Government agencies and private sector operators fly a huge range of special (helicopter) emergency medical services (HEMS/EMS), search and rescue (SAR), and firefighting missions, often in challenging conditions and over severe terrain. Not all new or pre-owned aircraft are delivered ready to meet all such challenges for a range of different operating models. As new tasks arise and new equipment becomes available, fit-outs can be an ongoing task for many operators worldwide.

Air medical missions in Scotland

Scotland’s Charity Air Ambulance’s (SCAA’s) new H145 D3 (G-NSCA) helicopter, in operation since October, has been heralded by the charity as “the most capable aircraft of its kind in the UK, operating in the most challenging environment”.

Based out of Aberdeen, the aircraft will cover the most rugged terrain and harshest weather conditions in the UK. Its medical fit-out has been specially designed for SCAA’s unique operating model, and represents a step change in helicopter pre-hospital care delivery by offering greater range, endurance and capacity, the operator said.

Compared with the EC135 rotorcraft it replaces, the H145 D3’s greater fuel capacity allows an additional 60 minutes of flight time, and can reach more remote areas and fly more missions without refueling. Weather radar and night vision allow safer and more efficient operation in darkness and poor visibility. Larger than the EC135, the H145 D3 can also carry an extra clinician and specialist equipment, and for the first time SCAA has designed a medical fit-out specific to its operating model, the charity stated.

“For the first time in our history, we have brought a brand-new aircraft into service, which meant we were able to work with our paramedics to review suppliers and design a medical fit-out which is optimal for SCAA’s unique operating model,” said SCAA Operations Manager Russell Mackay.

Working with aviation provider Babcock, SCAA identified Bucher Group emergency medical systems as its best fit for specialized equipment, Mackay said. Deciding factors were the standard of the equipment and fit-out on offer and a modular design that gives SCAA maximum flexibility to change parts of the fit-out as its equipment and services develop to meet future needs, he added.

“It was important to be able to have as much capacity [as possible] in the rear of the aircraft for patients and clinicians. Our Helimed 79 aircraft is tasked with four out of 10 of our missions with Emergency Medical Retrieval Service (EMRS) North, the doctor-led retrieval team, and this aircraft and fit-out allows us to carry four clinicians and a pilot while still having the ability to carry a patient on the stretcher and another available seat for a second patient or loved one if required. Prior to this, we were able only to carry three clinicians. With the Bucher fit-out, we were also able to identify the optimal location of each piece of medical equipment, which can be changed depending on the mission,” Mackay said.

Key improvements include improved flooring, which can be easily cleaned for infection control, reducing the time between missions; improved rolling stretchers for use on more challenging surfaces and an improved loading ramp; and a roof rail system and specifically designed center and rear stowage units, door stowage boxes, and stowage nets.

As the design is modular, we will constantly review the changing demands on the service and will invest in and upgrade the airframe where it brings benefits to the patient

“Where we were previously limited to three clinicians on board, with six seats in the aircraft we can now carry four for all EMRS and HEMS missions, bringing specialist care and additional resources to major incidents whilst not impacting our range and usable load,” Mackay stated. “As the design is modular, we will constantly review the changing demands on the service and will invest in and upgrade the airframe where it brings benefits to the patient. We will review the design, which was carefully considered, and make improvements in a sustainable way, prioritizing patient care.”

The importance of an air ambulance interior

Not all interiors and fit-outs are equal, and there reasons that specialists are needed to plan and execute the appropriate changes for a special missions platform. Thomas Redder, Vice President of International Sales at Spectrum Aeromed, explained how vital it is to have the correct air ambulance interior: “Air ambulance interiors are very different from standard aircraft interiors. This is one of the few areas in aviation where every design decision has a direct and immediate impact on human life. Patients are often transported in critical condition, crews are working under intense pressure, and the aircraft becomes an extension of the clinical environment. Focusing specifically on this sector allows interiors to be designed as true clinical workspaces that support patient care while giving crews the space, access, and functionality they need. When done correctly, the interior has a direct impact on efficiency, safety, and patient outcomes during critical missions.”

Getting an interior that meets the needs of the operator is a hugely important step. Even operators in the same sector have different needs and mission profiles that will determine the nuances of the work that is achieved, and the interior should be designed around the taskings performed. “The most important factor is mission suitability,” explained Redder. “An air medical interior must be designed around how the aircraft is actually used, including the types of patients being transported, the procedures performed on board, the crew configuration, and the operating environment. Because crews are delivering care in critical situations, the interior must support real clinical workflows and give them immediate access to the equipment and space they need. At the same time, the solution must be proven, reliable, and able to hold up over years of demanding use. When those elements come together, the interior becomes a dependable extension of patient care rather than a limitation during a mission.”

Furthermore, special missions are diverse so even a sole operator will use a mixed fleet of different platforms and different original equipment manufacturers. This means that modification companies have a challenge, and versatility in the ability to customize is key to helping their clients, said Redder: “Air medical aircraft vary widely across platforms and mission types. Fixed-wing and rotor-wing aircraft present very different challenges, and operators around the world prioritize different capabilities such as long-range transport, rapid response, or government and multi-mission operations. These differences are addressed through customized interior layouts, modular medical systems with flexible equipment mounting, and platform-specific engineering. Rather than applying a one-size approach, solutions are adapted to the aircraft type and operational context while building on proven concepts developed across many programs.”

These differences are addressed through customized interior layouts, modular medical systems with flexible equipment mounting, and platform-specific engineering

Challenges with interior modifications are not restricted to simple physical practicalities, but are also extended to regional regulatory and compliance issues, explained Redder: “Regulatory requirements can vary significantly from country to country, making early planning and clear communication essential. Spectrum Aeromed works closely with certification authorities, aircraft manufacturers, and completion centers to ensure requirements are understood and addressed from the beginning of the project.

“Experience working across multiple regions allows approvals to be managed efficiently while maintaining compliance. From the operator perspective, the goal is a certified aircraft that can enter service smoothly and operate reliably within its regulatory environment.”

Ultimately, when planning on a modification or a refit of an interior, communication is the core tenet to abide by – making sure that what is needed and what can be provided is a dialogue between the operator and the modification company. Redder described how this partnership achieves positive outcomes: “Every project begins with listening. We work closely with operators to understand their mission profile, patient care requirements, crew workflow, and operational challenges. From there, our teams collaborate to design an interior that supports real-world use and long-term needs. Ongoing communication throughout the project helps ensure the final solution is successful and fully supports the client needs once the aircraft is in service.”

Proven platform in France

France’s state emergency response and crisis management agency DGSCGC (Direction Générale de la Sécurité Civile et de la Gestion des Crises) brought its fleet of multi-role Dash 8-400 aircraft up to eight in 2023 and in 2025 marked 20 years of operating the type. France’s fleet of Dash 8-400MRE multi-role aircraft fight wildfires as well as responding to natural disasters and humanitarian crises, deploying in 2025 to carry emergency response crews and supplies to the cyclone-stricken French Indian Ocean island territory of Mayotte and to ship humanitarian supplies to Poland for transfer to Ukraine.

The multi-role aircraft’s ability to operate in civilian as well as military capacities makes it a good fit for national air forces, which are tasked with a wide range of responsibilities including SAR, EMS, firefighting, and emergency management missions.

“It is a proven platform offering first-in, last-out response to a variety of missions,” said Michael Benson, Director of Business Development at Conair Group, France’s supplier and outfitter for the Dash 8-400.

The Canadian aerial firefighting company boasts the world’s largest privately owned, fixed-wing fleet, with more than 70 land-based and amphibious aircraft, including its newest airtanker, the Dash 8-400AT.

“The Dash 8-400MRE can be customized,” said Benson. “For example, the aircraft can be delivered only including the roles needed by a customer. Or it is capable of being outfitted for additional roles, for instance installing ISR sensors and equipment to perform surveillance work, including gathering intelligence to map wildfires.”

Conair has delivered 27 Dash 8-400 airtankers to government agencies on three continents in the past 20 years, 22 of them in the past five years, with agencies either owning and operating their own fleet, such as France, or leasing the aircraft, crew, and maintenance using Conair’s fleet. Benson said the company was continuing to deliver four to five Dash 8-400s per year.

“Airtankers operate missions which fall outside of the flight environment the aircraft was originally manufactured to do,” he pointed out. “Our aircraft are outfitted with specialized safety features, designed to protect not only crews, but also the airworthiness of the airframe.”

Our aircraft are outfitted with specialized safety features, designed to protect not only crews, but also the airworthiness of the airframe

When designing the tank for the airtanker, Conair made the decision to engineer it to hang on the outside of the airframe, as opposed to being installed within the fuselage. The external tank is removable, enabling the aircraft to fly without the tank installed, while the airframe itself not being rigidly attached to the tank allows for a natural flex during turbulence, Benson pointed out.

“Installing an external tank ensures no large holes need to be drilled into the airframe for suppressant payload release over a wildfire, protecting the airframe’s airworthiness,” he said. “An external tank also means the entire cabin and cockpit can be pressurized during all phases of a wildfire mission or flight, preventing crew fatigue and enabling the cabin to be comfortably, and safely, outfitted for passenger transport.”

New Greek fleet

For the Hellenic Air Force (HAF), tasked in addition to its primary military role with a range of special missions including aerial firefighting over extremely rugged terrain, land and maritime SAR, and EMS/HEMS operations, an era of tinkering with an aging fleet is drawing to a close with the phasing out of aircraft including its elderly Polish-built M-18B Dromader (‘dromedary’) firefighters. Despite recent modifications, including larger fuel tanks and improved water release systems, the single-engined M-18B – originally designed as a crop duster, and in service in Greece since 1983 – can carry only 1,500–2,500L of retardant and is not capable of operating from water. The Air Tractor AT-802 amphibians that will replace them, with at least 20 of the type expected to be in service by 2027, will be fitted with 3,200L tanks.

In addition, seven new Canadair CL-515 firefighting aircraft are slated to join Greece’s fleet from 2028.

“This aircraft will feature upgraded operational capabilities, including nighttime firefighting,” said a HAF spokesperson.

As well as firefighting, sea and land-based SAR are also the responsibility of the HAF, and Greece is also assessing fit-outs of updated equipment to existing coastal patrol and SAR aircraft. “Replacing and upgrading the equipment used in maritime and SAR-related operations is currently ongoing and under active review,” said Lieutenant Colonel Alexandros Gkantiris, spokesman for the HAF’s SAR operations directorate.

Replacing and upgrading the equipment used in maritime and SAR-related operations is currently ongoing and under active review

Meanwhile, Greece has also taken delivery of three newly received Diamond DA62 MPP surveillance and reconnaissance aircraft. Fitted out for the fire observation mission, they are the first aircraft to be owned and operated by the Hellenic Fire Service. To date, all aerial firefighting missions in Greek skies have been carried out by the HAF.

The fleet enhancements are part of a €2.1 billion overhaul of Greece’s disaster response systems, largely financed by the European Regional Development Fund, the European Commission’s Recovery and Resilience Facility, and the European Investment Bank.

Making do in Guatemala

Greece can draw on the European Union’s considerable resources. Britain and France, whatever their current budget issues, are among the world’s largest economies. Operators in many developing countries are less well resourced and face a range of constraints on modifying or upgrading their platforms for special missions.

In Central America, making do with the resources and equipment available is often the only option, according to Chief Aircrewman Chris Sharpe of Black Wolf Helicopters, offering bespoke helicopter special operations consultancy and training. Based in Guatemala City, Black Wolf operates with Bell 206, AS350 (B3/B4), and Bell 412EPX privately owned or military aircraft.

“Apart from the airframe, for example with Helicópteros de Guatemala and its Bell 206 L4 Long Ranger that has a supplemental type certificated (STC’d) stretcher mount in the rear bulkhead, there is absolutely nothing available to maximize the performance of aircraft used for special missions,” Sharpe said.

Night vision equipment, for example, is available only to select military units, and civilian operators do not fly at night due to wire-strike risk, he added.

“Due to import taxes of at least 150%, operators in Central America have to generally just make it happen with the equipment available,” Sharpe said.

There are exceptions, he noted.

“Costa Rica has government-subsided services, so fully equipped STC upgrades are available there, but this is not the norm,” Sharpe said.

Costa Rica has government-subsided services, so fully equipped STC upgrades are available there, but this is not the norm

Fitting out for firefighting missions is also basic, he added. “For firefighting operations, military and civilian alike, it is a case of removing any extra weight – such as seats – from the aircraft and attaching a Bambi Bucket.

“There are absolutely zero options for upgrades, even within the military,” Sharpe stated. Cost is the limiting factor, he said.

“The price of a new rescue hoist will pay the salaries of four pilots for an entire year. The air force have had upgrades, such as night vision goggles (NVG)-compatible glass cockpits. In the private sector there is actually a real requirement, but the cost outweighs the cost returned. Generally, even though Central America is an International Civil Aviation Organization (ICAO) signatory and therefore has a legal requirement under ICAO chapter 12 for SAR services, that’s not happening unless the aviation community or an individual pay for a rescue, or as part of corporate social responsibility within the aviation community.

“Custom outfits are predominantly designed for ease of workload. Do you need a factory-made insert, or can you complete your mission with low-cost medical bags or SAR bags?

“We have looked at the Lifeseeker rescue system, but the cost is totally out of anyone’s budget in this part of the world. A permanent re-role of a helicopter does not fit with the flight profile and requirements to fly in the first instance. Therefore, we must resort to the traditional aircrew role of ‘re-role, make it happen’. Generally, that means adding specialized equipment in bags,” Sharpe concluded.

Extreme missions in New Zealand

In New Zealand, the Royal New Zealand Air Force’s (RNZAF’s) No 3 Squadron, a military utility helicopter unit, operates eight NH90 aircraft on a wide range of demanding SAR and HEMS missions in support of civil agencies including the country’s Rescue Coordination Centre (RCCNZ), Maritime New Zealand (the national maritime safety authority), and New Zealand Police, as well as the New Zealand Defence Force.

“We maintain an aircraft and crew at short notice 24/7 to respond to nationwide contingencies, including domestic SAR. The civil sector are the first responder for SAR and EMS in New Zealand,” said Squadron Leader Sam Estall.

“If we are called out it would typically be because the job requires the greater lifting capacity of the NH90 – for example, mass evacuations or a complex land SAR operation requiring large teams of personnel to be moved in and out of the search area – or the weather conditions are too poor for civilian helicopters to fly, or they are not available for the task, or the task exceeds the capabilities of the local operators, for example involving advanced rescue hoist capabilities or complex night operations.

“The aircraft were purchased directly from the European manufacturer NHIndustries, in the configuration we needed from the beginning. We have undertaken a range of upgrades of various avionics systems, including radios and navigation systems,” SQNLDR Estall said.

Rescue hoist equipment has been upgraded to use the LSC Triton II Harness, Life Flite Helicopter Rescue Sling Strop (for single- or double-strop lift methods), Helitack HotSeat, Helitack Stork infant carrier, and LSC rescue basket, he added.

“We have a range of ongoing upgrades in the works, mainly relating to communication and navigation systems,” SQNLDR Estall stated. “A recent example was upgrading our transponder systems to ADS-B Out to comply with Civil Aviation Rules that require ADS-B Out in New Zealand airspace.

“The NH90 has a massive cabin for its weight class, so reconfiguring the cabin for different roles (sometimes more than one at a time) is not really an issue,” he added. “Flexibility and the ability to move between roles seamlessly are important attributes to a multi-role unit like ours.”

Flexibility and the ability to move between roles seamlessly are important attributes to a multi-role unit like ours

A built-in locator system can find personal locator beacons, which have become much more common in New Zealand in recent years, he noted, and engine, main/tail rotor and horizontal stabilizer de-ice/anti-ice systems permit flying under instrument meteorological conditions (IMC) in icing conditions, which SQNLDR Estall described as “a huge enabler” for the Squadron in New Zealand winter conditions.

“The combination of being able to fly in icing conditions and some special provisions for military IFR procedures means that we can avoid dangerous visual flight rules (VFR) transits in poor weather, particularly by night,” he said.