Safety Recommendation A-06-015

We are aware that, in section 135.605, the final rule requires operators of helicopter air ambulances to equip these helicopters with TAWS. Accordingly, Safety Recommendation A 06-15 is classified CLOSED—ACCEPTABLE ACTION.

The FAA’s proposed revisions to 14 CFR Part 135 to mandate the use of helicopter terrain awareness and warning systems in helicopter air ambulance operations, if adopted, would satisfy this recommendation. Accordingly, pending the expeditious issuance oF the final rule as proposed, Safety Recommendation A-06-15 is classified OPEN—ACCEPTABLE RESPONSE.

-From Michael P. Huerta, Acting Administrator: On October 12, 2010, the FAA issued Notice of Proposed Rulemaking (NPRM), Air Ambulance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135 Aircraft Operations; Safety Initiatives and Miscellaneous Amendments. The comment period closed on January 10, 2011. The FAA received the comments submitted by the Board and is reviewing those comments as part of the rulemaking process. The NPRM proposes to add requirements for: • A load manifest for all aircraft operated under part 135 (§ 135.63(c)); • Radio altimeters for all helicopters operated under part 135 (§ 135.160);

• Initial and recurrent pilot testing to include procedures for aircraft handling in flat-light, whiteout, and brownout conditions (§ 135.293(a)(9)); • Competency checks that include a demonstration of the pilot's ability to maneuver solely by reference to instruments (§ 135.293(c)

Notation 8272: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) Notice of Proposed Rulemaking (NPRM) titled "14 CFR [Code of Federal Regulations] Parts 1, 91, 120, and 135 Air Ambulance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135 Aircraft Operations; Safety Initiatives and Miscellaneous Amendments; Proposed Rule," which was published at 75 Federal Register 62640 on October 12, 2010. The FAA proposes requiring that all helicopters used in air ambulance operations be equipped with helicopter terrain awareness and warning systems (H-TAWS).

H-TAWS would help HEMS pilots maintain situational awareness of surrounding terrain and obstacles, thereby reducing the risk of controlled-flight-into-terrain (CFIT) accidents.

The unique operating environment of HEMS flights requires pilots to maintain exceptional situational awareness because of the risks associated with low-altitude operations, including CFIT and obstacle strikes. H-TAWS alerts pilots to these hazards. An analysis conducted by the NTSB as part of its Special Investigation Report on Emergency Medical Services Operations found that 13 of 41 (31 percent) of the HEMS accidents studied may have been prevented if H-TAWS had been used. The NTSB concurs with this proposed regulation and notes that if adopted, it would meet the intent of Safety Recommendation A-06-15.

Safety Recommendation A-06-15 recommends that the FAA “require emergency medical services (EMS) operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations.” It is currently classified “Open—Unacceptable Response” and is on the NTSB’s Most Wanted List.

At the NTSB’s February 18, 2010, review of the Most Wanted List, the NTSB indicated that inclusion of a requirement for helicopter TAWS in the developing NPRM was a responsive action, but the NTSB remained concerned about the time required to develop and issue this requirement. Accordingly, the Board voted to retain the classification of OPEN -- UNACCEPTABLE RESPONSE for Safety Recommendation A-06-15 pending adoption of a requirement that all EMS operators equip their aircraft with and use TAWS.

Letter Mail Controlled 11/23/2009 2:32:06 PM MC# 2090695: - From J. Randolph Babbitt, Administrator: The FAA has supported the voluntary implementation of Terrain Awareness Warning Systems (TAWS). Prior to establishing a requirement, TAWS use in HEMS operations required a study of TAWS interoperability within the lower altitude HEMS environment and possible modification of TAWS system standards. At the FAA's request, RTCA, Inc., established a Special Committee, SC-212, to develop helicopter TAWS (HTAWS) standards for use in future FAA rulemaking projects. The final report was delivered to RTCA, Inc., in March 2008.

Following a review of those standards, the FAA issued Technical Standard Order (TSO) C194 for a Helicopter Terrain Awareness and Warning System, on December 17, 2008 (previously provided). TSO-C194 provides manufacturers with the minimum performance standards HTAWS must meet to receive FAA approval and identification with the applicable TSO marking. On January 12, 2009, the FAA had its inspectors with oversight responsibility of HEMS operators find out how many operators have adopted specific FAA-recommended best practices. All 74 operators were surveyed and validated by FAA inspectors. Forty-one percent indicated they were equipping with HTAWS.

The NPRM currently under development will also address this recommendation. We plan to complete work on this NPRM in January 2010 and publication will occur after clearance from the DOT and the OMB.

From the Accident Report: Crash during approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD, in District Heights, Maryland on September 27, 2008. The Board adopted this report on 10/27/2009. Terrain Awareness and Warning Systems The accident helicopter was not equipped with a terrain awareness and warning system (TAWS). NTSB investigators asked a manufacturer of TAWS to determine the pilot alerts expected if the helicopter had been equipped with TAWS.

The manufacturer ascertained that three aural terrain alerts would have been generated at 7, 4, and 2 seconds prior to tree impact, and an aural glideslope alert would have been generated 24 seconds prior to tree impact if a valid glideslope signal was being received. It is unlikely the glideslope warning would have caused the pilot to arrest his descent since it appears that he intentionally deviated from the glideslope. However, if the helicopter had been equipped with TAWS, the aural terrain alerts of Caution Terrain, Warning Terrain, and Pull-up, would have been provided.

These would have been more salient than the alert provided by the radar altimeter10 and likely would have caused the pilot to attempt to arrest his descent. Although it is unknown whether the pilot could have recovered in time to avoid hitting the trees, this scenario does illustrate the potential benefit of TAWS.

As a result of the aforementioned NTSB special investigation of aviation accidents involving aircraft performing EMS operations, the NTSB issued Safety Recommendation A-06-15, which asked the FAA to require emergency medical services (EMS) operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations. The FAA has not yet issued a rule to mandate the installation and use of TAWS on EMS flights, and as a result, on January 23, 2009, Safety Recommendation A-06-15 was classified Open Unacceptable Response.

The NTSB believes that this accident demonstrates the need for all EMS operators, both public and civil, to equip their aircraft with TAWS. Therefore, the NTSB reiterates Safety ecommendation A-06-15.

The National Transportation Safety Board met on October 28, 2008, to consider our list of Most Wanted Safety Improvements issued to Federal agencies. At this meeting, the issue Improve the Safety of Emergency Medical Services (EMS) Flights was added to the list, as were Safety Recommendations A-06-12 through -15, stated below. The Safety Board also reclassified three (A-06-12, -13, and -15) of the four recommendations.

All four recommendations were issued to the Federal Aviation Administration (FAA) as a result of the Safety Board’s special investigation of a number of aviation accidents between January 2002 and January 2005 involving aircraft performing EMS operations. In June 2006, at the FAA’s request, the Radio Technical Commission for Aeronautics (RTCA) established SC-212, a committee tasked with developing helicopter TAWS (H-TAWS) standards.

In March 2008, the RTCA completed the development of a set of minimum operational performance standards for H-TAWS; however, the FAA has not yet published a technical standard order (TSO) based on the RTCA-developed standards. A TSO must be published before the FAA may begin rulemaking to require H-TAWS on EMS flights.

The Safety Board believes that the delay in issuing the TSO and further delay in requiring H-TAWS is not acceptable; accordingly, pending issuance by the FAA of a TSO based on the RTCA set of minimum operational performance standards for H-TAWS and rulemaking action to mandate the installation and use of TAWS on all EMS flights, Safety Recommendation A-06-15 is classified OPEN -- UNACCEPTABLE RESPONSE.

Letter Mail Controlled 10/7/2008 1:08:49 PM MC# 2080609: - From Steven B. Wallace, FAA: The Radio Technical Commission for Aeronautics (RTCA), in March 2008, completed the development of a set of minimum operational performance standards for helicopter TAWS.

The Technical Standard Order (TSO) based on this work has been drafted and is being reviewed by FAA Aircraft Certification Service. Projected publication of the TSO is January 2009.

Rulemaking will be considered once the TSO is published. We expect that many operators may voluntarily equip their helicopters with TAWS once the TSO is published.

During the October 12, 2006, meeting, the FAA indicated that although there is a commercially available TAWS for helicopters, there does not yet exist a set of standards for these systems that would be needed if the FAA were to mandate their installation and use on helicopters. The FAA asked the Radio Technical Commission for Aeronautics (RTCA), a private, not-for-profit corporation that develops recommended standards for communications, navigation, surveillance, and air traffic management issues, to establish a committee to develop minimum operational performance standards for helicopter TAWS.

On June 27, 2006, RTCA established SC-212, a committee tasked with developing these standards, currently scheduled to be completed by March 2008. The FAA plans to issue a Technical Standards Order (TSO) based on the standards SC-212 develops. When the TSO is issued, the FAA will be in a position to require the installation and use of TAWS in helicopters.

Pending release by SC-212 of a set of minimum operational performance standards for helicopter TAWS, issuance by the FAA of a TSO based on these standards, and a requirement mandating the installation and use of TAWS in all EMS flights, Safety Recommendation A-06-15 is classified OPEN -- ACCEPTABLE RESPONSE.

Letter Mail Controlled 6/14/2006 10:24:44 AM MC# 2060276: - From Marion C. Blakey, Administrator: 5/30/06 The FAA supports the voluntary implementation of Terrain Awareness and Warning Systems (TAWS) and considered the possibility of including rotorcraft in the TAWS rulemaking process. The FAA concluded that there are a number of issues unique to VFR helicopter operations that must be resolved before the FAA considers mandating the use of TAWS in this area, such as modification of the standards used for these systems.

For example, helicopters typically operate at lower altitudes, so TAWS could potentially generate false alerts and "nuisance" warnings that could negatively impact the crew's response to a valid alert. The TAWS application to helicopter EMS would require the study of TAWS interoperability within the lower altitude helicopter EMS environment, and possibly a modification of TAWS standards. While the FAA and industry work to address issues related to installation of TAWS on EMS aircraft, we are working to address the controlled flight into terrain (CFIT) issue through a variety of avoidance strategies, with emphasis on effective preflight planning.

In Handbook Bulletin for Air Transportation 06-02, Helicopter Emergency Medical Services (HEMS) Loss of Control (LOC) and Controlled Flight Into Terrain (CFIT) Accident Avoidance Programs, issued in January 2006, the FAA emphasized the strategic avoidance of CFIT accidents. I have enclosed a copy of the bulletin for the Board's information.

At the October 25, 2008 Board meeting addressing the NTSB’s Federal Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations A-06-12 through A-06-015 on the Federal MWL under the issue category “Improve the Safety of Emergency Medical Services (EMS) Flights.”