After a 2008 fatal accident, the Maryland State Police Aviation Command (MSPAC) decided to seek Part 135 certification, replace its ageing helicopter fleet and adopt programmes to ensure the success of its vital mission: saving lives.
The MSPAC, headquartered at Martin State airport near Baltimore, is categorised as a multi-mission "public use" or Part 91 aircraft oper-ation, and the state of Maryland is the "boss" of its 160 staff members. It has operated more than 20,000 medevac flights since its launch in 1970. Delegations from China, Russia, Brazil and Italy have visited to study the MSPAC model.
The command's 50 pilots and 45 paramedics operate a fleet of 11 Eurocopter AS365s from seven bases, located throughout the state so aircraft are only 30min from any trauma centre. Air medical transport services, also referred to as helicopter emergency medical services (HEMS) operations, account for 80% of the command's multi-mission role, which spans search and rescue, airborne law enforcement - or police chases - Homeland Security, and disaster assessment. Two fixed-wing aircraft, a twin-engined Beechcraft Super King Air 350 and single-engined Cessna Centurion P210, are based at Martin State and used mainly for law enforcement, such as prisoner transport.
© MARYLAND STATE POLICE AVIATION COMMAND
The MSPAC's 50 pilots and 45 paramedics operate a fleet of 11 Eurocopter AS365s from seven bases
"We don't have to transport a single person or conduct a single flight for revenue," says Walter Kerr, helicopter operations quality assurance commander. "If any one of these aren't safe to launch, we don't have to concern ourselves with loss of revenue for our organisation."
This model minimises "helicopter shopping" - when a service provider turns down a request for medical transport due to bad weather, for example, and the person making the request in turn "shops around" for another operator who will take on the mission. Industry views the practice as a potential safety hazard as the desire for revenue could compel providers to take on high-risk missions.
Nevertheless, MSPAC missions have became fatal accident statistics. The command's first safety evolution followed the January 1986 crash of one of its BellRanger 206s that killed two crew members. The state reacted by procuring Eurocopter AS165s which, unlike the BellRangers, were designed for medevac operations. Additionally, the command adopted new safety procedures and higher standards of operation. "Not every mishap causes an evolution but it causes you to re-evaluate [operations]," says Kerr, a paramedic and licensed pilot who has been with the MSPAC for 23 years and flown on about 5,000 missions.
The MSPAC enjoyed 22 years without an accident until 27 September 2008, when a Eurocopter SA365 N1 crashed on a night approach to Runway 19 Right at Andrews AFB. The pilot, one flight paramedic, a field provider and one of two auto accident patients being transported were killed.
FAILURE TO ARREST DESCENT
The accident's probable cause, according to the US National Transportation Safety Board, was the pilot's "attempt to regain visual conditions by performing a rapid descent and his failure to arrest descent at minimum descent altitude". The board's probe highlighted several safety issues, including the operator's risk assessment capability, lack of helicopter terrain awareness and warning systems, pilot performance and training, and FAA air traffic control deficiencies. The incident occurred during an alarming increase in emergency medical service accidents. From 1992 to 2009, 135 accidents resulted in the deaths of 126 people, according to the FAA. The accident rate climbed with HEMS growth. According to the Association of Air Medical Services' Atlas and Database 2010, last year the number of service providers had reached 373, from 32 in 1980. In the same 1980-2010 span, the helicopter fleet grew from 39 to 900 and the number of patients transported annually increased to 500,000, from 17,000. In 2009, the MSPAC flew 2,292 missions, 2,079 of which were patient transports. In 2010, it flew 2,305 missions, 2,114 of which were medevacs. Most of its missions are from scene of accident to a trauma centre, whereas commercial operators usually fly hospital-to-hospital.
After the September 2008 accident, the MSPAC set to work on "fully embracing" recommendations by the NTSB, which had asked the FAA to mandate all emergency medical service operators comply with Part 135 operations on flights with medical personnel on board. It also advised such operators to develop flight-risk evaluation programmes, install helicopter terrain awareness and warning systems, and provide scenario-based training.
SAFETY MANAGEMENT SYSTEM
The NTSB has issued about 20 HEMS-related safety recommendations in the past 11 years. Many were issued at its February 2009-day hearing on HEMS safety and are contained in the resulting FAA notice of proposed rulemaking on improving HEMS safety. This was published on 12 October 2009.
After the NTSB's recommendations, the MSPAC introduced a safety management system - "a work in progress", says Mike DeRuggiero, who leads the group's safety management section. At its current level of development, crew members can report all safety concerns, which are in turn investigated and corrected by safety pilots.
DeRuggiero says the MSPAC is striving to obtain Part 135 certification for its medevac missions and adopting "at or above the Part 135 criteria for all its missions". It is evaluating proposals by certificated air carrier consultants to facilitate and develop a Part 135 programme, he adds. Part 135 criteria include setting higher weather minimums, conducting risk assessment before accepting a flight and installing helicopter terrain awareness and warning systems. Another certification requirement calls for compliance to the FAA's HEMS A021 visual flight rules specifications, which help crews determine minimum safe clearance altitude for all legs of a given mission.
© MARYLAND STATE POLICE AVIATION COMMAND
In 2009, the MSPAC flew 2,292 missions, 2,079 of which were patient transports
The switch to Part 135 will be sequential. The maintenance operation, a Part 145 repair station based at Martin State, will eventually be 100% Part 135-compliant and in February consultants devising operations specifications were evaluating whether Eurocopters should be included in the Part 135 helicopter terrain awareness and warning systems requirement. DeRuggiero added that retrofitting the ageing fleet - eight of 11 aircraft are more than 20 years old - would prove costly. The AS365s, which have full IFR capability, are equipped with forward-looking infrared radar altimeters, night vision goggles used solely by paramedics, a 81m (265ft) hoist capable of lifting 272kg (600lb) at 150ft/min and, on the tail, the NightSun searchlight.
Dick Bruns, a veteran MSPAC pilot, says flightcrew regard the Eurocopter type as a good multi-mission aircraft "but it's time to move on to new technology".
DIGITAL FLIGHT CONTROL
The Eurocopters will be phased out as Part 135-compliant aircraft are introduced. In October 2010, the state of Maryland placed a $72 million order for six five-bladed AgustaWestland AW139 medium-range helicopters, each powered by two Pratt & Whitney PT6C-67C turboshaft engines.
The first two should be delivered in April 2012. All six will be operating by October 2012. The AW139s will have a four-axis digital automatic flight control system, Honeywell Primus Epic integrated avionics, a helicopter terrain awareness and warning system, and cockpit voice and video recorders.
The MSPAC flies missions with a one pilot and one paramedic. The aircraft can carry two patients plus a contingency provider to assist the paramedics. DeRuggiero says the command envisages operating with two pilots and two paramedics.
MSPAC missions are far from cushy. Pilots and paramedics operate under hazardous conditions: often at night, in low-visibility, inclement weather and an obstacle-laden environment of wires, towers and buildings, or over rugged terrain. The minimum required size of landing zone is 14m x 14m.
To qualify, a candidate must hold a commercial pilot's licence and helicopter IFR rating and have logged a minimum of 2,000 flight hours - all in helicopters. A paramedic must be trained as a state trooper, hold national certification as an emergency medical technician-paramedic plus a Maryland paramedic certificate, and have three years of "advanced life support" emergency medical service experience. Both undergo rigorous training, according to MSPAC director of flight operations Bill Bernard. Pilots must pass IFR check rides twice a year and successfully execute two IFR approaches a month.
There is also annual hoist training and computer-based training is available so crew members remain current on regulations, aircraft systems, emergency procedures and the A021 database system.
Paramedics, says DeRuggiero, "wear many hats" within the operation, such as help with pre- and post-flight checks, navigation and radio communications, in addition to aiding the pilot in emergencies. Twice a year, the paramedics must review IFR procedures and take a course on how to land a helicopter if the pilot is incapacitated. When the AW139s are introduced, pilots will undergo two weeks of training on a full-flight simulator at AgustaWestland's Philadelphia facility to gain the type rating required for the aircraft, which weighs more than 5,670kg (12,500lb).
In addition, the MSPAC plans to install a "Level 7" flight training device at Martin State headquarters to enable pilots to perform on-scene and hoist scenario-based training. A work group formed after the 2008 accident estimated a flight simulator would save nearly $700,000 a year.
As MSPAC personnel continue to ensure patients get their "best shot", enhanced HEMS safety remains the focus of an ongoing industry effort. The FAA is evaluating the comments on its HEMS-related notice of proposed rulemaking, and expects to issue a final rule by April 2012.
In its 10 January response letter to the NPRM, the NTSB urges the FAA to consider in the final rule certain provisions critical to operational safety that were omitted in the proposed rulemaking. These include a requirement for operators to implement safety management systems and equip aircraft with flight recorders and night imaging systems.
NTSB member Robert Sumwalt believes "the problems industry had two years ago at the time of the safety board's HEMS hearing, still exist. [In the] 13 months following the hearing, there were 22 fatalities. We need to make changes so that people quit dying in helicopters that are in the business of saving lives."
OUT AND ABOUT WITH THE MARYLAND STATE POLICE AVIATION COMMAND
The symbiotic relationship between paramedic and pilot was evident when we joined paramedic John Peach and pilot Dick Bruns on their 12h shift.
The watch can go from "absolutely boring hurry-up-and-wait to running around in circles", says Bruns, who has been with the Maryland State Police Aviation Command since 1986. When they arrived at the base, they conducted a flight-risk assessment for the day. This included weather outlook as well as the readiness of aircraft and crew.
About 5h into their watch, Peach answers the telephone to Syscom, the command's dispatch centre in nearby Baltimore, which fields requests for transport only from 911 centres or police/fire responders and assigns them.
Peach jots down information and relays it to Bruns. "A PI [personal injury]. Car's on fire. The co-ordinates are..." Bruns abruptly swivels to the computer screen displaying the A020 system. Against the backdrop of the area's sectional, he punches in the location and triangulates the legs from base to accident scene to trauma centre. The system immediately displays obstacles and minimum altitude clearances en route. Bruns re-checks weather, fuel load and weight and balance data, and prints out the information.
Either crew member can decide the mission poses too high a risk and refuse the flight without fear of disciplinary action.
However, this mission is a "go". Peach, a former paramedic/firefighter with Baltimore City Fire Department, has been with the MSPAC since 2002. He and Bruns work their way to the hangar adjacent to the ready room. Peach swings into "fire watch" mode as Bruns starts each engine. The paramedic also checks door latches and lights, and looks for signs of hydraulic fuel leaks. All is clear. Peach tows the aircraft to the tarmac and the tower clears the aircraft for take-off.
Arriving on the scene, the pilot normally does high and low orbits of the landing zone to assess - with an assist from paramedic eyes - its safety. If it passes muster, the helicopter lands and the paramedic assesses and stabilises the patient. Category A and B patients, the most seriously injured, are candidates for immediate air transport to a trauma centre. Medical personnel assess if Category C and D patients - those with lesser injuries - should be transported by air or ground.
The MSPAC follows the "golden hour" rule, says Mike DeRuggiero, who leads the group's safety management section. A trauma patient's survival chances increase dramatically the sooner treatment is available, so getting to a facility as soon as possible is critical.
Inside the aircraft is equipment and medications one would find in an emergency room, only in smaller sizes or quantities: medical oxygen, about 40 drugs including sedatives and paralytics, defibrillators, equipment for intubation, IV supplies, splints, bandages.
Stress comes with the territory. Crews see all that can and does happen to the human body: stabbings, beatings, shootings, drownings, severed limbs, burns, brain damage. They relieve stress with black humour and good-natured ribbing. "Pilots call medics 'Band-Aid monkeys' and medics call pilots 'stick monkeys,' but they are terms of affection," says Peach. Like other paramedics Peach believes the pilots, who fly in impossible spaces under impossible conditions, are "criminally modest" about their skills. And Bruns, like other pilots, hold paramedics' life-saving skills in high regard. "You read each other real fast. I'm an armchair medic and he's an armchair pilot. We don't cross-train but we are aware of each other's job and help each other whenever possible."
Rewards can be great. Once, the crew were able to rescue a boy trapped in a car and save his leg from amputation. Another time a crew managed, while hovering at night amid thick, black smoke, to hoist several men trapped inside a blazing factory smokestack.
"This job gives you a deeper appreciation for your life and for family and friends in your life," says Peach. For Bruns, "what perhaps is the most satisfying is that you know you were the best shot they [patients] had and they would not have made it otherwise".