How EMS Workers Can Improve Air Ambulance Safety

By Chair Jennifer Homendy

Adapted from i-Chiefs magazine, originally published Feb 2021

Imagine for a moment that you’re an emergency medical services (EMS) worker.

You’re assisting a patient who requires transport to another facility. You decide to request a helicopter air ambulance (HAA). How do you pick the safest HAA operator?

In a perfect world, all companies would conduct a risk assessment before accepting the flight request to ensure everyone’s safety. They would consider factors such as weather, flight conditions, and which pilot is on duty. How — and if — those risks are assessed and mitigated can determine whether the medical transport flight you’re requesting is safe…or leads to tragedy.

Three years ago, we launched to a crash involving a medical transport flight where this scenario played out. Based on our investigation, we’ve learned that there are steps EMS workers and, indeed, anyone requesting air medical transport can take to improve safety.

Photograph of helicopter before crash (Source: The Columbus Dispatch)

Remembering Zaleski, Ohio

On January 29, 2019, a patient at Holzer Meigs Emergency Department in Pomeroy, Ohio, required transport to another hospital, located approximately 70 nautical miles away in Columbus. The emergency room technician contacted three helicopter air ambulance companies to help move the patient.

The first company immediately declined the flight request due to icing probability and snow squalls. The second company stated they would call back after conducting a weather check. Before hearing back, the emergency room technician reached out to a third company, Survival Flight, which quickly accepted the request. The second company then called back to decline the flight due to weather-related safety concerns.

Three Survival Flight crew members, the pilot, flight nurse, and flight paramedic departed for Pomeroy to pick up the patient. About 22 minutes into the flight, the pilot encountered two snow bands that decreased her visibility. The pilot attempted a maneuver to escape from the inadvertent instrument meteorological conditions (IIMC), in keeping with standard operating procedures, but did not maintain altitude. Tragically, the Survival Flight helicopter crashed into forested terrain near Zaleski, Ohio. All three crew members died.

What Went Wrong?

The NTSB was called in to investigate. Our investigation revealed numerous safety deficiencies that we can learn from. Here’s what went wrong.

Lack of comprehensive and effective flight risk assessment and risk management procedures. This means the pilot was unaware that other operators had refused to accept the flight due to weather concerns.

The lack of both a positive safety culture and a comprehensive safety management system (SMS). The casual behavior of Survival Flight management regarding risk assessment and safety programs was not indicative of a company with an established SMS program, which operators use to evaluate and address risk, as well as their pilots’ skills and flight behavior. The NTSB has long advocated for the adoption of a SMS in all flight operations. Indeed, this recommendation is so important that it has been associated with several issues on our Most Wanted List of Transportation Safety Improvements over the years.

Need for flight data monitoring (FDM) programs for HAA operators. Although the Federal Aviation Administration (FAA) requires helicopter air ambulance operators to have FDM recorders installed, it does not require that operators use the recorders and the data collected. But an FDM program that is part of a broader SMS has great potential to identify risky situations and make changes before a crash occurs. For example, an FDM program would have allowed Survival Flight to identify deviations from normal operations and potential safety issues.

Lack of HAA experience for principal operations inspector. The investigation revealed the FAA principal operations inspector assigned to oversee Survival Flight’s operation was unaware of deficiencies that were later identified in Survival Flight’s flight risk assessment.  

Lack of accurate terminal doppler weather radar data available on the HEMS (helicopter emergency medical services) Weather Tool. The current version of the HEMS Weather Tool does not incorporate terminal doppler weather radar data to display precipitation. As a result, the pilot could not tell if there were gaps in the data or if there were, in fact, no precipitation.  

Lack of a flight recorder. If a recorder system that captured cockpit audio, images, and parametric data had been installed, it would have enabled NTSB investigators to reconstruct the final moments of the crash and determine why the pilot did not maintain the helicopter’s altitude and successfully exit the IIMC encounter.

How You Can Promote Safe Air Medical Transports

Don’t underestimate the “power of the purse” to encourage the safest operating practices when selecting an air ambulance operator: only give your business to operators that take safety seriously. Here are some practical steps that can help you make an informed decision:

• Vet the companies in your area before you need air transport. Consider selecting a company that has earned accreditation from a respected third party. For example, the Commission on Accreditation of Medical Transport Systems (CAMTS) accredits medical transport organizations that pass their audit and agree to abide by certain best practices, which are usually more stringent than those required by regulations. It’s important to note that most helicopter air ambulance programs in the United States are CAMTS-accredited; in fact, the U.S. Department of Defense requires CAMTS accreditation for civilian contracts. Despite this being the “gold standard” for auditing and accrediting helicopter air ambulances, Survival Flight was not CAMTS accredited.
• Meet the helicopter air ambulance companies that serve your area. Some offer a shadowing opportunity for EMS workers. Ask the crew members you meet how they determine which flights to accept.
• Do some research. Find out which operators have shown a commitment to the highest levels of safety by obtaining FAA approval for an SMS program and have an FDM program that regularly evaluates data collected to identify and address flight safety issues. While HAA operators are not yet required by FAA to have either, some have implemented these measures voluntarily. Your patients and crews deserve the safety benefits that accompany SMS and FDM programs.

Finally, never hesitate to reevaluate the necessity of air transport as weather conditions change, especially when other helicopter operators turn down the same request due to weather or other safety concerns.

Do it not just for your patient, but for the helicopter crew. Do it to honor the lives lost in Zaleski three years ago.

NTSB Video Series Highlights Safety Benefits of Connected-Vehicle Technology, Raises Concern about Future of V2X

By Member Michael Graham

Today, the NTSB released a four-part video series: “V2X: Preserving the Future of Connected-Vehicle Technology.” Vehicle-to-everything (V2X) is one of the most promising life-saving technologies available today. While radars and sensors are limited to line-of-sight and are often impeded by inclement weather, V2X technology uses direct communication between vehicles and with infrastructure. Additionally, V2X technology increases the safety and visibility of vulnerable road users by alerting drivers to the presence of pedestrians, bicyclists, and motorcyclists that may be outside a driver’s or vehicle‑based sensor’s field of observation.

Despite the immense safety potential of V2X, the Federal Communications Commission’s (FCC’s) recent actions threaten its basic viability. In May 2021, the FCC finalized the rulemaking to substantially reduce the available spectrum for V2X applications by 60 percent. This ruling retained only 30 MHz for transportation safety applications and invited interference from the surrounding bands from unlicensed Wi-Fi devices. Research by the US Department of Transportation (DOT) demonstrated that expected interference into the spectrum would further compromise the integrity of safety applications—rendering V2X untenable.

In this video series, I had the privilege of interviewing eight experts from government, industry, academia, and associations about the safety benefits and the maturity level of V2X technology, the reasons for its scarce deployment, and the impact of the FCC’s recent actions to limit the spectrum available for transportation safety.

I talked with some of the leading voices in the V2X space, including:

• Debby Bezzina, Center for Connected and Automated Transportation, University of Michigan Transportation Research Institute
• Bob Kreeb, National Highway Traffic Safety Administration
• Ken Leonard, US Department of Transportation’s Intelligent Transportation Systems (ITS) Joint Program Office
• Laura Chace, ITS America
• Scott Marler, American Association of State Highway and Transportation Officials
• John Hibbard, Georgia Department of Transportation
• John Capp, General Motors
• John Kenney, Toyota

The NTSB first issued a safety recommendation to the FCC to allocate spectrum for V2X technology in 1995, and we continue to fervently believe in the promise of V2X technology to save lives.

This series was developed as part of the NTSB’s Most Wanted List safety topic, Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles. I sincerely appreciate each of the eight guests who graciously agreed to participate in the series.

I encourage you to watch all four episodes of this series on the NTSB YouTube channel. You can learn more about the video series, including our featured guests and supporting research, on the NTSB’s V2X web page.

Remembering Air Florida Flight 90 and the Progress Towards Eliminating Airline Icing Accidents

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

Forty years ago, on Jan. 13, 1982, a Boeing 737 jetliner crashed into Washington, DC’s 14th Street Bridge and plunged into the freezing Potomac River after departing National Airport during a snowstorm. The crash killed 73 of the 79 people aboard the airplane and 4 people in cars on the bridge; 4 others on the bridge were injured. A total of five passengers and a flight attendant escaped the airplane into the freezing, ice-filled Potomac River and clung to wreckage.

About 20 minutes after the crash, a National Park Service helicopter arrived. Showing remarkable flying skills, the pilot and paramedic worked so close to the water that at times the helicopter’s skids dipped beneath the surface. They managed to pull four of the survivors to shore. As a fifth survivor lost her grip on the helicopter’s lifeline, Lenny Skutnik—one of hundreds of bystanders—dove into the icy water and brought her to the riverbank.

(A U.S. Park Police helicopter pulls two people from the wreckage of an Air Florida jetliner that crashed into the Potomac River when it hit a bridge after taking off from National Airport in Washington, D.C., on Jan. 13, 1982. Photo by Charles Pereira, Associated Press)

A sixth survivor of the impact had taken the lifeline and flotation rings from the helicopter and passed them to others. When the helicopter returned for him, he was gone. The 14th Street Bridge is today named in honor of that passenger, Arland D. Williams.

NTSB investigators found that after traveling almost half a mile farther down the runway than was typical for a normal takeoff, the airplane lifted off and attained a maximum altitude of only about 350 feet before crashing into the bridge, which was less than a mile from the end of the runway. While the airplane was on its takeoff roll, the first officer remarked several times, “that don’t seem right, does it? Ah, that’s not right. That don’t seem right.” The captain did not respond.

The NTSB’s investigation identified numerous errors related to safely flying in snowy and icy conditions.

• Though the outside temperature was well below freezing and snow was falling, the crew did not activate the engine anti-ice system that prevents sensors in the engines from freezing and giving incorrect engine power readings. Although the pilots set the engines to the correct power setting, the NTSB’s analysis showed the engines were actually operating with substantially less power than was needed.
• After leaving the gate, the aircraft waited in a taxi line with many other aircraft for 49 minutes before reaching the takeoff runway. The pilot decided not to return to the gate for reapplication of deicing, fearing that the flight’s departure would be even further delayed. More snow and ice accumulated on the wings during that period.
• While waiting in line to take off, the pilots decided to maneuver closely behind a DC‑9 that was taxiing just ahead of them, mistakenly believing that the heat from the DC-9’s engines would melt the snow and ice that had accumulated on flight 90’s wings. This action, which went specifically against flight-manual recommendations for an icing situation, contributed to the icing on the Air Florida jet. The exhaust gases from the DC-9 turned the snow into a slush mixture that froze on the wings and the engine.
•  Although the crew was aware of the ice and snow on the wings, they decided to take off.

Air Florida flight 90 was just one of numerous airframe-icing-related crashes we’ve investigated. Between 1982 and 1997, we investigated eight fatal accidents of aircraft flown by professional flight crews that encountered icing conditions. Other professionally crewed flights were among the numerous icing accidents we investigated through April 2011, when the final report on such an accident was issued. These crashes killed 265 people. Similar problems were found by the Canadian Transportation Safety Board where two accidents in 1985 and 1989 killed 280 passengers and crew.

As a result of these accidents, we’ve issued several recommendations covering a variety of topics, including the following:

• Deicing fluid properties
• The number of minutes after which a plane can safety take off after being deiced
• Airport congestion and the time needed for air traffic control clearance, which can delay takeoff beyond when deicing fluid is effective
• The importance of deicing engine instruments that are used to set the proper engine power
• Prolonged autopilot use in icing conditions can mask developing problems with controllability until it is too late to avoid a crash
• Icing on swept wing aircraft (including most airliners) can cause an airplane to pitch up uncontrollably, leading to a stall
• Small amounts of ice on an airplane wing (comparable to the roughness of sandpaper) disrupt airflow and reduce the airplane wing’s ability to hold up the airplane
• FAA certification standard revisions for airplanes approved to fly in icing conditions
• Increasing stall speed in icing conditions

Because the NTSB identified airframe icing as a significant threat to aviation safety, it was on our Most Wanted List of Transportation Safety Improvements for 14 years.

After researching how ice forms on airplane wings in flight, and how that ice affects airplane performance, the FAA revised the standards for airplanes certified for flight in icing conditions. Pilot training and flight procedures were improved, and more attention was paid to minimizing the time between deicing and taking off.

Although the NTSB still investigates aviation accidents involving icing, the numbers are down drastically. We have not investigated a fatal icing-related crash involving a professional flight crew since the February 16, 2005, crash of a Cessna Citation 560 in Pueblo, Colorado.

At the NTSB, we draw knowledge from tragedy to improve the safety of all. The knowledge gained from our investigations of icing accidents, such as Air Florida flight 90, identified the actions needed to improve the safety of everyone who flies.