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Helicopter Emergency Medical Services (HEMS)

Industry Risk Profile

APRIL 2009

About the HEMS Industry Risk Profile An industry risk profile (IRP) presents a strategic risk picture of the key risk issues that face a nomi-nated sector within an industry at a given point in time. An IRP contains the definition of the context of the industry and the context of the risk profile, identification of risk issues, their associated impacts, the risk rating and presents proposed high level treatment strategies the associated residual risk and the risk ranking. An IRP provides the platform for industry to develop a detailed risk reduction plan, outlin-ing the agreed risk reduction measures, timelines for implementation and accountabilities.

About the Flight Safety Foundation

www.flightsafety.org

Flight Safety Foundation is an independent, nonprofit, international organization engaged in research, auditing, education, advocacy and publishing to improve aviation safety.

The Foundation’s mission is to pursue the continuous improvement of global aviation safety and the prevention of accidents.

The Foundation’s objectives are to:- Pursue the active involvement and participation of the

diverse elements of global professional aviation; - Anticipate, identify and analyze global aviation safety issues and set priorities; - Communicate effectively about aviation safety; and, - Be a catalyst for action and the adoption of best aviation safety practices.

About Aerosafe Risk Management

www.aerosafe.com.au

The Aerosafe Group is a global aviation safety and risk management company, which provides risk management services, support and tailored solutions to aviation compa-nies around the world. With offices in North America, Australia, India, China and New Zealand, Aerosafe is recognized as an international leader in this important field. The Aerosafe Group has been invited to set standards with aviation regulators, industry groups and companies alike and operates at the operational, enterprise, sector and industry levels in the application of modern risk management practices.

About the Foundation of Air Medical Research & Education

www.fareonline.org

The Foundation for Air Medical Research & Education (FARE) was established in 2001 to support charitable, scientific and educational programs and other initiatives, includ-ing outreach to the public, for the air medical and critical care medical transport com-munity. Everything we do is for the patients we serve. The Foundation for Air-Medical Research & Education (FARE) is a non profit 501 (c) (3) charity serving the international air-medical community through: - supporting essential air-medical and critical-care transport research and

education initiatives; - sponsoring educational opportunities and scholarships for air medical professionals; - advancing patient and aviation safety; - funding grants that result in important clinical, safety and operational research; - publishing award-winning public policy literature that helps air-medical practitioners

keep abreast of cutting-edge research and technologies; - providing financial support to families in crisis after an air medical accident; - informing the public about air medical and critical-care transport; - convening worldwide forums for industry leaders to discuss the global initiatives,

challenges and opportunities for air-medical and critical care transport systems.

FOUNDATION FOR AIR-MEDICAL RESEARCH & EDUCATION

APRIL 2009

Published by: Flight Safety Foundation

Developed by: Aerosafe Risk Management

Developed for: HEMS Industry, United States of America

Printed & Distributed by: Foundation of Air Medical Research & Education

Helicopter Emergency Medical Services (HEMS)

Industry Risk Profile

© Copyright Aerosafe Risk Management Inc, April 2009

This document has been developed by Aerosafe Risk Management Inc (Aerosafe) in response to a specific body of work that was commissioned and funded by industry. The background intellectual property expressed through the methodologies, models, copyright, patent and trade secrets used to produce the Industry Risk Profile remains the property of Aerosafe.

Aerosafe grants the Flight Safety Foundation an exclusive, world-wide, royalty-free licence to publish, release and distribute the IRP to industry. This licence includes the ability for Flight Safety Foundation to sub-licence printing and distribution of hard copy prints of the IRP. The intellectual property ex-pressed in this copyright information is governed by the contract between Aerosafe and Bell Helicopter Textron and the subsequent licensing agreement with the Flight Safety Foundation.

While the author and publisher have taken reasonable precaution and have made reasonable efforts to ensure accuracy of material contained in this report, Aerosafe does not guarantee that this publication is without flaw of any kind. The authors and publisher makes no warranties, express or implied, with respect to any of the material contained herein and therefore disclaims all liability and responsibility for errors, loss, damage or other consequences which may arise from relying on information in this publication.

IntRoductIon: Managing Risk in the HEMS IndustryForeword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

How to use the HEMS Industry Risk Profile (IRP) . . . . . . . . . . . . . 8

Next steps: Completing the risk management process. . . . . . . . . . 9

PARt 1: context of the Industry Risk Profile . . . . . . . . . . . . . . . . 11Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Risk Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Depth of Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Methodology: Risk Management Process . . . . . . . . . . . . . . . . . . . 19

Methodology: Industry Risk Profile Model . . . . . . . . . . . . . . . . . . 20

PARt 2: Summation of Results . . . . . . . . . . . . . . . . . . . . . . . . . . 23Summation of results risk profile . . . . . . . . . . . . . . . . . . . . . . . . . 24

Risk reduction plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

PARt 3: Industry Risk Profile tabulated data . . . . . . . . . . . . . . . 31

PARt 4: Supporting Appendices . . . . . . . . . . . . . . . . . . . . . . . . . 58 A. HEMS IRP stakeholder and distribution list . . . . . . . . . . . . . . . 59

B. Supporting documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

C. Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

D. Project contact details and project acknowledgements . . . . . . 62

Table of Contents

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IntRoductIon

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The Helicopter Emergency Medical Services (HEMS) industry is to be congratulated for taking a leadership role in developing an industry approach to the management of risk in the vital area of air medical transportation.

Aviation has a long and proud history of addressing and managing risk, but the very nature of HEMS calls for new and innovative ways of ensuring that risk, in all its forms, is subjected to a rigorous process for the management of risk at all levels of the industry.

Risk is all about understanding the effect of uncertainty on organizational or in the case of the HEMS industry, the industry’s objectives. This Industry Risk Profile is the starting point on the journey of addressing the objectives of HEMS participants, large and small, and the risks that they must manage in order to maximize their opportunities whilst minimizing threats.

The risk management process utilized in the HEMS Industry Risk Profile has many years of practical application throughout the world by all manner of industries including the full gamut of military and civilian aviation organizations. The adoption of the process set out in ISO FDIS 31000, which is derived from the long standing and well tested process of AS/NZS 4360:2004 is to be applauded.

Having received this Industry Risk Profile the challenge for the HEMS industry is to take the next step of developing their own unique risk framework to integrate the process into the management systems at all levels of the industry. This will allow those governing and leading the industry to fully under-stand the risks that must be effectively and efficiently managed if all the objectives of the industry are to be achieved.

This document is an excellent starting point and I congratulate those who commissioned this inde-pendent assessment, the authors, those who participated in its development and revision and the Flight Safety Foundation for their unwavering commitment to safety and the willingness to take on the role of custodian of the HEMS Industry Risk Profile.

Kevin W Knight AM CPRM, Hon FRMIA, FIRM (UK), LMRMIA

Chairman International Standards Organization (ISO) Working Group on Risk Management

Foreword

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How to use the HEMS Industry Risk Profile The HEMS IRP was developed for use at the national level by industry leaders, standard setters, industry associations, industry bodies and groups that have the ability to develop, resource and implement voluntary industry wide change initiatives to reduce the risk profile of the HEMS industry. The risk information presented in the HEMS IRP presents and assesses the identified risks and highlights appropriate performance based risk treatments or risk reduction measures.

Many of the treatments transcend the sphere of influence of any one individual organization such as an individual Air Medical Program or Operator and must therefore be managed across traditional divides. While the actions proposed are largely voluntary, it is accepted that some issues raised in the IRP may only be resolved by regulatory or mandated action by the customers that engage or utilize HEMS.

The HEMS IRP does not identify the risks of any particular individual or group of Air Medical companies rather it presents the systematic risks inherent in the entire industry landscape that ultimately have the potential to induce risk at many levels of the industry.

developing Risk Reduction PlanThis profile is based upon the assumption that there are four key ways of bringing change to the industry;

- Legislative change by Congress

- Regulatory change by the aviation, medical or state regulators

- Mandated change driven by the Customers

- Voluntary change by the industry

The HEMS IRP predominately focuses on the voluntary change that can be made by industry, yet the IRP rec-ognizes the intersection of the other three areas and can be used as an evidence based tool to inform change in these areas as well.

The true value of an industry level risk profile is not gained until an action plan is derived and commit-ted. The Industry groups listed at Annex A, upon receiving the HEMS IRP, also receive an open invita-tion to participate in an industry wide effort to develop and implement the Risk Reduction Plan.

The HEMS Industry Risk Reduction Action Plan will outline the detailed actions, tasks and activities designed to reduce risk. Each individual strategy will vary in its effectiveness, however when combined, the cumulative effect will be an overall reduction in the industry profile. The responsibility for the management and implementation of each treatment is assigned to an entity, association or organization. This accountability or responsibility for implementation is also indicated on the HEMS Industry Risk Reduction Action Plan.

the HEMS IRP will change over time Risk management is an iterative process. It is acknowledged that the HEMS IRP is dynamic and will change over time to reflect risk changes in the industry. This IRP provides a snapshot of the risk profile of the HEMS industry at the time of development (January – April 2009) based upon an analysis of the information available and accessed. As further data or information becomes available the risk profile can be updated. In addition to this, as risk reduction measures are completed the risk profile will reduce and the residual risk rating will be realized. It is anticipated that the HEMS IRP will be revisited every six months specifically with the intent of monitoring progress of risk reduction measures committed to by industry.

IntRoductIon

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next Steps: completing the risk management process The profile of the HEMS industry is dynamic. In order to provide confidence that the risks identified in this IRP are being effectively addressed and managed a plan for assurance monitoring has been outlined. The key focus is the identification, allocation and implementation of a detailed risk reduction plan and the associated accountabilities to ensure action or to provide assurance that action is already in progress. Timelines and activities are subject to industry participation.

ACtIvIty DEtAIlS tIMElInE

Launch of HEMS IRP to industry Release and distribution of HEMS IRP by FARE

Development of industry response including submission of current or proposed industry risk reduction measures Risk reduction planning conference Finalization of the HEMS Industry Risk Reduction Action Plan Release of HEMS Industry Risk Reduction Plan

Check point reporting

Update risk reduction plan

Report to indus-try on progress

Update HEMS IRP Continuous follow up until profile is reduced to an acceptable level

Launch coordinated by Flight Safety Foundation as industry custo-dian of the IRP. Technical briefing provided to the media. Registered downloadable electronic files available at www.flightsafety.org FARE has approved a grant to fund the printing and distribution of copies of the HEMS IRP to the industry distribution list outlined in Annex A. Additional copies available through FARE. www.fareonline.org An inclusive invitation is made for the full spectrum of industry stakeholders to work through the HEMS IRP and develop an individ-ual submission of those industry level risk treatment strategies that are either already being undertaken or are willing to be undertaken, resourced and implemented by the submitting organization. A step by step guide to aide the preparation of submissions can be downloaded from the Flight Safety Foundation website. One authorized representative from each stakeholder group will be invited to the inaugural risk reduction planning conference where risk reduction strategies will be agreed to and prepared as the HEMS Industry Risk Reduction Action Plan for presentation to industry. A small group of representatives from the industry to review the proposed HEMS Industry Risk Reduction Action Plan. An assurance regime for monitoring and reporting progress will be established. Industry Risk Reduction Plan formally released to industry.

Those industry stakeholders who have taken responsibility for an individual risk treatment strategy will provide a status report on their progress against the HEMS Risk Reduction Action Plan. This informa-tion will be compiled and a report card prepared for public release.

Upon receiving the progress report from the above activity, the HEMS Industry Risk Reduction Action Plan will be updated and pre-pared for presentation to the risk monitoring and assurance group.

A formal progress report will be released to industry.

As the context of the industry changes, appropriate triggers for a full update or overhaul of the HEMS IRP will be determined. These triggers may include significant progress in completion of the risk reduction measures, emergence of significant new risks, context of the industry shifts significantly or the accident profile of the industry is not visibility decreased. The Industry to continue on the six monthly cycles for the formal management of risk until an acceptable risk profile is achieved.

April 20, 2009

April 30, 2009

May 1, 2009 – July 15, 2009.

August 13-14, 2009

August 25, 2009

August 31, 2009

February 10, 2010

February 15, 2009

Feb 22, 2009

As determined Ongoing

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nt

HLy

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context of the Industry Risk Profile

PARt 1

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PARt 1 context of the Industry Risk Profile

1 Ira Blumen, An Analysis of HEMS Accidents and Accident Rates, 2009 NTSB Hearings into the EMS Industry, 2009

Background Air medical transportation has become a key component of healthcare in many countries throughout the world. Air medical transport services are particularly important in large countries where traveling times to hospital care may be excessive by surface vehicles or where remote communities might other-wise be deprived of the required level of healthcare service. In addition to acting as an air ambulance service, aircraft are particularly important in times of national emergency or to provide support to rescue and other emergency services.

While air medical services may at first glance appear expensive compared to traditional ground ambu-lances, an examination of the cost structures and benefits on an annual system wide basis demonstrates its cost effectiveness. In many cases, air medical services may be the only option and the difference be-tween life and death for the patient. In other circumstances timely, appropriate initial care may provide ongoing reduced cost over the lifetime of the patient. Integrated air medical resources are therefore an essential component of contemporary Emergency Medical Services (EMS) systems.

Helicopter Emergency Medical Services (HEMS) and EMS services are provided in the United States through a multitude of relationships involving Part 135 air carriers, public entities, hospitals and EMS providers, by both profit and not-for-profit organizations. It is estimated by the Association of Air Medi-cal Services (AAMS) that helicopters transport 400,000 patients annually in the United States.

As the medical benefits of rapid transport by air medical providers have become more recognized, there has been ongoing growth and expansion since the 1970’s with HEMS operations beginning in 1972. Recent data shows that since 1995 the number of helicopters used in the EMS industry increased by approximately 130% to 2008. Prior to 1995, there was a similar doubling of the number of helicopters being utilized within the HEMS Industry over a ten year period.

Current Safety ConcernsThe National Transportation Safety Board (NTSB) notes that there were 55 EMS related accidents (fatal and non-fatal) that occurred between January 2002 and January 2005 and that many of them could have been prevented with simple corrective actions including: oversight, flight risk evaluations, improved dispatch procedures and the incorporation of available technologies. In the last twelve months the NTSB investigated an additional nine fatal EMS accidents which killed 35 people. The Board has also added helicopter EMS safety to its “Most Wanted List” of transport safety improvements.

The recent increase in the fatal accidents has created general concern by the Air Operators, the Air Medical Programs and the broader public community. The HEMS industry is actively working on many fronts in an attempt to identify those issues that have led to these avoidable and, hence, unacceptable accidents. Parallel to these industry driven initiatives, the government also committed to proactively examining the causes of the high accident profile. This culminated in the February 2009 NTSB Public Forum regarding Operational Safety in the Helicopter EMS Industry and an agreement by the industry that a “call to action is required”.

Over recent years, many industries have recognized that effective management of risk allows regulators, organizations and operators to target resources strategically to meet both governance obligations, com-mercial objectives and improve levels of safety.

Risk management takes place at multiple levels. This Industry Risk Profile (IRP) provides at a strategic level, a description of risk for the HEMS industry as a whole. The risk management process allows

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operators within the industry to develop individual risk frameworks and risk management plans. It can also assist Regulators to develop regulatory solutions which achieve the statutory safety outcomes while allowing individual operators the flexibility to effectively meet their corporate goals.

An Industry Risk Profile can also be a “call to action” for all parties involved in the industry. It sets out in a clear and concise document both the problems and, more importantly, the solutions that are available to reduce the inherent risk profile.

Commission to Develop the HeMS Industry Risk Profile As part of the industry’s commitment to the efforts of the International Helicopter Safety Team (IHST) and the achievement of the published goal of an 80% reduction in global helicopter accidents in the next 10 years, the industry commissioned and funded the development of the HEMS IRP.

The IRP methodology utilized is usually applied by industry regulators or those industry sectors that have been delegated self administration by the regulator. This innovative step for the HEMS industry to adopt and utilize this methodology demonstrated a level of maturity that is not common in industries under the public and regulatory spotlight.

The industry recognized the need for a holistic and broader view of the systemic strategic risks that are inherent in the current national HEMS model. It was realized that a ‘different’ approach was needed and there was great value in an industry wide risk assessment that would provide a platform for the coordi-nation of nation wide initiatives to aggressively reduce the risk profile and the associated negative trend in safety.

PurposeThe purpose of the HEMS IRP is to identify the latent and systemic issues inherent in the current national HEMS structure and model that have the potential to induce operational or safety risk in order to proactively address issues that have not yet been subject to attention.

Based on the use of the Reason accident causation model, and the accepted hierarchy of layers, barriers and defenses that exist in any organizational or industry level system, the HEMS IRP focuses on the systemic issues that exist at the strategic level of the HEMS Industry.

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objectives 1. Identify the systemic risks inherent in the current HEMS structure that may induce operational, safety

or organizational risks taking the industry wide assessment beyond traditional analysis of historical data into a proactive, risk based approach.

2. Utilize a data driven, evidence based approach that leverages off the array of current and past investigations, reviews, studies, papers, analysis and knowledge publicly available on the topic of HEMS safety. These efforts have been harnessed and utilized as risk identification inputs into the HEMS IRP.

3. Provide the strategic view of industry risks in one document that can be commonly understood by all stakeholders (aviation, medical, EMS, industry, regulatory, customer and government) and used as a focal point for defining the accountability for change.

4. Utilize an accepted methodology (risk management) that is used broadly in both corporate America and the international aviation community allowing a common language to be adopted that is famil-iar to the industry and regulator alike.

5. Allow industry a tool to effectively rank and prioritize efforts for risk reduction, and where the risks are unable to be controlled by the industry itself, the IRP provides a platform for the transfer or referral of risk to the appropriate accountable body

6. Allow the alignment of accountability, responsibility and resourcing for the management and reduction of risk at multiple levels of the industry.

7. Provide industry with opportunity to develop alternate solutions that will achieve the reduction in risk that is expected or even demanded by the government and the community

8. To propose risk treatment strategies that are performance or outcome based solutions rather than the traditional prescriptive recommendations that often come out of studies, reviews or investigations

9. A platform for the coordinated management of risks across the Industry - Prioritize the identified risks in order of seriousness and to provide a general sense of urgency for the treatment of risks to meet the industry’s duty of care obligations

10. Assist the HEMS Industry in meeting recommendations from the National Transportation Safety Board (NTSB)

11. Provide an up-to-date formal document that can be used by the HEMS industry to track and monitor implementation of risk treatment and ultimately provide effective oversight and governance of the Industry

12. Provide Industry Associations with a vehicle to manage governance, compliance and liability issues by demonstrating a proactive and risk based approach to change

13. Provide a framework within which individual operators can develop their own organizational risk profiles and risk management plans to effectively position or respond to industry level risks

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AssumptionsThis Industry Risk Profile was developed within the context of the following assumptions:

1. Citizens of the United States of America have the right to expect a reasonable standard of emergency medical transportation regardless of their location within the country.

2. The current accident and fatality rate in HEMS transport is unacceptable to Industry as a whole, individual operators, regulators and the public.

3. The information provided to Aerosafe Risk Management by the HEMS Industry for the purposes of developing this industry risk profile is complete, true and correct

4. Matters of concern raised in the consultation process, which could not be substantiated or verified by other risk identification sources, were considered as perceived risk for the purposes of the profile.

5. The Industry Risk Profile will be provided to stakeholders and interested parties for use in strategic planning, business planning, reporting and other processes to ensure appropriate monitoring and oversight.

6. Statements made during the NTSB hearing (February 2009) were regarded as stakeholder interviews and those interviewed included in the stakeholder list.

7. Formal position papers, documents and resources lodged on the public docket for the NTSB hearing were used in the HEMS IRP literature review and included in the documentation list.

8. Formal position papers by AMOA, AAMS and HAI were taken as a representative view of the members it represents and this data input source was used in the HEMS IRP development process – follow on discussions and surveys with individuals from these organizations augmented this initial data input source.

9. The definition of the HEMS Industry is taken to mean the full spectrum of stakeholders involved in HEMS activities at all levels and is not simply the part 135 operators.

10. That all invited industry stakeholders will actively participate in the development of the HEMS Risk Reduction Work Plan and that this plan will acknowledge the many current initiatives already underway and in progress.

11. The Aerosafe Risk Management risk profiling model and methodologies revealed to the HEMS Industry will not be used, modified or reproduced without formal consent.

12. Addresses HEMS operations in the United States of America.

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LimitationsThis Industry Risk Profile is subject to the following limitations:

1. The Industry Risk Profile is confined to rotary wing operations. However, many of the risks identified will be common to, and useful in, the development of a broader risk profile for EMS operations. This profile excludes fixed wing air medial operations.

2. The IRP specifically addresses both commercial for-profit and not-for-profit operations which operate under Part 135 of the Federal Aviation Regulations.

3. This IRP does not cover the full spectrum of risk and other issues associated with public use HEMS operators (County and Police) which conduct business as private category operations under Part 91 of the Federal Aviation Regulations.

4. Not every stakeholder in the industry was subject to an individual interview in preparing the HEMS IRP.

5. During the consultation phase (review and interaction with the industry on the draft risk profile made available from February 12, 2009 to April 10, 2009) a large degree of fragmentation and differ-ing understanding of the risk management process was noted.

6. The current environment and the sensitive debate around proposed legislative change affected the ability of some stakeholder groups to effectively participate in this process.

7. The risk treatment strategies listed in the HEMS IRP have not been agreed or allocated to the industry at the time of release.

8. The HEMS Risk Reduction work plan is under development and was not sufficiently developed by industry to release concurrently with the release of the HEMS IRP.

9. The current context and structure of the HEMS industry does not lend itself to a collaboration, ready agreement or a collective responses to risk.

10. The existing regulatory regimes across aviation, healthcare and EMS are not visibly integrated.

11. The HEMS IRP does not claim to have utilized every data source available to the industry. However a rigorous and comprehensive process has been used and as a result, an 85% confidence rating in the integrity of the data and associated profile is acknowledged.

12. The industry have actively and visibly communicated the desire for voluntary change, yet the ability for the industry to implement such change has not been evaluated or assessed.

Risk criteriaThe following criteria were developed to allow the evaluation and quantification of risks. Since risk has two components, likelihood and consequence, consideration was given to issues including:

- The positions of Association of Air Medical Services, Helicopter Association International and the Air Medical Operators Association, as stated in their paper to the NTSB Hearing, February 2009, that they “maintain a position of zero tolerance for accidents in the air medical industry.” It is implied by this criteria that all reasonable measures will be taken to ensure that accidents do not happen and that risks are appropriately managed.

- A positive perception of the Industry by the public, families of the deceased, the media, politicians, legislatures, the Regulators and investigators is vital to the continued viability of the industry.

- A person/patient transported by a HEMS operator has the right to the same protections as any other member of the public traveling by air transport.

- Where the person/patient transported by a HEMS operator does not have a choice of carrier, a

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higher protection or duty of care than that of the travelling public exists.

- While the safety of the patient is the most important factor to be considered, the safety of the medical personnel and other crew on board is also critically important.

- Where emerging technologies will mitigate risk at reasonable costs, they should be considered as optional adjuncts for operational safety.

depth of AnalysisThe following is a synopsis of the depth of analysis used to develop the HEMS Industry Risk Profile:

- Context of the profile: This Industry Risk Profile has been developed in the context of providing a detailed, data-driven analysis of the issues that affect the key objectives of the HEMS Industry. By defining and focusing on the HEMS Industry as a single entity, this profile can provide insight into the various elements of the Industry and how the elements interact to achieve Industry objectives. The risk profile will be developed to cover the next ten year period commencing in January 2009.

- Literature review of publicly available documentation: A comprehensive review of a large and varied range of publicly available documents published over the past two decades was conducted. This review contributed to the development of an understanding of the HEMS Industry from a historical perspective. The documentation review also provided the basis on which key industry risk issues were identified. A total of 267 Documents were reviewed during the document review process.

- Stakeholder Analysis: A comprehensive stakeholder analysis was conducted in order to identify the stakeholders within the Industry that could provide the insight into the operations, status and issues impacting the HEMS Industry. The analysis identified stakeholders from public, private and government organizations, enabling the project team to conduct interviews with key industry decision makers. A total of 161 stakeholders were identified during the initial stakeholder analysis process and an additional 21 stakeholders were identified in the review of the draft HEMS IRP.

- Stakeholder Interviews: Once the industry stakeholders had been identified, several decision makers and opinion leaders within the industry were personally interviewed in order to collect a wide variety of information, both from the medical arena and the aviation industry. During these interviews a significant number of industry risk issues were identified.

- note: In line with the risk management process, the identified stakeholders were examined and it was determined whether formal communication, consultation or interaction was needed at the identification, review or solution development phase of work. As a matter of clarification, the stakeholder analysis determined the best match of risk identification method to each stakeholder group. As a result, formal interviews or surveys were not conducted on every stakeholder. Alternate risk identification methods were exercised on those remaining stakeholders.

- Collection of Risk Issues: A total of 1280 risk issues were identified from the initial risk identification sources. During the review of the draft HEMS IRP, and additional 200+ issues were identified and cross mapped to the risks listed in the HEMS IRP. The tabulated data was updated with these additional inputs. The main additions or amendments were in the risk impacts, a minor adjustment in the risk calculation and some additional proposed risk treatment strategies. Culminating in the presentation of 26 industry level risks worthy of attention, the HEMS IRP was finalized within the specific context outlined above.

- Risk Identification: This risk profiling methodology allows for a greater level of depth in the identification, selection and analysis of the risk information used in the risk identification step. In general available risk data consists primarily of qualitative information. As an attempt to minimize subjectivity, fourteen separate risk identification methods were used and the data collected from these sources layered and cross mapped for themes and grouping against the IRP model.

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Rationale for Analysis Methodology The HEMS Industry is committed to providing timely, quality patient transportation throughout the United States. This objective carries significant challenges considering the large landmass involved, the diverse terrain, weather conditions encountered and the complexity of the business and regulatory models. Solutions which are appropriate and effective in highly urbanized areas may not work in rural and isolated environments. Given such variability in mission profiles, options which ensure overall system safety, while allowing local flexibility, require evaluation.

In recent years, developments such as the Reason Model have been used in the analysis of accidents and incidents in the aviation industry. Reason identified that accidents occur when there are multiple failures in the various levels of defenses - “when the holes line up”. This model can also be used to design safety systems by identifying “defenses in depth”. Analysis of “defenses in depth” allows safety experts to identify potential points of failure and minimize the possibility of total system failure. Risk analysis (identification and assessment) is the tool that identifies potential points of failure in the Reason Model.

Defenses in Depth and the Relationship with Risk Reduction A systems approach also allows a structured consideration of possible defenses which can be layered to provide safe outcomes. A systems approach also has the further advantage of identifying the defenses which are necessary for overall system integrity. In locations where specific tools for risk mitigation prove ineffective or inappropriate, alternatives can be derived to manage the risk. A hierarchy of defenses (legislative, regulatory, mandated customer driven change and voluntary change by industry), which link directly to the risk treatment or risk reduction strategies, will be developed and presented in order of outcome effectiveness.

Methodology: Risk Management Process

Risk Management ProcessThe International Standards Organization (ISO) draft standard on risk management (FDIS ISO31000) outlines the methodology and risk management process used to develop the Industry Risk Profile. The following pictorial model is consistent with FDIS ISO31000 and provides the structure to classify, present and prioritize risk information. The risk profile was developed using the following process:

INDUSTRY STRUCTURE

& OVERSIGHT ORGANIZATIONAL

OPERATIONAL

ADAPtED FRoM REASon ACCIDEnt CAUSAtIonAl MoDEl

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Throughout every step of the risk management process a decision is made as to what level of communication or consultation is required. Over 161 stakeholders were identified in the initial and review stages of the HEMS IRP development each possessing a different perspective on the industry and the issues requiring attention. The opportunity for review and comment on the draft HEMS IRP was provided to 33 different stakeholder groups. Additional resource, dedicated briefings or a workshop was held with AAMS, AHS, AMOA, AMPA, CAMTS, FAA, FARE, Flight Safety Foundation, GAO, HAI, House Aviation Sub Committee, International Helicopter Safety Team, NEMSPA, NTSB, The Joint Commission.

At this industry level, the scope, definition and context of the industry itself was required in order to place some boundaries around the assessment. For the purposes of the IRP, the HEMS industry includes the aviation, medical and EMS disciplines. The FAA confirmed there were 74 Part 135 Operators approved to operate HEMS activities. The IRP excluded fixed wing air medical operations and any air medical operations conducted by public use operators.

For Industry level risk profiling 10-14 risk identification methods are normally used to extract risk issues that are then run through the risk management process. In the case of the HEMS IRP, 14 different risk identification methods were used which included a comprehensive literature review, stakeholder analysis, interviews, environmental scan, risk dimension analysis, data analysis, causal factor analysis, cultural assessment and task analysis. This process produced over 1400 data input sources to the IRP process.

Using the principles of the Reason accident causation model, a layering and classification process was then used to analyze the risk data. From this process, 26 industry level risks were identified. The consequence and likelihood of each of these 26 risk issues were assessed. A semi-quantative risk analysis tool was then used to calculate the level of risk associated with each of the 26 risks.

Building upon the risk analysis step above, the risks were then ordered and ranked from highest to lowest. Where more than one risk attracted the same risk rating, sub criteria was then applied to determine the ranking.

Multiple treatments were identified to address each risk. They vary in their scope but are designed to complement each other and provide a comprehensive risk response. It is recog-nized that some treatments can be undertaken by regulators while others can be addressed by various industry bodies, the customer that requests the HEMS service or individual operators themselves. A residual risk calculation was then made in light of the effectiveness of the risk treatment strategy listed. The risk treatment strategies listed in the HEMS IRP are performance or outcome based. These solutions require actual tasks to be derived, allocated and resourced in order to produce the HEMS Industry Risk Reduction Work Plan. It is recognized that many activities are already underway, this final step of the risk process calls for these and future initiatives to be captured and presented in this joint industry assurance and accountability tool.

It is to be noted that the context, the risks and their significance will change over time. The HEMS IRP is a dynamic document and reflects the assessment of the risk profile at a point in time. The most critical aspect of the monitor and review stage of the risk process is the follow through and implementation of the risk treatment strategies. Ultimately it is these actions that will reduce the risk.

Analyse the Risks

Evaluatethe Risks

Treatthe Risks

Monitorand Review

Communication & Consultation

Establish the Context

Identify the Risks

International Risk Management Standard (ISO31000)*

20


Methodology: Industry Risk Profile Model The industry risk profile model is used to classify and catalogue the risks identified in the HEMS IRP. This structure is used across the aviation industry and groups the issues into categories that generally guide the level of action required. The first three elements of the IRP model (oversight, compliance and assurance) combine to form the governance of the industry.

From here, other important elements are then depicted. It is to be noted, that each of these areas can be further examined and assessed to a greater level of depth. For example the efforts of the International Helicopter Safety Team’s JSAT, JSIT and subsequent HEMS Safety Committee or the efforts of the NTSB individual accident investigation process would be the next layer of depth provided in the safety profile element of the HEMS IRP model.

HEMSINDUSTRY

RISK PROFILE

ovERSIgHt ModEL

coMPLIAncE REgIME

ASSuRAncE ModEL

oPERAtoR PRofILE

ActIvIty PRofILE

AIRcRAft cAPABILIty

PRofILE

InduStRy oPERAtIng

EnvIRonMEnt

PASSEngER & PARtIcIPAnt

PRofILE

SyStEMS PRofILE

SAfEty PRofILE

© Aerosafe 2008

21

ovERSIgHt ModEL: The governance regime that exists within the industry in all facets at the highest level. In the case of the HEMS industry this includes gover-nance for the aviation, medical and emergency management services aspects. This element of the IRP model is closely aligned with the compli-ance and assurance elements.

coMPLIAncE REgIME:Considers the statutory and regulatory and framework in which the industry operates. The compliance element, along with the assurance element is a sub component of the overall over-sight model. At the industry risk profiling level, these two pieces are addressed individually.

ASSuRAncE ModEL:What level of assurance is provided and to what level of depth? These aspects are explored in the assurance element of the Industry Risk Profile. The objective of assurance is to provide ‘confidence’.

oPERAtoR PRofILE:The operator profile looks at the composition, structure and models of the operator group within the industry. A greater level of depth can be provided to this element if required by conducting an individual risk profile of each operator within the industry sector. Individual operator risk profiles are normally undertaken by the regulator as part of the regulators routine surveillance and intervention regime.

ActIvIty PRofILE:This element of the Industry Risk Profile examines the range of operational activities un-dertaken by the industry. In relation to the HEMS industry risk profile the activity profile includes inter facility transfers, scene flights, speciality team transports, training, maintenance, commu-nication functions to name a few.

AIRcRAft cAPABILIty PRofILE:This element looks at the aircraft capability, technology and equipment.

InduStRy oPERAtIng EnvIRonMEnt:The industry operating environment includes the overall setting and landscape of the environment in which the industry operates in its entirety.

PASSEngER & PARtIcIPAnt PRofILE:Considers the demographics of the passengers or participants who are involved in the activity. This element excludes aircrew or employees of the aviation operator which is covered in the operator profile.

SyStEMS PRofILE:The definition and maturity of the various man-agement systems available and utilized within the industry are covered in the scope of this element of the Industry Risk Profile. This includes but is not limited to management systems, business systems, information systems and safety management systems.

SAfEty PRofILE:This element of the Industry Risk Profile takes into account the incident and accident statistics and the overall safety profile of the industry sec-tor. Much of the information and data covered in this element is historical in nature.

23

Summation of Results

PARt 2

24

PARt 2 Summation of Results

VeRy HIGH

(1)

VeRy HIGH

(1)

VeRy HIGH

(1)

the results of the HEMS IRP can be examined in the following ways:

Risks presented by Risk Ranking (Pages 24-28)The tabulated data indicated below in table 1 presents the risks from highest to lowest. For those risks that have the same number (see numbering system in the far right hand column) this indicates the risk has been quantified at the same level. Where this is the case, sub criteria have been used to rank the risks within this classification. The summation of results in this presentation format only depicts the risk assessment, being the identification and quantification of risk and does not list any solutions to reduce the risk. This information is provided as a snapshot of the issues from highest to lowest and is to be read in association with Part 3.

Risks presented against risk matrix (Page 29)Risk is a measure of consequence and likelihood, the presentation of results against the risk matrix provide a visual representation of the risks scatter plot. The two matrix provide a visual representation of the ‘before’ and ‘after’ risk treatment. The second being referred to as residual risk, or the risk that is remaining after full implementation of risk reduction measures are achieved.

Risks presented against the IRP Model Categories (Pages 32-58)Part 3 of the HEMS IRP provides the risk information catalogued against the elements of the Industry Risk Profiling model. This functional grouping allows the reader to examine risks in the related cat-egory. The information is presented in this fashion, as it is often the case that high level stakeholders are looking for information against these classification elements (such as governance, aircraft capability, safety etc).

tAblE 1 Risks Presented by Risk Ranking

nUMbER RISKS RISK lEvEl

1 Risks associated with the lack of or limited definition of the national EMS structure or governance framework for HEMS. The current regime was not purposefully designed and has evolved over the past twenty years to the current regime in the absence of a framework. (Risk Reference 1 HEMS IRP)

2 The risk that the current medical reimbursement model (primary payer model) is no longer adequate to provide the appropriate level of financial coverage for either the current operating costs of the service or the impending upgrade of capability required through the addition of technology. (Risk Reference 15 HEMS IRP)

3 The risks associated with the complexity, non alignment and lack of clarity around the roles and scope of federal, state and county agencies involved in oversight of the HEMS industry. (Risk Reference 3 HEMS IRP)

25

VeRy HIGH

(2)

VeRy HIGH

(2)

VeRy HIGH

(2)

VeRy HIGH

(2)

VeRy HIGH

(3)

HIGH(4)

4 Cumulative risk associated with the variability among States over licensing requirements and standards for HEMS programs, as well as inconsis-tent interpretation of the States’ authority to determine a need for, and location of, new or existing HEMS programs and bases, has produced widespread variability in quality and safety in HEMS transport. (Risk Reference 8 HEMS IRP)

5 There are significant risk entrenched within the current tasking continuum used for allocating HEMS air medical assets. This inconsistency and lack of standardization in the tasking continuum spans the following process flow that includes:

- The evaluation of the patient need for care- The necessity of utilization of an aircraft for the passenger transport - The requesting agency - The tasking process including the

allocation of the task to a specific resource- The acceptance of a task by a HEMS operator- Through to operational control once the task has been

accepted and undertaken (Risk Reference 16 HEMS IRP)

6 The industry has many different business models that often have competing objectives and interests. The diversity in this industry structure has the potential to induce industry and organizational level competition and growth in turn increasing the operational and safety risk exposure of the industry. (Risk Reference 10 HEMS IRP)

7 Safety management systems are only starting to be introduced in the HEMS industry are not yet sufficiently mature to manage the level and depth of change required in the safety philosophies, processes and practices required. (Risk Reference 21 HEMS IRP)

8 The industry does not have one accredited agency that provides collective definition, oversight or monitoring for the combined aviation, health-care and emergency management functions that shape the HEMS (or broader air medical) industry. (Risk Reference 2 HEMS IRP)

9 The broad spectrum of stakeholders to the HEMS industry are not aware of the entire industry risk profile leading to an inability for the industry to effectively identify, analyze and reduce the risks in a orchestrated and cohesive way. (Risk Reference 4 HEMS IRP)



26


HIGH

(4)

HIGH

(4)

HIGH

(4)

HIGH

(5)

HIGH

(6)

10 The lack of National Airspace System and other infrastructure constraints in the airspace where HEMS operate dictate the conditions for the operational profile for flight removing the option to HEMS Operators to fly IFR. (Risk Reference 17 HEMS IRP)

11 The complexity of the oversight, compliance and regulatory regimes does not provide the structure required for the industry to have an inclusive assurance regime or program of audits, accreditation and checking leading to an inability to provide confidence that the industry is being appropriately managed. (Risk Reference 7 HEMS IRP)

12 Owing to the nature of the task profiles conducted in HEMS and the close working relationship the aircrew have with medical personnel involved in the tasks, there is increased blurring of lines of role and responsibility in respect to the medical personnel contribution to safe operation of the aircraft. This risk of ambiguity is increased with medi-cal personnel involvement in NVG operations, passenger briefing, task briefing, loading and unloading of aircraft, operational risk manage-ment assessments and crew briefing and debriefing processes. (Risk Reference 20 HEMS IRP)

13 The risks associated with the lack of development of a tangible safety culture that truly understands risk and the management of risk. (Risk Reference 26 HEMS IRP)

14 There is inherent complexity in the compliance regime used to govern the HEMS industry which is confusing and dictated by a myriad of non-related stakeholders leading to an increased chance that HEMS opera-tors are non-compliant. This risk is induced by a number of factors that includes: - There are three distinct disciplines that all set the compliance

regime that affects the HEMS industry (aviation, healthcare and emergency services)

- The overlap or interface between these compliance regimes has not been clearly mapped out or is not easily accessible

- There is no agreed inter-discipline hierarchy for regulation, policy or standards of either the national ascending hierarchy

(Risk Reference 6 HEMS IRP)



27

HIGH

(6)

HIGH

(6)

HIGH

(7)

HIGH

(7)

HIGH

(7)

HIGH

(8)

15 Risk that the current definition and scope of the industry is not well defined leading to limitations in the ability or appropriate agencies and stake-holders to effectively govern their aspect of the industry. The key risk induced by this issue is the limitations on the ability for a complete and industry wide data driven national solution to manage the landscape to be identified, coordinated and effectively implemented. (Risk Reference 9 HEMS IRP)

16 The current safety analysis and monitoring of the HEMS industry is not data driven leading to an inability for the Regulator or the Industry itself to have an accurate picture of real safety picture. (Risk Reference 24 HEMS IRP)

17 The operating environment and the associated infrastructure and standard industry practices for the two routine task profiles (inter-facility & scene flights) is not sufficiently designed at the HEMS System level, leading to the increased variance and application of flight profiles, safety standards and safety risk exposure to patient, aircraft, aircraft and the public. (Risk Reference 12 HEMS IRP)

18 Lack of integration and alignment of accountability, responsibility and resourcing for the standardization of helipad operations in the inter facil-ity environment by hospitals, impacting upon operation, maintenance and continuous hazard management of helipads in the inter-facility envi-ronment by hospitals, primary HEMS operator and other helipad users. (Risk Reference 18 HEMS IRP)

19 The current training regime for a high percentage of the HEMS industry does not employ the use of simulators and advanced training methods broadly used in other parts of the aviation industry predominately due to cost. (Risk Reference 25 HEMS IRP)

20 The current regulatory philosophy combined with the financial risks induced by the funding model of the industry engender a mind set or culture in the HEMS industry to only meet minimum prescribed standards rather than managing risks in the operation through the implementation of better practices. (Risk Reference 5 HEMS IRP)



28


HIGH

(8)

HIGH

(8)

HIGH

(8)

HIGH

(8)

HIGH

(8)

HIGH

(9)

21 There is no activity or task profile definition set for the HEMS industry sector making it difficult to oversee the risks associated with the vari-ous task profiles at an industry, national or State level. In addition to this, changes to the trends in industry activities are not easily identified or monitored and the platform for data driven monitoring does not exist to the level of maturity required to capitalize. (Risk Reference 11 HEMS IRP)

22 The risk that the HEMS industry does not consistently identify, adopt, utilize and maximize aircraft technology available in the aviation industry to enhance safety parameters leading to a decrease in the risk of an accident or incident. (Risk Reference 13 HEMS IRP)

23 The risk associated with the inability to effectively resource and manage the operational, technical and cultural change related to the introduction of new technology into service. (Risk Reference 14 HEMS IRP)

24 The profile of the passenger or participant (patient and medical crew) profile in the HEMS industry differs significantly from that of other sectors of the aviation community by virtue of the fact that the patient does not have a choice in the operator allocated to undertake their transport. (Risk Reference 19 HEMS IRP)

25 Aviation and medical safety management systems are not integrated at a compliance or policy level leading to incoherent, conflicting or com-peting priorities or practices which may stifle the effective introduction of the SMS within the HEMS Industry. (Risk Reference 22 HEMS IRP)

26 Lack of effective and sound implementation of operational control arrangements within the HEMS industry leading to the increased increases the risk of poor operational decisions and misalignment of accountability and responsibility for flight operations. (Risk Reference 23 HEMS IRP)



29

LIKELIHood

LIKELIHood

cERtAIn LIKELy PoSSIBLE unLIKELy

cERtAIn LIKELy PoSSIBLE unLIKELy

tAblE 2 Risks Presented against Risk Matrix

tAblE 2.A: bEFoRE RISK tREAtMEnt

tAblE 2.b: AFtER RISK tREAtMEnt. RESIDUAl RISK

EXtREME

cRItIcAL

MAJoR

MInoR

EXtREME

cRItIcAL

MAJoR

MInoR

co

nSE

Qu

Enc

Ec

on

SEQ

uEn

cE

VeRy HIGH

(1)

VeRy HIGH

(1)

VeRy HIGH

(3)

VeRy HIGH

(3)

VeRy HIGH

(2)

VeRy HIGH

(2)

HIGH(6)

HIGH(6)

MeDIUM(11)

MeDIUM(11)

LOW(15)

LOW(15)

HIGH(5)

HIGH(5)

HIGH(10)

HIGH(10)

HIGH(8)

HIGH(8)

HIGH(4)

HIGH(4)

HIGH(7)

HIGH(7)

MeDIUM(13)

MeDIUM(13)

MeDIUM(14)

MeDIUM(14)

LOW (16)

LOW (16)

HIGH(9)

HIGH(9)

MeDIUM (12)

MeDIUM (12)

31

Industry Risk Profile tabulated data

PARt 3

How to Read tabulated dataPart 3 of the HEMS IRP is a technical document which has been written to provide the in-depth iden-tification, analysis and proposed management strategies to treat the risk. When reading the tabulated data, the contents are to be read from left to right. These risks are not ordered in priority from highest to lowest, but rather are grouped and classified against the IRP Model elements outlined on page 20. The table sub heading at the top of each page in the blue bar reflects the relevant IRP model element for each risk.

Each page of the tabulated data contains explicit, in depth information. The far left column labelled “Description of the Risk” provides an overview of the risk statement. It is to be noted that these risks statements are worded as risks (the chance something could happen - not the certainty that it is hap-pening) to this end the risk statement is to be read in concert with the likelihood column for that item for a complete picture of the risk.

The column to the right of the Risk Description is the impact that that risk may have on the HEMS Industry. These dot points are potential consequences written long hand and are to be read in concert with the ‘Consequence” column in the risk assessment component of the table. This consequence rating is the semi-quantative assessment of the word picture outlined in the “Impact” column. In essence these two columns indicate one and the same thing using different language and methods.

Risk level is calculated by multiplying consequence and the likelihood on a two dimensional matrix. The risk level is indicated by both a word e.g. “High” and a number e.g.”(5)”. This number correlates to the placement on the matrix as indicated on page 29 given each risk level spans a number of boxes.

The most critical aspect to the whole tabulated data and the IRP itself is the identification, resourcing and implementation of risk reduction measures known as “Risk Treatment Strategies”. For the purposes of this IRP, the risk treatment strategies listed in this tabulated data are “Performance or Outcome based” and are not specific tasks allocated to any one group in industry. These reduction measures need to be further developed into actual tasks that can be implemented, tracked and measured. This information will be held in the HEMS Industry Risk Reduction Action Plan.

The residual risk rating uses this same process as the risk assessment step while taking into account the forecast of the risk level calculation (of both consequence and likelihood) once the proposed set of treatments has been implemented. The residual risk can only be claimed by the industry once the treat-ments have been allocated, resourced and completed. A progress report against the implementation should be undertaken regularly to track a downward motion of the risk profile.

The far right hand column labelled “Priority” provided an indication of where that itemized risk falls in the risk ranking from 1-26.

32

Ris

ks a

sso

ciat

ed w

ith

the

lack

of

or

limite

d

defi

niti

on

of

the

na-

tion

al E

MS

stru

ctu

re

or

gove

rnan

ce f

ram

e-w

ork

fo

r H

EM

S. T

he

curr

ent r

egim

e w

as n

ot

pu

rpo

sefu

lly d

esig

ned

an

d h

as e

volv

ed

over

the

pas

t tw

enty

ye

ars

to th

e cu

rren

t re

gim

e in

the

abse

nce

o

f a

fram

ewo

rk.

- T

he d

evel

opm

ent o

f st

ate

base

d EM

S sy

stem

s w

hich

are

not

con

nect

ed o

r co

nsis

tent

- D

iver

genc

e in

sta

ndar

ds a

t a S

tate

leve

l w

hich

can

hav

e na

tiona

l im

plic

atio

ns-

Incr

ease

d ch

ance

of

confl

ictin

g le

gisl

ativ

e an

d re

gula

tory

pra

ctic

es n

atio

n w

ide

- C

onfu

sion

in th

e in

dust

ry a

roun

d ac

cep

ted

pra

ctic

es-

The

con

tinuu

m o

f in

divi

dual

pat

ient

car

e an

d th

e le

vel o

f he

alth

care

is in

terr

upte

d or

not

str

eam

lined

-

Incr

easi

ng v

aria

nce

in b

usin

ess

mod

els

crea

ting

pot

entia

l con

flict

loca

lly a

nd n

atio

nally

-

No

pub

licly

vis

ible

acc

ount

abili

ty

stru

ctur

e fo

r th

e in

dust

ry

- In

crea

sed

occu

rren

ce o

f co

mp

etin

g in

tere

sts

- C

halle

nges

in g

aini

ng a

gree

men

t on

st

anda

rds,

acc

redi

tatio

n, p

ract

ices

and

p

roce

dure

s in

use

acr

oss

the

indu

stry

- V

aria

nce

in c

rite

ria

for

pro

fess

iona

ls w

orki

ng in

this

fiel

d-

Diffi

culti

es fo

r H

EMS

pro

gram

s to

nav

igat

e th

roug

h th

e co

mp

lianc

e re

gim

e -

Lack

of

desi

gn o

f th

e EM

S sy

stem

cou

ld

stifl

e gr

owth

or

exp

ansi

on-

Dup

licat

ion

of r

esou

rces

- D

isp

arity

in m

atch

ing

app

rop

riat

e re

sour

ces

to th

e he

alth

care

nee

ds-

Lack

of

confi

denc

e by

the

stak

ehol

ders

that

ef

fect

ive

heal

thca

re c

an b

e ef

fect

ivel

y de

liver

ed

- G

reat

er r

elia

nce

on th

e H

EMS

oper

ator

s to

mak

e de

cisi

ons

rega

rdin

g p

olic

y an

d p

ositi

on o

n

pat

ient

tran

spor

t – r

athe

r th

an b

eing

abl

e to

rel

y on

end

orse

d an

d ac

cep

ted

natio

nal p

roto

cols

-

Incr

ease

pro

babi

lity

of in

duce

d un

der

or o

ver

utili

zatio

n of

res

ourc

es

- La

ck o

f le

ader

ship

and

dir

ectio

n on

the

futu

re o

f EM

S an

d in

par

ticul

ar H

EMS

- Po

tent

ial f

or in

crea

sed

cont

rol b

y St

ates

- C

onve

ne a

task

forc

e of

key

indu

stry

an

d re

gula

tory

bod

ies

to c

olla

bora

tivel

y re

view

the

natio

nal E

MS

defin

ition

, fr

amew

ork

and

arra

ngem

ents

for

thei

r su

itabi

lity

and

effe

ctiv

enes

s -

Follo

win

g re

view

and

acc

epta

nce,

ado

pt t

he

enha

ncem

ents

or

rede

sign

of

the

natio

nal

EMS

fram

ewor

k to

cat

er fo

r th

e na

tiona

l, st

ate

and

loca

l nee

ds o

f th

e he

alth

care

com

mun

ity.

Thi

s bo

dy o

f w

ork

shou

ld in

clud

e an

as

sess

men

t/co

mp

aris

on o

f m

ultip

le o

ptio

ns-

Con

firm

the

pol

itica

l pos

ition

up

on

whe

ther

acc

ess

to a

ir m

edic

al

tran

spor

tatio

n is

con

side

red

an e

ssen

tial

serv

ice

(em

erge

ncy

med

icin

e)

- A

pp

oint

an

app

rop

riat

e jo

int a

genc

y to

p

rovi

de th

e hi

ghes

t lev

el o

f ac

coun

tabi

lity

for

the

effe

ctiv

e im

ple

men

tatio

n of

th

is e

nhan

cem

ent e

ffor

t to

imp

rove

th

e na

tiona

l EM

S fr

amew

ork

- T

he N

atio

nal E

MS

fram

ewor

k to

incl

ude

per

form

ance

bas

ed r

equi

rem

ents

for

the

Stat

es to

des

ign

and

imp

lem

ent

the

EMS

syst

em c

onsi

sten

t with

the

fram

ewor

k w

ithin

thei

r St

ate

- D

evel

op o

ptio

ns to

res

olve

the

ques

tion

of

fede

ral v

s st

ate

over

sigh

t of

the

med

ical

co

mp

onen

t of

HEM

S op

erat

ions

.-

Imp

lem

ent t

he e

nhan

ced

Nat

iona

l EM

S de

finiti

on a

nd s

truc

ture

(fr

amew

ork)

Seri

al n

o. 1

o

vER

SIG

Ht

Mo

DEl

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL vERy HIgH (1)

LIKELIHood: cERtAIn

conSEQuEncE: EXtREME

PRIoRIty: 1

RESIduAL RISK: MEdIuM (12)

33

Th

e in

du

stry

do

es n

ot

hav

e o

ne

accr

edite

d

agen

cy th

at p

rovi

des

co

llect

ive

defi

niti

on

, ov

ersi

ght o

r m

on

itor-

ing

for

the

com

bin

ed

avia

tion

, hea

lthca

re

and

em

erge

ncy

m

anag

emen

t fu

nc-

tion

s th

at s

hap

e th

e H

EM

S (o

r b

road

er A

ir

Med

ical

) in

du

stry

- La

ck o

f vi

sibl

e di

rect

ion

and

auth

ority

for

this

in

dust

ry s

ecto

r –

no o

ne b

ody

in c

harg

e -

Cha

lleng

es in

pro

vidi

ng a

n ad

equa

te le

vel o

f as

sura

nce

that

is c

omp

lete

and

enc

omp

assi

ng in

nat

ure

- C

omp

lex

and

mul

tiple

rep

ortin

g an

d co

mp

lianc

e re

quir

emen

ts o

ver

-bur

deni

ng in

divi

dual

op

erat

ors

- Po

tent

ial f

or fr

agm

enta

tion

in th

e in

dust

ry

by H

EMS

oper

ator

s si

ding

or

pre

ferr

ing

one

accr

edita

tion

pro

gram

ove

r an

othe

r

- La

ck o

f co

mbi

ned

over

sigh

t for

med

ical

, EM

S an

d av

iatio

n fu

nctio

ns is

not

pro

vide

d to

the

cust

omer

or

the

com

mun

ity a

t lar

ge

- C

ontin

ued

and

enha

nced

deb

ate

abou

t w

heth

er th

e av

iatio

n or

med

ical

indu

stry

is th

e p

rim

ary

auth

ority

or

cont

rolle

r re

spon

sibl

e fo

r ul

timat

e st

anda

rd s

ettin

g an

d as

sura

nce

- C

onfli

cts

of

or c

omp

etin

g in

tere

sts

- G

row

th o

f m

ultip

le a

genc

ies

and

accr

edita

tion

bodi

es

that

hav

e a

som

e st

ake

in s

ettin

g in

dust

ry s

tand

ards

- Po

tent

ial f

or th

e du

plic

atio

n of

eff

orts

by

sep

arat

e or

gani

zatio

ns o

r en

titie

s to

add

ress

th

e sa

me,

or

sim

ilar

indu

stry

ris

k is

sues

- B

est p

ract

ice

oper

atio

ns a

nd p

roce

dure

s ar

e no

t pro

pag

ated

thou

gh th

e in

dust

ry.

- C

onfu

sion

ove

r w

hat e

ntity

has

juri

sdic

tion

ov

er is

sues

ove

rsig

ht a

nd r

esol

utio

n

- N

on a

lignm

ent o

f ac

coun

tabi

lity,

res

pon

sibi

lity

and

re

sour

cing

for

the

man

agem

ent o

f in

dust

ry le

vel r

isks

-

Incr

ease

d co

st to

HEM

S O

per

ator

s an

d th

eref

ore

the

incr

ease

d ov

erhe

ad to

the

indu

stry

’s op

erat

ing

cost

- Se

ek a

ckno

wle

dgem

ent o

f H

EMS

as it

s ow

n in

dust

ry o

win

g to

the

uniq

ue fe

atur

es a

nd r

elia

nce

on th

e in

tero

per

abili

ty a

nd in

ters

ectio

n of

avi

atio

n,

heal

thca

re a

nd e

mer

genc

y se

rvic

es

- Es

tabl

ish

an in

tera

genc

y ta

sk fo

rce

char

ged

w

ith id

entif

ying

, defi

ning

and

ass

essi

ng th

e is

sues

ass

ocia

ted

with

the

inte

rsec

ting

poi

nts

of th

e th

ree

disc

iplin

es in

the

HEM

S in

dust

ry

from

a g

over

nanc

e an

d ov

ersi

ght p

ersp

ectiv

e

- In

dust

ry to

est

ablis

h a

volu

ntar

y cu

stod

ian

grou

p to

ove

rsee

and

mon

itor

the

risk

pro

file

of th

e in

dust

ry

- Id

entif

y th

e le

gisl

ator

, reg

ulat

or, c

usto

mer

an

d in

dust

ry fo

r th

e av

iatio

n, m

edic

al

and

emer

genc

y se

rvic

es a

spec

ts o

f H

EMS

(eg

loca

te th

e re

gula

tor

for

heal

thca

re a

spec

ts o

f H

EMS)

- D

evel

op o

ptio

ns to

res

olve

lack

of

clar

ity

rega

rdin

g fe

dera

l vs

stat

e ov

ersi

ght o

f th

e m

edic

al c

omp

onen

t of

HEM

S op

erat

ions

.-

Esta

blis

h a

join

t tas

k fo

rce

or e

ntity

(a

lbei

t it t

emp

orar

y) to

ove

rsee

al

ignm

ent o

f re

gula

tion

as r

equi

red

Seri

al n

o. 2

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng


LIKELIHood: cERtAIn

conSEQuEncE: cRItIcAL

PRIoRIty: 4

RESIduAL RISK: LoW (15)

34

Th

e ri

sks

asso

ciat

ed

with

the

com

ple

xity

, n

on

alig

nm

ent a

nd

la

ck o

f cl

arity

aro

un

d

the

role

s an

d s

cop

e o

f fe

der

al, s

tate

an

d

cou

nty

age

nci

es

invo

lved

in o

vers

igh

t o

f th

e H

EM

S in

du

stry

- In

cons

iste

ncy

with

the

crite

ria

and

pro

toco

ls

that

dic

tate

the

use

of H

EMS

asse

ts

- C

halle

nges

for

the

indu

stry

in m

app

ing

out

the

requ

irem

ents

that

they

sho

uld

eith

er b

e co

mp

lyin

g w

ith o

r st

rivi

ng to

ach

ieve

-

Lack

of

clar

ity a

roun

d th

at b

ody

or

agen

cy is

trul

y ac

coun

tabl

e -

No

sing

le r

egul

ator

y bo

dy h

as r

esp

onsi

bilit

y fo

r ov

ersi

ghtin

g th

e EM

S sy

stem

as

a w

hole

- C

onfli

ctin

g re

gula

tory

pri

oriti

es m

ay p

lace

op

erat

ors

in a

p

ositi

on w

here

they

mak

e de

cisi

ons

that

are

not

op

timal

fo

r ei

ther

the

avia

tion

or m

edic

al a

reas

of

the

sect

or-

Regu

lato

rs c

an m

ake

inde

pen

dent

dec

isio

ns w

hich

m

ay c

omp

rom

ise

safe

ty in

the

othe

r ar

ea-

The

sco

pe

and

defin

ition

of

the

indu

stry

rem

ains

un

clea

r le

adin

g to

inab

ility

to im

ple

men

t an

ef

fect

ive

natio

nal g

over

nanc

e re

gim

e -

Econ

omic

cha

lleng

es a

nd p

oten

tial c

hang

es to

Fed

eral

, St

ate

and

pri

vate

insu

ranc

e re

imbu

rsem

ent r

egim

es

- U

nder

take

a d

etai

led

anal

ysis

of

all b

odie

s w

ithin

the

USA

that

hav

e so

me

leve

l of

acco

unta

bilit

y or

res

pon

sibi

lity

for

the

regu

lato

ry a

spec

ts o

f th

e H

EMS

syst

em in

or

der

to d

evel

op a

cen

tral

ized

sta

keho

lder

da

taba

se a

nd r

efer

ence

poi

nt fo

r ch

ange

- C

lari

fy a

nd p

ublis

h th

e de

finiti

on o

f ro

les

of th

e va

riou

s st

akeh

olde

rs

- D

esig

n na

tiona

l lev

el p

erfo

rman

ce

base

d re

quir

emen

ts fo

r na

tiona

l us

e no

ting

the

need

for

cons

iste

nt

imp

lem

enta

tion

at th

e St

ate

leve

l -

As

par

t of

the

key

indu

stry

and

reg

ulat

ory

body

task

forc

e in

1 a

bove

, est

ablis

h

wor

king

gro

up to

dev

elop

an

inte

grat

ed

over

sigh

t mod

el fo

r H

EMS

that

take

s in

to a

ccou

nt th

e le

gal j

uris

dict

ion

and

ac

coun

tabi

litie

s of

the

vari

ous

stak

ehol

ders

. -

Dev

elop

op

tions

to r

esol

ve th

e la

ck o

f cl

arity

ar

ound

thos

e ar

eas

that

cro

ss th

e bo

unds

of

both

fede

ral a

nd s

tate

ove

rsig

ht r

egim

es.

- D

efine

the

legi

slat

or, r

egul

ator

, cus

tom

er

and

indu

stry

for

the

avia

tion,

med

ical

and

em

erge

ncy

serv

ices

asp

ects

of

HEM

S -

Onc

e th

e m

edic

al r

egul

ator

is lo

cate

d,

deve

lop

and

set

min

imum

sta

ndar

ds

for

air

ambu

lanc

e m

edic

al c

are

- Im

ple

men

t tre

atm

ents

from

num

ber

1 an

d 2

Seri

al n

o. 3

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng


LIKELIHood: cERtAIn


PRIoRIty: 3


35

Th

e b

road

sp

ectr

um

o

f st

akeh

old

ers

to th

e H

EM

S in

du

stry

are

no

t aw

are

of

the

entir

e in

du

stry

ris

k p

rofi

le

lead

ing

to a

n in

-ab

ility

fo

r th

e in

du

stry

to

eff

ectiv

ely

iden

tify,

an

alys

e an

d r

edu

ce th

e ri

sks

in a

orc

hes

trat

ed

and

co

hes

ive

way

- T

he fu

ll ex

tent

of

the

risk

pro

file

of th

e H

EMS

indu

stry

has

not

bee

n id

entifi

ed, a

naly

sis

or

mea

sure

d an

d is

ther

efor

e no

t com

ple

tely

kno

wn

an

d ca

n th

eref

ore

not b

e en

tirel

y m

anag

ed.

- In

abili

ty fo

r th

e H

EMS

indu

stry

to r

egai

n

confi

denc

e by

the

com

mun

ity th

at th

e ri

sks

are

bein

g ef

fect

ivel

y m

anag

ed-

Ris

ks a

re n

ot a

pp

rop

riat

ely

iden

tified

, as

sess

ed o

r m

anag

ed

- Pr

olon

ged

ques

tion

arou

nd th

e in

tegr

ity o

f th

e H

EMS

indu

stry

and

ass

ocia

ted

oper

ator

s fr

om th

e p

atie

nt a

nd h

osp

ital c

omm

uniti

es

- T

he in

dust

ry m

ay n

ot e

ffec

tivel

y m

anag

e th

e st

rate

gic,

saf

ety,

op

erat

ion,

tech

nica

l, tr

ansi

tiona

l and

co

mp

etiti

on r

isks

cur

rent

ly p

rese

nt in

the

indu

stry

-

The

rig

ht b

odie

s, o

rgan

izat

ions

or

agen

cies

may

no

t be

awar

e of

the

role

they

pla

y in

pro

vidi

ng a

ke

y so

lutio

n th

at w

ould

red

uce

the

risk

pro

file

-

Inci

dent

or

acci

dent

rat

e co

uld

cont

inue

at

an

unac

cep

tabl

e le

vel

- Lo

ss o

f co

nfide

nce

by th

e in

sura

nce

indu

stry

le

adin

g to

the

pri

ce o

f in

sura

nce

bein

g dr

iven

up

or

in s

ome

case

s no

t und

erw

ritte

n

- T

he e

ffor

ts to

pro

vide

a s

olut

ion

to th

e ar

ray

of in

dust

ry is

sues

may

not

be

coor

dina

ted

-

Incr

ease

d ch

ange

in d

uplic

atio

n of

eff

ort i

n

som

e ar

eas

and

lack

of

cove

rage

in o

ther

s -

Incr

ease

d le

vel o

f ‘s

ilo’ b

ehav

ior

acro

ss

the

indu

stry

due

to la

ck o

f cr

oss

func

tiona

l kn

owle

dge,

aw

aren

ess

of o

wne

rshi

p

- N

egat

ive

imp

act o

n th

e in

dust

ry’s

nat

iona

l rep

utat

ion

-

Loss

of

pub

lic c

onfid

ence

in th

e in

dust

ry’s

abili

ty to

ad

equa

tely

pro

vide

ove

rsig

ht a

nd m

anag

e th

e re

sour

ces

and

pub

lic m

oney

pro

vide

d to

fund

med

ical

tran

spor

t -

Incr

ease

d sp

ot li

ght b

y re

gula

tors

and

legi

slat

ors

- In

crea

se c

hanc

e th

at le

gisl

ativ

e so

lutio

ns w

ill b

e p

ursu

ed-

Div

isio

n in

the

indu

stry

– le

adin

g to

ulti

mat

e im

pac

t up

on th

e de

liver

y of

pat

ient

car

e

- D

evel

op th

e H

EMS

Indu

stry

Ris

k Pr

ofile

and

as

soci

ated

HEM

S In

dust

ry R

isk

Redu

ctio

n

Plan

whi

ch is

der

ived

from

the

pro

pos

ed

risk

trea

tmen

ts p

rese

nted

in th

e p

rofil

e -

Form

ally

pro

vide

op

por

tuni

ty fo

r in

dust

ry

to s

eek

com

mitm

ent f

or th

e de

velo

pm

ent,

spon

sors

hip

and

imp

lem

enta

tion

of

risk

trea

tmen

t str

ateg

ies

to r

educ

e th

e ri

sk p

rofil

e of

the

indu

stry

-

Esta

blis

h an

indu

stry

leve

l cus

todi

an

grou

p to

mon

itor

the

imp

lem

enta

tion

of

the

HEM

S In

dust

ry R

isk

Redu

ctio

n Pl

an

- Li

nk th

is c

usto

dian

gro

up w

ith th

e in

tern

atio

nal e

ffor

ts o

f re

duci

ng

acci

dent

rat

es th

roug

h th

e In

tern

atio

nal

Hel

icop

ter

Safe

ty T

eam

(IH

ST)

- Es

tabl

ish

a se

lf a

ccou

ntab

ility

reg

ime

that

hol

ds th

e in

dust

ry to

acc

ount

for

the

imp

lem

enta

tion

of r

isk

redu

ctio

n

stra

tegi

es p

ublic

ly c

omm

itted

-

Rele

ase

the

HEM

S In

dust

ry R

isk

Profi

le

to in

dust

ry fo

r th

eir

use.

As

par

t of

this

co

mm

unic

atio

n ca

mp

aign

, est

ablis

h fo

rmal

br

iefin

gs to

indu

stry

ass

ocia

tion

grou

p B

oard

of

Dir

ecto

rs, N

atio

nal L

evel

Reg

ulat

ors,

Sta

te

Gov

erno

rs/E

MS

Age

ncie

s/Li

cens

ing

Bod

ies,

th

e cu

stom

ers,

med

ia a

nd th

e in

dust

ry

itsel

f. C

ondu

ct a

tech

nica

l bri

efing

with

the

med

ia in

ord

er to

pro

vide

the

full

spec

trum

of

info

rmat

ion

rega

rdin

g th

e ri

sk p

rofil

e.

- A

lign

the

curr

ent e

ffor

ts o

f th

e in

dust

ry a

nd m

easu

re

Seri

al n

o. 4

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (4)

LIKELIHood: LIKELy


PRIoRIty: 9


36

Th

e cu

rren

t reg

ula

tory

p

hilo

sop

hy c

om

bin

ed

with

the

fin

anci

al

risk

s in

du

ced

by

the

fun

din

g m

od

el o

f th

e in

du

stry

en

gen

der

a

min

d s

et o

r cu

lture

in th

e H

EM

S in

du

stry

to o

nly

mee

t m

inim

um

pre

scri

bed

st

and

ard

s ra

ther

than

m

anag

ing

risk

s in

the

op

erat

ion

thro

ugh

th

e im

ple

men

tatio

n

of

bet

ter

pra

ctic

es.

- Pr

escr

iptiv

e re

gula

tory

reg

imes

pro

vide

det

aile

d

desc

rip

tions

of

how

com

plia

nce

mus

t be

achi

eved

ra

ther

than

pro

vidi

ng o

pp

ortu

nitie

s fo

r m

eetin

g th

e re

gula

tion

thro

ugh

app

rop

riat

e ac

tions

that

are

sp

ecifi

c an

d ac

hiev

able

to in

divi

dual

op

erat

ors

- T

hey

limit

the

abili

ty o

f op

erat

ors

to im

ple

men

t effi

cien

t sy

stem

s to

mee

t the

saf

ety

inte

nt o

f th

e re

gula

tions

- O

per

ator

s m

ay c

ondu

ct V

FR fl

ight

s du

e to

lim

itatio

ns in

the

regu

latio

ns-

Op

erat

ors

may

not

imp

lem

ent r

equi

red

chan

ges

due

to d

elay

s in

up

datin

g re

gula

tions

- O

per

ator

s m

ay in

cur

com

plia

nce

cost

s fo

r ac

tions

whi

ch h

ave

limite

d sa

fety

val

ue-

Incr

ease

s th

e p

ract

ice

with

in in

dust

ry o

f w

aitin

g fo

r p

resc

rip

tive

regu

latio

ns to

be

rele

ased

rat

her

than

that

taki

ng a

pro

activ

e be

tter

pra

ctic

e st

ance

- In

dust

ry to

dev

elop

and

ado

pt a

n ac

tion

ag

enda

to im

ple

men

t vol

unta

ry c

hang

e to

add

ress

the

key

risk

are

as th

e in

dust

ry

is in

a p

ositi

on to

con

trol

and

influ

ence

-

Indu

stry

to d

evel

op o

r re

cogn

ize

bette

r p

ract

ice

stan

dard

s (c

omm

unity

pra

ctic

es)

that

ex

ceed

the

min

imum

reg

ulat

ory

com

plia

nce

- En

cour

age

a p

erfo

rman

ce b

ased

p

hilo

sop

hy to

be

adop

ted

for

the

spec

trum

of

new

dev

elop

ed r

egul

atio

ns

per

tain

ing

to th

e H

EMS

Indu

stry

-

Imp

lem

ent a

n ed

ucat

ion

cam

pai

gn a

cros

s th

e in

dust

ry o

n th

e p

urp

ose,

ben

efit a

nd

usag

e of

per

form

ance

bas

ed r

egul

atio

n

- Im

ple

men

t an

exec

utiv

e le

ader

ship

pro

gram

fo

r th

e cu

stom

ers

(hos

pita

l exe

cutiv

es, E

MS

per

sonn

el a

nd P

art 1

35 e

xecu

tive)

on

the

natu

re, r

ole

and

resp

onsi

bilit

ies

asso

ciat

ed

with

per

form

ance

bas

ed r

egul

atio

n

- Fo

rmal

ly s

how

case

bet

ter

pra

ctic

e m

odel

s w

ith a

focu

s of

shi

ftin

g th

e ba

se m

ind

set a

nd c

ultu

re

Seri

al n

o. 5

C

oM

PlIA

nC

E R

EGIM

E

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (8)

LIKELIHood: PoSSIBLE


PRIoRIty: 20


37

Th

ere

is in

her

ent

com

ple

xity

in th

e co

m-

plia

nce

reg

ime

use

d

to g

over

n th

e H

EM

S in

du

stry

wh

ich

is

con

fusi

ng

and

dic

tate

d

by a

myr

iad

of

no

n-

rela

ted

sta

keh

old

ers

lead

ing

to a

n in

crea

sed

ch

ance

that

HE

MS

op

erat

ors

are

no

n-

com

plia

nt.

Th

is r

isk

is

ind

uce

d b

y a

num

ber

o

f fa

cto

rs th

at in

clu

des

: -

The

re a

re th

ree

dist

inct

dis

cip

lines

th

at a

ll se

t the

co

mp

lianc

e re

gim

e th

at a

ffec

ts th

e H

EMS

indu

stry

(av

iatio

n,

heal

thca

re a

nd

emer

genc

y se

rvic

es)

- T

he o

verl

ap o

r in

ter-

face

bet

wee

n th

ese

com

plia

nce

regi

mes

ha

s no

t bee

n cl

earl

y m

app

ed o

ut o

r is

not

ea

sily

acc

essi

ble

- T

here

is n

o ag

reed

in

ter-

disc

iplin

e hi

er-

arch

y fo

r re

gula

tion,

p

olic

y or

sta

ndar

ds

of e

ither

the

natio

nal

asce

ndin

g hi

erar

chy

or c

ross

func

tiona

l di

scip

lines

- St

anda

rds

or r

equi

rem

ents

cou

ld

beco

me

confl

ictin

g in

nat

ure

- In

crea

sed

risk

exp

osur

e fr

om a

le

gal a

nd s

afet

y p

ersp

ectiv

e -

Incr

ease

d ch

ance

sta

ndar

ds a

nd

crite

ria

are

not b

eing

met

- In

dust

ry fa

lls b

ack

onto

vol

unta

ry s

tand

ards

an

d ac

cred

itatio

n bo

dies

as

they

do

not h

ave

the

cap

acity

or

are

not a

war

e of

the

dep

th

and

com

ple

xity

of

the

issu

es a

t han

d

- T

he in

dust

ry d

oes

not a

dop

t or

imp

lem

ent a

ccep

ted

stan

dard

s-

Incr

ease

s th

e p

ossi

bilit

y of

diff

erin

g in

terp

reta

tions

or

opin

ions

-

The

link

bet

wee

n th

e re

gula

tory

reg

ime

and

th

e op

erat

iona

l sta

ndar

ds c

ould

incr

ease

co

nfus

ion

amon

g in

dust

ry p

artic

ipan

ts-

The

his

tori

cal b

asis

for

deci

sion

s is

no

t ade

quat

ely

docu

men

ted

-

Requ

irem

ents

or

stan

dard

s ca

n be

eas

ily c

hang

ed

with

a r

e-w

rite

of

a m

anua

l or

docu

men

t -

Com

plia

nce

requ

irem

ents

may

not

be

met

- In

duce

con

flict

or

disa

gree

men

t be

twee

n in

dust

ry s

take

hold

ers

- In

cons

iste

ncy

acro

ss th

e in

dust

ry

- O

per

atin

g st

anda

rds

and

pro

toco

ls m

ay b

e di

sjoi

nted

in

nat

ure

and

dup

licat

ion

may

be

exce

ssiv

e -

Incr

ease

bur

den

on th

e op

erat

or to

est

ablis

h

- Es

tabl

ish

a cr

oss

disc

iplin

e ov

ersi

ght

task

forc

e to

iden

tify

the

inte

rsec

tions

of

the

HEM

S in

dust

ry a

t the

hig

hest

leve

l -

Dev

elop

a s

tand

ard

com

plia

nce

road

m

ap w

hich

info

rms

the

HEM

S in

dust

ry

of th

e co

mp

lexi

ties

of th

e m

ultid

isci

plin

e co

mp

lianc

e re

gim

e to

pro

vide

a

mea

ns o

f lo

cal l

evel

nav

igat

ion

arou

nd

fede

ral a

nd s

tate

req

uire

men

ts

- Re

gula

tors

in th

e th

ree

func

tiona

l ar

eas

mee

t to

agre

e on

col

labo

rativ

e ar

rang

emen

ts to

str

eam

line

com

plia

nce

defin

ition

, mon

itori

ng a

nd in

terv

entio

n

- D

evel

op o

ptio

ns to

res

olve

the

ques

tion

of

lack

of

clar

ity a

nd in

ters

ect p

oint

s of

fede

ral v

s st

ate

over

sigh

t of

cert

ain

co

mp

onen

t of

HEM

S op

erat

ions

.-

Key

indu

stry

sta

keho

lder

and

org

aniz

atio

ns

coop

erat

e to

iden

tify

and

addr

ess

stru

ctur

al a

nd o

per

atio

nal s

afet

y is

sues

Seri

al n

o. 6

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (6)

LIKELIHood: cERtAIn

conSEQuEncE: MAJoR

PRIoRIty: 14

RESIduAL RISK: HIgH (7)

38

Th

e co

mp

lexi

ty o

f th

e ov

ersi

ght,

com

plia

nce

an

d r

egu

lato

ry r

egim

es

do

es n

ot p

rovi

de

the

stru

ctu

re r

equ

ired

fo

r th

e in

du

stry

to h

ave

an in

clu

sive

ass

ura

nce

re

gim

e o

r p

rogr

am o

f au

dits

, acc

red

itatio

n

and

ch

ecki

ng

lead

ing

to a

n in

abili

ty to

pro

-vi

de

con

fid

ence

that

th

e in

du

stry

is b

ein

g ap

pro

pri

atel

y m

anag

ed

- T

he a

uditi

ng a

nd c

heck

ing

that

doe

s ta

ke p

lace

doe

s no

t cov

er th

e fu

ll co

ntex

t of

the

HEM

S op

erat

ion

- T

he n

eed

for

mul

tiple

aud

its, a

ccre

dita

tion

an

d ch

ecki

ng p

rogr

ams

- In

abili

ty fo

r in

tegr

atio

n an

d ec

onom

ies

of s

cale

to

redu

ce th

e co

mp

lianc

e bu

rden

for

oper

ator

s -

No

one

body

hol

ds th

e co

mp

lete

pic

ture

of

com

plia

nce

and

assu

ranc

e to

giv

e th

e le

vel o

f co

nfide

nce

requ

ired

-

Tho

se a

genc

ies

or a

ccre

dita

tion

bodi

es th

at o

ffer

ac

cred

itatio

n m

ay n

ot h

ave

pro

tect

ion

unde

r a

stat

utor

y au

thor

ity to

form

ally

aut

hori

se o

r sa

nctio

n

par

ticip

ant o

ther

that

the

with

hold

ing

of a

ccre

dita

tion.

- O

per

ator

s ha

ve to

com

ply

or

achi

eve

mul

tiple

ac

cred

itatio

n or

aud

its a

s th

ere

is n

o on

e al

l em

brac

ing

assu

ranc

e re

gim

e th

at m

eets

all

need

s -

The

re is

a la

ck o

f cl

arity

aro

und

ex

actly

who

exp

ects

wha

t -

Lack

of

cons

iste

ncy

arou

nd w

heth

er th

e le

vel o

f se

rvic

e re

quir

ed is

bei

ng d

eliv

ery

and

achi

eved

- Po

tent

ial f

or a

udits

form

diff

eren

t bod

ies

to

issu

e co

nflic

ting

findi

ngs

and

requ

irem

ents

- Po

tent

ial f

or d

iffer

ent s

tand

ards

be

ing

requ

ired

in e

ach

Stat

e.

- Re

gula

tors

in th

e th

ree

func

tiona

l are

as

(avi

atio

n, h

ealth

care

and

EM

S) to

mee

t an

defi

ne th

e re

latio

nshi

ps

betw

een

the

gove

rnan

ce a

nd o

vers

ight

arr

ange

men

ts

in o

rder

to r

emov

e la

ck o

f cl

arity

aro

und

w

ho p

rovi

des

wha

t ass

uran

ce

- A

t a v

olun

tary

leve

l dev

elop

an

indu

stry

le

vel a

ssur

ance

reg

ime

as p

art o

f th

e in

dust

ry s

elf

gove

rnan

ce a

rran

gem

ents

m

app

ing

wha

t nee

ds to

be

chec

ked,

to

wha

t lev

el o

f as

sura

nce

and

by w

hat e

ntity

-

As

par

t for

the

indu

stry

leve

l ass

uran

ce

regi

me,

dev

elop

an

inte

grat

ion

map

of

all a

vaila

ble

indu

stry

acc

redi

tatio

n an

d

cert

ifica

tion

pro

gram

s to

aid

e in

edu

catin

g th

e in

dust

ry o

n th

e si

mila

ritie

s an

d di

ffer

ence

s -

Whe

re p

ossi

ble

iden

tify

any

pot

entia

l ga

ps

or o

verl

aps

whi

ch c

ould

be

mut

ually

ac

cred

ited

via

an a

pp

rove

d p

aral

lel p

ath.

-

Con

side

ratio

n of

a s

elf

adm

inis

trat

ion

mod

el

for

cert

ain

asp

ects

of

the

HEM

S in

dust

ry w

ith

the

app

rop

riat

e m

anda

te fo

r ut

iliza

tion.

Seri

al n

o. 7

A

SSU

RA

nC

E M

oD

El

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (4)

LIKELIHood: LIKELy


PRIoRIty: 11


39

Cu

mu

lativ

e ri

sk

asso

ciat

ed w

ith th

e va

riab

ility

am

on

g St

ates

ove

r lic

ensi

ng

req

uir

emen

ts a

nd

st

and

ard

s fo

r H

EM

S p

rogr

ams,

as

wel

l as

inco

nsi

sten

t in

terp

reta

-tio

n o

f th

e St

ates

’ au

tho

rity

to d

eter

min

e a

nee

d f

or,

an

d lo

ca-

tion

of,

new

or

exis

ting

HE

MS

pro

gram

s an

d

bas

es, h

as p

rod

uce

d

wid

esp

read

var

iab

ility

in

qu

ality

an

d s

afet

y in

HE

MS

tran

spo

rt

- N

atio

nal l

evel

con

sist

ency

is n

ot a

chie

ved

-

Stat

es d

evel

op th

eir

own

requ

irem

ents

in li

eu o

f no

t ha

ving

gui

danc

e in

duci

ng a

div

erge

nce

of o

per

atio

ns

- H

EMS

pro

gram

s op

erat

ing

in m

ore

than

one

sta

te

have

to tr

ack

and

met

diff

eren

t req

uire

men

ts

for

licen

sure

in e

ach

of th

e st

ates

-

Incr

ease

d cr

eatio

n of

var

iabi

lity

and

dist

ract

ion

fr

om fo

cus

on p

atie

nt s

afet

y an

d qu

ality

tran

spor

t-

Incr

ease

d co

mp

lexi

ty in

the

com

plia

nce

regi

me

that

nee

ds to

be

man

aged

at t

he o

per

ator

leve

l -

Num

erou

s an

d di

ffer

ent i

nter

pre

tatio

ns

by S

tate

lega

l cou

nsel

lors

and

cre

ated

w

ides

pre

ad a

mbi

guity

and

con

fusi

on-

Une

qual

dis

trib

utio

n of

HEM

S se

rvic

es

in s

ome

area

s w

hile

oth

er a

reas

may

be

unde

serv

ed o

r no

t ser

ved

at a

ll -

Exp

ecta

tions

for

an e

qual

leve

l of

heal

th c

are

acro

ss

the

coun

try

is n

ot a

chie

ved

or d

eliv

ered

by

the

curr

ent e

mer

genc

y m

edic

al tr

ansp

ort s

yste

m

- A

CS

leve

l 1 tr

aum

a ca

re w

ithin

two

hour

s of

inju

ry is

not

ach

ieve

d, th

us fa

iling

to

mee

t a fu

ndam

enta

l exp

ecta

tion

of m

any

Am

eric

ans

and

trau

ma

care

pro

vide

rs

- So

me

area

s ha

ve p

oten

tial t

o be

sat

urat

ed w

ith a

ircr

aft

or H

EMS

asse

ts a

nd o

ther

are

as n

ot s

ervi

ced

at a

ll

- In

fight

ing

over

com

ple

tion

for

fligh

ts-

An

incr

easi

ng n

umbe

r of

sm

all o

per

ator

s ru

nnin

g on

pag

ers

and

not a

dher

ing

to

FAR

s, d

amag

ing

indu

stry

rep

utat

ion

- A

ssem

ble

the

app

rop

riat

e in

dust

ry

stan

dard

set

ters

and

ove

rsee

rs to

id

entif

y th

e in

ters

ect p

oint

s fo

r th

e va

riou

s di

scip

lines

that

fall

with

in th

e H

EMS

indu

stry

and

con

duct

inte

grat

ion

m

app

ing

to id

entif

y an

y ga

ps

or p

oten

tial

over

lap

s in

gov

erna

nce

arra

ngem

ents

-

Imp

lem

ent a

n en

hanc

ed n

atio

nal H

EMS

Fram

ewor

k an

d as

soci

ated

sys

tem

s,

requ

irem

ents

, sta

ndar

ds a

nd p

erfo

rman

ce

(out

com

e) b

ased

req

uire

men

ts th

at d

o

not r

estr

ict y

et r

athe

r p

rovi

de fl

exib

ility

fo

r ad

apta

ble

loca

l lev

el im

ple

men

tatio

n

with

in a

con

sist

ent i

nter

oper

able

reg

ime

- N

atio

nal p

erfo

rman

ce b

ased

req

uire

men

ts

to b

e de

velo

ped

and

pro

vide

d to

th

e St

ates

for

imp

lem

enta

tion

-

Imp

lem

ent a

form

al c

omm

unic

atio

n st

rate

gy

to th

e St

ate

Bas

ed a

utho

rize

s w

ith th

is

resp

onsi

bilit

ies

and

imp

lem

ent a

n in

dust

ry

netw

ork

pro

gram

mod

el fo

r ed

ucat

ion,

st

anda

rdiz

atio

n an

d sh

arin

g of

info

rmat

ion

-

conn

ect t

hese

sta

keho

lder

s as

a fo

rmal

gro

up

Seri

al n

o. 8

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng


LIKELIHood: LIKELy


PRIoRIty: 5


40

Ris

k th

at th

e cu

rren

t d

efin

itio

n a

nd

sco

pe

of

the

ind

ust

ry is

no

t w

ell d

efin

ed le

adin

g to

lim

itatio

ns

in th

e ab

ility

or

app

rop

riat

e ag

enci

es a

nd

sta

ke-

ho

lder

s to

eff

ectiv

ely

gove

rn th

eir

asp

ect o

f th

e in

du

stry

. Th

e ke

y ri

sk in

du

ced

by

this

is

sue

is th

e lim

itatio

ns

on

the

abili

ty f

or

a co

mp

lete

an

d in

du

stry

w

ide

dat

a d

rive

n

nat

ion

al s

olu

tion

to

man

age

the

lan

dsc

ape

to b

e id

entifi

ed,

coo

rdin

ated

an

d e

f-fe

ctiv

ely

imp

lem

ente

d

- T

he tr

ue s

cop

e of

the

indu

stry

and

its

act

iviti

es is

not

kno

wn

-

The

info

rmat

ion

pre

sent

ed m

ay n

ot b

e re

flect

ive

of th

e en

tire

indu

stry

, but

rat

her

thos

e w

ho a

re m

ost a

ctiv

e or

vis

ible

- T

he p

rofil

e of

the

airc

raft

flee

t of

the

indu

stry

sec

tor

can

not b

e m

onito

red

-

The

pro

file

of th

e ai

rcre

w (

pilo

ts)

of th

e in

dust

ry s

ecto

r ca

n no

t be

mon

itore

d-

The

true

pro

file

of th

e ac

tiviti

es u

nder

take

n

by th

e in

dust

ry u

s no

t kno

wn

-

An

accu

rate

cal

cula

tion

of th

e p

reci

se r

isk

exp

osur

e is

una

ble

to b

e de

term

ined

- T

he o

vers

ight

mod

el is

dri

ven

from

an

exp

erie

ntia

l ba

se r

athe

r th

an a

dat

a ba

sed

mod

el

- T

he c

omm

unity

will

not

get

a c

lear

pic

ture

of

the

HEM

S in

dust

ry a

s th

e as

sura

nce

mod

el

is n

ot fu

lly d

efine

d an

d th

e sy

stem

s an

d

pro

cess

es fo

r co

llect

ing

data

are

inad

equa

te

- A

com

par

ison

, ide

ntifi

catio

n of

cha

nge,

or

the

mon

itori

ng o

f tr

ends

can

not

eas

ily b

e ac

hiev

ed

- T

he s

cop

e of

ris

k of

the

indu

stry

sec

tor

and

in

par

ticul

ar th

e sa

fety

exp

osur

e is

unk

now

n

- O

verr

elia

nce

on p

ast i

ncid

ent d

ata

as

a p

seud

o co

mp

lete

ris

k p

rofil

e

- T

he v

olun

tary

eff

orts

of

indu

stry

to r

educ

e th

e ri

sk p

rofil

e m

ay b

e m

isgu

ided

and

not

fo

cuse

d in

the

high

est a

rea

of n

eed

- C

omm

issi

on a

bod

y of

wor

k to

acc

urat

ely

defin

e th

e in

dust

ry, d

evel

opin

g a

stak

ehol

der

mat

rix

for

use

by a

ny n

atio

nal o

r in

dust

ry

wid

e en

hanc

emen

t to

the

HEM

S in

dust

ry (

eg

Air

Med

ical

Tra

nsp

ort A

gend

a fo

r th

e fu

ture

)-

Dev

elop

the

crite

ria

for

data

and

in

form

atio

n th

at n

eeds

to b

e co

llect

ed fo

r th

e p

urp

ose

of e

nhan

ced

self

ove

rsig

ht

- Se

t up

cen

tral

dat

a co

llect

ion

poi

nts,

for

key

indu

stry

pro

filin

g in

form

atio

n, a

t ap

pro

pri

ate

pla

ces

with

in th

e in

dust

ry

to d

evel

op a

n ac

cura

te a

nd u

p to

dat

e p

rofil

e of

the

indu

stry

as

a w

hole

- Es

tabl

ish

an in

dust

ry d

ocum

enta

tion

regi

stry

to

ena

ble

a si

ngle

sou

rce

poi

nt fo

r in

dust

ry

liter

atur

e, s

tudi

es, r

esea

rch

and

reso

urce

- T

hrou

gh th

e H

EMS

Indu

stry

Ris

k Pr

ofile

up

date

s, tr

ack

and

mon

itor

the

shift

in

indu

stry

pro

file

(nat

iona

l sys

tem

leve

l ap

plic

atio

n of

FO

QA

like

pro

gram

) an

d us

e th

is d

ata

to a

dequ

atel

y dr

ive

the

calc

ulat

ed fu

ture

evo

lutio

ns to

th

e EM

S Fr

amew

ork

and

mod

el

Seri

al n

o. 9

o

PER

Ato

R P

Ro

FIlE

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (6)

LIKELIHood: cERtAIn

conSEQuEncE: MAJoR

PRIoRIty: 15


41

Th

e in

du

stry

has

man

y d

iffe

ren

t bu

sin

ess

mo

del

s th

at o

ften

hav

e co

mp

etin

g o

bje

ctiv

es

and

inte

rest

s. T

he

di-

vers

ity in

this

ind

ust

ry

stru

ctu

re h

as th

e p

o-

ten

tial t

o in

du

ce in

du

s-tr

y an

d o

rgan

izat

ion

al

leve

l co

mp

etiti

on

an

d

grow

th in

turn

incr

eas-

ing

the

op

erat

ion

al

and

saf

ety

risk

exp

o-

sure

of

the

ind

ust

ry

- T

he in

dust

ry h

as n

o se

t sta

ndar

ds o

r gu

idel

ines

fo

r th

e go

vern

ance

of

indi

vidu

al o

rgan

izat

ions

- In

crea

sed

sens

itivi

ty to

taki

ng lo

w c

ost s

olut

ions

-

Span

of

cont

rol i

s w

ide

reac

hing

and

ha

rd to

sur

vey,

mon

itor

or c

ontr

ol

- In

crea

sed

chan

ce th

at th

e in

dust

ry w

ill

be r

atio

naliz

ed a

nd c

onso

lidat

ed-

Con

flict

ing

com

mer

cial

obj

ectiv

es in

duce

d

com

pan

ies

to ta

rget

com

mer

cial

lucr

ativ

e lo

catio

ns

or r

egio

ns in

crea

sing

the

com

pet

ition

- T

he h

osp

ital o

r p

atie

nt d

eman

d fo

r ai

r m

edic

al s

ervi

ce d

oes

not d

rive

gro

wth

- T

he c

hanc

e fo

r in

app

rop

riat

e ut

iliza

tion

of a

sset

s is

incr

ease

d

-

Furt

her

frag

men

tatio

n in

the

indu

stry

may

occ

ur

- Fi

nanc

ially

via

ble

loca

tions

will

be

over

ser

vice

d w

hile

th

ose

with

low

er v

olum

es m

ay b

e un

der

serv

iced

-

Incr

ease

d p

ress

ures

for

pro

gram

s an

d cu

stom

ers

to

com

pen

sate

and

run

non

-via

ble

pro

gram

s at

a lo

ss-

Incr

ease

d oc

curr

ence

of

com

pet

ing

pro

gram

s en

croa

chin

g on

est

ablis

hed

EMS

pro

gram

op

erat

ions

-

Inad

vert

ent fl

ow d

own

pre

ssur

e fo

r cr

ews

to a

ccep

t any

or

all t

asks

to a

ssis

t with

th

e su

rviv

abili

ty o

f th

eir

pro

gram

and

the

subs

eque

nt s

ecur

ity o

f th

eir

emp

loym

ent

- A

n in

crea

se th

at fu

rthe

r hy

brid

bus

ines

s m

odel

s w

ill

aris

e co

uple

d w

ith th

e co

mm

erci

al d

rive

rs a

nd p

ress

ures

fo

r vi

abili

ty w

ill s

hap

e th

e in

dust

ry e

nvir

onm

ent

- Po

tent

ial f

or e

xace

rbat

ing

othe

r m

isun

ders

tand

ings

w

ithin

the

indu

stry

aro

und

agen

das

and

pol

itica

l dri

vers

-

Incr

ease

the

diffi

culty

of

stan

dard

izin

g p

roce

ss,

pro

cedu

res

and

cultu

res

thro

ugho

ut th

e in

dust

ry-

The

cur

rent

op

erat

iona

l and

saf

ety

risk

exp

osur

e as

soci

ated

with

com

pet

ition

bet

wee

n H

EMS

pro

gram

s in

clo

se o

r ov

erla

pp

ing

geog

rap

hic

pro

xim

ity to

eac

h

othe

r th

at e

ncou

rage

s tr

ansp

ort t

eam

s to

acc

ept t

aski

ng

in o

rder

to m

axim

ize

fligh

t vol

umes

that

are

nec

essa

ry

to p

rese

rve

the

finan

cial

via

bilit

y of

pro

gram

s.

- A

s p

art o

f th

e N

atio

nal E

MS

Fram

ewor

k,

deve

lop

a s

et o

f co

rpor

ate

gove

rnan

ce

requ

irem

ents

that

nee

d to

be

met

by

the

all b

usin

ess

mod

els

in o

rder

to p

rovi

de a

n

app

rop

riat

e le

vel o

f se

lf g

over

nanc

e an

d

corp

orat

e ov

ersi

ght t

hat w

ill e

ffec

tivel

y id

entif

y, a

sses

s an

d m

anag

e th

e co

mp

any

or e

nter

pri

se r

isks

that

indu

ce u

nsaf

e co

mm

erci

al, o

per

atio

nal o

r sa

fety

pra

ctic

es.

(defi

ne e

xpec

tatio

ns a

roun

d co

rpor

ate

leve

l ac

coun

tabi

lity

and

man

agem

ent o

f av

iatio

n

oper

atio

ns o

r co

ntra

ctor

s). I

nteg

rate

this

re

sour

ce w

ithin

hea

lthca

re e

thic

s re

gim

e.

- D

evel

op a

viat

ion

cont

ract

or m

anag

emen

t gu

idel

ine

and

thos

e bu

sine

ss m

odel

s th

at d

o no

t op

erat

e th

eir

own

Part

135

(m

odel

off

oth

er p

arts

of

the

avia

tion

in

dust

ry s

uch

as p

ower

/ene

rgy

com

pan

ies,

m

inin

g in

dust

ry, o

il an

d ga

s in

dust

ry)

- C

ondu

ct a

nat

iona

l sem

inar

ser

ies

for

HEM

S In

dust

ry B

oard

Cha

irm

an, C

EOs

(acc

ount

able

exe

cutiv

e) a

nd P

rogr

am

Dir

ecto

rs in

the

area

s of

cor

por

ate

over

sigh

t, co

rpor

ate

gove

rnan

ce, r

isk

man

agem

ent

and

safe

ty m

anag

emen

t sys

tem

s

Seri

al n

o. 1

0

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng


LIKELIHood: LIKELy


PRIoRIty: 7


42

Th

ere

is n

o a

ctiv

ity o

r ta

sk p

rofi

le d

efin

itio

n

set f

or

the

HE

MS

ind

ust

ry s

ecto

r m

akin

g it

dif

ficu

lt to

ove

rsee

th

e ri

sks

asso

ciat

ed

with

the

vari

ou

s ta

sk

pro

file

s at

an

ind

ust

ry,

nat

ion

al o

r St

ate

leve

l. In

ad

diti

on

to th

is,

chan

ges

to th

e tr

end

s in

ind

ust

ry a

ctiv

ities

ar

e n

ot e

asily

iden

ti-fi

ed o

r m

on

itore

d a

nd

th

e p

latf

orm

fo

r d

ata

dri

ven

mo

nito

rin

g d

oes

no

t exi

st to

th

e le

vel o

f m

atu

rity

re

qu

ired

to c

apita

lize

- T

he r

isk

pro

file

or c

hang

es to

the

risk

pro

file

may

not

be

iden

tified

ow

ing

to th

e la

ck o

f st

ruct

ural

defi

nitio

n of

the

indu

stry

-

The

bas

elin

e in

the

indu

stry

of

curr

ent u

sage

is n

ot a

vaila

ble

- T

here

is n

o co

mm

on p

latf

orm

for

lang

uage

or

mea

sure

men

t for

the

indu

stry

to c

omp

are

or c

ontr

ast a

t the

Fed

eral

or

Stat

e le

vel

- T

he s

cop

e, r

ole

and

task

pro

files

for

EMS

oper

ator

s ar

e no

t defi

ned

- Re

sour

ces

and

effo

rts

may

be

dire

cted

into

the

low

er r

isk

or lo

wer

exp

osur

e ac

tiviti

es o

r ta

sks

and

not m

axim

izin

g th

e im

pac

t or

opp

ortu

nity

-

Cha

nges

or

deve

lop

men

ts in

indu

stry

act

iviti

es m

ay

occu

r be

fore

the

regu

lato

ry r

egim

e ca

n ad

equa

tely

ac

com

mod

ate

the

com

plia

nce

imp

licat

ions

- D

evel

op a

nd m

aint

ain

a se

t of

stan

dard

ta

sk p

rofil

es fo

r th

e st

anda

rd n

atio

nally

ap

pro

ved

HEM

S ac

tiviti

es a

ssoc

iate

d

with

var

ious

sta

ndar

d ta

sks

- U

tiliz

e th

ese

task

pro

files

to d

evel

op a

set

of

oper

atio

nal r

isk

pro

files

and

link

to in

dust

ry

driv

en F

OQ

A s

yste

ms

to id

entif

y, c

aptu

re,

anal

yze

and

rep

ort d

evia

tions

from

the

norm

- A

dop

t op

erat

iona

l ris

k m

anag

emen

t m

odul

e as

par

t of

the

SMS

- K

ey s

take

hold

ers

to d

evel

op n

atio

nally

ac

cep

ted

EMS

tran

spor

t ter

ms

and

defin

ition

s.-

Cha

nge

curr

ent H

EMS

defin

ition

to r

emov

e th

e p

ossi

bilit

y of

a ‘e

mer

genc

y’ d

rive

n

cultu

re (

chan

ge n

ame

of in

dust

ry to

Air

M

edic

al T

rans

por

t rat

her

than

HEM

S)-

Embe

d th

e ac

tivity

pro

file

defin

ition

set

in

to a

ny in

dust

ry w

ide

data

col

lect

ion

in

orde

r to

acc

urat

ely

mon

itor

the

chan

ge

in th

e in

dust

ry o

vera

ll ac

tivity

pro

file

- Pr

ovid

e in

divi

dual

op

erat

ors

or a

ir

med

ical

pro

gram

with

the

crite

ria

for

activ

ity p

rofil

es in

ord

er to

allo

w

indi

vidu

al c

omp

anie

s to

mon

itor

the

chan

ge in

thei

r ow

n p

rofil

e ov

er ti

me

Seri

al n

o. 1

1 A

CtI

vIt

y P

Ro

FIlE

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (8)



PRIoRIty: 21


43

Th

e o

per

atin

g en

viro

nm

ent a

nd

the

asso

ciat

ed in

fras

tru

c-tu

re a

nd

sta

nd

ard

in

du

stry

pra

ctic

es f

or

the

two

ro

utin

e ta

sk

pro

file

s (i

nte

r-fa

cilit

y &

sce

ne

flig

hts

) is

no

t su

ffici

ently

des

ign

ed

at th

e H

EM

S Sy

stem

le

vel,

lead

ing

to th

e in

crea

sed

var

ian

ce

and

ap

plic

atio

n

of

flig

ht p

rofi

les,

sa

fety

sta

nd

ard

s an

d

safe

ty r

isk

exp

osu

re

to p

atie

nt,

airc

raft

, ai

rcra

ft a

nd

the

pu

blic

.

Inte

r-fa

cilit

y tas

k Pr

ofile

Fo

rmal

task

s p

rofil

es a

re n

ot e

vide

nt fo

r ri

sk m

anag

emen

t of

inte

r-fa

cilit

y tr

ansf

er

fligh

ts.

Issu

es in

min

imiz

ing

risk

for

are

:-

Inte

r-fa

cilit

y fli

ghts

are

oft

en u

nder

take

n

VFR

/NV

FR a

t low

leve

l whe

n IF

R m

ight

be

pos

sibl

e gi

ven

nece

ssar

y in

fras

truc

ture

- T

here

is a

gre

ater

pot

entia

l for

CFI

T o

r lo

ss o

f co

ntro

l due

to in

adve

rten

t IM

C e

ncou

nter

ed-

Pote

ntia

l for

traf

fic c

onfli

ctio

ns n

ear

busy

hos

pita

l he

lipad

s, e

spec

ially

if it

iner

ant u

sers

ap

pea

r-

No

stru

ctur

ed a

pp

roac

h to

inte

r-fa

cilit

y fli

ghts

Scen

e Flig

hts t

ask

Profi

le-

Scen

e fli

ghts

var

iabl

e p

rofil

es, c

an b

e hi

gh

risk

, man

y re

quir

e V

FR o

per

atio

ns.

- Fl

ight

s ar

e ge

nera

lly V

FR, e

ven

in

mar

gina

l wea

ther

con

ditio

ns-

The

cri

tical

ski

ll of

tran

sitin

g fr

om V

FR to

inst

rum

ent

fligh

t req

uire

d by

rec

over

y fr

om lo

ss o

f vi

sual

ref

eren

ce

is n

ot c

omm

only

ach

ieve

d ac

ross

the

indu

stry

-

Flig

hts

are

at lo

w le

vel w

ith le

ss m

argi

n fo

r er

ror

- Fl

ight

s at

nig

ht c

an e

ncou

nter

ver

y da

rk c

ondi

tions

w

hich

incr

ease

the

risk

for

VFR

op

erat

ions

- Fl

ight

s m

ay e

ncou

nter

inad

vert

ent I

MC

- Pi

lots

may

not

be

able

to fl

y by

vis

ual r

efer

ence

- Pi

lots

may

not

be

able

to n

avig

ate

by v

isua

l ref

eren

ce-

Pilo

ts m

ay n

ot h

ave

curr

ent t

rain

ing

to r

egai

n V

MC

- Pi

lots

may

not

hav

e re

curr

ent t

rain

ing

in r

ecov

ery

from

em

erge

ncy/

failu

re c

ondi

tions

at l

ow a

ltitu

de-

All

legs

of

an E

MS

fligh

t are

not

req

uire

d to

be

con

duct

ed to

the

sam

e st

anda

rd le

adin

g to

lead

ing

to le

sser

mar

gin

of s

afet

y

- Im

ple

men

t tas

k br

iefin

g an

d de

brie

fing

pro

cess

es a

cros

s th

e H

EMS

indu

stry

-

Imp

lem

ent a

n IF

R r

oute

str

uctu

re a

s p

art o

f th

e N

atio

nal A

irsp

ace

Syst

em-

Dev

elop

and

ado

pt n

eces

sary

infr

astr

uctu

re

to a

llow

the

IFR

inte

r-fa

cilit

y fli

ghts

to b

e co

nduc

ted

in a

mor

e co

ntro

lled

‘sta

ndar

d

fligh

t pro

file’

sim

ilar

to th

at o

f a

rout

ine

avia

tion

oper

atio

n th

at fl

ys fr

om k

now

n

poi

nt to

kno

wn

poi

nt. I

nfra

stru

ctur

e fo

r th

is to

incl

ude

Wea

ther

Ser

vice

, Pub

lishe

d

IFR

dep

artu

res

and

arri

vals

, IFR

rou

te

stru

ctur

e, A

DS

(B),

ded

icat

ed c

omm

on

use

freq

uenc

y fo

r ho

spita

l hel

ipad

s-

Equi

p a

ircr

aft s

o th

ey c

an s

afel

y re

gain

vis

ual fl

ight

con

ditio

ns if

they

en

coun

ter

inad

vert

ent I

MC

- Eq

uip

air

craf

t with

tech

nolo

gy to

ass

ist

in lo

w le

vel V

FR o

per

atio

ns e

spec

ially

at

nigh

t suc

h as

NV

G, H

TW

AS,

AD

S(B

) -

Dev

elop

a s

et o

f st

anda

rd

indu

stry

task

pro

files

- D

evel

op a

nd im

ple

men

t an

indu

stry

wid

e st

rate

gy to

sec

ure

fund

ing

subs

idy

or a

on

e of

f in

fras

truc

ture

/equ

ipm

ent c

apita

l fu

ndin

g in

ject

ion

give

n th

e na

tiona

l

Seri

al n

o. 1

2

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (7)

LIKELIHood: LIKELy

conSEQuEncE: MAJoR

PRIoRIty: 17


44

Th

e ri

sk th

at th

e H

EM

S in

du

stry

do

es

no

t co

nsi

sten

tly

iden

tify,

ad

op

t, u

tiliz

e an

d m

axim

ize

airc

raft

te

chn

olo

gy

avai

lab

le

in th

e av

iatio

n in

du

stry

to

en

han

ce s

afet

y p

a-ra

met

ers

lead

ing

to a

d

ecre

ase

in th

e ri

sk o

f an

acc

iden

t or

inci

den

t

- Te

chno

logi

es a

re e

mer

ging

that

can

ass

ist i

n th

e m

itiga

tion

of r

isk

from

low

leve

l VFR

op

erat

ions

- A

dop

tion

of n

ew te

chno

logi

es r

equi

res

a fo

rmal

cha

nge

man

agem

ent p

lan

incl

udin

g tr

aini

ng, p

roce

dure

s am

endm

ent e

tc.

- A

ircr

aft a

nd c

rew

cap

abili

ty m

ay n

ot m

atch

th

e ta

sk p

rofil

e of

the

oper

ator

, the

sta

te

or th

e H

EMS

indu

stry

as

a w

hole

- B

oth

pro

activ

e an

d re

activ

e te

chno

logi

cal

enha

ncem

ents

may

not

be

-

Ass

essm

ent p

roce

sses

mus

t ide

ntify

tech

nolo

gy o

ptio

ns

whi

ch p

rovi

de th

e m

ost i

mp

act f

or fu

nds

avai

labl

e-

Tech

nolo

gies

mus

t be

asse

ssed

for

thei

r im

pac

t on

pilo

t per

form

ance

for

exam

ple

, inc

reas

e/re

duct

ion

of p

ilot w

orkl

oad,

hum

an fa

ctor

s is

sues

su

ch a

s fix

atio

n w

ith ta

sk w

ithin

the

cock

pit

etc,

-

Incr

ease

d fa

tigue

and

wor

kloa

d is

sues

-

Incr

ease

d re

lianc

e an

d ne

ed to

und

erta

ke

and

imp

lem

ent f

orm

al tr

aini

ng a

nd

com

mit

the

requ

ired

res

ourc

es

- Es

tabl

ish

an in

dust

ry/r

egul

ator

wor

king

gr

oup

to s

pec

ify a

nd a

sses

s cu

rren

t, em

erge

nt a

nd fu

ture

tech

nolo

gy

- Fo

r ke

y p

iece

s of

indu

stry

ap

plic

able

w

ide

tech

nolo

gy, a

ris

k an

d op

por

tuni

ty

asse

ssm

ent t

o be

con

duct

ed b

y th

e te

chno

logy

wor

king

gro

up

and

mad

e av

aila

ble

to in

dust

ry

to a

ide

in d

ecis

ion

mak

ing

- A

sses

s th

e su

itabi

lity

and

need

for

the

pot

entia

l cre

atio

n of

a n

ew fe

dera

l av

iatio

n re

gula

tion

spec

ific

to H

EMS

and

fix

ed w

ing

aero

-med

ical

tran

spor

t.-

Man

date

the

use

of c

erta

in p

erfo

rman

ce

stan

dard

s (o

utco

me

base

d) th

at c

an

be a

chie

ved

thro

ugh

tech

nolo

gy

- D

evel

op r

esou

rce

pla

n fo

r in

dust

ry

for

fund

ing

inje

ctio

n to

aid

e si

gnifi

cant

tech

nolo

gy u

pgr

ade

- A

gree

men

t fro

m m

anuf

actu

rers

that

cer

tain

p

erfo

rman

ce s

tand

ards

will

man

date

a

stan

dard

fit o

f so

me

tech

nolo

gy b

ased

on

the

addi

tiona

l saf

ety

limits

ach

ieve

d-

Purc

hase

, im

ple

men

t and

man

age

tech

nolo

gy

intr

oduc

tion

such

as

NV

Gs,

HTA

WS,

FD

R e

tc

Seri

al n

o. 1

3 A

IRC

RA

Ft C

APA

bIl

Ity

PR

oFI

lE

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (8)



PRIoRIty: 22


45

Th

e ri

sk a

sso

ciat

ed

with

the

inab

ility

to

effe

ctiv

ely

reso

urc

e an

d m

anag

e th

e o

per

atio

nal

, tec

hn

i-ca

l an

d c

ultu

ral

chan

ge r

elat

ed to

the

intr

od

uct

ion

of

new

te

chn

olo

gy

into

ser

vice

- T

here

will

be

a si

gnifi

cant

shi

ft in

the

oper

atio

nal c

onte

xt fo

r H

EMS

pro

vide

rs

- T

he in

dust

ry c

an n

ot k

eep

pac

e th

e ra

pid

adv

ance

of

tech

nolo

gy

- T

he in

dust

ry c

an n

ot in

dep

ende

ntly

val

idat

e th

e ef

ficac

y of

em

ergi

ng te

chno

logi

es

- T

he c

urre

nt w

orkf

orce

cap

abili

ty m

ay n

ot

pos

sess

the

skill

s an

d co

mp

eten

cies

req

uire

d

to w

ork

in th

is n

ew e

nvir

onm

ent

- Su

bseq

uent

new

ris

ks m

ay b

e in

duce

d th

at w

ere

not i

dent

ified

, ass

esse

d or

pot

entia

lly m

anag

ed

- T

he r

apid

imp

lem

enta

tion

of n

ew te

chno

logy

can

in

duce

unf

ores

een

risk

s in

to th

e op

erat

ing

envi

ronm

ent

- O

per

ator

s m

ay u

nder

estim

ate

the

reso

urce

s, ti

me

and

com

mitm

ent t

o in

trod

uce

new

tech

nolo

gy

- T

here

may

be

a sk

ills

shor

tage

in th

e in

dust

ry o

f su

itabl

e qu

alifi

ed in

stru

ctor

s to

aid

e th

e tr

aini

ng

and

imp

lem

enta

tion

of n

ew te

chno

logy

-

The

imp

lem

enta

tion

of n

ew te

chno

logy

w

ithou

t ind

ustr

y le

vel c

oord

inat

ion

can

lead

to

non

sta

ndar

d in

dust

ry c

onfig

urat

ions

- T

he p

oten

tial t

hat f

unds

are

inef

ficie

ntly

allo

cate

d-

The

op

por

tuni

ties

and

bene

fits

that

tech

nolo

gy

offe

rs m

ay c

omp

rom

ised

or

not m

axim

ized

-

A b

elie

f m

ay d

evel

op th

at n

ew te

chno

logy

is

a “

silv

er b

ulle

t” a

nd o

ther

form

s of

saf

ety

defe

nces

may

be

negl

ecte

d le

adin

g to

a

fals

e p

erce

ptio

n of

saf

ety

boun

dari

es

- O

ther

req

uire

d ch

ange

s to

the

oper

atin

g en

viro

nmen

t, st

anda

rds

and

trai

ning

may

not

be

as r

apid

ly im

ple

men

ted

gene

ratin

g a

lag

effe

ct

- T

he fi

nanc

ial m

odel

of

the

HEM

S in

dust

ry

need

s to

be

accu

rate

ly a

sses

sed

to

confi

rm v

iabi

lity

of in

crea

sed

stan

dard

s

- D

evel

op a

nd r

elea

se to

indu

stry

a “

chan

ge

man

agem

ent”

pac

kage

and

tool

kit t

o

assi

st H

EMS

orga

niza

tion

to m

anag

e th

e ri

sk o

f in

trod

uctio

n of

new

tech

nolo

gy

- D

evel

op a

sui

te o

f H

EMS

indu

stry

sp

ecifi

c ri

sk b

ased

- c

hang

e m

anag

emen

t too

l ki

ts fo

r 1)

intr

oduc

tion

of n

ew a

ircr

aft 2

) op

enin

g of

a n

ew b

ase

3) in

trod

uctio

n

of n

ight

vis

ion

gogg

les

4) in

trod

uctio

n

of e

nhan

ced

airc

raft

saf

ety

equi

pm

ent

5) in

trod

uctio

n of

saf

ety

man

agem

ent

syst

ems

6) m

erge

rs a

nd a

cqui

sitio

ns-

FAA

to c

onsu

lt w

ith s

take

hold

er to

p

lan

the

stru

ctur

ed a

dop

tion

of e

xist

ing

and

emer

ging

tech

nolo

gy. C

onsi

der

sup

por

ting

guid

ance

to th

e in

dust

ry in

th

eir

mat

urity

of

upta

ke. E

xam

ine

cultu

ral

fact

ors

such

as

rew

ard

and

ince

ntiv

es.

Seri

al n

o. 1

4

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (8)



PRIoRIty: 23


46

Th

e ri

sk th

at th

e cu

rren

t med

ical

re

imb

urs

emen

t mo

del

(p

rim

ary

pay

or

mo

del

) is

no

lon

ger

adeq

uat

e to

pro

vid

e th

e ap

pro

-p

riat

e le

vel o

f fi

nan

cial

co

vera

ge f

or

eith

er

the

curr

ent o

per

atin

g co

sts

of

the

serv

ice

or

the

imp

end

ing

up

grad

e o

f ca

pab

ility

re

qu

ired

thro

ugh

the

ad

diti

on

of

tech

no

log

y

- Re

tent

ion

of th

e in

cons

iste

ncie

s in

the

pay

or m

odel

from

Sta

te to

Sta

te-

Tech

nolo

gy m

ay n

ot b

e ab

le to

be

affo

rded

by

the

indu

stry

- Pr

icin

g p

ress

ure

on o

per

ator

s -

Del

ays

in th

e ad

optio

n an

d up

take

of

tech

nolo

gy-

Med

icar

e re

imbu

rsem

ent a

lone

(w

ithou

t add

ition

al

com

mer

cial

insu

ranc

e so

urce

s of

rei

mbu

rsem

ent)

w

ill n

ot a

llow

HEM

S tr

ansp

ort p

rogr

ams

to m

eet

oper

atio

nal e

xpen

ses

and

mai

ntai

n fin

anci

al v

iabi

lity.

-

Adv

ance

d an

d sa

fer

helic

opte

r eq

uip

men

t, e.

g., t

win

-eng

ines

, IFR

equ

ipp

ed, H

TAW

S,

NV

G a

nd m

ore

adeq

uate

ly tr

aine

d tr

ansp

ort

team

s m

ay n

ot b

e af

ford

able

or

amor

tized

-

The

Med

icar

e p

aym

ent m

odel

rei

mbu

rsem

ent f

or o

nly

tran

spor

t “lo

aded

mile

s” c

reat

es a

n un

real

istic

mod

el

for

pro

gram

s in

that

the

cove

ring

the

over

head

exp

ense

fo

r im

ple

men

ting

app

rop

riat

e ai

rcra

ft e

quip

men

t an

d cr

ew tr

aini

ng to

max

imiz

e sa

fety

is in

adeq

uate

- M

edic

are

reim

burs

emen

t for

HEM

S tr

ansp

ort f

oste

rs

the

pro

lifer

atio

n of

new

pro

gram

s th

at o

per

ate

in r

ural

ar

eas

and

that

incu

r th

e lo

wes

t op

erat

iona

l ove

rhea

d.-

The

hig

her

reim

burs

emen

t fro

m M

edic

are

for

tran

spor

ts fr

om r

ural

are

as, w

hich

pay

s on

ly fo

r “l

oade

d m

iles,

” in

adve

rten

tly p

enal

izes

tran

spor

t p

rogr

ams

oper

atin

g in

urb

an a

nd s

ubur

ban

area

s -

Prog

ram

ove

rhea

d m

ay b

e hi

gher

than

for

thos

e p

rogr

ams

oper

atin

g in

rur

al a

reas

not

co

ntem

pla

ted

in t

he s

tand

ing

mod

el

- In

crea

sed

pre

ssur

es o

n p

rogr

ams

to u

se lo

wer

cos

t ov

erhe

ad m

odel

s to

max

imiz

e fin

anci

al m

odel

-

Acc

epte

d sa

fety

trai

ning

pra

ctic

es s

uch

as th

e us

e of

sim

ulat

or tr

aini

ng m

ay b

e se

en a

s a

luxu

ry r

athe

r th

an a

n es

sent

ial t

ool f

or s

afet

y ow

ing

to th

e co

st

- N

egot

iatin

g re

imbu

rsem

ent f

or H

EMS

tran

spor

t w

ith M

edic

are

regi

onal

offi

ces

is fr

eque

ntly

co

nfro

ntat

iona

l, co

nsum

es c

onsi

dera

ble

time,

is in

effic

ient

and

was

tes

reso

urce

s

- D

evel

op a

pla

n to

rea

sses

s, e

valu

ate

and

rede

velo

p if

req

uire

d th

e m

edic

al

reim

burs

emen

t mod

el th

at u

nder

pin

s th

e re

venu

e ba

se o

f th

e H

EMS

indu

stry

in

ord

er to

pro

vide

ass

uran

ce th

at th

e ri

sks

curr

ently

indu

ced

have

bee

n

min

imiz

ed, r

emov

ed o

r at

the

leas

t ac

cep

ted

by th

e ap

pro

pri

ate

auth

ority

-

Reso

lutio

n th

at c

omp

etiti

on n

eeds

to b

e el

evat

ed a

nd o

ccur

at a

reg

iona

l or

stat

e le

vel r

athe

r th

an o

n a

task

by

task

bas

is

- A

dop

tion

and

imp

lem

enta

tion

of a

m

edic

al r

eim

burs

emen

t (or

rev

enue

m

odel

) th

at a

dequ

atel

y co

vers

bot

h

the

oper

atin

g co

sts

and

the

inve

stm

ent

in fu

ture

cap

abili

ty im

pro

vem

ents

Not

e: I

nter

vent

ion

from

hig

her

auth

ority

may

im

pro

ve q

uant

ifica

tion

of r

esid

ual r

isk.

Seri

al n

o. 1

5 In

DU

StR

y o

PER

AtI

nG

En

vIR

on

MEn

t R

ISK

S

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng


LIKELIHood: cERtAIn


PRIoRIty: 2

RESIduAL RISK: HIgH (4)

47

Th

ere

are

sign

ifica

nt

risk

s en

tren

ched

w

ithin

the

curr

ent t

ask-

ing

con

tinu

um

use

d

for

allo

catin

g H

EM

S ai

r m

edic

al a

sset

s. T

his

in

con

sist

enci

es a

nd

la

ck o

f st

and

ard

iza-

tion

in th

e ta

skin

g co

ntin

uu

m s

pan

s th

e fo

llow

ing

pro

cess

fl

ow th

at in

clu

des

: -

The

eva

luat

ion

of th

e p

atie

nt n

eed

for

care

- T

he n

eces

sity

of

utili

zatio

n of

an

ai

rcra

ft fo

r th

e p

as-

seng

er tr

ansp

ort

- T

he r

eque

st-

ing

agen

cy

- T

he ta

skin

g p

roce

ss

incl

udin

g th

e al

loca

-tio

n of

the

task

to a

sp

ecifi

c re

sour

ce-

The

acc

epta

nce

of a

task

by

a H

EMS

oper

ator

- T

hrou

gh to

op

era-

tiona

l con

trol

one

the

task

has

bee

n ac

cep

t-ed

and

und

erta

ken

- T

here

is q

uest

ion

rais

ed a

roun

d th

e ap

pro

pri

ate

utili

zatio

n of

air

craf

t-

Som

e ar

eas

satu

rate

d w

ith a

ircr

aft,

othe

r ar

eas

less

ser

vice

d-

Alte

rnat

e m

eans

of

tran

spor

t are

no

t con

side

red

or e

ngag

ed

- In

crea

se in

occ

urre

nces

of

over

util

izat

ion

or

und

er u

tiliz

atio

n of

air

craf

t -

Stan

dard

s or

pro

toco

ls a

re n

ot c

onsi

sten

t -

Safe

ty r

isk

is in

duce

d at

any

com

pon

ent o

f th

e co

ntin

uum

, and

in s

ome

case

s, a

cum

ulat

ive

tota

l -

Com

pet

ition

for

task

s ca

n p

lace

pre

ssur

e on

cr

ews

to ta

ke m

argi

nal a

ssig

nmen

ts-

The

ran

ge o

f ri

sks

asso

ciat

ed w

ith th

e cu

rren

t ta

skin

g p

roce

ss fr

om a

sses

smen

t of

pat

ient

ne

ed, t

o th

e al

loca

tion

and

disp

atch

of

the

asse

t, th

roug

h to

op

erat

iona

l con

trol

is n

ot

stan

dard

ized

or

cons

iste

nt in

the

indu

stry

-

Incr

ease

d p

ress

ure

lead

ing

to a

n

incr

ease

in c

rew

fatig

ue-

Syst

emic

issu

es a

nd r

isks

indu

ced

in th

e ta

skin

g p

roce

ss a

re n

ot a

ble

to b

e m

inim

ized

or

rem

oved

- A

s p

art o

f th

e re

desi

gn o

f th

e N

atio

nal

EMS

Fram

ewor

k, r

edes

ign

the

syst

em

cont

inuu

m fo

r ta

sk id

entifi

catio

n, a

lloca

tion

an

d m

anag

emen

t to

achi

eve

alig

nmen

t of

pra

ctic

e fo

r th

e fu

ll sp

ectr

um o

f ta

skin

g ag

enci

es (

incl

udin

g Po

lice,

Fir

e,

EMS,

Hos

pita

ls e

tc)

that

util

ize

HEM

S -

As

par

t of

the

abov

e ac

tivity

, ide

ntify

and

de

fine

the

num

ber,

typ

e an

d va

rian

ce o

f ag

enci

es th

at a

re c

urre

ntly

invo

lved

in th

e ta

skin

g co

ntin

uum

in o

rder

to e

nhan

ce

the

curr

ent s

yste

m a

nd in

dica

te th

e sc

ope

of im

ple

men

tatio

n ef

fort

s re

quir

ed

- D

evel

op n

atio

nal t

aski

ng p

roto

cols

to

be im

ple

men

ted

by th

e St

ates

usi

ng th

e ‘p

erfo

rman

ce b

ased

’ ap

pro

ach

to p

roto

cols

de

velo

pm

ent (

use

CD

C g

uide

lines

as

sam

ple

)-

Imp

lem

ent e

nhan

ced

stru

ctur

e fo

r ta

skin

g ag

enci

es, c

ontr

ol a

nd c

omm

unic

atio

n ce

ntre

s

Seri

al n

o. 1

6

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng


LIKELIHood: LIKELy


PRIoRIty: 6

RESIduAL RISK: tBc

48

Th

e la

ck o

f N

atio

nal

A

irsp

ace

Syst

em a

nd

o

ther

infr

astr

uct

ure

co

nst

rain

ts in

the

airs

pac

e w

her

e H

EM

S o

per

ate

dic

tate

the

con

diti

on

s fo

r th

e o

per

atio

nal

pro

file

fo

r fl

igh

t rem

ovin

g th

e o

ptio

n to

HE

MS

Op

erat

ors

to fl

y IF

R

- Re

mov

e th

e ab

ility

for

the

indu

stry

to m

axim

ize

the

opp

ortu

nity

to h

arne

ss th

e sa

fety

ben

efits

of

tech

nolo

gy

- Re

stri

cted

low

leve

l inf

rast

ruct

ure

forc

es o

per

ator

s to

em

plo

y V

FR w

hen

IFR

mig

ht o

ther

wis

e be

pos

sibl

e-

Incr

ease

d ex

pos

ure

owin

g to

the

volu

me

and

gr

owth

of

HEM

S tr

affic

in th

e vi

cini

ty o

f he

lipad

s -

Lack

of

wea

ther

ser

vice

s p

reve

nt I

FR o

per

atio

ns-

Nat

iona

l Air

Sp

ace

Syst

em is

not

sui

tabl

e an

d

does

not

allo

w fo

r th

e ri

sk in

duce

d th

roug

h

the

airs

pac

e op

erat

ing

envi

ronm

ent t

o be

re-

duce

d to

as

low

as

reas

onab

ly p

ract

icab

le

- A

ssur

ance

for

an e

quiv

alen

t lev

el o

f sa

fety

can

not

be

assu

red

- A

ny d

esir

ed s

tand

ard

of I

FR o

per

atio

ns c

ould

no

t be

effe

ctiv

ely

imp

lem

ente

d w

ithin

the

cur-

rent

reg

ime

of a

irsp

ace

infr

astr

uctu

re

- N

o co

mm

unic

atio

n se

rvic

es fo

r ho

spita

l hel

ipad

s-

Flig

hts

are

unde

rtak

en a

t low

leve

l whe

n

they

cou

ld b

e us

e IF

R p

roce

dure

s-

In m

argi

nal w

eath

er c

ondi

tions

gro

und

co

llisi

on r

isks

are

incr

ease

d-

The

re a

re n

o p

ublis

hed

coor

dina

tion

pro

cedu

res

for

oper

atio

ns a

roun

d fa

cilit

y he

lipad

s w

hich

may

cau

se

colli

sion

ris

ks, e

spec

ially

if it

iner

ant o

per

ator

s ap

pea

r-

Lack

of

pub

lishe

d ap

pro

ach/

dep

artu

re p

roce

-du

res

forc

e lo

w le

vel a

rriv

als/

dep

artu

res

- In

abili

ty to

man

age

the

broa

der

indu

stry

ex

pos

ure

for

inte

ract

ion

of H

EMS

oper

ator

s w

ith

the

broa

der

gene

ral a

viat

ion

com

mun

ity

- In

crea

sed

risk

of

mid

air

col

lisio

n of

ai

rcra

ft in

and

aro

und

airp

orts

and

pre

-do

min

atel

y un

cont

rolle

d ai

rsp

ace

- A

viat

ion

regu

lato

r an

d In

dust

ry to

join

tly

deve

lop

a n

atio

nal p

lan

for

infr

astr

uctu

re

- In

tegr

ate

requ

irem

ents

of

the

HEM

S co

mm

u-ni

ty (

and

the

broa

der

helic

opte

r co

mm

unity

as

a w

hole

) w

ith th

e p

lan

for

infr

astr

uctu

re

imp

rove

men

t in

the

Nat

iona

l Air

spac

e Sy

stem

an

d fu

ndin

g p

rop

osal

s to

sup

por

t thi

s p

lan.

- If

a s

uita

ble

pla

n is

not

abl

e to

be

reso

urce

d

or im

ple

men

ted

tran

sfer

the

risk

to th

e ap

-p

rop

riat

e ag

ency

for

acce

pta

nce

and

sign

off

-

Dev

elop

a n

atio

nal l

evel

low

rou

te

infr

astr

uctu

re fo

r he

licop

ter

oper

atio

ns

- U

tiliz

e a

loca

tion

base

d ri

sk p

rofil

ing

met

hodo

logy

to r

ank

and

pri

oriti

ze th

e or

der

and

timel

ines

by

whi

ch th

is n

atio

nal

infr

astr

uctu

re is

fund

ed a

nd in

trod

uced

Seri

al n

o. 1

7

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (4)

LIKELIHood: LIKELy


PRIoRIty: 10


49

Lack

of

inte

grat

ion

an

d a

lign

men

t of

acco

un

tab

ility

, re

spo

nsi

bili

ty a

nd

re

sou

rcin

g fo

r th

e st

and

ard

izat

ion

of

hel

ipad

op

erat

ion

s in

the

inte

r fa

cilit

y en

viro

nm

ent b

y h

osp

itals

. im

pac

ting

up

on

op

erat

ion

, m

ain

ten

ance

an

d

con

tinu

ou

s h

azar

d

man

agem

ent o

f h

elip

ads

in th

e in

ter-

faci

lity

envi

ron

men

t by

ho

spita

ls, p

rim

ary

HE

MS

op

erat

or

and

o

ther

hel

ipad

use

rs

- La

ck o

f st

anda

rds

for

hosp

ital h

elip

ads

incr

ease

the

risk

of

sub

stan

dard

faci

litie

s-

Unc

oord

inat

ed d

epar

ture

s/ar

riva

ls in

crea

se c

ollis

ion

risk

- La

ck o

f p

roce

dure

s in

crea

ses

risk

of

CFI

T-

Lack

of

wea

ther

dat

a as

par

t of

the

app

rove

d

wea

ther

ser

vice

mak

e IF

R o

per

atio

ns d

ifficu

lt-

Lack

of

inte

grat

ions

bet

wee

n fa

cilit

ies

on

acco

unta

bilit

y a

nd r

esp

onsi

bilit

y-

Inab

ility

to s

tand

ardi

zed

SOP’

s fo

r in

ter

faci

lity

helip

ads

- C

onfu

sion

bet

wee

n op

erat

ors

on S

OPs

and

p

refe

rred

pra

ctic

e fo

r va

ryin

g he

lipad

s-

Inab

ility

to c

ondu

ct a

udits

and

ev

alua

tions

to a

n in

dust

ry s

tand

ard

- D

ata

on h

osp

ital h

elip

ads

is n

ot r

eadi

ly a

vaila

ble

thro

ugh

the

Aer

onau

tical

Inf

orm

atio

n Se

rvic

es (

AIS

)-

The

re is

lim

ited

(and

info

rmal

) sh

arin

g of

op

erat

iona

l dat

a on

hel

ipad

s in

adj

acen

t loc

atio

ns-

Lack

of

infr

astr

uctu

re a

nd lo

w le

vel A

TC

sys

tem

.

- Id

entif

y th

e di

ffer

ent l

evel

and

typ

es o

f he

lipad

s in

use

acr

oss

the

HEM

S in

dust

ry,

and

whe

re a

vaila

ble,

iden

tify

the

rele

vant

co

mp

lianc

e re

gim

e un

der

whi

ch is

op

erat

es-

Whe

re a

man

dato

ry b

ased

com

plia

nce

regi

me

is n

ot a

vaila

ble,

dev

elop

and

im

ple

men

t vol

unta

ry s

tand

ards

to

ensu

re e

quiv

alen

t lev

els

of s

afet

y an

d ha

zard

man

agem

ent

- A

dop

t the

op

erat

iona

l ris

k m

anag

emen

t he

lipad

pro

filin

g m

odel

to a

sses

s th

e ri

sks

asso

ciat

ed w

ith h

elip

ads

- Im

ple

men

t a n

atio

nal l

evel

web

bas

ed

data

base

for

helip

ad in

form

atio

n th

at is

op

enly

ava

ilabl

e to

the

HEM

S in

dust

ry-

Imp

lem

ent a

sui

tabl

e se

lf a

dmin

iste

red

ov

ersi

ght r

egim

e fo

r th

e m

anag

emen

t of

helip

ads

used

for

HEM

S op

erat

ions

-

Esta

blis

hmen

t of

a na

tiona

l lev

el a

genc

y w

here

hel

ipad

non

-com

plia

nces

or

brea

ches

of

ap

pro

ved

pra

ctic

e ca

n be

rep

orte

d an

d

a su

itabl

e in

dust

ry b

ased

sur

veill

ance

and

in

terv

entio

n re

gim

e be

imp

lem

ente

d

Seri

al n

o. 1

8

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (7)

LIKELIHood: LIKELy

conSEQuEncE: MAJoR

PRIoRIty: 18


50

Th

e p

rofi

le o

f th

e p

as-

sen

ger

or

par

ticip

ant

(pat

ien

t an

d m

edic

al

crew

) p

rofi

le in

the

HE

MS

ind

ust

ry d

iffe

rs

sign

ifica

ntly

fro

m th

at

of

oth

er s

ecto

rs o

f th

e av

iatio

n c

om

mu

nity

by

vir

tue

of

the

fact

th

at th

e p

atie

nt d

oes

n

ot h

ave

a ch

oic

e in

the

op

erat

or

al-

loca

ted

to u

nd

erta

ke

thei

r tr

ansp

ort

.

- T

he im

plie

d du

ty o

f ca

re fo

r bo

th th

e p

atie

nt a

nd

med

ical

per

sonn

el o

n bo

ard

the

airc

raft

is n

ot m

et

- T

he r

isk

crite

ria

for

wha

t con

stitu

tes

that

leve

l of

saf

ety

is in

crea

sed

owin

g to

the

pat

ient

s’

inab

ility

to e

lect

ivel

y se

lect

HEM

S p

rovi

ders

- In

crea

sed

chan

ce o

f un

-nec

essa

ry e

xpos

ure

to

the

pos

sibi

lity

of a

n ac

cide

nt o

r in

cide

nt-

Publ

ic o

utra

ge a

nd in

crea

sed

in m

edia

atte

ntio

n

- Ex

pec

tatio

n th

at th

e ri

sk a

ssoc

iate

d w

ith

pro

vidi

ng th

e p

artic

ipan

ts o

f a

HEM

S tr

ansp

ort

fligh

t with

an

equi

vale

nt, a

ccep

tabl

e le

vel

of s

afet

y is

exp

ecte

d by

soc

iety

. -

Incr

ease

in a

ccep

tanc

e of

task

s in

cir

cum

stan

ces

that

are

usu

ally

urg

ent o

r em

erge

nt th

at

wou

ld o

ther

wis

e no

t be

take

n

- In

crea

se in

pol

itica

l atte

ntio

n or

in s

ome

case

s p

oliti

cal i

nter

vent

ion

in th

is in

dust

ry

- Eq

uiva

lent

leve

ls o

f sa

fety

whe

n co

mp

ared

to o

ther

se

ctor

s of

the

avia

tion

indu

stry

can

not

be

met

put

ting

the

par

ticip

ants

of

a H

EMS

fligh

t at g

reat

er r

isk

- A

n eq

uiva

lent

leve

l of

safe

ty fr

om o

ne p

rovi

der

to th

e ne

xt c

an n

ot b

e de

finite

ly p

rovi

ded

-

Com

mun

ity e

xpec

tatio

ns to

pro

vide

an

envi

ronm

ent

with

an

acce

pta

ble

leve

l of

safe

ty is

not

pro

vide

d

- Te

HEM

S op

erat

or a

nd S

tate

s’ r

esp

onsi

bilit

ies

to h

onou

r p

ublic

trus

t in

pro

vidi

ng s

afe

tran

spor

t is

jeop

ardi

zed

- T

he n

atio

nal H

EMS

Syst

em is

que

stio

ned

an

d co

mes

und

er in

crea

sed

scru

tiny

-

Pock

ets

of p

erce

ived

or

real

uns

afe

pra

ctic

es

that

hav

e p

oten

tial t

o gr

eatly

und

erm

ine

pub

lic

confi

denc

e an

d tr

ust o

f th

e en

tire

indu

stry

- Q

uest

ion

rais

ed o

ver

indu

stri

es a

bilit

y to

con

tinue

to

sel

f m

anag

e un

der

curr

ent r

egim

e.

- C

onsi

der

man

datin

g th

at a

ll H

EMS

oper

atio

ns

whe

ther

a p

atie

nt is

on

boar

d or

not

, co

mp

ly w

ith P

art 1

35 s

tand

ards

alte

rnat

ivel

y co

nsid

er a

sp

ecia

l pur

pos

e ru

le –

the

ultim

ate

obje

ctiv

e to

ass

ure

an e

quiv

alen

t and

co

nsis

tent

leve

l of

safe

ty fo

r th

e w

hole

flig

ht

Seri

al n

o. 1

9 PP

ASS

EnG

ER &

PA

RtI

CIP

An

t PR

oFI

lE

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (8)



PRIoRIty: 24


51

Ow

ing

to th

e n

atu

re

of

the

task

pro

file

s co

nd

uct

ed in

HE

MS

and

the

clo

se w

ork

-in

g re

latio

nsh

ip th

e ai

rcre

w h

ave

with

m

edic

al p

erso

nn

el

invo

lved

in th

e ta

sks,

th

ere

is in

crea

sed

b

lurr

ing

of

lines

of

role

an

d r

esp

on

sib

ility

in

resp

ect t

o th

e m

edic

al

per

son

nel

co

ntr

ibu

tion

to

saf

e o

per

atio

n o

f th

e ai

rcra

ft. T

his

ris

k o

f am

big

uity

is in

crea

sed

w

ith m

edic

al p

erso

n-

nel

invo

lvem

ent i

n

NV

G o

per

atio

ns,

pas

-se

nge

r b

riefi

ng,

task

b

riefi

ng,

load

ing

and

u

nlo

adin

g o

f ai

rcra

ft,

op

erat

ion

al r

isk

man

-ag

emen

t ass

essm

ents

an

d c

rew

bri

efin

g an

d

deb

riefi

ng

pro

cess

es.

- T

he d

ivis

ion

of th

is is

sue

in in

dust

ry

rem

ains

un-

reso

lved

-

Indi

vidu

al H

EMS

oper

ator

s m

ake

calc

ulat

ed

or in

form

al d

ecis

ions

by

virt

ue o

f th

e ac

tiviti

es

thei

r m

edic

al p

erso

nnel

are

invo

lved

in

- In

abili

ty fo

r m

edic

al p

erso

nnel

to m

et th

e cu

rren

t av

iatio

n st

anda

rds

and

crite

ria

(eg

drug

and

alc

ohol

sc

reen

ing,

cre

w fi

tnes

s st

anda

rds,

trai

ning

req

uire

men

ts)

- In

crea

sed

exp

osur

e fo

r in

dust

rial

rel

atio

n is

sues

-

The

pre

mis

e up

on w

hich

the

crew

com

pos

ition

is

op

erat

ing

on fr

om a

reg

ulat

ory

per

spec

tive

is o

utda

ted

and

inco

rrec

t and

doe

s no

t re

flect

com

mon

pra

ctic

e or

rea

lity

- C

onfu

sion

incr

ease

s fo

r bo

th p

ilots

and

med

ical

cre

w

abou

t sp

ecifi

c ro

les

in p

rom

otin

g av

iatio

n sa

fety

and

ho

w to

ap

ply

and

use

the

educ

atio

n th

ey h

ave

each

re

ceiv

ed in

Air

Med

ical

Res

ourc

e M

anag

emen

t (A

MR

M)

- In

tern

al c

onfli

ct a

nd c

ontr

over

sy a

roun

d in

fli

ght r

oles

cha

lleng

ed a

nd e

xace

rbat

ed-

The

true

ext

ent o

f th

e le

gal r

amifi

catio

ns

and

cost

imp

licat

ions

is u

nkno

wn

-

The

bas

is fo

r th

e w

hole

par

ticip

ant m

odel

is fl

oore

d

lead

ing

to a

n in

accu

rate

foun

datio

n of

defi

nitio

n-

The

par

ticip

ant m

edic

al c

rew

, pat

ient

s, p

ublic

who

en

gage

in m

edic

al tr

ansp

ort d

o no

t tru

ly u

nder

stan

d

the

risk

pro

file

asso

ciat

ed w

ith E

MS

syst

em in

w

hich

the

HEM

S op

erat

ors

unde

rtak

e th

ese

task

s -

The

line

bet

wee

n ai

rcre

w a

nd m

edic

al

per

sonn

el o

n bo

ard

mig

ht b

ecom

e bl

urre

d-

The

pro

cess

for

asse

ssin

g w

heth

er a

par

ticip

ant

is in

form

ed is

mig

ht n

ot b

e cl

earl

y de

fined

.-

The

ass

ocia

ted

indu

stri

al is

sues

ass

ocia

ted

with

any

ty

pe

of c

hang

e w

ill r

equi

re d

elib

erat

e m

anag

emen

t

- Re

gula

tory

cla

rific

atio

n of

the

stat

us

of o

n bo

ard

med

ical

per

sonn

el

need

s to

be

pro

vide

d-

Onc

e p

rovi

ded,

the

imp

lem

enta

tion

of th

is

pos

ition

and

enf

orce

men

t of

com

plia

nce

with

th

ese

requ

irem

ents

nee

ds to

be

unde

rtak

en

Seri

al n

o. 2

0

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (4)

LIKELIHood: LIKELy


PRIoRIty: 12


52

Gen

eral

ly, s

afet

y m

anag

emen

t sys

tem

s ar

e o

nly

sta

rtin

g to

b

e in

tro

du

ced

in th

e H

EM

S in

du

stry

are

n

ot y

et s

uffi

cien

tly

mat

ure

to m

anag

e th

e le

vel a

nd

dep

th

of

chan

ge r

equ

ired

in

the

safe

ty p

hilo

so-

ph

ies,

pro

cess

es a

nd

p

ract

ices

req

uir

ed

- Pu

sh b

ack

from

with

in E

MS

orga

niza

tions

re

sulti

ng in

neg

ativ

e p

erce

ptio

ns to

war

ds w

hat

a SM

S is

and

why

it s

houl

d be

imp

lem

ente

d-

Lack

of

confi

denc

e fr

om o

per

ator

s to

war

ds

the

regu

lato

r as

a r

esul

t of

not p

rovi

ding

gu

idan

ce fo

r im

ple

men

tatio

n

- SM

S be

com

es a

non

pri

ority

and

th

e st

atus

quo

take

s af

fect

- Su

pp

ort f

or S

MS

from

indu

stry

is s

egm

ente

d

dela

ying

com

plia

nce

dead

lines

if s

et-

Inab

ility

to s

tand

ardi

ze r

egul

ator

y ev

alua

tion

and

p

ract

ice

of S

MS

crea

ting

conf

usio

n in

indu

stry

-

Fall

behi

nd H

EMS

inte

rnat

iona

l bes

t pra

ctic

e-

The

pot

entia

l tha

t key

SM

S el

emen

ts

are

not i

mp

lem

ente

d in

a c

onsi

sten

t m

anne

r ac

ross

the

HEM

S in

dust

ry.

- O

per

ator

s ar

e un

able

to o

btai

n a

clea

r p

ictu

re o

f th

e sa

fety

ris

ks th

at im

pac

t on

thei

r or

gani

zatio

n.-

Safe

ty in

form

atio

n is

not

col

lect

ed-

Stra

tegi

c an

d op

erat

iona

l dec

isio

ns m

ay

be m

ade

with

out a

full

know

ledg

e of

the

safe

ty p

ositi

on o

f th

e H

EMS

oper

ator

-

The

indu

stry

is n

ot y

et in

a p

ositi

on

whe

re s

afet

y ef

fort

s ar

e da

ta d

rive

-

The

saf

ety

risk

pro

file

for

the

avia

tion

asp

ects

of

the

SMS

are

cate

red

for

app

rop

riat

ely

- In

cide

nt r

epor

ting

may

not

get

ade

quat

ely

fed

back

to

the

lead

ers

driv

ing

chan

ge in

the

HEM

S in

dust

ry

- T

he r

eal s

afet

y cu

lture

with

in th

e H

EMS

indu

stry

may

rem

ain

unkn

own

- T

here

is n

o re

quir

emen

t for

op

erat

ors

to

have

a S

afet

y M

anag

emen

t Sys

tem

in li

ne

with

avi

atio

n in

dust

ry s

tand

ards

-

Safe

ty in

form

atio

n w

ithin

the

oper

ator

s or

gani

zatio

n an

d p

arac

hutin

g in

dust

ry

mig

ht n

ot b

e ad

equa

tely

dis

sem

inat

ed-

Con

tinue

d la

ck o

f SM

S p

rofe

ssio

nals

- C

all t

he in

dust

ry to

act

ion

to c

omm

it to

the

imp

lem

enta

tion

of S

afet

y M

anag

emen

t Sys

tem

s p

rior

to it

s m

anda

ted

com

plia

nce

base

d tim

elin

es-

Seek

the

indu

stry

’s c

omm

itmen

t to

ad

opt a

n in

tegr

ated

SM

S th

at c

over

s th

e m

edic

al, a

viat

ion

and

com

mun

icat

ion

as

pec

ts o

f H

EMS

indu

stry

- D

evel

op p

ract

ical

res

ourc

es fo

r th

ose

com

men

cing

imp

lem

enta

tion

- D

evel

op a

nd m

ake

avai

labl

e to

indu

stry

ed

ucat

ion

and

trai

ning

for

thos

e th

at a

re le

adin

g th

e im

ple

men

tatio

n

and

intr

oduc

tion

of th

eir

SMS

- Pr

ovid

e a

mec

hani

sm to

mea

sure

th

e up

take

and

eff

ectiv

enes

s of

SM

S im

ple

men

tatio

n –

pro

vidi

ng a

ben

chm

ark

for

indu

stry

that

mat

ures

ove

r tim

e

Seri

al n

o. 2

1 SS

ySt

EMS

PR

oFI

lE

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng


LIKELIHood: LIKELy


PRIoRIty: 8


53

Avi

atio

n a

nd

med

ical

sa

fety

man

agem

ent

syst

ems

are

no

t in

te-

grat

ed a

t a c

om

plia

nce

o

r p

olic

y le

vel l

ead

ing

to in

coh

eren

t, co

nfl

ict-

ing

or

com

pet

ing

pri

ori

ties

or

pra

ctic

es

wh

ich

may

stifl

e th

e ef

fect

ive

intr

od

uct

ion

o

f th

e SM

S w

ithin

th

e H

EM

S In

du

stry

- T

he H

EMS

Op

erat

or S

MS

from

a p

ure

regu

lato

ry

per

spec

tive

only

add

ress

es h

alf

the

oper

atio

n

(avi

atio

n as

pec

t), h

alf

the

airc

raft

and

hal

f th

e cr

ew

(per

sonn

el e

mp

loye

d by

cer

tifica

te h

olde

r)-

Lack

of

agre

emen

t bet

wee

n av

iatio

n an

d

med

ical

lead

ers

of a

HEM

S O

per

ator

on

the

imp

orta

nce,

sco

pe

and

reso

urci

ng o

f th

e SM

S -

A k

ey fu

nctio

nal p

art o

f th

e H

EMS

indu

stry

m

ay n

ot b

e ca

tere

d fo

r w

ithin

the

HEM

S-

The

saf

ety

man

agem

ent s

yste

m a

dop

ted

do

es n

ot c

over

the

full

spec

trum

of

activ

ities

co

vere

d by

the

HEM

S O

per

ator

-

Dup

licat

ion

of e

ffor

ts, p

olic

ies

and

pra

ctic

es in

re

spec

t to

the

avia

tion

and

med

ical

SM

S an

d

othe

r ex

istin

g sy

stem

s su

ch a

s th

e m

edic

al q

ualit

y m

anag

emen

t / q

ualit

y im

pro

vem

ent s

yste

ms

- D

iffer

ent u

nder

pin

ning

phi

loso

phi

es a

re a

dop

ted

fo

r th

e tw

o ke

y as

pec

ts o

f th

e H

EMS

team

- D

iffer

ence

s of

op

inio

n of

lead

ers

of th

e H

EMS

indu

stry

or

the

HEM

S O

per

ator

s

- La

ck o

f al

loca

tion

of r

esou

rce

or

com

mitm

ent t

o ef

fect

ivel

y im

ple

men

t-

Incr

ease

d oc

curr

ence

of

the

HEM

S in

dust

ry s

imp

ly

re-b

rand

ing

thei

r cu

rren

t saf

ety

pro

gram

as

an S

MS

-

Op

erat

iona

l ris

k p

rofil

es (

risk

ass

essm

ent)

onl

y ta

ke

into

acc

ount

par

t of

the

deci

sion

mak

ing

pro

cess

-

The

op

por

tuni

ty to

incr

ease

the

rate

of

imp

lem

enta

tion

of

SM

S ac

ross

the

EMS

Indu

stry

is lo

st-

Atti

tude

with

in th

e in

dust

ry th

at S

MS

is n

ot n

eede

d

or w

ill n

ot b

e im

ple

men

ted

unle

ss it

is d

rive

n

by th

e re

gula

tor

of th

e sp

ecifi

c di

scip

line

- T

he g

ener

al a

bsen

ce o

f an

y co

ntra

ctua

l re

quir

emen

t for

saf

ety

man

agem

ent s

yste

ms

betw

een

Med

ical

Pro

gram

s an

d EM

S Pr

ogra

ms.

- A

viat

ion

and

med

ical

reg

ulat

ors

or s

tand

ard

sette

rs to

con

vene

to

deve

lop

op

tions

for

com

pat

ible

of

inte

grat

ed S

MS

regu

lato

ry r

equi

rem

ents

sp

ecifi

cally

for

the

HEM

S in

dust

ry

- T

he H

EMS

indu

stry

to a

dop

t an

“i

nteg

rate

d sa

fety

man

agem

ent s

yste

m”

that

link

s th

e av

iatio

n SM

S w

ith th

e m

edic

al S

MS

or e

quiv

alen

t sys

tem

- D

evel

op a

n in

dust

ry p

ublic

atio

n th

at

pro

vide

s a

mea

ning

ful r

efer

ence

on

th

e as

pec

ts o

f sy

stem

s in

tegr

atio

n

- Fo

r ce

rtai

n bu

sine

ss m

odel

s, b

uild

in

the

requ

irem

ent f

or th

e in

tegr

atio

n

and

alig

nmen

t of

syst

ems

with

in th

e co

ntra

ct b

etw

een

the

vari

ous

par

ties

- In

dust

ry a

ssoc

iatio

ns to

faci

litat

e th

e sh

arin

g of

bes

t pra

ctic

es a

cros

s th

e in

dust

ry.

Seri

al n

o. 2

2

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (8)



PRIoRIty: 25


54

Th

e p

ote

ntia

l ris

k as

so-

ciat

ed w

ith in

effe

ctiv

e im

ple

men

tatio

n o

f o

per

atio

nal

co

ntr

ol a

r-ra

nge

men

ts w

ithin

the

HE

MS

ind

ust

ry le

adin

g to

the

incr

ease

d

chan

ce o

f p

oo

r o

per

atio

nal

dec

isio

ns

no

t bei

ng

iden

tified

an

d in

terc

epte

d.

- M

isal

ignm

ent o

f ac

coun

tabi

lity

and

re

spon

sibi

lity

for

fligh

t op

erat

ions

. -

Task

ing

deci

sion

s ca

n be

mad

e w

ithou

t the

pilo

t ha

ving

acc

ess

to a

ll th

e ne

cess

ary

info

rmat

ion

- D

ecis

ion

mak

ing

en r

oute

can

be

mad

e w

ithou

t th

e p

ilot h

avin

g al

l the

nec

essa

ry in

form

atio

n-

Pilo

t may

be

unaw

are

of k

ey c

hang

es to

op

erat

iona

lly s

igni

fican

t inf

orm

atio

n-

Poor

info

rmat

ion

flow

and

sub

optim

al d

ecis

ion

m

akin

g bo

th p

re a

nd d

urin

g fli

ght.

- M

anag

emen

t of

reso

urce

s m

ay b

e le

ss e

ffec

tive

- T

he p

roba

bilit

y of

flyi

ng in

to I

MC

and

in p

artic

ular

ha

zard

ous

cond

ition

s su

ch a

s fo

g at

nig

ht a

re in

crea

sed

- In

crea

sed

pot

entia

l for

abo

rted

mis

sion

s-

Poor

com

mun

icat

ion

and/

or a

dmin

istr

ativ

e p

roce

dure

s

- A

dop

tion

of a

dvan

ced

oper

atio

nal

cont

rol a

rran

gem

ents

- C

omm

issi

on a

form

al c

omp

arat

ive

stud

y be

twee

n th

e op

erat

iona

l con

trol

mod

el o

f Pa

rt 1

21 a

nd P

art 1

35 o

per

ator

s to

ass

ess

the

bene

fits

and

suita

bilit

y of

the

app

roac

h

to th

e co

ntex

t of

HEM

S op

erat

ions

- D

evel

op fo

rmal

str

ateg

ies

to r

evie

w a

nd

imp

rove

com

mun

icat

ion

both

bet

wee

n

oper

ator

s op

erat

ing

in th

e sa

me

area

an

d in

tern

ally

with

in c

omp

anie

s.

- In

res

pec

t to

send

ing

and

rece

ivin

g as

pec

ts o

f th

e H

EMS

oper

atio

nal e

quat

ion,

co

nsid

er th

e vi

abili

ty o

f th

e ap

plic

atio

n

and

adap

tatio

n of

‘op

erat

iona

l con

trol

’ to

th

e he

alth

care

and

EM

S ar

rang

emen

ts –

an

d if

imp

lem

ente

d ad

opt a

per

form

ance

or

out

com

e ba

sed

regi

me

to p

rovi

de

flexi

bilit

y ye

t con

sist

ency

in a

pp

licat

ion

Seri

al n

o. 2

3 S

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (9)

LIKELIHood: unLIKELy


PRIoRIty: 26


55

Th

e cu

rren

t saf

ety

anal

ysis

an

d m

on

itor-

ing

of

the

HE

MS

ind

us-

try

is n

ot d

ata

dri

ven

le

adin

g to

an

inab

ility

fo

r th

e R

egu

lato

r o

r th

e In

du

stry

itse

lf to

hav

e an

acc

ura

te p

ictu

re

of

real

saf

ety

pic

ture

- Sa

fety

pri

oriti

es a

re d

rive

n fr

om a

n ex

per

ient

ial

base

rat

her

than

a d

ata

base

d m

odel

-

The

re is

no

cent

raliz

ed d

ata

sour

ce th

at th

e In

dust

ry

can

draw

up

on to

dri

ve in

dust

ry s

afet

y ch

ange

-

The

indu

stry

is d

rive

n by

rea

ctiv

e da

ta (

acci

dent

st

atis

tical

ana

lysi

s) r

athe

r th

an p

roac

tive

risk

bas

ed s

urve

illan

ce a

nd a

naly

sis

- D

ata

colle

ctio

n ac

tiviti

es a

re fr

agm

ente

d

and

may

pos

ses

gap

s -

The

sco

pe

of r

isk

of th

e in

dust

ry s

ecto

r an

d in

p

artic

ular

the

safe

ty e

xpos

ure

is u

nkno

wn

-

With

out a

n on

goin

g an

alys

is o

f st

anda

rdiz

ed in

dust

ry

data

the

pot

entia

l exi

sts

that

ear

ly w

arni

ng o

f in

dust

ry

safe

ty r

isks

will

not

be

iden

tified

in ti

me

for

the

imp

lem

enta

tion

of c

orre

ctiv

e ac

tion

acro

ss th

e in

dust

ry-

Dat

a co

llect

ed c

anno

t be

accu

rate

ly c

olle

cted

–

do y

ou m

ean

cann

ot b

e va

lidat

ed?

- A

com

par

ison

, ide

ntifi

catio

n of

cha

nge,

or

the

mon

itori

ng o

f tr

ends

can

not

eas

ily b

e ac

hiev

ed

- H

EMS

oper

ator

s ar

e al

way

s “fi

ghtin

g fir

es”

in r

egar

ds to

saf

ety

issu

es-

Safe

ty m

onito

ring

is n

ot d

ata

driv

en le

adin

g to

em

otiv

e ra

ther

than

fact

bas

ed c

hang

e -

Safe

ty a

nd r

isk

docu

men

tatio

n st

agna

tes

and

loss

es r

elev

ance

to o

per

atio

ns.

- D

egen

erat

ive

cultu

re th

at d

oesn

’t fu

lly

com

pre

hend

con

sequ

ence

of

actio

ns-

Inab

ility

to tr

end

accu

rate

ly r

esul

ting

in p

oor

data

ana

lysi

s an

d in

corr

ect fi

ndin

gs w

ith

subs

eque

ntly

inap

pro

pri

ate

trea

tmen

t str

ateg

ies

- N

o ev

olut

ion

of d

ata

anal

ysis

- T

he d

own

side

of

risk

s ar

e on

ly e

ver

eval

uate

d

mis

sing

op

por

tuni

ties

that

may

pre

sent

them

selv

es.

- “G

ood

catc

hes”

are

not

rec

ogni

zed,

an

alyz

ed o

r re

war

ded

resu

lting

in p

oor

mor

ale

amon

gst E

MS

per

sonn

el-

Neg

ativ

e m

edia

cov

erag

e, in

dust

ry s

afet

y st

atis

tics

and

mis

man

agem

ent o

f SM

S-

Inac

cura

te s

tatis

tics

and

rep

ortin

g.

- In

dust

ry le

vel d

ata

colle

ctio

n

requ

irem

ents

and

sp

ecifi

catio

ns

deve

lop

ed,

agre

ed a

nd im

ple

men

ted

-

Nat

iona

l lev

el d

ata

colle

ctio

n,

anal

ysis

and

man

agem

ent s

trat

egy

be

deve

lop

ed w

ith th

e p

urp

ose

of a

dvis

ing

of th

e da

ta b

ase

requ

irem

ents

-

Ado

ptio

n of

FO

QA

and

ORV

R p

rogr

ams

-

Esta

blis

h a

vehi

cle

for

shar

ing

stat

istic

al

data

for

tren

d an

alys

is p

urp

ose

- Em

bed

the

crite

ria

for

rep

ortin

g on

cr

itica

l asp

ects

of

the

data

equ

atio

n

into

com

plia

nce

base

d re

gim

es to

ac

hiev

e m

anda

ted

rep

ortin

g st

atus

. -

Revi

ew, a

lignm

ent a

nd c

onfir

mat

ion

that

the

app

rop

riat

e le

gal p

rote

ctio

ns a

re in

pla

ce to

p

rote

ct d

ata

(pri

vacy

, con

fiden

tialit

y an

d an

ti-tr

ust)

alo

ng w

ith a

n as

sess

men

t of

how

op

en

safe

ty r

epor

ting

cultu

res

can

be c

ultiv

ated

Seri

al n

o. 2

4 SA

FEty

PR

oFI

lE &

PA

RtIC

IPA

nt

PRo

FIlE

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (6)

LIKELIHood: cERtAIn

conSEQuEncE: MAJoR

PRIoRIty: 16


56

Th

e cu

rren

t tra

inin

g re

gim

e fo

r a

hig

h

per

cen

tage

of

the

HE

MS

ind

ust

ry d

oes

n

ot e

mp

loy

the

use

o

f si

mu

lato

rs a

nd

ad

van

ced

trai

nin

g m

eth

od

s b

road

ly u

sed

in

oth

er p

arts

of

the

avia

tion

ind

ust

ry p

re-

do

min

atel

y d

ue

to c

ost

- C

rew

are

unp

rep

ared

for

unus

ual o

r ra

re s

ituat

ions

- C

rew

are

unp

rep

ared

for

emer

genc

y si

tuat

ion

such

as

engi

ne fa

ilure

- C

rew

coh

esiv

enes

s no

t as

stro

ng

and

stru

ctur

e as

it m

ight

be

- Tr

aditi

onal

trai

ning

met

hods

do

not p

rovi

de a

pp

rop

riat

e tr

aini

ng fo

r un

usua

l or

emer

genc

y si

tuat

ions

- Li

mite

d kn

owle

dge

of s

tren

gths

and

w

eakn

esse

s of

new

tech

nolo

gy-

Dec

isio

n m

akin

g an

d ri

sk m

anag

emen

t le

ss s

truc

ture

d th

at it

cou

ld b

e-

An

esta

blis

hed

cultu

re th

at h

as b

uilt

a re

sist

ance

to c

hang

e as

a r

esul

t of

inad

equa

te

safe

ty a

nd r

isk

man

agem

ent e

duca

tion

th

roug

h th

e EM

S ed

ucat

iona

l pro

cess

- La

ck o

f co

nfide

nce

with

in th

e H

EMS

com

mun

ity

beca

use

of th

e va

ryin

g ed

ucat

iona

l req

uire

men

ts

and

limite

d st

anda

rdiz

ed a

cros

s th

e co

untr

y -

Inab

ility

to a

udit

and

eval

uate

ag

ains

t an

indu

stry

cri

teri

a.-

Inab

ility

to b

ench

mar

k ag

ains

t in

tern

atio

nal t

rain

ing

stan

dard

s-

The

des

ired

leve

l of

pilo

t ski

ll ba

sed

and

trai

ning

st

anda

rds

are

not a

dequ

atel

y ac

hiev

ed

- D

evel

op a

nat

iona

l tra

inin

g st

rate

gy fo

r th

e H

EMS

indu

stry

, thi

s st

rate

gy w

ould

cov

er

the

full

spec

trum

of

trai

ning

nee

ds a

naly

sis

(eg

HEM

S Ed

ucat

ion

& T

rain

ing

Age

nda)

- T

he F

AA

and

Op

erat

ors

to c

onve

ne to

re

view

and

est

ablis

h m

inim

um s

cena

rio

ba

sed

sim

ulat

or tr

aini

ng r

equi

rem

ents

.-

Esta

blis

h a

helic

opte

r sa

fety

edu

catio

n

cons

ortiu

m to

pro

vide

the

full

spec

trum

of

acc

redi

ted

safe

ty tr

aini

ng

- C

oop

erat

ion

amon

g op

erat

ors

in th

e us

e of

sim

ulat

ors

for

new

air

craf

t.-

Iden

tify

reso

urce

and

exp

ertis

e in

res

pec

t of

sim

ulat

or w

orki

ng g

roup

s at

eith

er th

e na

tiona

l or

inte

rnat

iona

l lev

el (

eg R

Aes

)

Seri

al n

o. 2

5 S

dES

cRI

PtIo

n

IMPA

ct

of

tHE

RISK

on

RI

SK

RISK

tRE

AtM

Ent

RESI

du

AL

of

RISK

tH

E H

EMS

Ind

uSt

Ry

ASS

ESSM

Ent

StRA

tEg

y RA

nKI

ng

RISK LEvEL HIgH (7)

LIKELIHood: LIKELy

conSEQuEncE: MAJoR

PRIoRIty: 19


57

Th

e ri

sks

asso

ci-

ated

with

the

lack

o

f d

evel

op

men

t of

a ta

ngi

ble

saf

ety

cultu

re

that

tru

ly u

nd

er-

stan

ds

risk

an

d th

e m

anag

emen

t of

risk

- T

he d

esir

ed le

vel o

f p

ilot s

kill

base

d an

d tr

aini

ng

stan

dard

s ar

e no

t ade

quat

ely

achi

eved

-

The

indu

stry

cul

ture

can

rew

ard

risk

taki

ng b

ehav

ior

- T

he in

dust

ry is

just

beg

inni

ng to

imp

lem

ent

safe

ty m

anag

emen

t sys

tem

s-

Seni

or m

anag

emen

t may

not

be

awar

e of

th

e im

por

tanc

e of

a r

epor

ting

cultu

re-

The

sta

tus

quo

is m

aint

aine

d as

a r

esul

t of

inad

equa

te r

egul

atio

n an

d gu

idan

ce fr

om in

dust

ry-

The

HEM

S in

dust

ry b

ecom

es n

on s

usta

inab

le-

The

indu

stry

dev

elop

s a

poo

r re

put

atio

n

in th

e av

iatio

n se

ctor

res

ultin

g in

inab

ility

to

attr

act a

sus

tain

able

wor

kfor

ce-

“old

sch

ool o

f th

inki

ng”

is m

aint

aine

d le

adin

g to

in

crea

sed

chal

leng

es to

trul

y ac

hiev

e th

e de

sire

d cu

lture

-

Imp

lem

enta

tion

of c

hang

e ta

kes

long

er th

an r

equi

red

- Re

silie

nt s

taff

ove

r-m

otiv

ated

to tr

ansp

ort

and

care

for

criti

cally

inju

red/

ill p

atie

nts

- La

ck o

f hu

man

fact

or to

ols/

initi

ativ

es

- D

evel

op a

n 10

poi

nt in

dust

ry p

lan

for

cultu

ral c

hang

e in

clud

ing

the

indu

stry

’s lis

t of

mos

t una

ccep

tabl

e be

havi

ours

, p

ract

ices

and

atti

tude

s an

d se

ek

com

mitm

ent f

rom

Air

Op

erat

ors,

cus

tom

er

and

indu

stry

gro

ups

alik

e to

join

the

cam

pai

gn to

enh

ance

the

cultu

re

- Im

ple

men

t an

agre

ed in

dust

ry w

ide

educ

atio

n ca

mp

aign

for

the

indu

stry

in

res

pec

t to

the

com

ple

xitie

s of

the

safe

ty e

quat

ion

in th

e H

EMS

indu

stry

-

Imp

lem

ent a

ded

icat

ed e

xecu

tive

sem

inar

ser

ies

for

seni

or le

ader

s w

ithin

the

indu

stry

at t

he g

over

nanc

e an

d p

rogr

am m

anag

emen

t lev

els

- Im

ple

men

t a d

edic

ated

cus

tom

er a

nd

user

trai

ning

ser

ies

to e

ncou

rage

the

cust

omer

bas

e to

pla

y a

mor

e ac

tive

role

in o

vers

ight

and

gov

erna

nce

- D

evel

op a

ser

ious

soc

ialis

ed m

arke

ting

and

com

mun

icat

ions

cam

pai

gn to

p

rom

ote

and

inst

il th

e ke

y m

essa

ges

and

beha

viou

rs w

ithin

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58

Supporting Appendices

PARt 4

59

Appendix AHeMS IRP StAKeHOLDeR AnD DIStRIbUtIOn LIStAerospace Medical Association (AsMA) Aerosafe Risk Management Air Medical Operators Association: United in Safety (AMOA)Air Medical Operators holding a Part 135 Certificate (copy per organization) Air Medical Programs (copy per organization) Air Medical Physicians Association (AMPA)Air and Surface Transport Nurses Association (ASTNA)American Academy of Pediatrics (AAP)American Ambulance Association (AAA)American Association of Critical Care Nurses (AACN)American Association for Respiratory Care (AARC)American College of Emergency Physicians (ACEP)American College of Surgeons (ACS)American Hospital Association (AHA)American Helicopter Society (AHS) American Society for Healthcare Engineers (ASHE) American Society for Healthcare Risk Management (ASHRM)Association of Air Medical Services (AAMS)Aviation Safety Network Executive Group (ASN)Aviation Safety Network Alumni (ASN Alumni) Bell Helicopters TextronCommission Accreditation of Medical Transport Systems (CAMTS)Department of Health and Human ServicesEmergency Nurses Association (ENA)Federal Aviation Administration (FAA)Flight Safety FoundationFoundation for Air-Medical Research and Education (FARE)Government Accountability Office (GAO)Helicopter Association International (HAI)Helicopter Emergency Medical Services Committee House Aviation Sub Committee International Association of Flight Paramedics (IAFP)International Helicopter Safety Team (IHST)International Standards Organization Committee for Risk Management National Association of Air Medical Communications Specialists (NAACS)National Air Transport Association (NATA) National Association of EMS Physicians (NEMSP)National Association of Emergency Medical Technicians (NAEMT)National Association of Neonatal Nurses (NANN)National Association of State EMS Officials (NEMSO)National EMS Pilots’ Association (NEMSPA) National Transportation Safety Board (NTSB)Patients First Air Ambulance Alliance (PFAA)Risk & Insurance Management Society Inc (RIMS)

The Joint Commission

60

PARt 4 Supporting Appendices

Appendix BSUPPORtInG DOCUMentAtIOn Accompanying Documentation: - Executive Summary: An executive summary is provided to assist the industry in understanding the

background, scope and contents of the HEMS IRP. The next steps for risk reduction are also outlined.

- HEMS Industry Risk Reduction Plan: the main driver of assessing risk is to proactively reduce risk through the implementation of risk treatment strategies of solutions to the risk issues. Following the release of the HEMS IRP a facilitated process will take place calling for submission by stakeholders who wish to take carriage of industry wide risk reduction measures. This work will be compiled into the HEMS Industry Risk Reduction Plan.

Information Packages- Technical Media Briefing Package: Given the comprehensive nature of the information presented

in the HEMS IRP, a technical briefing was delivered to the media on Monday April 20, 2009 at the National Press Club in Washington DC.

- FAQs: Frequently asked questions are provided as a supporting resource.

Guide & template- Industry Submission – Risk Treatment Strategies: Guidance material has been made available to indus-

try to assist in the preparation of their submission of risk treatment strategies that will be compiled in the HEMS Industry Risk Reduction Plan.

- Guide for Associations – How to use the HEMS IRP: Provided for use by industry associations and groups to inform their members and boards.

- Guide for Air Medical Operators – How to use the HEMS IRP: Provided for use by Part 135 Operators to assist in understanding how the HEMS IRP can be utilized at an organizational level by Board Members, CEOs and Company Executives.

- Guide for Air Medical Programs – How to use the HEMS IRP: Provided for use by Air Medical Pro-grams to assist in understanding how the HEMS IRP can be utilized at an organizational level by Board Members, Hospital Executives CEOs, Program Directors, Program Executives.

- Guide for State EMS Agencies – How to use the HEMS IRP: Provided to State EMS Agencies in order to provide information on how the HEMS IRP could be utilized at the State level.

61

Appendix cAbbReVIAtIOnS

AAMS Association of Air Medical Services

ADS(B) Automatic Dependent Surveillance - Broadcast

AHS American Helicopter Society

AMOA Air Medical Operators Association: United in Safety

AMRM Air Medical Resource Management

ATC Air Traffic Control

CRM Crew Resource Management

EMS Emergency Medical Services

FAA Federal Aviation Administration

FARE Foundation for Air-Medical Research and Education

FOQA Flight Operation Quality Assurance

FSF Flight Safety Foundation

GAO Government Accountability Office

HAI Helicopter Association International

HEMS Helicopter Emergency Medical Services

HTWAS Helicopter Terrain Warning Avoidance System

IFR Instrument Flight Rules

IHST International Helicopter Safety Team

IMC Instrument Meteorological Conditions

IRP Industry Risk Profile

IRSMS Integrated Risk & Safety Management Systems

ISO International Standards Organization

JSAT Joint Safety Analysis Team (part of IHST)

JSIT Joint Safety Implementation Team (part of IHST)

NTSB National Transportation Safety Board

NVG Night Vision Goggles

SMS Safety Management Systems

VFR Visual Flight Rules

62

PARt 4 Supporting Appendices

Appendix dPROjeCt COntACt DetAILS AnD PROjeCt ACKnOWLeDGeMentS

Project Contact Kimberley Turner Chief Executive Officer Aerosafe Risk Management 1325 G Street NW Washington DC Ph: 202 449 7693 Fax: 202 449 7701 [email protected]

Staff Acknowledgments In addition to the contact named above, Bradley Glassington, HEMS IRP Project Manager; Robin Graham, Senior Risk Advisor (Aviation); John W.Overton, Jr., M.D., Senior Risk Advisor (Medical) and Katherine Robinson, Senior Planner & Communications Manager have all made key contributions to this report. Graphic Design provided by GraphikExposure.

Technical Review Special thanks to Kevin W Knight, Chairman ISO Standards Committee Risk Management for undertaking a technical review of the HEMS IRP.

Custodian of the Flight Safety Foundation is to be commended for their enthusiasm in taking HEMS IRP on the role as custodian of this body of work. It is with great appreciation

and deepest thanks to Joan Sullivan Garrett, Vice Chairman Flight Safety Foundation; William R. Voss President and CEO Flight Safety Foundation; Emily McGee, Director of Communications for the support and interest in this initiative.

Review & comment The opportunity for review and comment on the draft HEMS IRP was providedon the Draft HEMS IRP to 33 different stakeholder groups. Additional resource, dedicated briefings

or a workshop was held with AAMS, AHS, AMOA, AMPA, CAMTS, FAA, FARE, Flight Safety Foundation, GAO, HAI, House Aviation Sub Committee, International Helicopter Safety Team, NEMSPA, NTSB and The Joint Com-mission. The project team would like to thank these organizations for the time taken to review, discuss and provide feedback on either the concept of utilizing risk management at the industry level or the provision of comment on the draft HEMS IRP over the period February 12, 2009 – April 15, 2009.

Obtaining Copies Flight Safety Foundations web site www.flightsafety.org Copies are availableof the HEMS IRP at no cost.

Order by mail The Foundation of Air Medical Research and Education has taken on respon-or phone sibility for printing and distribution of the HEMS IRP to industry. Contact

details for ordering copies are on the back cover of this document. Special acknowledgment and thanks to FARE Board, their Chair Dr Kevin Hutton and staff for their ongoing commitment to safety research & education.

foR MEdIA InQuIRIES, contAct:

EMILy McgEE, director, communicationsflight Safety foundation, 601 Madison Ave, Alexandria vA 22314 Phone: 703 739 6700 Email: mcgee@flightsafety .org

foR InQuIRIES on tHE HEMS IRP, contAct:

BRAdLEy gLASSIngton, HEMS IRP Project ManagerAerosafe Risk Management, 1325 g Street nW, Washington dcPhone: 202 449 7693 Email: bglassington@aerosafe .com .au

to REQuESt youR coPy of tHE HEMS IRP contAct:

AMBER BuLLIngton, Program Managerfoundation Air Medical Research and Education526 King Street, Suite 415, Alexandria, vA 22314Phone: 703 836-8732 Email: abullington@aams .org

FOUNDATION FOR AIR-MEDICAL RESEARCH & EDUCATION

The HEMS Industry Risk Profile helps fulfill FARE’s mission of raising awareness, and advancing research in the emergency-medical-transport field. FARE is distributing this document, in its hardcopy form, to air-medical service professionals and others interested in the field to be used as a tool in advancing safety for the entire HEMS community.

To order your copy of the HEMS IRP go to

www.fareonline.org