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Category: EMS Operations

Topic: Air Medical

Level: Critical Care

Next Unit: Air Medical Pilot Standards

21 minute read

Air Medical Safety Standards

Aviation is one of the most highly regulated industries in the United States. Until recently, air ambulances and other air medical services operated outside much of the legislation that governed the rest of the aviation industry. After a string of devastating air ambulance fatalities and the resulting loss of many talented young professionals in the mid-2000s; safety has become a primary focus in the operation of any respectable air medical program. This section will review the basic culture of safety that has become a focal point in our industry.


Culture of Safety

The key to flight medicine safety is the idea of Just culture. Just culture refers to a values-supportive model of shared accountability. It's a culture of people holding companies or agencies accountable for the systems they design and for how they respond to personnel decisions fairly and justly. This is largely where the "3 to go, 1 to say no" comes from. Three to go, one to say no has become commonplace among helicopter emergency medical service (HEMS) providers. In most agencies, there are 3 people aboard the aircraft: pilot, flight nurse, and flight paramedic. With this practice, any of those 3 can speak up and say no to a flight and it will not be questioned by the agency or the crew for that matter out of the just culture model. The "no" to not take an air medical call request could be because of any of the following reasons:

  • Questionable weather
  • The pilot/crew is fatigued due to calls leading up to that call for a flight
  • Simply a "gut" feeling that something isn't right about the call and airing on the side of safety for the whole crew is paramount
  • Questionable aircraft problems, mechanical or otherwise

This practice is understood among those in most of the helicopter emergency medical service (HEMS) community. However, some crew members may not respect this practice. If you come into this situation, you're the person that must say something. Toxic attitudes are part of the problem and are very dangerous. Be an advocate for your life and the lives of everyone on that aircraft by speaking up.



Lack of or miscommunication is a major theme in patient harm. Someone started the wrong medication and another staff member saw it, thought it was odd, but went on their way because they didn't want to "ruffle feathers" or question someone of authority. They failed to communicate their concern and therefore the patient was harmed or possibly died as a result. That individual is responsible for the mistake, yes. But think about how much the person who didn't speak up is also responsible.

We all have a responsibility to speak up if something seems out of place. If nothing else, just to clarify the plan as a precaution to ensure everyone knows what is going on. This is, in part, where closed-loop communication comes into play. Talk about the plan, reconfirm the plan with all involved, and report when the plan has been executed to reconfirm that what you or others on the team have done is still part of the plan. That's closing the loop. It works. It also frees up the minds of those who may question, "did we do this?" or "did we complete this task?".

Knowing when to remain silent is also a critical skill, a "sterile cockpit" refers to the absence of any noncritical safety-related communication during critical phases of the flight such as takeoff, landing, and in controlled airspace with multiple aircraft present.


Crew Resource Management

Quality improvement is an important aspect of any industry. When it affects the loss of life, it is paramount. Six Sigma is a methodology that is used to improve processes by using actual data analysis. When it comes to air medical crashes and incidents, it has been determined that the most powerful resource to aid in not only gathering that data but improving the safety culture among air medical clinicians is crew resource management.

Crew resource management (CRM) came about in the 1970s after the infamous crash on a runway in Tenerife, Canary Islands between two 747's, one operated by the KLM Dutch Royal Airlines and the other by Pan American Airlines. Over 500 people were killed. The crash occurred due to miscommunication between air traffic control (ATC) and the pilot of the KLM aircraft where the air traffic controller was confirming the position for takeoff. The KLM pilot could not hear the entire radio transmission due to some radio interference and just assumed that they had been cleared for takeoff. That assumption caused what is still considered the deadliest airline crash in aviation history.


Air Medical Resource Management (AMRM)

Per the Federal Aviation Administration (FAA):

  • Air Medical Resource Management (AMRM) addresses the challenge of optimizing the human/machine interface and related interpersonal issues, with maximum focus on communication skills and team building curricula. These issues include effective teambuilding, information transfer through communications, problem-solving, decision-making, maintaining situational awareness, and establishing an operational environment conducive to optimal human performance even in challenging situations. AMRM is comprised of four elements:

  • Presentation Skills Profile (Train-the-Trainer),

  • Initial Indoctrination/Awareness,
  • Recurrent Practice and Feedback, and
  • Continuing Reinforcement.

The goal: Maximize a culture of safety in order to minimize the risk of accident, injury, and death. The FAA document regarding Air Medical Resource Management (AMRM) is found at this link: https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_00-64.pdf


Basic Safety Standards


While human error is a leading cause of air medical crashes, the weather is the most significant contributing factor to that. Understand what weather conditions impact flight operations and why. Be aware of weather patterns that change especially during the changing of seasons and during certain times when dangerous weather is most popular such as Tornado Alley, a wide stretch of area that extends from the upper midwest and plains to the deep south and into parts of the southeast of the United States of America in the Spring and Summer-time.

  • FAA Part 135 defines several weather-related standards for air ambulances.
    • A system for routine weather checks must be in place.
    • In marginal conditions that are rapidly changing, these checks must occur more frequently.
    • Trending weather using national and local resources should be done, with the goal of detecting inclement weather before it occurs.

Flight Following:

One of the worst possible situations is if an accident occurs with a medical aircraft and it goes unnoticed until hours later when the crew was expected at a medical facility. To avoid these situations the FAA and CAMTS have established "flight following" standards which state that there should be some form of communication between air traffic control and the flight crew every 15 minutes. Increasingly satellite tracking and automated reporting are used to fulfill this requirement.

Takeoff and Landing

The beginning and end of a flight are critical periods that can result in disaster if basic planning is overlooked. The medical crew will be responsible for knowing the following safety standards and procedures.

  • Marking a landing zone of 75 feet by 75 feet during the day and 100 feet by 100 feet at night.
  • Ensuring that there is communication with personnel on the ground in the event that a landing is occurring on the scene of an accident or in an area not specifically marked for helicopter landings.
  • Ensuring the landing zone is free of debris that could become airborne hazards upon landing or takeoff
  • A windsock or wind direction device must be present at the primary landing point for any aircraft.
  • Lighting must be present at this primary landing pad for night operations.
  • No smoking may occur within 50 feet of any primary landing pad.

Standard Equipment

The FAA defines several standards for rotorcraft that are used in the aeromedical setting.

  • All rotor-wing aircraft must have a 400,000 candlepower searchlight capable of rotating 180 degrees.
  • HTAWS (Helicopter terrain awareness and warning system) is required on all aircraft. This requirement was made mandatory after several high-profile crashes.