A95C0250 - Collision with Frozen Lake - Wollaston Lake, Saskatchewan 1 nm NE - 25 November 1995

Safety Action Taken
(as presented in the TSB Report)

Stretcher Installations and Patient Restraints

During this investigation, it became evident that the Air Navigation Order (ANO) concerning the installation of a stretcher, incubator, or similar device in an aircraft (ANO Series II, No. 2, subsection 4(2)) was open to different interpretations. The ambiguity could have resulted in the approval of an installation which negated the airworthiness of both the device (e.g., stretcher) and patient restraint. This shortfall has been redressed by Canadian Aviation Regulations (CAR) subsection 605.23, which states that each person carried on a stretcher, in an incubator, or other similar device must be provided with a "restraint system." Such a "restraint system," under the provisions of CAR 605.06, Aircraft Equipment Standards and Serviceability, must meet applicable standards of airworthiness (i.e., the equipment and its installation must be approved by Transport Canada).

Additionally, Transport Canada (TC) has taken action to update its air ambulance-related publications (Guide to Air Ambulance Operations, TP 10839E and Stretcher Installation in Aircraft, ASI 32) to reflect the changes brought about by the introduction of the CARs.

Dissemination of Information

The Board believes that those agencies involved in contracting for air ambulance services should be made aware of the safety issues identified during this investigation. As such, the final report on this occurrence investigation is being distributed to the appropriate authorities in the federal government as well as all provincial and territorial governments.

Safety Action Required
(as presented in the TSB Report)

Regulatory Overview of Air Ambulance Operations

The term "air ambulance operations" refers to the transport of medical patients by air. The missions can range from a straightforward patient transfer to an emergency medical evacuation (MEDEVAC). At present, air ambulance operations are considered by TC to be a commercial air service and as such are governed by Part VII of the CARs. The granting of an Air Operator Certificate, which allows for the transport of fare-paying passengers, also permits the operator to adapt the operation for an air ambulance service. The CARs contain no specific reference to or standards with respect to the conduct of air ambulance operations, and conducting such a service does not require an amendment to the Operations Specification. As such, TC might not be aware that an operator is conducting an air ambulance service and, therefore, might not include aspects specific to air ambulance operations in any TC audit and surveillance of the operator.

TC currently relies on operators to voluntarily make the necessary changes to aircrew training and operational procedures, and to seek TC airworthiness approval of equipment installations before offering air ambulance service to the public. However, in this occurrence, the operator was conducting an air ambulance service without a TC-approved stretcher installation, additional aircrew training, and amended manuals to reflect specific air ambulance procedures.

As noted earlier, several provinces have set standards for aircraft, passenger restraints, aero-medical equipment, ground facilities, and personnel training. However, these standards are reportedly difficult to enforce in situations where the flight is arranged or paid for by an organization other than an agency of the respective provincial government.

As recognized in Transport Canada's air ambulance guidance documents and in the efforts by some provincial governments to regulate the air ambulance services in their respective provinces, the provision of consistently safe air ambulance service requires equipment, training, and procedures considerably different from those required for regular passenger-carrying operations. The Board understands that in other occurrences (e.g., TSB A89O0280), patient safety has been compromised by inadequate protective measures (vis-à-vis those afforded a normal passenger). Notwithstanding measures taken by some provinces to enhance patient safety in air ambulance operations, the Board believes that a consistent level of safety across Canada will not be attained through voluntary measures. Crews and patients will remain at risk to the extent that patients are transported with inappropriate equipment or by crews that have not been adequately trained in meeting the special needs of non-ambulatory medical patients. Therefore, the Board recommends that:

The Department of Transport require all air carriers operating air ambulance services in the course of their business to provide the equipment, procedures, and crew training necessary to ensure a level of safety for patients consistent with that provided by commercial air services to fare-paying passengers. (A97-01)

Transport Canada's Response:

Transport Canada concurs with the recommendation and is currently reviewing the adequacy of the Canadian Aviation Regulations (CARs) pertaining to Medevac operations.

A proposal will be made to the Canadian Aviation Regulation Advisory Council (CARAC) to strike a working group to consider what amendments to the CARs may be required. Membership on this working group will be sought from numerous stakeholders, including Health Canada, the provincial and territorial health authorities, commercial air operator associations, state operators, the unions/organizations representing the doctors, nurses and paramedics.

Safety Concern
(as presented in the TSB Report)

The Board is concerned that the continuing involvement of MEDEVAC and air ambulance flights in accidents is disproportionate to the activity rate. Too often, patients become victims of air accidents, as in this accident.

In a previous occurrence report involving a MEDEVAC, the Board wrote:

Between 1976 and 1994, there were 38 occurrences involving aircraft engaged in air ambulance or medical evacuation flights. Fifteen of these accidents took place in Canada's designated North.... Twenty-one of the MEDEVAC accidents occurred during VFR flights, and 18 occurred on dark nights (i.e. notwithstanding reported flight visibility conditions, the absence of ambient lighting, either from surrounding built-up areas or from the moon, created extra problems for conducting flight by visual outside reference). Twelve of the 38 MEDEVAC accidents were CFIT [controlled flight into terrain] accidents, which occurred at night.

This accident at Kuujjuaq underlines the Board's earlier concern in that MEDEVAC flights may be conducted on an ad hoc basis without operators having met any particular standards for conducting such flights in the harsh physical environment of the Arctic. (TSB A94Q0182)

This accident at Wollaston Lake also raises questions as to the adequacy of the regulatory oversight for the maintenance of safety standards for air ambulance operations.

Although this accident involved a commercial air service, approximately 12% of air ambulance occurrences involve "State-owned" aircraft, usually on behalf of a provincial government. The Board has previously made observations on the different level of safety that is required for such state-owned operations, vis à vis that required for commercial air services. For example, a recent Board report (TSB A93Q0245) stated:

...when passengers are regularly carried on state aircraft, it is reasonable for these passengers to expect that the aircraft and the aircrew involved in state operations are subject to the same regulatory requirements as commercial carriers.... Therefore the Board recommends that:

The Department of Transport require that the operators of state aircraft be subject to regulatory overview, as practicable, equivalent to that of similar commercial operations. (A96-03, issued April 1996)

In essence, Transport Canada rejected this recommendation.

Although the Board finds no particular fault with state-owned air ambulance services at this time, it remains concerned about continuing disparities between state and commercial operations in the levels of safety offered. The Board is not making a further recommendation in this regard as a result of this accident involving a commercial aircraft. Nevertheless, it is for consideration that any differences in safety standards between state and commercial air services with respect to the conduct of air ambulance operations should be eliminated.

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