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Category: EMS Operations

Topic: Air Medical

Level: Critical Care

Next Unit: In-Flight Emergencies

13 minute read

Air Medical Pilot Standards

The Commission on Accreditation of Medical Transport Services (CAMTS) specifies several standards for pilots of air ambulances. These standards exist to ensure that pilots are aware of the unique challenges of working in an air medical aircraft and with a medical flight crew.

The training that air ambulance or helicopter EMS (HEMS) pilots receive makes them valuable members of the air medical team. They are capable of far more than simply flying the aircraft and can be invaluable in assisting you as they are able while you care for your patient. That being said, their number one job is to fly the aircraft safely.


Federal Aviation Administration (FAA) Regulations

The Federal Aviation Administration categorizes flight operations in 2 areas:

•    Title 14 CFR Part 135 – Covers all commercial aviation which includes the operations of all air ambulances regardless of the aircraft type.
•    Title 14 CFR Part 91 – Covers all general aviation operations of all aircraft within the United States of America and applies to private aviation.

Part 135 defines several standards for air medical pilots. 

These pilots should have an ATP (airline transport pilot) rating. This is the highest civilian pilot rating available. Those certified to fly in instrument meteorological conditions (IMC) utilizing instrument flight rules (IFR) must be recertified every six months.


Pilot Duty Requirements

For each flight-ready aircraft that is in operation, four flight-ready pilots should be available. In reality, they will often work in shifts with strict hourly limits and backup pilots available on-call for fatigue, illness, injury, or excessive call volume. For helicopter operations, these pilots must have a minimum of the following:
•    2000 overall flight hours, 1500 of those hours must be in a helicopter. The rest may be in a fixed-wing aircraft
•    1000 hours as the pilot in command (PIC)
•    200 hours of nighttime flying 

Similar to many workplace policies for EMS organizations, pilots also have standards when not on the job that must be maintained in order to fly. Bottle to throttle time is a phrase that has become a mainstay in the aviation industry and is important for you as the flight paramedic to know. Bottle to throttle time is the minimum time requirement (8 hours) a pilot must have between completing their last alcoholic drink and flying an aircraft. Their blood alcohol level must be under 0.04 as tested with a breathalyzer or a urine specimen. Random drug testing is also done on a regular basis.



Air Medical pilot training is typically general air medical operations, but further training required will vary depending on the location of the air medical program where the pilot will be operating the aircraft. An example would be mountainous terrain orientation and training versus a flattened landscape closer to sea level with artificial obstructions such as office buildings and radio towers. Instruction is specific to the operation of the airframe (what kind of helicopter), safety issues with the local environment they operate in, and special training in the interactions with local EMS agencies and hospitals. Some of their specific areas of training include:

  • Terrain and weather avoidance
  • Infection control
  • Aircraft medical systems such as oxygen and radios
  • Patient loading and unloading
  • Orientation to local hospitals, EMS agencies, and flight hazards
  • Regular training regarding local operating procedures and plans
  • Night vision training


Specific Flight Standards

Air medical pilots are tasked with knowing the capabilities of the aircraft and the conditions in which it can safely fly. This responsibility extends to all crew members who work in or on the aircraft, as all crew must be trained to recognize and report potentially unsafe conditions.

When it comes to flying, the most critical information for non-pilots is knowing the difference between visual flight rules (VFR) and instrument flight rules (IFR) and how instrument meteorological conditions (IMC) impact both.

Visual flight rules (VFR): The ability to navigate an aircraft by direct visualization of landmarks through line-of-sight. In short, the ground/water must be unobstructed by cloud layers/fog. If you cannot see the ground, you are not flying in conditions approved for VFR.

  • Weather is the most common reason an aircraft cannot fly VFR.
  • VFR requires 1/2 mile of visibility during the day and 1 mile at night uninterrupted by clouds or weather. These changes are based on the altitude and local patterns of air traffic.

Instrument flight rules (IFR): The ability to navigate an aircraft without ANY visual input from outside the aircraft in a safe and controlled manner.

  • Aircraft flying IFR requires specific aviation equipment, regular communication with air traffic control, and additional pilot training.
  • The majority of air medical crashes occur when a helicopter being flown VFR encounters IFR conditions.


Pilot Apparel / Safety Equipment

Apparel and safety equipment for helicopter EMS (HEMS) pilots is standardized and largely identical to that of the medical crew; this will be further reviewed in other sections.