manual (AIM), Official Guide to Basic Flight Information and ATC Procedures, $20.00/year.

(7) AC 43.13-1A, Acceptable Methods, Techniques and Practices - Aircraft Inspection and Repair, dated April 17, 1972, #SN 050-007-00806-6, $18.00.

(8) AC 43.13-2A, Acceptable Methods, Techniques and Practices - Aircraft Alterations, dated June 9, 1977, #SN 050-007-00625-0, $5.50.

NOTE: Copies of (6) through (8) above may be purchased from: Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402.

b. Other Documents.

(1) NFPA Publication 410-1980: Fire Protection/ Aircraft, may be obtained from: National Fire Protection Association (NFPA), Battery Park, Quincy, Massachusetts 02269.

Air Ambulance Guidelines, DOT HS 806703 Revised May 1986, U.S. Department of Transportation, National Highway Traffic Safety Administration, may be obtained from: U.S.

Department of Transportation, Distribution Requirements Section, M-443.2, Washington, DC 20590.

BACKGROUND • Transportation by aircraft of sick or injured persons may have originated during World War I when wounded were transported from battle fronts to field hospitals in an open cockpit biplane. Since that time, the transportation of patients needing medical attention has burgeoned into a significant industry operating modern aircraft equipped with state-of-the-art medical equipment carrying thousands of patients each year.

introduction of civil airplanes dedicated exclusively to EMS began about 1973. The operators of these aircraft can provide patient care while en route from city to city or from remote sites to urgent care facilities. Many airplane/air ambulance ii

flights are conducted with small, nondedicated aircraft operated by FAR Part 135 on-demand air carriers. There is also a contingent of private and public service aircraft operators conducting air ambulance flights. This AC provides guidance to operators conducting or planning EMS/A operations.

DEFINITIONS. This paragraph defines terms used for the purpose of this AC. Other definitions may be found in FAR Part 1, "Definitions and Abbreviations," and the "Pilot/Controller Glossary" supplement to the AIM.

a. Aeromedical Director. A licensed physician within an air ambulance service who is ultimately responsible for patient care during patient transport missions. The aeromedical director is responsible for assuring that appropriate medical personnel and equipment are provided for each patient.

b. Air Ambulance and/or EMS Airplane. An airplane designated for 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 aircraft is equipped with the medical equipment necessary to support these levels of care in flight with trained medical personnel.

Air Ambulance Service and/or EMS. The use of an aircraft in transportation, for carriage of ambulatory or other patients requiring special care, including BIS or ALS, during flight, and/or transport of body organs for medical reasons.

air ambulance or EMS airplane 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 CHDO is 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. Flight Crewmember. A pilot, flight engineer, or flight navigator assigned to duty in an aircraft during flight time is considered a crewmember.

iii

f. Medical Personnel. A person trained in air medical environment and assigned to perform medical duties during flight including, but not limited to, doctors, nurses, paramedics, respiratory therapists or emergency medical technicians. Medical personnel may also be trained and assigned to perform other duties by the certificate holder.

i. Principal Avionics Inspector (PAI). An FAA inspector assigned by the FAA Administrator to oversee the avionics functions of the certificate holder.

Principal Maintenance Inspector (PMI). An FAA inspector assigned by the FAA Administrator to oversee the maintenance functions of the certificate holder.

k. Principal Operations Inspector (POI). An FAA inspector assigned by the FAA Administrator to oversee the operations functions of a certificate holder.

pubiic Aircrait. An aircraft used only in the service of a government or a political subdivision. It does not inciude any government-owned aircraft engaged in carrying persons or property for commercial purposes.

NOTE: Public Law 100-223, December 30, 198/, Section 207, Public Aircraft Defined. Section 101(36) has been amended thus: "For the purposes of this paragraph, used exclusively in the service or means, for otner than tne redera.

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."

NOTE: Persons that exercise operational control over FAR Part 135 EMS/A missions must be listed in the operator's manual as required by FAR Section 135.77.

Ш • Levels of Medical Care:

Basic Life Support. Refers to the air-medical provider offering airborne patients transport staffed by a minimum of one medical person who is experienced and qualified by training, certification, and current competency in BLS care.

iv

This medical person practices through the orders of a physicianmedical 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 victim recovers, or the medical person stops procedures, or until ALS is available. In air medical transports, BLS includes airto-ground communications to ensure continuity of care.

("Standards for CPR and ECG," JAMA, February 18, 1974.)

Advanced Life Support. Refers to the air-medical provider offering airborne patients transport staffed by a minimum of two medical personnel who are experienced and qualified by training, certification, and current competency in emergency critical care. The medical personnel practice through the 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 recomended for ALS:

(i) BLS.

(ii) 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.)

homas C. Accard Tan Cal Acting Director, Flight Standards Service vi

vii (and viii) . 16 General. 8.

. 16 SAFETY PROGRAM. CHAPTER 4.

. 14 General 7.

. 14 OPERATIONS. CHAPTER 3.

.10 General. 6 .

.10 TRAINING PROGRAM. CHAPTER 2.

8 Manual. 5.

8 Facilities. 4 .

7 Operations Specifications 3.

....... 2. Records.........

... 1. General.........

..... 1 CHAPTER 1. CERTIFICATION Page No.

CONTENTS AC 135-15 11/19/90

CHAPTER 1. CERTIFICATION GENERAL. Aircraft operators desiring to commence Air Ambulance service 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 Flight Standards District Office (FSDO) located in the area where the 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 of an EMS/A operator to obtain a FAR Part 135 certificate.

NOTE: For those operators presently conducting operations under FAR Part 135, new or revised operations specifications may be required prior to initiating EMS/A operations.

Inspections. Inspection at the principal base of operations will include items such as operations and maintenance facilities, equipment (including installation of special/medical equipment), lease agreements, and contract maintenance records.

Before issuance of operations specifications authorizing FAR Part 135 operations, FSDO personnel will perform the following inspections to ensure that the applicant meets requirements for FAR Part 135 air carrier certification:

(1) Manuals to assure they contain information required by FAR Section 135.23.

(2) Recordkeeping system.

(3) Aircraft used in air transportation service.

NOTE: Lease agreements are considered proprietary documents and will be handled with confidentiality by FAA personnel.

(4) 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 the appropriate FAR. This particular inspection will be accomplished to determine adequacy of tools, spare parts, special tools, and that properly trained personnel are available.

Chap 1 Par 1 1

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 method (using data approved by the aircraft manufacturer, an EMS equipment manuiacturer, or the FAA Administrator). The FAA may approve add-on 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, 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:

(1) 9.0G forward, 6.6G downward, and 3.0G upward, and 1.5G sideward; and

(2) tie-down, 13.5G forward, 9.9G downward,

4.5G upward, 2.25G sideward.

Supplemental Type Certificate (STC) or Field Approval. All items of additional equipment must be installed in accordance with the 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.

If the certificate holder is unsure of the requirements on the proposed equipment, they should contact the PMI before installation is initiated.

(4) Maintenance Flight Test. 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 all items of carry-on medical equipment intended to be used for patient transport. Results of the flight tests verifying acceptability should be entered into the appropriate permanent records of the aircraft.

chap 1 2 Par 1

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.

Additional Equipment/Other. The following additional items of equipment are recomended for EMS operations:

(1) Radios Capable of Air-to-Ground Communications.

To ensure a safe and satisfactory completion of transportation and to coordinate with ground transportation service when necessary for the patient.

(2) 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 e 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.

NOTE: Information concerning equipment installation in the referenced advisory circulars are applicable to airplanes and helicopters.

Supplemental Lighting Systems. Some aircraft may require additional interior lighting since standard aircraft lighting may not be sufficient for adequate patient care. An emergency lighting system with a self-contained 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.

chap 1 Par 1 3

(4) EMS Electrical Power. All wiring, electrical components, and installation procedures must conform to the requirements of FAR Parts 23 or 25. An electrical load analysis must be performed to preclude an overload on the aircraft generating system. The system should be designed to give the pilot a fast means of shedding electrical load in an emergency situation.

(5) Motor-driven Vacuum/Air Pumps. Motors and/or Any motor-driven device should be installed in a way to preclude pumps must be installed in accordance with FAR Parts 23 or 25. in materiale contact with any flammable fluid, gas, or foreign materials that may cause heat buildup and possibly fire. Aircraft should be flight-tested with electrical motors running to check for RFI/EMI.

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, 6.6G downward; and (i1) 9.0G forward, 1.5G sideward.

NOTE: If pull test data are not provided by the equipment manufacturer to verify 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.

NOTE: 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 nc interference with the instruments and equipment that are required by the FAA airworthiness certificate for safe operation of the aircraft.

Chap 1 4 Par 1