As the number of worldwide air ambulance flights increases, so the repatriation market grows. But the balancing act between cost pressure and quality also deepens. From my perspective, there are two key factors explaining the cost growth: One factor concerns improvements in regulations and standards for providers regarding issues such as response times, the expansion of geographical coverage, clinical equipment and standards during the past few years, especially in Europe.

This affects crew resources (stand by requirements) and medical and technical devices (state-of-the-art equipment required), thereby resulting in increased costs.

A less acceptable cause for the cost increase is the dramatic change in the general operating conditions due to the requirements of the joint aviation authorities and the general price increase for aircraft operations.

As a result, FAI has estimated that over the past two years maintenance costs have increased by 10 per cent, fuel by 20 per cent, crew training also by 20 per cent, and insurance by 10 per cent.

Another well-established European operator has estimated the following cost increases between 1996 and 2004: Handling and landing fees + 107 per cent; fuel + 89 per cent; all risk insurance / general insurance + 120 per cent; medical care + 37 per cent; and staff + 17 per cent.

Just to give readers an idea about the impact of new legal requirements regarding aircraft operations, we would like to mention that over the last four years an air charter operator would have typically had to add the following equipment in each aircraft: TCAS / Mode S ($300,000), RVSM ($240,000), ELT ($16,000), ICAO Annex 120 ($72,000). This amounts to an investment of the order of $600,000 per aircraft!

Looking at those figures it is easy to understand how overall aeromedical evacuation costs have increased, though price in the air ambulance market have actually been quite stable over the last few years with only moderate increases.

This means, however, that air ambulance companies have to operate more economically, relying on innovative methods. One successful and cost efficient strategy is the planning of combined flights. The models of the 'floating base' and 'wing-to-wing transfers' are just two possible approaches to planning economically priced flights.

The first point refers to setting up a seamless, efficacious succession of two or more air ambulance flights without the required return of an aircraft to its home base, as long as the staff resources available are sufficient and the aircraft can be used further, from a technical point of view.

The second point alludes to the use of the specific performance capabilities of different aircraft or aircraft types in order to optimise resource utilisation. All those procedures or combinations thereof can, through better routings and resource utilisation, bring about a more economical solution for successive assignments.

Even when pilots and medical crews have to be changed for parts of the combination flights and the costs related to this must be borne, these models have, by and large, proven themselves to be cost efficient.

Given the cost increases described above, we anticipate consolidation among air ambulance providers in the coming years; in the long term the only companies that will be able to survive commercially will be those with the ability for cost optimisation through a flexible operation and a larger fleet of aircraft. In addition, interesting models such as wing-to-wing transfers must be developed for the clients through partnerships and cooperation between providers.

Volker Lemke,

Director of Sales and Marketing,

Member of the Executive Board,

FAI rent-a-jet.