Classification of air ambulance operations
Date issue released
Safety Issue Description

Although air ambulance flights involved transporting passengers, in Australia they were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of regulatory requirements than other passenger-transport operations (including requirements for fuel planning flights to remote islands).

Issue number
Transport Function
Aviation: Air transport
Issue Owner
Civil Aviation Safety Authority
Mode of Transport
Issue Status Justification

Based on the wording of CASR Parts 121, 135 and 133, the requirements for passenger transport operations will be very similar to those for medical transport operations. Accordingly, the ATSB is satisfied that safety issue has been addressed.

Proactive action
Action number
Civil Aviation Safety Authority
Action date
Action Status
Action description

As outlined in the safety actions to address safety issue AO-2014-190-SI-10, in July 2010 CASA issued the Notice of Proposed Rule Making (NPRM) 1003OS (Carriage of Fuel on Flights to a Remote Island). The NPRM proposed amending Civil Aviation Order (CAO) 82.0 to require air ambulance flights to Australian remote islands to carry sufficient fuel for an alternate aerodrome. This change was implemented in December 2014.

In June 2012 (during the original investigation into the 18 November 2009 accident involving VH‑NGA), CASA advised the ATSB of its intent to regulate air ambulance/patient transfer operations as follows:

Air Ambulance/Patient transfer operations in the proposed operational Civil Aviation Safety Regulations (CASRs) will be regulated to safety standards that are similar to those for passenger operations.

While CASR Parts 138/136 will be limited to domestic operations and, if CASA decides to retain Air Ambulance/Patient transfer operations in these rule suites, any such operation wishing to operate internationally will also be required to comply with CASR Part 119. If, however, CASA decides to move these operations into CASR Parts 121/135/133 they will already be required to comply with CASR Part 119. Either way, Air Ambulance/Patient transfer operations will be regulated to the same standard as Air Transport Operations (ATO). In relation to Norfolk and Lord Howe Islands, all ATO which include Air Ambulance/Patient transfer, will be required to carry mainland alternate fuel.

CASR Parts 119/121/135/133 are expected to be finalised by the end of 2012 and are currently proposed to commence in June 2014. CASR Parts 138/136 are expected to be made by June 2013 and are proposed to commence in June 2014. Given that the drafting of these CASR Parts are subject to third party arrangements (Attorney-General’s Department) and CASA and the industry’s ability to effectively implement the new rule suite, these timelines are subject to change.

In July 2013, CASA issued the Notice of Proposed Rule Making (NPRM) 1304OS (Regulations of aeroplane and helicopter ‘ambulance function’ flights as Air Transport operations). With the release of the NPRM, CASA stated:

The purpose of this NPRM is to advise the public and aviation community of CASA's intent to regulate, to the greatest extent practicable, ambulance function flights to the same safety standards that are currently applicable to AT operations. This will extend to adoption of AOC certification requirements, operating standards and maintenance standards.

The NPRM outlines a new and updated policy that specifically categorises Medical Transport (MT) flights so that they operate under the requirements of an AT AOC (issued under Part 119 of CASR) and the applicable operational rule set (i.e. Part 133 of CASR for helicopter operations and either Part 121 or 135 of CASR for aeroplane operations).

The proposed policy will ensure that appropriate mechanisms are included within the AT regulations to afford MT flights with:

sufficient operational flexibility

the safety benefits available under Part 119 of CASR.

CASA considers that Part 119 of CASR, with its robust operator management systems, should be implemented by (and integrated into) these essential passenger transport services. This policy and change of classification is based on CASA’s recognition that the focus of these operations is primarily passenger-carrying in nature, albeit in a highly specialised manner, and conforms more closely to international norms for the conduct of these operations.

However, CASA acknowledges that, in some cases, applying all of the Air Transport Operations suite of standards to MT flights would not be practicable. Due to the highly specialised nature of some MT flights, some of the rules in these operational Parts will not apply and other requirements that are not characteristic of normal AT operations will be addressed specifically for MT flights.

In October 2014, CASA published a summary of responses to the NPRM. Its conclusion stated:

From the responses received, CASA believes there is strong support for the movement of the current aerial work purpose ‘ambulance functions’ into the AT rule set under the CASR 1998 operational and certification rule structure.

In this regard, CASA acknowledges the industry's desire for some possible amendments to the proposal and the need for close consultation throughout this regulatory change project and its ongoing development.

CASA agrees with the industry feedback regarding fatigue management of flight and other crew members in MT operations. Without limiting the availability of access to an FRMS, a specific appendix for CAO 48.1 will be required. The development of this appendix will be part of a separate project to be managed by CASA Standards SMS and Human Factors Section subject matter experts.

CASA will now commence compiling final policy and drafting instructions to move this project forward and will (when these are in a suitable form) organise a consultation meeting with the MT industry to review these developments.

In March 2017, CASA advised the ATSB:

Drafting instructions have been issued to the Office of Parliamentary Counsel (OPC) to incorporate medical transport flights into the applicable Air Transport Parts.

Initial drafts of CASR Parts 119, 133, and 135, with medical transport operations included, have been received from the OPC and reviewed by CASA. In addition, these drafts have been road tested by internal review teams. The results of these reviews are now being compiled into further instructions for the OPC.

The continuing development of these amendments, together with the drafting of the MOS for each Part, is ongoing.

ATSB Response

The ATSB acknowledges CASA has introduced improved fuel planning requirements for air ambulance flights to Australian remote islands. The ATSB also acknowledges CASA has taken significant steps since 2012 to reclassify air ambulance (medical transport) operations as air transport operations. However, the ATSB is concerned that over 4 years since the NPRM, this change has not yet been introduced. Accordingly, the ATSB issues the following recommendation.

Action number
Civil Aviation Safety Authority
Action date
Action Status
Action description

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority continue reviewing the requirements for air ambulance / medical transport operations and address the limitations associated with the current classification of these flights as aerial work rather than air transport.

Organisation Response
Date Received
Civil Aviation Safety Authority (CASA)
Response Status
Response Text

Categorisation of aeroplane and helicopter 'ambulance function' flights as Air Transport Operations is the policy position outcome from Project OS 14/08 which has been incorporated into draft CASR Parts 119, 121, 133 and 135 drafts, which have been publicly consulted previously and are scheduled to be consulted again during 2018.

Finalising the CASR operations Parts is presently CASA's highest priority. The commencement date is not set; however, the making of the regulations is anticipated to be completed by late 2018.response and will continue to monitor CASA's development and delivery of changes to relevant requirements and guidance.

ATSB Response

The ATSB notes CASA's response and will continue to monitor CASA's progress in developing changes to the relevant requirements.

Date Received
Response Status
Response Text

In December 2018, Civil Aviation Safety Regulation (CASR) Parts 121, 135 and 133 were introduced. CASR Part 121 outlined requirements for Australian air transport operations for large aeroplanes (that is, aeroplanes with a maximum operational passenger seat configuration of more than 9 or a maximum take-off weight of more than 8,618 kg). Part 135 outlined requirements for Australian air transport operations for smaller aeroplanes, and Part 133 outlined requirements for Australian air transport operations for rotorcraft. These regulations come into force in March 2021.

In April 2019, relevant definitions associated with these Parts were amended or introduced. These definitions included the following:

An air transport operation is a passenger transport operation, a cargo transport operation, or a medical transport operation, that:

a)          is conducted for hire or reward; or

b)          is prescribed by an instrument issued under regulation 201.025.

A medical transport operation is an operation:

a) the primary purpose of which is to transport one or more of the following:

(i) medical patients;

(ii) medical personnel;

(iii) blood, tissue or organs for transfusion, grafting or transplantation; or

b) of a kind prescribed by the Part 119 Manual of Standards for the purposes of this paragraph.

Passenger transport operation:

a) means an operation of an aircraft that involves the carriage of passengers, whether or not cargo is also carried on the aircraft; but

b) does not include the following:

(i) an operation of an aircraft with a special certificate of airworthiness;

(ii) a cost-sharing flight;

(iii) a medical transport operation.