Safety, security & sanctuary

When the call for an air ambulance transfer comes in, the most immediate consideration tends to be the patient’s condition. But what if the patient is in Iraq, or Syria, or Afghanistan? Then the considerations have to include the risks faced by the crew flying in to collect that patient. Mandy Langfield looks into the issue in more detail
First published in the ITIJ Air Ambulance Review 2017.
Whether it’s flying into conflict zones, or countries where there is a known risk of corruption and a lack of security around an airstrip, air ambulance crew members are often placed in situations that could potentially pose a threat to their wellbeing. It is up to security departments within those air ambulance companies to establish whether or not the level of risk is acceptable, and what measures need to be taken to ensure the safety of the crew, the aircraft and the medical equipment onboard.
According to John Rose, chief operating officer of iJet International, there are two main threats to ambulance crews. Firstly the threat of robberies, ‘because they possess equipment and medicine that is highly valuable on the black market’: “South Africa just put restrictions on where air ambulances can land for this reason. Air ambulances should be landing on airstrips with extra security. Often on remote airstrips there is the risk of criminal robbery.”
Often on remote airstrips there is the risk of criminal robbery
The second major risk areas, he added, are those surrounding airports. He had the following advice for companies operating flights in potentially dangerous locations: “Know what weapons the bad actors have that could potentially harm aircraft and crew, because some parts of world are in conflict and airstrips are truly valuable to the bad guys. You control the airstrip, you control what gets in and out.”
Andrew Nicholson of MedAire, an International SOS company, told the Air Ambulance Review that with crews spending so little time on the ground or in ground transportation, the risk profile is determined more by the threats inherent to the locations to which they are flying. “Short-notice requirements to fly to unknown, potentially higher risk and more remote destinations, with limited infrastructure, mean that the understanding of the risks can be limited,” he explained, “and it is this that can create an environment that is of particular threat to crew members.” However, this risk is balanced to some degree by the fact that there is usually a short turn-around time, the aircraft and crew usually remain within the confines of the airport, and they have the ability to get away quickly.
Essential information
Speakers at last year’s ITIC Global event in Berlin all agreed on one major point – information is key. Without the necessary information about the situation on the ground where the patient is located, a mission cannot be safely executed. Once an air ambulance company is aware of all the pertinent facts, such as the location of the nearest airstrip, the security measures in place in the surrounding area, and the potential for disruption to the patient’s transfer from ambulance to aircraft, a proper risk assessment can take place and decisions taken as to the feasibility of the mission itself.
“The best form of security,” said Nicholson, “is to avoid [problems] altogether, but that is only possible if you know the situation there. Making a full assessment of the environment, with information from a number of sources, is critical.” Also vital to the risk assessment process, he said, is recognising how the patient will be transferred to the airport, as the risk level can be heightened by the method used: “For example, a high-profile military or military-style transfer of a casualty to an airport may attract significant unwanted attention.”
The best form of security … is to avoid [problems] altogether, but that is only possible if you know the situation
The source used for the security information, said AMREF Flying Doctors’ (AMREF) chief executive Dr Bettina Vadera, depends on the intended location. AMREF flies into countries such as South Sudan to collect patients in need of a higher level of medical care. “We make use of reliable contacts within the United Nations,” said Dr Vadera, “as well as government security agencies and defence forces. Additionally, we retain contact with local security agents. We usually also check with other operators and the civil aviation authority of the country in question.”
Dirk Loreth, deputy chief operating officer and safety manager for Germany-based FAI rent-a-jet, said that when preparing to perform a risk assessment for a mission, there are several resources utilised – European Aviation Safety Agency (EASA) safety information bulletins, International Civil Aviation Organization (ICAO) conflict zone information, and information provided by the German Federal Ministry. “In addition,” he added, “FAI holds a contract with MedAire for security information, aviation travel security briefings for specific aircraft, security briefings for specific countries, and airspace assessments.”
Dawn Cerbone, senior vice-president of sales and marketing for US-based REVA Inc., said that the firm relies on information from the Department of Homeland Security, which will issue a threat advisory through the National Terrorism Advisory System: “If a country is believed to be listed as a security concern, we request a security briefing to determine its stability.”
Rose of iJet suggests that the risk assessment necessary for air ambulance crews ‘depends on the threat’. “You start off with the threat,” he explained. “A threat assessment evaluates which threats pose a risk to your particular organisation or crew. For example, if bad actors have certain weapons but they are too far away – you are not at risk. Again, this really comes down to the security of the airspace and what weapons the bad actors have.”
If a country is believed to be listed as a security concern, we request a security briefing to determine its stability
Airspace assessments are key to crew security, as the risk of being caught in the crossfire between warring factions in any given region is a very real threat. Nicholson of MedAire said that the company’s airspace assessments consider each region based on the available weaponry that could pose a threat to aviation: “We look at the capabilities of the weapon system, who has control of the system, how they procured it, their training capability for that system, their spares, maintenance and command and control capability, documented use against military and civilian aviation, as well as a number of other criteria.” Using a consistent and quantified methodology allows the company to make an assessment regardless of whether the country/region under scrutiny in considered to be a war zone.
Regional problems
When asked about the most hazardous flight zones in the world at the moment, iJet’s senior director of category intelligence Katherine Harmon provided additional insight on specific locations: “Immediately, Syria comes to mind. Perhaps Yemen. They readily lob explosives and missiles back and forth and both places, Syria in particular, show absolutely zero regard for medical personnel. Additionally, the overt use of chemical weapons in Syria presents an extremely hazardous situation for air crew, ground folks, and potentially contaminated patients.”
John Rose then pointed out that it’s a difficult and changeable situation regarding specific ‘no-go’ locations. “The landscape of political unrest is pretty fluid and could change,” he said. “We would evaluate based on threat assessment.”
Loreth of FAI notes Afghanistan, Mali and Somalia as the main hazardous areas of operations for his company, while Nicholson cited Iraq and Afghanistan as obvious examples of locations where risk mitigation strategies will need to be employed by air ambulance operators. But even there, operators safely fly in and out every day. The most dangerous places to fly, he explained, are the ones where the risks aren’t widely understood – South and Central America, for example, are regions where risks are routinely underestimated. “The threat to small jets flying through areas of South and Central America is often overlooked,” he said. “The counter-narcotics’ shoot-down policies in parts of the region are aggressive, and are targeted at the profile of the narcotics traffickers, who use small aircraft. Therefore, the risk to air ambulances in the region is heightened unless all the correct procedures are followed precisely.”
Flying into regions or countries where there is the potential for loss of life and aircraft can be an intimidating prospect, and while some companies give their staff the option of declining such a mission, others do not. Asked whether a crewmember can decline to take part in a mission if they consider it to be too dangerous, Dr Vadera said: “The mission is either considered safe or unsafe and hence it’s not a decision by crew, but by our safety and security department.”
For FAI, however, if a mission is considered to be more dangerous than normal, then the pilot is given the right to refuse to fly it, said Loreth.
Insurance for air ambulance operators doesn’t come cheap, and when you’re heading into potentially dangerous territories, many standard insurance providers will cease to offer cover, necessitating specialist policies. For AMREF, additional insurance cover is needed for flights to Yemen, South Sudan and the Democratic Republic of Congo during periods of increased security.
[Syria and Yemen] show absolutely zero regard for medical personnel
FAI, meanwhile, said that ‘due to the specific type of operations’ (United Nations and missions to hostile areas it routinely carries out), it has specific insurance coverage in place for all of its aircraft.
REVA, Inc., by contrast, does not carry unique insurance. “However,” said Cerbone, “carrying a medical/professional liability policy with $3 million in coverage and an additional $4 million in an umbrella policy, our insurance exceeds industry standards and will cover REVA for such missions.”
An ongoing issue
The safety and security of air ambulance crewmembers has always been an issue, but it seems that as political and civil unrest becomes more violent and widespread, so the corresponding requests for help from the air ambulance industry become more frequent. According to Dirk Loreth, more and more calls for air ambulance evacuations from potentially dangerous areas are coming in. “In 2016,” he told the Air Ambulance Review, “We were getting requests on an almost daily basis. During the year, we received 327 requests just for Afghanistan, Iraq, Mali and Somalia, mainly from insurance or assistance clients.” 
The good news seems to be that as long as appropriate risk assessments and mitigation strategies are correctly carried out, air ambulances can continue doing the job they are being asked to do. Nicholson of MedAire concluded: “The vital and life-saving work that air ambulances conduct can push the risk assessment envelope and can drive the need to operate into warzones and other locations that might be considered too dangerous.”