Small Helicopter Air Ambulance Operator Reports

Helicopter Air Ambulance Operator Reports

Copy of HAA_Flight_Operations_Reporting_Template Corrected Draft 2018.xlsx

Small Helicopter Air Ambulance Operator Reports

OMB: 2120-0761

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2120-0761 can be found here:

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Overview

INSTRUCTIONS
REPORT PG 1 DATA
REPORT PG 2 ACCIDENTS

Sheet 1: INSTRUCTIONS

HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

INSTRUCTIONS

Paperwork Reduction Act Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2170-0761. Public reporting for this collection of information is estimated to be approximately 6-16 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are mandatory according to Public Law 112-95. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ASP-110.

This Data Collection Worksheet is the method authorized by the FAA Administrator for collection of Helicopter Air Ambulance Operations Flight Activity Data. Each Helicopter Air Ambulance Operator authorized by Operations Specification paragraph A021 must submit a report regarding their flight operations as directed below. This collection effort is mandated by Congress via Section 306 of the FAA Modernization and Reform Act of 2012.

This is a multi-page Micorsoft Exel 2003 .xls workbook, compatible with most installed Excel systems. The DETAILED INSTRUCTIONS, BY TOPIC below will explain how to properly complete this form. Make entries on the "REPORT" and "ACCIDENT DESCRIPTION" tabs of this template. Select from the tabs appearing near the bottom margin of this page to access those worksheets. Return to this page by selecting the "INSTRUCTIONS" tab.

DEFINITIONS- FLIGHT- For the purpose of this report, the term "FLIGHT" is intended to be the period from a takeoff to the next landing. Each landing made ends a Flight. The terms "Flight" and "Leg" are synonomous. Each IFR Flight is made against a single clearance to a destination. Multiple flights (legs) in a row, each requiring an individual clearance, constitute separate flights. OPERATION- A Helicopter Air Ambulance Operation (Operation) is a flight or a series of flights (legs) made for the intent of completing one medical transport from one departure point to one final destination point, of one or more patients, and/or transplant organs or tissue. An Operation may include multiple take offs and landings.

Unless otherwise specified by your Principal Inspector, your reporting period will be the calendar year beginning January 1st and ending December 31st of the same year. Submit your report within the 30 day period following the end of the reporting period.

The following file naming convention MUST be observed, submittals that are not identified in the following manner may not be accepted. The file name shall start with the calendar year of the reporting period, followed by the company designator, and end with "HAA". For example: a company with designator ABCD1234, reporting for calendar year (CY) 2015 would name their submittal file: "CY2015ABCD1234HAA.XLS". Make submittals via e-mail attachment and send your email to:

<9-AFS-HELICOPTERAIRAMBULANCEDATA@FAA.GOV>

If you have any difficulty and need further assistance, please contact you Principal Operations Inspector.

TOPIC

DETAILED INSTRUCTIONS, BY TOPIC

REPORTING PERIOD-

Enter the reporting period as follows: Enter first date of reporting period, inclusive, in BEGINS cell. Enter last date of reporting period, inclusive, in ENDS cell.

COMPANY IDENTITY-

Enter Operator Name in NAME cell, enter FAA designator code (full 8 characters) in DESIGNATOR cell.

IFR FLIGHTS-

Report the total number of flights made during which helicopters were operated under IFR in the IFR FLIGHTS cell. Report the total number of flight hours during which helicopters performed Helicopter Air Ambulance operations under IFR in the IFR HOURS cell.

UNUSED TRANSPORTS-

Report in the UNUSED TRANSPORTS cell, the total number of incidents (not flightst) in which a helicopter was not directly dispatched and arrived to transport patient(s) but was not utilized for patient transport . (EG: helicopter arrives to transfer patient to another facility or from an accident scene to the trauma center, but for whatever reason, transport was not possible or needed).

ACCIDENTS-

List the number of accidents which occurred during performance of Helicopter Air Ambulance operations in ACCIDENTS cell. If one or more accidents occurred during the reporting period, describe the accident on the ACCIDENT DESCRIPTION Worksheet attached, (see third TAB below).

FLIGHTS ACCEPTED VS. DECLINED-

Report total number of flight requests received by and that were ACCEPTED BY THE OPERATOR, by type (Scene response, Inter-facility Transfer, Organ Transport, Repositioning, or Ferry (Maintenance)). Report total number of flight requests that were received by and that were DECLINED BY THE OPERATOR, by type. If a helicopter is out of service due to maintenance, no record of requests declined is required.

TIME OF DAY-

List the aggregate number of flights which were performed by time of departure (UTC), rounded to the nearest hour, within the FLIGHTS cell under TIME OF DAY.

BASE LOCATIONS-

List each base by FACILITY identifier if available, or Base name, and CITY, and STATE.

FLIGHT ACTIVITY by HELICOPTER USED-

List each helicopter separately columnwise, by registration number (N#). For each N#, indicate the total number of HAA FLIGHTS made by that helicopter within the reporting period total and the total number of flight HOURS logged performing HAA operations by that same helicopter within the reporting period.

EXAMPLE:

REPORTING PERIOD

IFR OPERATIONS

FLIGHTS ACCEPTED VS. DECLINED

BEGINS

ENDS

IFR FLIGHTS

473

IFR HOURS

210.6

TYPE

ACCEPTED

DECLINED

1/1/14

12/31/14

SCENE RESPONSE

7502

INTER-FACILITY TRANS.

28534

COMPANY IDENTITY

UNUSED TRANSPORTS

ORGAN TRANSPORT

144

NAME

Helicopter Air Ambulance Co.

REPOSITION

18761

DESIGNATOR

HAAC1234

ACCIDENTS

FERRY

248

TOTAL

55189

TIME OF DAY (UTC)

FLIGHT ACTIVITY BY HELICOPTER

DEPARTED

FLIGHTS

DEPARTED

FLIGHTS

HOURS

FLIGHTS

HOURS

FLIGHTS

HOURS

1135

1784

1410.0

0.0

0000-0059

410

1200-1259

123HA

1024

820.0

0100-0159

725

1300-1359

124HA

760

590.0

0200-0259

1400-1459

0300-0359

1500-1559

0400-0459

1600-1659

0500-0559

1700-1759

0600-0659

1800-1859

0700-0759

1900-1959

0800-0859

2000-2059

0900-0959

2100-2159

1000-1059

2200-2259

1100-1159

2300-2359

BASE LOCATIONS

FACILITY

CITY

STATE

KDCA

ARLINGTON

Sheet 2: REPORT PG 1 DATA

HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

PAGE 1 of 2

SUBMIT TO:

9-AFS-HELICOPTERAIRAMBULANCEDATA@FAA.GOV

OMB CONTROL NUMBER: Control #

2170-0761

EXPIRATION DATE:

2/28/2018

REPORTING PERIOD

IFR OPERATIONS

FLIGHTS ACCEPTED VS. DECLINED

BEGINS

ENDS

IFR FLIGHTS

IFR HOURS

TYPE

ACCEPTED

DECLINED

SCENE RESPONSE

INTER-FACILITY TRANS.

COMPANY IDENTITY

UNUSED TRANSPORTS

ORGAN TRANSPORT

NAME

REPOSITION

DESIGNATOR

ACCIDENTS

FERRY

TOTAL

TIME OF DAY (UTC)

FLIGHT ACTIVITY BY HELICOPTER

DEPARTED

FLIGHTS

DEPARTED

FLIGHTS

HOURS

FLIGHTS

HOURS

FLIGHTS

HOURS

0.0

0000-0059

1200-1259

0100-0159

1300-1359

0200-0259

1400-1459

0300-0359

1500-1559

0400-0459

1600-1659

0500-0559

1700-1759

0600-0659

1800-1859

0700-0759

1900-1959

0800-0859

2000-2059

0900-0959

2100-2159

1000-1059

2200-2259

1100-1159

2300-2359

BASE LOCATIONS

FACILITY

CITY

STATE

Sheet 3: REPORT PG 2 ACCIDENTS

ACCIDENT SUMMARY:

PG 2 OF 2

Company

Reporting Period

From:

Designator

To:

Instructions:

NTSB Number-

Enter the accident identification number assigned by the NTSB.

Date-

Enter the date of occurrence of the accident.

Registration Number-

Enter the registration number of the helicopter involved.

Make/Model Aircraft-

Enter the helicopter make and model.

Type of Flight-

Enter the type of flight from the drop-down menu.

Event Severity-

Enter the severity of the accident in terms of aircraft damage (Destroyed, major, minor) and Casualties (fatalities, injuries, no injuries)

Location-

Enter the GPS geo-coordinates or the radial and distance from the nearest VOR.

Brief Description-

Describe the circumstances leading to the accident. Include the approximate time of day, adverse weather, terrain or obstructions, apparent mechanical failure if any, pilot flight time since reporting for duty that day, approval for use of NVIS, number of persons aboard, number of fatalities (if applicable), and any other pertinent information.

IF AN ACCIDENT OCCURRED WITHIN THE REPORTING PERIOD, PLEASE ENTER FOLLOWING INFORMATION (FROM NTSB PRELIMINARY ACCIDENT SUMMARY): If no accidents were suffered, enter "NONE" in the first NTSB No. Cell.

NTSB No.

BRIEF DESCRIPTION:

REGISTRATION #

MAKE/MODEL

EVENT SEVERITY

LOCATION

NTSB No.

BRIEF DESCRIPTION:

REGISTRATION #

MAKE/MODEL

EVENT SEVERITY

LOCATION

NTSB No.

BRIEF DESCRIPTION:

REGISTRATION #

MAKE/MODEL

EVENT SEVERITY

LOCATION

NTSB No.

BRIEF DESCRIPTION:

REGISTRATION #

MAKE/MODEL

EVENT SEVERITY

LOCATION

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