In the mid-1990’s a new business model emerged in air medical flight operations. The helicopter operators, who for a decade-and-a-half had been hobbled by a competitive bid process that killed profitability, needed to improve their bottom lines. The hospital customers, looking to lower overhead costs, were anxious to save money on their aviation operations. This new way of doing business had the helicopter operators branching out to actually become ambulance companies- nurses, paramedics, and EMTs, previously supplied by the hospital, became employees of the helicopter operator. Billing the patients for the air ambulance service was taken on as well. Accordingly, the hospitals could reduce their staff and now the hospital only had to supply facilities to house the helicopter and crew.
In the early 2000’s the air ambulance subscription service saw growth. In this model the helicopter air ambulance company, operating independently of any medical customer, sold subscriptions to the general public that pre-paid for a helicopter air-ambulance transport should it ever be needed. By placing a large number of second-hand (therefore cheaper in cost) helicopters regionally with overlapping coverage, this became a profitable way to operate helicopters.
Regardless of the operational model used- legacy, turn-key, or subscription- it remained tough to turn a profit in the helicopter air ambulance market. Costs can very easily get out of hand and margins are always thin.
As the air ambulance business evolved there continued to be mishaps and crashes, some fatal. For the air crewmembers air ambulance flying continued to be high risk in spite of the industry’s efforts to mitigate that risk. The ‘go or no go’ decision before a flight was undertaken, once the sacred domain of only the pilot-in-command, was expanded to include the medical crew- everyone aboard had to agree that it was safe to depart for (and to continue) a flight. When that tactic proved to be only partially successful, the helicopter operators were required by the FAA to establish national dispatch centers with who the pilot would communicate several times each shift. (A collateral issue of ‘operational control’ a very specific definition born of Federal Aviation Regulations, also played a role in the establishment of these centers.)
Today air ambulance helicopters continue to crash far too frequently. Most of these aircraft are flown by a sole pilot and until the one-pilot model is abandoned the air medical safety record will not improve.
There are a few two-pilot air medical operations in existence in the U.S. and they have a better record than their single-pilot counterparts. Unfortunately, most two pilot operations opt to fill the copilot’s seat with a relatively inexperienced (and therefore low-cost) copilot. This is a false economy. Several years ago an air ambulance with two pilots aboard crashed and it could be argued a second pilot is apparently not a valid solution. But I think it is. The solution is for the air medical helicopter industry to adopt the operational model used in corporate aviation.
Corporate helicopters (and airplanes) are routinely crewed by two experienced pilots, both in their own right a qualified aircraft captain. Upon joining a corporate flight department a pilot attends an aircraft qualification course at Flight Safety International or CAE Simuflite. The two week initial training course includes a comprehensive review of aircraft systems and avionics followed by flight training performed in a full-motion simulator. The flight training includes VFR and IFR operations along with in-flight emergency procedures. Pilots train in both seats, i.e. as pilot-in-command and as second-in-command.
After completion of initial training corporate pilots return to school for recurrent training every six months. Recurrent training includes a two day review of aircraft systems and three or four simulator flights. In the simulator pilots review in-flight emergency procedures and accomplish an instrument flight review. (The reality is that most helicopter pilots who possess an instrument rating have very little experience flying in instrument conditions; this is a weakness that can be mitigated by simulator training and by flying with another instrument rated pilot on board.)
This method of training is expensive, no question about it, but large companies with in-house flight departments demand a high level of competency and expertise from their pilots. Undergoing high-quality formal training at one of these schools is one way of ensuring well-prepared pilots.
Some hospital customers currently require their pilots to attend courses at FSI or Simuflite. Flight Safety has obliged EMS customers by offering customized courses designed for EMS pilots. But the majority of EMS helicopters are flown by a single pilot who never attend one of these schools. The one pilot cockpit is air medical’s greatest flaw, in my opinion. Until the dual pilot cockpit becomes the industry standard for EMS operations the accident rate will remain unsatisfactory. Having two pilots up front will not eliminate accidents, to be sure, but one only needs to compare the safety record of corporate operations against that of air medical operations. I will stipulate the limited risks corporate helicopters are exposed to- one never observes a corporate aircraft landing on a road side next to a car accident at three a.m., for example.
Replacing the current fleet of one-pilot helicopters will be very costly, running into hundreds of millions of dollars. Doubling the number of EMS pilots will be expensive and training them will cost tens of millions of dollars. Two-pilot helicopters, typically twin-engine and larger than their single-pilot counterparts, will require additional maintenance. Larger helicopters have the space on their instrument panels for more sophisticated avionics such as weather radar and terrain awareness systems.
Two pilot operation represents a paradigm shift for the air medical industry. Many EMS operations in existence today would close due to the increased cost of operations. But until the single-pilot EMS helicopter concept in use today is abandoned the air medical accident rate will remain unacceptable. Single pilot IFR operations don’t go far enough, in my opinion, but SPIFR is a step in the right direction.
So is there any room at all for single pilot operations? I suppose there could be if weather minimums are increased and consideration given to the proximity of weather information to the intended route of flight. For example if day-local and cross-country minima were set at 2,000ft & 5sm and 3,000ft & 5sm, respectively, and at night 3,000ft & 6sm and 5,000ft & 10sm. For off- airport operations a weather report would only be valid if within 10 miles of the route of flight, perhaps. I acknowledge these are severe limitations, but too many air medical helicopters crash in bad weather! Even with a two pilot crew the absence of valid weather reports for off-airport operations presents heightened risk.
Until the air medical industry adopts the two-pilot IFR concept, those who operate (or cause to be operated) air medical helicopters are tacitly acknowledging that the current fatality rate is acceptable. EMS remains one of the few commercial aviation activities with one pilot alone in the cockpit; I don’t understand why, but this needs to change.
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