Detailed flight planning key to air ambulance missions

pilot briefing
Getting your ducks in a row

Proper preparation enables more successful missions. James Paul Wallis goes behind the hangar door with global air ambulance operators to find out more about the effort that goes into ensuring safe and high-quality repatriation flights go off without a hitch

The cabin door is closed, the crew take their seats, the plane taxis to the runway and, with a roar of the engines, the aircraft accelerates down the tarmac and takes off; the mission has started. In truth, of course, the mission started hours earlier. Long before the flight team reaches ‘wheels up’, the operations centre begins the painstaking work of getting everything in place so the mission will be a success.

For AMREF Flying Doctors, planning begins with selecting an appropriate aircraft and crew members, explained Mike Black, COO and Accountable Manager. Next comes detailed route planning, along with a host of tasks such as obtaining flight permits, hotel accommodation, crew and patient transport, fuel releases, and arranging ground handling services. 

Border crossing

Despite the apparent freedom of soaring above the clouds, the need to obtain overflight and landing permits for the countries over which the plane will fly or land in adds time to the planning stage, as Glenn Salt, Operations Manager for Capital Air Ambulance, explained to ITIJ: “This process can take anywhere between 12 to 24 hours before all the required permits have been granted. The cost involved to overfly a country varies from country to country, however, the costs are anywhere between US$50 to $400.”

Sometimes, we are instructed by the client for medical reasons to start a mission even if we do not have all necessary permits in place.
Philipp Schnieder

In some cases, a mission will launch before the permits are obtained, said Philipp Schneider, Key Account Manager at Germany’s Quick Air Jet Charter: “Sometimes, we are instructed by the client for medical reasons to start a mission even if we do not have all necessary permits in place.

In these urgent medical cases, most of them concerning African countries, we inform the authorities of the affected countries that the urgent air ambulance mission has already started.” Schneider added that the company has always experienced a good level of co-operation from these particular authorities and gained the necessary permits, even if the request goes in at the last minute. He added: “For those cases, we definitely have a fall-back option in place, which means that we, worst case, have to pause the mission until a missing permit can be issued. This could lead to extra costs, for example, for an additional required landing. The client always has to be involved in [developing] Plan B, as they will be the responsible party concerning the costs and alternative outcome.”

team debrief

Visas for the crew are less of a hindrance, noted Salt, saying that due to the nature of the flight, generally, visas for flight and medical teams can be obtained upon arrival, with the exception of a handful of countries. Irena Dimitrijevic, Head of Sales and Business Development for Jet Executive, shed light on the question of where this might present a problem: “One example is Russia or China, as these countries insist on a valid crew visa before arrival. If our operating crew on this mission doesn’t hold a permanent visa – this is the case especially for medical specialists who don’t work on a regular basis for us – they need to visit the embassy in Germany before the flight date to obtain the visa.”

Short vs long-haul

While some elements of planning are common to all flights, longer missions bring extra complexity, noted Salt of Capital Air Ambulance. For the UK-based provider, operating within the European Economic Area (EEA), North Africa and parts of the Middle East generally requires just the standard landing and handling arrangements, but going further afield requires greater planning and preparation before the aircraft can be dispatched.

Long-haul flights need at least 24-hours notice, often even longer depending on which geographical region we are flying to, due to all the overflight and landing permits we need to obtain in advance

Dimitrijevic highlighted the difference in planning time for short and long-haul missions. For short-haul flights: “We can set up a flight within more or less one hour, and maybe another two hours until our crews reach the facilities at our home base airport, equip the aircraft, check-in and start towards the patient’s pick-up destination.

Long-haul flights need at least 24-hours notice, often even longer depending on which geographical region we are [flying] to, due to all the overflight and landing permits we need to obtain in advance.”

Another factor is that very long flights can need additional crews to be prepositioned en route to ensure the flight crew remain within their flight and duty limits, said Black of AMREF Flying Doctors. This prepositioning can be achieved by sending crew members out on scheduled passenger flights, explained Dimitrijevic.


A major consideration is the security and travel risks associated with countries where the crew may make a fuel stop or overnight stay, said Glenn Salt. Considerations need to be for the crew and also for the parked-up aircraft, he said. To find the necessary information, providers can take advantage of aviation travel security briefs offered by a number of companies, which provide country-specific medical and security data. Salt added: “If a patient is in a country deemed unsafe to visit where an overnight layover is required, a neighbouring country would be selected for the layover, where the risk factor is much lower. The aircraft could then fly over to the country in which the patient is located and, subject to the patient’s condition, a tarmac handover of the patient may be performed, whereby a suitably qualified team bring the patient to the air ambulance.”

The political environment also needs to be taken into account, said Philipp Schneider, as this can affect airport availability: “The current situation between Pakistan and India affecting airway closures leads to an extended flight time on the way, for example, to Southeast Asia, directly affecting possible flight crew duty times, which have to be considered carefully. Safety warnings issued by the European Aviation Safety Agency and the Federal Aviation Administration have to be taken in consideration on a daily basis.”

paperwork debrief misison

Factoring in the unexpected

And then you get to the issue of fuel, and here, the planning goes well beyond simply scheduling stopovers at set distances. “When we consider all of the many aspects good flight planning involves, perhaps the most important is the fuel planning,” said Philipp Schneider. “Temperatures, for example in India or Sudan, can easily be a limiting factor for the amount of fuel we are able to uplift. Flight schedules have to be adapted to the daily temperature forecast, avoiding fuel stops during a midday temperature peak.”

Extra fuel is carried in case the weather is not as predicted, or in case of other emergencies, said Schneider: “There are many situations where a different airport other than the original is needed. Finding an alternative airport is an important factor that needs to be considered with good flight planning.”

Emergencies on the ground are an uncommon, but potential, source of disruption, which can make an alternative landing destination a much-needed option

Emergencies on the ground are an uncommon, but potential, source of disruption, which can make an alternative landing destination a much-needed option. “In 2016,” continued Schneider, “two of our ambulance aircraft were on their way to Brussels Airport when the terrorist attack lead to a total airport closure. In 2018, one of our aircraft was heading to Schipol Airport in Amsterdam when an electrical failure lead to a blackout of the whole airport, causing an airport closure. Such situations are rare, but they happen.”

Doing your homework in advance helps to control fuel costs. Glenn Salt explained that existing relationships with fuel suppliers are a vital link in the chain: “An established credit account needs to be in place with several suppliers who offer fuel prices via portals. This gives you the ability to cross reference suppliers and select the most competitive price for your trip. A fuel release will be provided by your supplier to ensure fuel is supplied down route for the crew, avoiding any need to provide a credit card.”

Returning to the theme of preparing your Plan B, Mike Black commented: “Unexpected events need to be addressed very quickly if the patient is onboard at the time. How the challenge is dealt with will depend on its nature and may even require another aircraft to be dispatched should the aircraft have a technical issue en route that affects its airworthiness and ability to continue the flight, although this is an extremely rare event.” More common challenges, said Black, include a delay in the patient’s discharge from hospital, or the planned ground time on a technical/refuelling stop being exceeded, both of which could require the flight planning to be revised and changes made to clearances, landing slots, and so on. He added: “Each flight is closely monitored by the company’s aviation operations department to make sure any adjustments to the flight plan are made quickly and where necessary, the relevant authorities communicated with, including the receiving hospital.”

medical team debrief


No two flights are identical, as either the mission profiles (details such as origin, destination and patient condition) differ, or external factors (such as political situations) change over time. As an example, Philipp Schneider highlighted how flying within Europe is increasingly challenging: “European airways are more crowded than they have ever been in the history of commercial flying, and so even as an active air ambulance aircraft, we are facing difficulties in finding practicable routings during peak times. Two years ago, we faced, for the first time in our company history as an air ambulance operator, problems with airport availability for our air ambulance aircraft.” He added that on occasion during the summer season, repatriation missions from Ibiza, Mallorca and Lisbon have had to be scheduled according to available airport slots, without any option of prioritisation due to patient needs.

Operations teams also have to keep up to date with current flight restrictions, including NOTAMS (notices to airmen) issued by air authorities. Volker Lemke, Director of Sales and Marketing for Germany’s FAI Flight Ambulance, noted that since flight restrictions can occur relatively quickly, a detailed audit is essential.

Mid-flight surprises can require operations staff to pull out all the stops to make the mission a success. Lauren Dulin, Chief Operations Officer at Air Ambulance Worldwide, recalled one such flight: “While working on a mission to Guyana, we were told that permissions would not be granted for the N-registered aircraft at the time of our estimated arrival. However, our team didn’t accept the initial deterrent and were able to reach the embassy, where the ambassador to the Republic of Suriname was the person whose influence helped bring our trip together.”

Sometimes, however, a swift change of plan can be used to control costs, even when the mission can’t be completed as originally hoped. Dulin recounted one such time: “While en route from Denver [US] to Cancun [Mexico], we received devastating news that our patient in Cancun had passed prior to us getting there to pick them up. Through ATC and our Garmin communication, we were able to reach our crew, who were mid-flight repositioning to pick up this patient, allowing [them] to put down in Texas. By the quick response of our dispatch and their efficient communication with our crew, we were able to redirect the aircraft mid-flight and save the client additional costs.”

Reflecting on the need to expect the unexpected, Irena Dimitrijevic put it this way: “Aviation is challenging, exciting, and external factors such as the weather are changing all the time, so our teams need to be professional and experienced to consider all these challenges – aviation can never be foreseen 100 per cent, we are creating individual services and no flight is like another.”

global flight meeting

Bringing it all together

The true art of planning an efficient mission is to balance all of the factors at play to find the optimal outcome. Lauren Dulin commented: “On longer missions in which crew near duty day limits, our co-ordinators will assess the benefits of the required overnight, keeping the aircraft and crew out an additional day and accruing the cost of such, or [whether] scheduling a fuel stop slightly outside of our line of flight to swap pilot crews would be more beneficial, both in cost to the client and to the company to have the aircraft return to base in a more timely manner.” As a specific example, Dulin said that for missions between Mexico to Canada, the company will look at the benefits of planning for a fuel stop in the US to avoid costly navigation fees, or incurring a slightly higher cost by choosing to overfly the US, offering the patient a direct flight.

The team behind the scenes are always looking at the combination of superior clinical care, appropriate aircraft and routing, support to our clients both in service and financially, as well as keeping each mission successful and safe
Lauren Dulin

Summarising the flight planner’s art, Dulin said: “The team behind the scenes are always looking at the combination of superior clinical care, appropriate aircraft and routing, support to our clients both in service and financially, as well as keeping each mission successful and safe.”

The end of planning is the handover to the crew so the flight can begin. Volker Lemke said: “As the final step prior to boarding the aircraft, the crew must be fully briefed on all aspects of the mission … including any restrictions, any refuelling issues, and any required procedures prior the start of the flight. The operations department is responsible for all the above issues. Operations also creates a flight order of the route which has all the necessary details included. The pilot takes ownership of all the documents, which include fuel releases, flight orders, NOTAMs, hotel and transportation bookings, etc.”

And with that, it’s time to board the aircraft, close the door and fasten seatbelts, en route to bring another patient home safely.