The operator and air ambulance provider did not have a structured process in place to conduct pre-flight risk assessments for air ambulance tasks, nor was there any regulatory requirement for such a process.
The ATSB notes the operator and air ambulance provider both took safety action to reduce the risk of this safety issue, and the operator also undertook broader safety action in relation to hazard identification processes that also potentially reduced the risk associated with this safety issue (see Safety issue AO-2014-190-SI-08). The ATSB also notes the operator ceased air ambulance operations with the air ambulance provider in mid-2010.
In December 2009, the operator issued a formal notice to its Westwind flight crew that aviation safety was the primary consideration regarding flight continuation, and the condition of the patient was a secondary consideration. The notice also included detailed requirements for pre-flight safety briefings with medical personnel (see Operator’s emergency procedures and cabin safety).
In addition, the operator also introduced a requirement for all air ambulance flights to depart with a portable satellite phone on board. A formal notice to pilots stated:
The provision of this communication tool not only allows the Company to improve operational support to flight crew, but allows crews to advise the Company of departure times, delays, flight times, diversions, delayed arrivals (beyond 15 minutes), and actual arrival times, including intermediate stops.
The notice also outlined a format for text messages providing trip updates.
The operator also provided retraining for all Westwind flight crew in many areas, as outlined in the safety actions to the other safety issues.
In July 2013, CASA issued the Notice of Proposed Rule Making (NPRM) 1304OS (Regulations of aeroplane and helicopter ‘ambulance function’ flights as Air Transport operations). This NPRM is further discussed below in relation to safety issue AO-2014-190-SI-12. Annex A of the NPRM stated:
An HMT or AMT operator will have outlined in their exposition a formal policy and standard operating procedures for compliance with Part 121,133 or 135 of CASR in regard to operational control. These documents will include:
▸a tasking dispatch risk assessment tool
▸an inflight risk assessment and management process (using operational decision point go / no go processes)
▸a flight-following procedure and capability that is able to update the pilot on operational matters during flight, if required by the risk management aspects of the operation, or at the next landing point if in flight updates are not required.
In September 2015, CASA issued the Notice of Proposed Rule Making (NPRM) 1519OS (Aerial Work Operations). The NPRM proposed a requirement for pre-flight risk assessments for aerial work operations (dependent on size and nature of operation).
In March 2017, CASA was asked whether requirements for pre-flight risk assessments would also be extended to air ambulance or medical transport flights, when such flights were no longer classified as aerial work. CASA advised:
NPRM 1519OS is for the development of CASR Part 138 Aerial Work Operations. The risk, in an aerial work context, is particular to the specific operation and the environment in which it is being conducted. However, that does not preclude conducting an initial generic risk assessment before developing a tailored assessment for a particular task. With the classification of Medical Transport flights as Air Transport, CASR Part 138 is not applicable in a medical transport context.
However, pre-flight risk in an air transport context is managed by the flight planning requirements which in essence are a formalised assessment of the hazards and associated risks of the flight. Please note that CASR Part 135 contains specific pre-flight planning requirements for flights to isolated aerodromes.
In April 2015, CareFlight advised the ATSB that its medical directors normally scrutinised all missions for clinical risk and management of those clinical risks. Following the 18 November 2009 accident, they added fatigue to their scrutiny, with a view to postpone or push back timing so that it reduced the potential for fatigue (that is, if it were tasked on an mission that was deemed not urgent, it would push the mission back to align with daylight hours).
It also advised that it had a lowered threshold for overnighting crews rather than return to base when timing was marginal or overnight flights were required to position back to base.
