8900.1 CHG 395



Section 1  Background and Definitions

4-916    INTRODUCTION. This chapter contains background information on air ambulance operations. It also contains information, direction, and guidance to be used by inspectors, including principal operations inspectors (POI), when determining if an operator is eligible to hold out, advertise for, and conduct air ambulance operations in accordance with Title 14 of the Code of Federal Regulations (14 CFR) part 119, § 119.5(k); as well as how to evaluate a helicopter air ambulance (HAA) operator’s compliance with 14 CFR part 135 subpart L requirements. This chapter provides detailed guidance for the evaluation of an operator’s air ambulance procedures, air‑ambulance-specific sections of their General Operations Manual (GOM), and the unique requirements an operator must meet prior to being issued Operations Specification (OpSpec) A021, Air Ambulance Operations—Helicopter; or OpSpec A024, Air Ambulance Operations—Airplane. This chapter contains operational procedures for both airplane and helicopter air ambulance (HAA) operations. Specific HAA training requirements are contained in several sections of Volume 3, Chapter 19. A sequential breakdown of this chapter follows:

A.    Section 1. Contains general background information, such as air ambulance OpSpecs, definitions of terms, and references to source documents.

B.    Section 2. Contains guidance for inspectors evaluating an operator’s initial request to be certificated as a part 135 HAA operator or for existing operators to be issued OpSpec A021 or A024 for operations under part 135 air ambulance service.

C.    Section 3. Contains guidance for the evaluation of subject-matter-specific operational procedures pertaining to part 135 airplane or HAA services.

D.    Section 4. Reserved. (Previously this section contained training information, which is now contained in Volume 3, Chapter 19.)

E.    Section 5. Contains guidance to be used by inspectors when evaluating a part 135 HAA operator’s risk analysis program.

4-917    BACKGROUND.

A.    Associations. The aviation and medical professions have combined various aspects of their industry to form a sophisticated system to provide life-sustaining care for ill or injured people. Air ambulance operators have met the public need and demand for such services by equipping aircraft specifically for this purpose. The Flight Standards Service (AFS), in consultation with air ambulance operators, medical care providers, and other industry organizations, created specific OpSpec paragraphs to establish regulatory compliance standards designed to enhance safety in air ambulance operations. Most of these standards were later codified under part 135 subpart L.

B.    Emergency Operations. Situations will arise where a true medical emergency exists and no air carrier with an air ambulance authorization is reasonably available. An air carrier without an air ambulance authorization may conduct an air ambulance operation to save a human life. That operator must file a report with the local Flight Standards District Office (FSDO) within 10 days as required by part 135, § 135.19. The FSDO must investigate the circumstances and determine if an actual emergency appeared to exist at the time of the operation (see Volume 14, Chapter 1). Repeated air ambulance operations by an operator without an air ambulance authorization should be determined as holding out to the public to conduct an operation which is not authorized by their OpSpecs. (See paragraph 4-921, FAA Policy Regarding Compensation or Hire Considerations for Charitable Flights or Life Flights, for additional information.)

C.    OpSpecs. Specific air ambulance OpSpecs (A021 for HAA and A024 for airplane air ambulance operations) are available to authorize such flights. Operators who wish to provide air ambulance services must implement appropriate service-specific policies, procedures, training, and in some cases, install equipment to facilitate safe air ambulance operations in accordance with regulations. These requirements are further discussed in this section and in the following sections of this chapter.

4-918    DEFINITIONS/ABBREVIATIONS. The following terms are defined according to their use in this handbook.

A.    Accident/Incident Plan/Post-Accident/Incident Plan (AIP/PAIP). Includes emergency response procedures that should be used as a basis for training or for reference in the event of a mishap or other emergency.

B.    Advisory Circular (AC).

C.    Aeromedical Director. A licensed medical professional associated with an HAA operation, ultimately responsible for patient care during air transport. The Aeromedical Director has no operational control authority, and may not exert any influence over decisionmaking related to the safe conduct of flights.

D.    Air Ambulance. An aircraft used in air ambulance operations. The aircraft need not be used exclusively as an air ambulance aircraft, and the equipment need not be permanently installed.

E.    Air Ambulance Operation.

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1)    Airplanes. Air ambulance operation of an airplane includes:
a)    Unscheduled air transportation in an airplane of a person(s) with a health condition that requires:

1.    Medical personnel to provide special care, including, but not limited to, basic life support (BLS) or advanced life support (ALS); and

2.    Medical equipment necessary to support the level of care required for the patient(s), such as medical oxygen, suction, and/or a stretcher, isolette, or other approved patient restraint/containment device as determined by a health care provider.

b)    Holding out to the public as willing to provide air transportation to a person with a health condition that requires medical personnel including, but not limited to, advertising, solicitation, or association with a hospital or medical care provider.
2)    Helicopters. A flight, or sequence of flights, with a patient or medical personnel on board, for the purpose of medical transportation, conducted by a part 135 certificate holder authorized by the Administrator to conduct air ambulance operations. An HAA operation includes, but is not limited to:
a)    Flights conducted to position the air ambulance at a site where medical personnel, a patient, donor organ, or human tissue will be picked up.
b)    Flights conducted to reposition an air ambulance after completing transportation of the medical personnel, patient, donor organ, or human tissue transport.
c)    Flights initiated for the transport of a patient, donor organ, or human tissue that are terminated due to weather or other reasons. (Refer to § 135.601.)

F.    Air Medical Resource Management (AMRM). A dynamic process including pilots, medical personnel (not limited to those participating in HAA flights), maintenance technicians, operational support personnel and management staff that optimizes human–machine interface and related interpersonal issues, with maximum focus on communication skills and team building curricula. (Refer to the current edition of AC 00-64, Air Medical Resource Management.)

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G.    Airplane Night Vision Goggle Operations (ANVGO). That portion of a flight that occurs during the time period from 1 hour before sunrise to 1 hour after sunrise, where the pilot maintains visual surface reference using Night Vision Goggles (NVG) in an aircraft that is approved for such operations. (Refer to 14 CFR part 61, § 61.1.)

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H.    Autorotational Distance. The distance a rotorcraft can travel in autorotation as described by its manufacturer in its approved Rotorcraft Flight Manual (RFM). (Refer to § 135.168.)

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I.    Certificate-Holding District Office (CHDO). The Federal Aviation Administration (FAA) AFS CHDO with responsibility for management of an air carrier’s certificate, charged with the overall inspection and surveillance of that certificate holder’s operations. (Refer to 14 CFR part 1, § 1.2.)

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J.    Code of Federal Regulations (CFR).

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K.    Communications Specialist (CS). An individual trained and qualified by the operator to receive and coordinate one or more of a range of activities, including, but not limited to, receiving flight requests for HAA operations; communications with medical, first response, and other HAA organizations; communications with HAA crews; and flight locating. The employment and training of CSs has been identified as an HAA industry best practice.

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L.    Crew Resource Management (CRM). The use of all the available resources, information, equipment, and people to achieve safe and efficient flight operations; approved CRM training is required for flightcrews in accordance with § 135.330. (Refer also to § 135.330 and the current edition of AC 120-51, Crew Resource Management Training, for more information.)

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M.    Data Link. A general term referring to a variety of technologies used to transmit and receive wireless electronic data between on-aircraft systems and off-aircraft systems.

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N.    Emergency Medical Service (EMS). The term “emergency medical service” has been replaced with the term “air ambulance operations.”

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O.    Extended Overwater Operation. Per § 1.1, with respect to helicopters, an operation over water at a horizontal distance of more than 50 nautical miles (NM) from the nearest shoreline and more than 50 NM from the nearest offshore heliport structure.

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P.    Flight Following. Active contact with an aircraft throughout a flight (including time on the ground), either through voice radio contact with the pilot or through automated flight following systems. Considered a best practice in the HAA industry.

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Q.    Flight Locating. The certificate holder is required by regulation to use flight locating procedures (refer to § 135.79) unless an FAA flight plan is filed and activated. Flight locating by HAA operations, even where it is not required by regulation, is recommended as an HAA industry best practice.

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R.    Flight Standards District Office (FSDO).

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S.    General Operations Manual (GOM). Required to be compiled to include, at minimum, sections mandated by regulation, including visual flight rules (VFR) flight planning procedures (§ 135.615) and an FAA‑approved preflight risk analysis (§ 135.617). A GOM requires acceptance by the FAA to be valid.

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T.    Geographic Information Systems (GIS). A collection of computer hardware, software, and geographic data designed to efficiently capture, store, manage, map, analyze, and display geographically referenced information.

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U.    Helicopter Air Ambulance (HAA). A helicopter, defined for the purposes of § 135.619, that is identified as being capable of air ambulance operations in the operator’s OpSpecs. It need not be used exclusively as an HAA. HAA-specific equipment need not be permanently installed.

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V.    Helicopter Emergency Medical Service (HEMS). Obsolete term. The FAA and industry are moving to the term HAA for enhanced accuracy. HAA flights do not constitute an emergency flight. Replacement of the term HEMS with HAA will take place over the next several years as each relevant document is updated. The term HAA will be used exclusively throughout this document.

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W.    Helicopter Landing Area (also Heliport or Landing Zone (LZ)). An area of land or water or a structure used or intended to be used for the landing and takeoff of helicopters. OpSpec A021 grants latitude to a helicopter operator for landing site selection as well as the authority to land on appropriate sites during both day and night in HAA operations. (Refer to § 1.1; the current edition of AC 150/5390-2, Heliport Design; and OpSpec A021.)

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X.    Helicopter Night Vision Goggle Operations (HNVGO). That portion of a flight that occurs during the time period from 1 hour after sunset to 1 hour before sunrise, where the pilot maintains visual surface reference using NVGs in an aircraft that is approved for such operations. (Refer to § 61.1.)

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Y.    Helicopter Terrain Awareness and Warning System (HTAWS). A terrain and obstacle database‑driven awareness and warning system configured specifically for a helicopter’s operating environment. This system correlates ship’s position, altitude, direction of flight, and speed with digital obstacle and terrain maps. (Refer to § 135.605.)

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Z.    Inadvertent Instrument Meteorological Conditions (IIMC). An emergency condition when an aircraft inadvertently transitions from visual meteorological conditions (VMC) into instrument meteorological conditions (IMC).

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AA.    Instrument Flight Rules (IFR). Operations when weather conditions are below the minimum for flight under VFR.

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BB.    Instrument Meteorological Conditions (IMC). Meteorological conditions expressed in terms of visibility, distance from clouds, and ceiling that are less than that specified for VMC, requiring flight to be conducted under IFR.

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CC.    Landing Zone (LZ). See subparagraph 4-918W, Helicopter Landing Area (also Heliport or Landing Zone (LZ)).

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DD.    Local Flying Area (LFA). A geographic area of not more than 50 NM in any direction from a location designated by an HAA operator and approved by the FAA in OpSpec A021. (Refer to § 135.609(b)(1).)

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EE.    Medical Personnel. Medical personnel are individuals with medical training, carried aboard air ambulance flights or HAA operations, including: flight nurses, paramedics, respiratory specialists, neonatal specialists, and other aviation-trained specialists. (Refer to § 135.601(b)(2).)

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FF.    Mountainous. Designated mountainous areas as listed in 14 CFR part 95. OpSpec A021 provides different minimums for mountainous and non-mountainous areas. To ensure commonality with IFR requirements, mountainous areas are identified as those designated as mountainous areas in part 95. (Refer to § 135.601.)

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GG.    Night Vision Goggles (NVG). An NVG is a Night Vision Imaging System (NVIS) (q.v.) appliance worn by crewmembers that enhances the ability to maintain visual surface reference under low-light flight conditions.

Indicates new/changed information. Indicates new/changed information.

HH.    Night Vision Imaging System (NVIS). An approved light amplification appliance enhancing visual sensitivity in low light conditions, combined with specialized lighting systems that are type certificate (TC)‑approved for the type of aircraft in which it is installed and are compatible with NVGs being used in that aircraft.

Indicates new/changed information.

II.    Non-Mountainous. Areas other than mountainous areas as listed in part 95. (Refer to § 135.601.)

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JJ.    Operations Control Center (OCC). An OCC is a dedicated facility staffed by trained HAA Operations Control Specialist(s) (OCS) (see subparagraph 4-918JJ). The OCC is described in § 135.619. OCC review includes a wide range of safety-related items detailed in § 135.619(a). (Refer to the current edition of AC 120-96, Operations Control Center (OCC) for Helicopter Air Ambulance (HAA) Operations.)

NOTE:  OCCs are required for certificate holders authorized to conduct HAA operations with 10 or more HAAs assigned to their OpSpecs and are strongly encouraged for all operators. (Refer to § 135.619.)

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KK.    Operations Control Specialist (OCS). An individual within the OCC who provides operational support for the certificate holder’s air ambulance operations and is both initially and recurrently trained as specified in § 135.619(d) and (f). An OCS interfaces with the HAA pilot(s) prior to each flight request acceptance.

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LL.    Operations Specification (OpSpec). Issued by the FAA to specify the commercial air operations it has authorized the certificate holder to carry out. OpSpec A021 authorizes HAA service. Before OpSpec A021 can be issued, the operator must meet the regulatory requirements of part 135 subpart L. OpSpec A024 authorizes airplane air ambulance service. (Refer to the current edition of AC 120-96 and AC 135-14, Helicopter Air Ambulance Operations.)

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MM.    Overwater Flight. Operation of a rotorcraft beyond autorotational distance from the shoreline. (See subparagraph 4-918YY, Shoreline.)

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NN.    Patient. A person under medical treatment. For the purpose of this definition, though human transplant organs or tissue are not patients, these are explicitly included under HAA operations, regulations, and practices. They are treated in the same manner as people under medical treatment.

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OO.    Pilot in Command (PIC). The PIC of an aircraft is directly responsible for its safe and legal operation.

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PP.    Principal Avionics Inspector (PAI). The PAI at the CHDO specifically responsible for aviation safety inspection and oversight of an HAA operator.

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QQ.    Principal Maintenance Inspector (PMI). The PMI at the CHDO specifically responsible for aviation safety inspection and oversight of an HAA operator.

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RR.    Principal Operations Inspector (POI). The POI at the CHDO specifically responsible for aviation safety inspection and oversight of an HAA operator.

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SS.    Regional Flight Standards Division (RFSD).

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TT.    Residual Risk. Residual risk is the safety risk that exists after all controls have been implemented or exhausted and verified (to ensure that the risk acceptance is in accordance with a preexisting documented risk analysis procedure).

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UU.    Response Scene. Unimproved ad hoc LZ sites and other offsite locations where HAA flight landings are authorized under the authority of OpSpec A021.

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VV.    Risk Analysis. A formal methodology for guiding HAA decisionmaking. Its FAA-approved procedures, principles, and policies are documented and are the subject of training by HAA operators. They include multiple people with defined roles that have been documented and are the subject of training. As risks grow, approval to conduct a flight must be obtained from higher levels of management (refer to §§ 135.615 and 135.617(a)(5)). Process documentation should identify risk factors the HAA operator may consider as part of the regulatory-required risk analysis. The operator should assign to each risk factor an appropriate numerical value reflecting both the likelihood of occurrence and severity of outcome. Section 135.617 requires HAA operators have a documented procedure for elevating the management level required for flight approval when risk analysis exceeds predetermined levels of quantified risk.

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WW.    Safety Management System (SMS). An SMS is a formal, top-down approach to managing safety risk. It is a system to manage safety, including the necessary organizational structures, accountabilities, policies, and procedures. For the HAA operator, implementing an SMS can provide useful tools for complying with the requirements of § 135.617. Additional information and resources on SMS can be found in the current edition of AC 120-92, Safety Management Systems for Aviation Service Providers; and AC 135-14, chapter 8 and appendix B.

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XX.    Second in Command (SIC).

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YY.    Shoreline. Land adjacent to the water of an ocean, sea, lake, pond, river, or tidal basin that is above the high-water mark at which a rotorcraft could be landed safely. This does not include land areas unsuitable for landing, such as vertical cliffs or land intermittently under water. (Refer to § 135.168.)

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ZZ.    Standard Operating Procedures (SOP). An established or prescribed method to be followed routinely for the performance of a designated operation or in a designated situation and is used to guide training to meet such contingencies.

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AAA.    Suitable Offshore Heliport Structure. A heliport structure that can support the size and weight of the rotorcraft being operated where a safe landing can be made.

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BBB.    Supplemental Type Certificate (STC). A TC issued when an applicant has received approval to modify an aircraft from its original design.

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CCC.    Unimproved Landing Zone (LZ)/Area. A scene where an air ambulance operation is conducted that may involve nonroutine, hazardous conditions.

Indicates new/changed information.

DDD.    Visual Flight Rules (VFR).

4-919    RELATED SOURCE MATERIAL. Current editions of the following documents are applicable to air ambulance operations.

A.    ACs:

    AC 00-64, Air Medical Resource Management.

    AC 27-1, Certification of Normal Category Rotorcraft.

    AC 27-1 MG 6, Miscellaneous Guidance (MG) for Emergency Medical Service (EMS) Systems Installations.

    AC 29-2, Certification of Transport Category Rotorcraft.

    AC 91-21.1, Use of Portable Electronic Devices Aboard Aircraft.

    AC 91-32, Safety In and Around Helicopters.

    AC 120-27, Aircraft Weight and Balance Control.

    AC 120-49, Certification of Air Carriers.

    AC 120-51, Crew Resource Management Training.

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    AC 120-92, Safety Management Systems for Aviation Service Providers.

    AC 120-96, Operations Control Center (OCC) for Helicopter Air Ambulance (HAA) Operations.

    AC 135-5, Maintenance Program Approval for Carry-On Oxygen Equipment for Medical Purposes.

    AC 150/5390-2, Heliport Design.

    AC 150/5230-4, Aircraft Fuel Storage, Handling, Training, and Dispensing on Airports.

B.    Handbooks, Manuals, and Pamphlets:

    FAA Order 8040.4, Safety Risk Management Policy.

    FAA-H-8083-21, Rotorcraft Flying Handbook.

    FAA-H-8083-16, Instrument Procedures Handbook.

    Aeronautical Information Manual (AIM).

    DOT/FAA/PM-86/45, Aeronautical Decision Making for Helicopter Pilots.

    DOT/FAA/DS-88/7, Risk Management for Air Ambulance Helicopter Operators.

    FAA Safety Team (FAASTeam) Library, Flying in Flat Light and White Out Conditions.

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    National EMS Pilots Association (NEMSPA), Preparing a Landing Zone. NEMSPA’s address is P.O. Box 2128, Layton, UT 84041-9128.

C.    Other:

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1)    Helicopter Association International (HAI). HAI is located at 1920 Ballenger Avenue, 4th Floor, Alexandria, VA 22314-2898, telephone (703) 683-4646. Check their website (https://www.rotor.org) for other documents and links to resources, including their Fly Neighborly Guide.
2)    The National Fire Protection Association (NFPA) is located at 1 Batterymarch Park, Quincy, MA 02169-7471, telephone (617) 770-3000. They have many publications about fire protection; the 400 series may be the most helpful. For example, the current edition of NFPA 418, Standard for Heliports, has fire standards for heliports.
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3)    The International Association of Medical Transport Communications Specialists’ (IAMCTS) address is 2311 Yellow Mountain Road, Roanoke, VA 24014, telephone (262) 409-8884. Check their website (http://www.iamtcs.org) for links to resources, including training courses.
4)    Special Airworthiness Information Bulletin (SAIB) SW-10-43, Non-Aviation Transmitters (includes, for example, 800 megahertz (MHz) radios used to communicate with hospitals).
5)    Policy Letter (PL) ASW-2001-01, Certification Guidelines for Compliance to the Requirements for Electro-Magnetic Compatibility (EMC) Testing.
6)    DOT/FAA/AR-99/50, High-Intensity Radiated Fields (HIRF) Risk Analysis.
7)    FAA Technical Standard Order (TSO)-C194, Helicopter Terrain Awareness and Warning System (HTAWS).
8)    International Civil Aviation Organization (ICAO) Doc 9977 AN/489, Manual on Civil Aviation Jet Fuel Supply.
9)    RTCA, Inc., DO-160, Environmental Conditions and Test Procedures for Airborne Equipment.
10)    RTCA, Inc., DO-178B, Software Considerations in Airborne Systems and Equipment Certification.
11)    RTCA, Inc., DO-254, Design Assurance Guidance for Airborne Electronic Hardware.
12)    RTCA, Inc., DO-309, Minimum Operational Performance Standards (MOPS) for Helicopter Terrain Awareness and Warning System (HTAWS) Airborne Equipment.
13)    OpSpecs:

    A005, Exemptions and Deviations.

    A008, Operational Control.

    A010, Aviation Weather Information.

    A021, Air Ambulance Operations—Helicopter.

    A024, Air Ambulance Operations—Airplane.

    A050, Helicopter Night Vision Goggle Operations (HNVGO).

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    A051, Airplane Night Vision Goggle (ANVG) Operations.

    A061, Use of Electronic Flight Bag.

    A096, Actual Passenger and Baggage Weight Program for All Aircraft.

    A097, Small Cabin Aircraft Passenger and Baggage Weight Program.

    D085, Aircraft Listing.

4-920    OVERVIEW OF AIR AMBULANCE SERVICES. This paragraph provides a general overview of air ambulance operations. Details are contained in the appropriate section of this chapter.

A.    Regulatory Requirements. An air ambulance operator must comply with all requirements of the 14 CFR part under which it is certified. Air ambulance operators are not exempt from any requirement of 14 CFR. To ensure industry standardization and a clear understanding between the FAA and air ambulance operators, OpSpecs A021 (helicopter) and A024 (fixed wing) identify specific means by which air ambulance operators can comply with 14 CFR. Some of these rules are as follows:

1)    Management Qualifications. Part 135 operators are required to have their management personnel identified per § 119.69. The pertinent parts of this section state (emphasis added):
(a) Each certificate holder must have sufficient qualified management and technical personnel to ensure the safety of its operations. Except for a certificate holder using only one pilot in its operations, the certificate holder must have qualified personnel serving in the following or equivalent positions:
(1) Director of Operations.
(2) Chief Pilot.
(3) Director of Maintenance.
(d) The individuals in the positions required or approved under paragraph (a) ... of this section and anyone in a position to exercise control over operations conducted under the operating certificate must—
(1) Be qualified through training, experience and expertise;
(2) To the extent required by their responsibilities, have a full understanding of the following material with respect to the certificate holder’s operation—
(i) Aviation safety standards and safe operating practices;
(ii) Title 14 CFR Chapter I (Federal Aviation Regulations);
(iii) The certificate holder’s operations specifications;
(iv) All appropriate maintenance and airworthiness requirements of this chapter (e.g., parts 1, 21, 23, 25, 43, 45, 47, 65, 91, and 135 of this chapter); and
(v) The contents of the manual system required by § 135.21; and
(3) Discharge their duties to meet applicable legal requirements and to maintain safe operations.
2)    Certification Under a 14 CFR Part. Part 119 specifies that the selection of the particular 14 CFR part used to certify an operator is to be based on the type and size of aircraft that the certificate holder operates. An air ambulance operator must hold either a 14 CFR part 121 or part 135 air carrier certificate and must then comply with all provisions of the specific part under which the operator is certified. The carriage of a person or persons requiring medical personnel and/or medical equipment on a scheduled air carrier, operating under parts 121 or 135, does not constitute air ambulance operations. However, a scheduled air carrier transporting a person or persons requiring medical personnel and/or equipment on an unscheduled flight (charter) is engaged in air ambulance operations. All HAA operations must be conducted under part 135, and specifically must comply with part 135 subpart L in addition to general part 135 regulations.
3)    Certification Under Part 121. Most air ambulance operations are conducted under part 135. The information, direction, and guidance contained in this chapter applies to operations under part 135. If a part 121 operator requests air ambulance OpSpecs to apply to an airplane to be operated under part 121, the POI receiving that request should contact the Air Transportation Division (AFS-200) through the applicable RFSD for direction and guidance.

B.    Advertising. According to § 119.5(k), an operator may not advertise or conduct operations not authorized by the operator’s operating certificate and OpSpecs. An operator without an air ambulance authorization is explicitly prohibited, in OpSpec A004, Summary of Special Authorizations and Limitations, from conducting air ambulance operations.

C.    OpSpec Paragraphs. All operators are initially prohibited by OpSpec A004 from conducting air ambulance operations. Those who desire to advertise and/or conduct air ambulance operations must have this prohibition removed through the issuance of the appropriate air ambulance OpSpecs. Operators holding part 135 OpSpecs but without OpSpec A021 or A024 may transport medical personnel as passengers accompanying a sick or injured person, but must meet the following requirements:

1)    The operator may not advertise air ambulance or in-flight patient care services.
2)    Any in-flight patient care equipment and medical personnel that accompany the passenger must be provided solely for the patient’s comfort. If any medical care provider has determined that medical personnel are required for patient safety and/or life support, the flight is an air ambulance operation.

NOTE:  When a life-threatening situation exists, the PIC may exercise the PIC’s emergency authority in accordance with 14 CFR part 91, § 91.3; part 121, § 121.557; or § 135.19 to conduct air ambulance operations. A PIC taking such action must subsequently report that action to the appropriate FSDO within 10 days. The inspector investigating such a report should first determine whether information available to the operator and PIC at the time the flight began indicated that a life-threatening emergency existed. Then the inspector should determine whether a suitably equipped air ambulance was not reasonably available within the time acceptable to the requesting medical care provider.

3)    OpSpec A021 HAA operations are more complex and are regulated to a much greater degree (part 135 subpart L) than general part 135 helicopter operations. (Refer to AC 135-14 for the requirements for HAA operations.)
4)    OpSpec A024 airplane air ambulance operations do not differ significantly from other types of airplane air carrier operations. OpSpec A024 specifies operational requirements and grants the operator authorization for airplane air ambulance service.

4-921    FAA POLICY REGARDING COMPENSATION OR HIRE CONSIDERATIONS FOR CHARITABLE FLIGHTS OR LIFE FLIGHTS. Various organizations and pilots are conducting flights that are characterized as “volunteer,” “charity,” or “humanitarian.” These flights are referred to by numerous generic names, including “lifeline flights,” “life flights,” “mercy flights,” and “angel flights.” These types of flights will be referred to as “life flights” in this section.

A.    Purposes for Life Flights. The types of organizations and pilots involved with or conducting life flights vary greatly. The most common purpose of life flights is to transport ill or injured persons who cannot financially afford commercial transport to appropriate medical treatment facilities, or to transport blood or human organs. Other “compassionate flights” include transporting a child to visit with a dying relative or transporting a dying patient to return to their city of birth.

B.    FAA Policy. The FAA’s policy supports “truly humanitarian efforts” to provide life flights to needy persons, including “compassionate flights.” This also includes flights involving the transfer of blood and human organs. Since Congress has specifically provided for the tax deductibility of some costs of charitable acts, the FAA will not treat charitable deductions of such costs, standing alone, as constituting “compensation or hire” as defined by § 61.113 or part 135. Inspectors should not treat the tax deductibility of costs as constituting “compensation or hire” when the flights are conducted for humanitarian purposes.

4-922    OVERVIEW OF HAA SERVICES. HAA operations have complex requirements not applicable to airplane air ambulance operations. This paragraph provides a general overview of some of those requirements. AC 135-14 provides more extensive introductory material to HAA operations and their regulation.

A.    OpSpec A021 Authorizations. A continuing trend of accidents during aeromedical operations resulted in the regulations now embodied in part 135 subpart L. Regulations include weather limitations for VFR flight, improvements in IFR operating limitations, added equipage requirements, pilot instrument qualifications and demonstrations, the implementation of VFR planning and risk assessment procedures, medical personnel safety briefings and training, and, for operations involving 10 or more HAA-designated helicopters, OCCs staffed by trained OCSs. These regulations must be met prior to issuance of OpSpec A021 (see Volume 3, Chapter 1, Section 1 for additional background information on OpSpecs). This OpSpec authorizes HAA service for hospital‑to-hospital patient transfer operations, scene response operations, and other offsite ad hoc operations. This OpSpec grants latitude to an HAA operator for the following:

1)    Unimproved Landing Sites. Selection and use.
2)    Higher Minimums. HAA operations are subject to higher ceiling and visibility minimums in uncontrolled airspace than those that are required for conventional part 135 operations.
3)    Night Landings. Night landings at unimproved sites are permitted with adequate lighting, consistent with NVIS if authorized and used, for the pilot to identify the landing site and surrounding hazards.

NOTE:  “Adequate” lighting is lighting that allows a helicopter pilot to conduct a safe approach and landing during conditions of darkness while avoiding terrain and obstacles. The source of this lighting may be on the helicopter or on the surface and includes the possibility of automobile lights being used to illuminate the landing site. Pyrotechnic road hazard flares are not recommended for marking the touchdown area.

B.    LFA. If an operator chooses to designate LFAs (LFAs are not required), it must establish and document a procedure for the development of LFAs. Pilots authorized by an operator to use reduced ceiling and visibility minimums must periodically demonstrate their familiarity with the features of the LFA. Details are contained in AC 135-14 and Volume 4, Chapter 5, Section 3, paragraph 4-947. Each LFA must be listed in the operator’s OpSpec A021, Table 1.

C.    OCC. After April 22, 2016, if the operator is required by regulation to have and maintain an OCC, the requirements of § 135.619 must be met before OpSpec A021 may be issued. When an OCC is not required but an operator chooses to voluntarily implement similar capabilities or functions, the operator’s applicable policies and procedures (and details of training in them) must be documented. This documentation must be accepted by the POI to be effective.

4-923    IFR AND VFR REQUIREMENTS. Operators of HAAs must comply with the following requirements for IFR and VFR.

A.    IFR Operations. After April 22, 2017, § 135.603 requires that no certificate holder may use, nor may any person serve as a PIC of an HAA flight, unless that person meets the requirements of § 135.243 and holds a helicopter instrument rating or an Airline Transport Pilot Certificate (ATPC) with a category and class rating for the aircraft that is not limited to VFR.

B.    Evaluation. POIs of HAA operators conducting IFR operations should carefully evaluate the operator’s procedures, training and qualification program, and the operating environment before granting the operator the authority to conduct single-pilot IFR operations with an autopilot (refer to §§ 135.611 and 135.613). Such evaluation applies especially with respect to point in space (PinS) approaches, IMC-to-visual transitions following a PinS approach, and visual-to-IFR transitions between the takeoff point and the initial departure fix before granting the operator the authority to conduct single-pilot IFR operations with an autopilot. (Refer to §§ 135.611 and 135.613.)

C.    VFR Operations. When conducting VFR flight, the operator must comply with the weather minimums specified in § 135.609 and as authorized by OpSpec A021. Operator requests for lower-than-standard VFR minimums must be coordinated with AFS-200 through the appropriate RFSD.

RESERVED. Paragraphs 4-924 through 4-930.