ITIC Global 2025 | Air Ambulance Forum: Uncertainties facing air ambulances – operating safely in a volatile world

The ITIJ team are reporting from ITIC Global in Venice this week (2–6 November 2025), sharing the discussions that take place at the conference. Read all reports

The Air Ambulance Forum was moderated by Ian Cameron, ITIC Chairman and ITIJ Editor-in-Chief. He started the session by introducing the panellists: Daniela Wilson, Director of Aviation at Airlec; Tom Hienckes, Business Development Manager at European Air Ambulance; and Tyson Smith, General Manager for Jet Air Ambulance at LifeFlight.

Geopolitical risks: flight restrictions and permission complexities

The panellists were asked by Cameron their opinions on the flight restriction and complexities of air ambulances (AAs) flying over or around countries that have geopolitical difficulties and the risks involved.

Wilson started by saying that every day was different and the abilities for AA companies to perform and do their job depended on the circumstances of the transfer. She said that the red zones were currently a maze and the need for clearances was complex. She added that the problem of avoiding the red zones could mean that some flights could double their distance, and increase costs and duty times of the staff, so AA companies need to clearly explain and justify the added expenses to the assistance companies.

Cameron asked whether the market had been skewed and was less competitive with organisations that had permission and authorisation to overfly red zones.

Smith said that there were some companies that did have the ability to fly over these red zone countries, but they did not necessarily have the equipment, training, and support for the patients, and so the extra expense could be justified by going with a company that might fly a longer route, as long as they are a safer medical transport.

Hienckes said that his company was always as transparent as possible to explain the complexity and the costs involved to help the assistance company know why and what was involved. He also said that you should always have a backup plan in case of emergent situations.

There were a couple of comments from the audience that noted the importance of transparency and trust between AA companies and assistance companies, which help streamline the process of transporting a patient.

How US involvement in other conflict zones is affecting air ambulance operations

Smith said that the US didn’t just affect operations from the wars in which it was involved, but the government shutdown also affected things, and the big bases or stations it keeps in foreign countries with lots of staff and families stationed there can have an impact on emergency transfers if a global health crisis occurs like Covid-19, or a conflict does break out.

Hienckes said that uncertainty was a huge factor, and US foreign policy could really mean that contingency plans had to be made and changed frequently, and it made it very hard.

An audience member asked how a conflict zone was defined, and wanted to point out the insurance consequences for these events. Cameron asked how liability responsibilities accounted for when a situation changes.

Smith said that when the Myanmar military took control of the government overnight, it changed the LifeFlight policy and communication regarding the actual safety and the coverage of the staff and people involved in the situation.

In active war zones, Wilson said that flight crew and medical crew had to be voluntary for those flights as well, as they would not and could not force anyone to fly into those areas.

Insurance costs and route restrictions

Wilson pointed out that there were additional costs when there were changes in conflict zones because it became much more risky.

An audience member asked if there was a way in the market to show what costs might be expected beforehand. Smith said that it would be good to have a way to express the data much more frequently so that AA companies and insurers would know what the variables and trends were that would show changes in risks.

Another audience member said that there were so many different factors that were changing every day that were then passed along to the clients and customers that it would be hard to publish a usable data source.

Payments: managing sanctions

Hienckes pointed out that they had to adhere to a strict code defined by the government, but in changing situations, such as the sanctions against Russia recently, there were so many varying details to the sanctions that it was unclear which sanctions affected exactly which components of the flights and services.

Smith agreed that the depths of the legal ramifications were complicated, and when, for example, dealing with a business that had had its own deals with a sanctioned country, there were layers of the sanctions to take into consideration.

Smith also pointed out that Russian airspace was so huge that even though the major conflict with Russia was on the Ukraine border, flying near the border with Japan was still affected.

Hienckes said, though, that the flights still had to occur, so it was up to each company to decide and weigh up what was least risky and best for the patients and staff.

US tariffs and the effect of price increases

Smith said that a lot of the parts for them were from Bombardier, and they could go through long supply chain routes and these could be affected by the tariffs.

Wilson said that the supply chains were complex, and so now she has ensured that her hangars are full of spare parts for potential use in future due to costs and long lead times. She said that, previously, lead times were eight to 10 days, but now they could average 14 months. They wanted an engine for 23 months recently, consequently having a grounded aircraft for all that time.

Smith said that the supply chain was affected by manufacturers focusing on new aircraft sales, and if you had an older platform, there were just fewer parts being built to support the market. He said that even if there was the availability of used aftermarket parts, it was harder to certify them.

Hienckes said that even if you ordered a part, there was no commitment for delivery, which added a level of uncertainty to the process.

Wilson said that 20% of aircraft for large commercial operators were sitting on the ground waiting for parts, and if even they couldn’t fly full fleets, then small AA operators had little chance of influencing or fixing the market as a whole.

She and Hienckes also pointed out the prices increasing just generally regardless of the tariffs, and that brake pads, a regular consumable, had increased in cost by €100,000.

Cameron asked if companies needed a merger to create a bigger customer with a buying influence.

Smith said that his helicopter fleet used Goodrich hoists, but so did the US military, which had booked up all the slots for three years of servicing, meaning that they couldn’t operate. Smith said that he formed an alliance with other operators and coast guards, and they lobbied Goodrich together to get those servicing contracts back, but this took years to form.

What are the options regarding transfers of multiple patients?

Wilson said that for availability and sustainability, patients could be put together, assuming it was medically and practically viable. It saves costs because, rather than sending two teams with two aircraft, one extended team and one aircraft is more efficient, and she said that it was something that she was trying to encourage more. Wilson said that she had trained her staff to identify the situations in which pooling transports would be acceptable and put it to the assistance companies and the patients to approve.

An audience member said that the possibility of something going wrong needed to be taken into account, and what if something went wrong with one or both patients at the same time; how would they manage the consequences. Wilson said that she would only ever do a less complicated transfer where the timings matched, done in close coordination with an extended team. Sometimes problems do occur, but the extended team does mitigate any problems should they arise.

Hienckes said that the basic principle was nice, but even if the destination were slightly different for the two patients, then complexity increased vastly.

An audience member said that she was working on this process, and that she wanted to work together with more partners to help make this happen more often for less complex and less risky cases.

Smith said that sometimes he performed dual patient transfers not because of cost or choice, but in some parts of the world, they are performed out of necessity, because it is a matter of life or death.