Primum non nocere
We are entrusted by patients and the public with medicine's first precept, primum non nocere—first, do no harm. While the benefits we bring to our patients are immeasurable, we must ensure that the benefits we bring outweigh risks in every instance. This unique characteristic of our mission—choice—must take center stage and guide our every decision, for ourselves and, more importantly, for those we serve.
Sometimes these columns are written in advance. Unfortunately, we continue to experience tragedy across the community. Since writing my last column, the community has experienced 10 crashes, 6 with fatalities. Somehow we are not getting it right.
While causes of accidents and incidents are multifactorial and the debate intensifies on accident numbers versus accident rates as measured by flight numbers and hours, a single unique element in air medicine frames the safety issue. Unlike any other arena of aviation, our passengers by and large do not get a choice—neither a choice of carrier or, in many cases, transportation in and of itself. The lack of choice increases our responsibility for our patients' welfare multiple-fold. We must always choose benefit over risk.
There isn't actually a great deal of mystery. The number of EMS aircraft has substantially increased in the past decade—more than doubled, in fact, as programs have increased. Visual flight rule operations have increased dramatically, flight hours are up, and we haven't actually seen any change in the cause of accidents since the last rapid growth in the community with resultant tragic years (the late 1980s).
There is some argument about accident rates as measured in 100,000 flight hours. There is no argument about numbers of accidents. After a period averaging 5 or fewer accidents per annum for most of the 1990s, accident numbers have accelerated to an average of 13 per annum since 1997. HEMS accident rates are now at the top range of all helicopter accident rates.
It is actually quite simple. Flying an aircraft in low-visibility conditions predominantly at night under inadvertent instrument meteorological conditions (IMC) equals a dramatically increased risk of crashing. Choosing flights with weather at minimums and lacking good weather reporting, radar altimeters, terrain awareness warning systems, enhanced vision systems, and regular IMC training also increases the risk.
However, a great deal is going on in the background. The National EMS Pilots Association (NEMSPA), Air Medical Safety Advisory Council, AAMS, the Operators CEO Forum, Helicopter Association International (HAI), Federal Aviation Administration (FAA), and National Transportation Safety Board (NTSB) have all convened work groups of one sort or another. Information sometimes closely held in a competitive environment is beginning to be shared, and conversations are occurring. The FAA is working with the transport community on updating the HAI/AAMS Root Cause Study of 2001.
Positions and recommendations are being formulated. AAMS has agreed this will become the year of standards, recognizing that a lack of operations data is essential in understanding the risk equation. The major air operators have agreed to work with AAMS to develop an operations database that will finally measure accident rates and identify risk areas. The database will be up and running by the end of the first quarter of 2005.
We also are setting a goal that every single person in the transport community completes AMRM by AMTC in 2008 and looks at each and every part of operations to identify risks and develop strategies to reduce those risks. The Part 135 ARC is in final stages, and the Aeromedical Workgroup and the FAA EMS Task Force are discussing Ops Specs and FAR options. We are forging a new relationship—a partnership between our safety/CORE industry committee and the FAA and NTSB. Much discussion and debate will ensue, but there are a number of emerging themes and growing consensus, such as:
•Competition: While it is difficult to quantify whether intense competition within shared market areas has led to more accidents, consensus holds that there is increased pressure to accept flight requests. In a number of cases in the past 2 years, accidents have occurred after one or even multiple other flight programs have declined a flight for weather or visibility reasons. Rapid growth in the community does appear to be a factor in increased accident numbers.
•Weather minima: There is near consensus that weather minima need to be recalibrated either through Ops Specs or FAR. The Part 135 ARC Aeromedical Work Group, FAA Task Force, and HAI Safety Committee have put forth position statements to increase weather minima and tier the weather minima based on whether a program is rated for instrument flight rules (IFR) or uses night vision devices (NVDs). There is discussion as to incorporating a window of time after which all HEMS programs are IFR-certified.
•Equipment: There is near consensus that, at minimum, radio altimeters must be installed on all EMS aircraft. Additional calls are for mandatory terrain-avoidance warning systems and promotion of NVDs.
•Part 91/135 interface: It appears that there is an increased risk of accident on flight legs being accomplished under Part 91. The Aeromedical Workgroup and FAA Task Force are working on concepts that any and all flights with medical personnel on board be accomplished under Part 135 FAR.
•Standards: The FAA Task Force has noted that accreditation by the Commission on Accreditation of Medical Transport Systems (CAMTS) suggests an important quality standard. It is interesting to note that CAMTS weather minima exceed current FAR and the proposals for increasing weather minima reflect or exceed CAMTS standards.
•Training: Currently there are no requirements in Ops Specs for specific IMC recovery training. The FAA Task Force recommends the requirement of a specific training program.
•Weather reporting investments: The direct correlation between accidents and diminished visibility or rapid weather changes is clear. It is hard to imagine that any pilot deliberately breaks weather minima in accepting a flight. The problem is more that weather is known at the point of departure and perhaps a point of return—either the same as departure or another hospital. Operations in the middle of these points may have little to no weather reporting accuracy, and weather reporting in rural areas is in decline in most places. This area needs major investment.
•Increased oversight: The FAA has identified holes in their oversight process, and state EMS directors are looking at updating the complete patchwork of rules and regulations.
All of these ideas are provocative, and they will increase costs on the path to reducing risk. We must maintain awareness of the balance between benefit and risks. The only absolutely safe way to avoid an accident is to never fly, but we are at a point where the debates must move to action.
At the Spring Conference, which will occur as this issue publishes, we will bring the community leadership together to work on the political agenda, including funding for many of these initiatives, as well as formalizing positions on many of the ideas being debated. See you in D.C. and then Austin.
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