CJI ANALYSIS • AIR AMBULANCES
Active ageing, active fleets
European air ambulance operators are flying more than ever. But what’s driving growth and how is the industry responding to demand? Words: Yves Le Marquand
Above: Aero-Dienst operates a diverse air ambulance fleet, featuring aircraft like the Dornier 328JET, Learjet 60XR, Challenger 300/604 and King Air 350.
CJI ANALYSIS
Active ageing, active fleets
European air ambulance operators are flying more than ever. But what’s driving growth and how is the industry responding to demand? Words: Yves Le Marquand
AIR AMBULANCES
Above: Aero-Dienst operates a diverse air ambulance fleet, featuring aircraft like the Dornier 328JET, Learjet 60XR, Challenger 300/604 and King Air 350.
YOUNG people draw criticism for being less active than previous generations. But their grandparents are travelling more frequently and further than ever before – often overwintering in faraway warm climates. This is good news for older people looking forward to an active retirement – and for air ambulance operators.
“A lot of people are spending their retirement during the winter in Southeast Asia,” says Tom Hienckes, business development manager at European Air Ambulance. “You can imagine, if you’re an 80-year-old getting sick, the first thing you do is call your insurance to take you back to your home country.” Air ambulance operators are mainly dependent on repatriating older patients who suffer medical emergencies abroad.
This is creating a problem for insurance companies because in the past people paid insurance premiums but seldom claimed against their policies, says Hienckes. “Now they’re using them much more often.”
European Air Ambulance is a brand of non-profit Luxembourg Air Rescue used to sell air ambulance services to third-party clients. The organisation uses a membership subscription model where members pay an annual fee, which provides access to free global repatriation flights, without any additional fees.
The brand predominantly operates ambulance flights for insurance companies, says Hienckes. “We receive a request, provide a quotation, and then it’s up to the insurer or assistance provider. I’d say around 70% of our flights are for insurance and assistance companies,” he explains. “We then have brokers, governmental institutions and direct clients, which I’d estimate at around 10 -15% and the remainder is for our members.”
European Air Ambulance also has a government contract in France for organ transport flights. It operates about 150 flights per year and dispatches another 750 organ flights with partner aircraft. “It’s a public tender that we have held for about 14 years and we’ve just won it again for the next seven years,” says Hienckes.
A membership model is also how Aero-Dienst does business, although it operates differently. The company operates flights for members of ADAC, which is the second largest automobile club in the world with a membership of more than 23m.
Oliver Kosing, MD, Aero-Dienst, tells CJI: “ADAC is growing strongly. At the same time, placing patients on commercial airlines is becoming more difficult, so demand for air ambulance services is increasing rather than decreasing. We have a very high workload at the moment.”
Aero-Dienst was founded in 1958 and has been conducting air ambulance flights for ADAC since 1978. During the pandemic, the operator supported the German government extensively, including flights from Bergamo, Italy, transporting Italian patients to German hospitals.
Today, it continues to support government missions, including transporting severely injured Ukrainian soldiers and civilians from the border to hospitals in Germany.
About 95% of its flights are conducted for ADAC members. “If someone needs to be transported within Germany or nearby countries such as Austria, road transport is usually sufficient. But if a member flies to a faraway holiday destination and becomes ill or injured, our aircraft will bring them back,” says Kosing. Every German who travels abroad and is an ADAC Plus or Premium member or has an ADAC international health insurance is entitled to repatriation.
“Naturally, most patients are elderly. However, we also see younger patients–for example, cyclists in the Pyrenees who suffer serious accidents, or a young rider injured in a horse-riding accident in Montana. But overall, elderly patients make up the majority.”
Nuremberg-based FAI Medical Services has a different customer split. About 50% of its ambulance business turnover comes from travel insurers and their assistance companies, which specialise in individual tourists or corporate clients. As for the rest, around one third comes from government customers, with the remainder divided relatively evenly between private customers, hospitals and brokers.
Volker Lemke, MD at FAI Medical Services tells us: “FAI is one of the very few air ambulance companies that truly operates worldwide. Accordingly, our fleet has been adapted and expanded over the last 20 years to accommodate long-haul flights.”
FAI also serves the “classic” tourist destinations throughout Europe with its Learjet 60, but it is the large Challenger fleet that allows the company to operate on all continents.
“This is our response to the increased demand for aircraft types that can handle urgent medevacs as turnaround flights from Africa or the Middle East to Europe, for example, or easily complete patient transport distances of over 7,000 nautical miles,” says Lemke.
European Air Ambulance operates about 150 flights per year and dispatches another 750 organ flights with partner aircraft.
European Air Ambulance operates about 150 flights per year and dispatches another 750 organ flights with partner aircraft.
Changing travel patterns
Being based in Luxembourg, most of European Air Ambulance’s business is within the continent after which it was named.
With many flights originating from or returning to Europe, traditionally this meant there was distinct seasonality to operator activity. It would be common to see more Mediterranean destinations in summer and Alpine regions in winter. While there are still some seasonal peaks, since the Covid pandemic demand has become much more consistent year round.
Hienckes explains: “Before Covid, there was a clear low season and high season. Now it’s almost high season all year. Travel patterns have changed. People without children avoid school holidays, so the season starts earlier and ends later.”
Travel habits changed after Covid, he adds. “People now travel outside peak holiday periods, and older travellers are travelling more and further. Retirees no longer stay close to home – travel globally, even at 80 or 90 years old. That increases demand for medical repatriation.”
People also underestimate medical risks in remote or developing destinations, warns Hienckes.
“Cruise ships are another issue. If something happens onboard, passengers are often offloaded at the nearest port, which can mean limited medical facilities,” he says. “That creates major challenges for insurers.”
Increased long-haul demand
European Air Ambulance is also seeing shifts in long-haul demand, says Hienckes.
Two years ago, the organisation flew a high number of missions from India. This year it’s been Brazil. Demand from and to North America has changed as well. “Europeans are travelling less to the US, while Americans are travelling more to Europe, so we now fly more patients from Europe back to the US,” he explains.
Additionally, Southeast Asia has become a major market, especially in winter, because many European retirees spend months in places such as Thailand or Vietnam, says Hienckes.
These changes have prompted fleet diversification for many air ambulance operators who need aircraft that can fly farther.
European Air Ambulance currently operates around 500 to 600 flights per year. Its fleet comprises two Bombardier Challenger 605 jets for long-range missions and three Bombardier Learjet 45XRs for shorter trips.
Before Covid it did more flights because it had a larger fleet of Learjet 45s, says Hienckes. “We later sold three of them and added two [Bombardier] Challenger 650s,” he notes. “The fleet got smaller in aircraft numbers, but flight hours increased because the Challengers fly long-haul missions.”
Aero-Dienst has two new Bombardier Challenger 650 aircraft on order. It purchased the second Challenger just before Christmas 2025. The first will be delivered in summer 2026 and the second in March 2027. The company currently operates a fleet of two Bombardier Learjet 60XRs and two Dornier 328 Jets with an average age of 15 years.
“Starting from 2026, we will improve our services on long-distance repatriations for our members,” says Kosing. “The operational requirements are essentially the same as for shorter missions: permits, crew management and regulatory compliance.”
About 50% of company operations are positioning flights, which are compensated by an average load factor of 2.2 passengers per flight, according to Kosing.
Aero-Dienst does not fly to high-risk or war zones like Russia or Syria. Kosing says there are “more and more” regions that are off-limits, such as Gaza, Venezuela and Sudan.
“For example, flights to China require significant detours because we cannot overfly Russia. That is one of the operational burdens we face,” explains Kosing.
"Before Covid, there was a clear low season and high season. Now it’s almost high season all year. Travel patterns have changed."
"Flights to China require significant detours because we cannot overfly Russia. That is one of the operational burdens we face."
Choosing the right aircraft is key. Cabin doors must be wide enough to admit a patient on a stretcher.
Is the Learjet’s popularity dimming?
The Learjet range is the go-to aircraft series in the air ambulance operator’s toolkit. Decades after its introduction, it remains a common sight on medevac ramps, valued for its speed, economics and familiarity. Yet as medical missions become longer, more complex and more ICU-intensive, its suitability is coming into question.
With a few exceptions, most aircraft used in the air ambulance industry worldwide are older airframes. The average age of aircraft in FAI Medical Services’ fleet is about 25 years, says Lemke.
“However, the process of fleet renewal is continuing, with the Learjet 60 Classic gradually being replaced by the Learjet 60XR and the Challenger 604 by the Challenger 605,” he explains.
“This means that the average age will be around 10 to 15 years in the future, which is significantly younger than most of our competitors. Since the air ambulance market has unfortunately always been dominated by small margins, we will continue to place greater emphasis on lower investment costs in the future, with performance and efficiency coming second.”
FAI’s Learjet 60 and Challenger 604 aircraft can transport the vast majority of patients with a wide variety of medical conditions, says Lemke. However, due to its cabin size and range, the Challenger is suited to special tasks.
“These can be transporting specialised medical equipment such as an isolation unit or a heart-lung machine and, if necessary, an additional medical team, bariatric patients with heavy weight special equipment, or simply a larger number of accompanying persons,” he explains.
The operator also has a Bombardier Global Express which it uses for ultra-long-haul transport. “We repeatedly receive enquiries for transcontinental flights that are to be completed without a technical stop,” says Lemke.
At European Air Ambulance, the Learjet continues to play a central operational role, particularly for short-haul European missions.
“The Learjet 45 is the perfect aircraft for ambulance on short range,” says Hienckes. “Some operators even use them for long-range missions because the compromise between range, costs and the aircraft is just perfect.”
For European Air Ambulance, the aircraft’s strengths lie in predictable regional flying. “We primarily use the Learjets within Europe, so they rarely leave Europe,” Hienckes explains. “We use them for flights from Spain to Scandinavia, from Cyprus to the UK and for organ flights.”
That versatility, combined with operational familiarity, has made the Learjet difficult to replace. “You can put two stretchers, the range is good, the payload is good,” says Hienckes. “The medical crews love it. The pilots love it. Although, the spare part availability is constantly decreasing, which is causing us some headaches for the years to come.”
This sentiment is echoed across the sector. “If you look at ambulance providers in Europe, there are still a lot of them flying Learjet 35s and 45s,” he adds.
However, at Aero-Dienst, the Learjet is increasingly viewed as a constraint rather than an asset, particularly as medical expectations rise.
“In our opinion, the fuselage is too small,” says Kosing. “Our doctors work on the aircraft and care for the patient. On critical missions, one medical professional is often not enough. Two people may need to work simultaneously, and the space in a Learjet simply does not allow that.”
Cabin height is another decisive factor. “We want to offer the best medical service,” Kosing explains. “That includes a minimum cabin height of 1.8m so medical staff can stand and work properly.”
Reliability has also become an issue as fleets get older. “Our Learjets are ageing. We fly them very intensively – around 1,200 hours per year,” he says. “The Learjet was not designed for that level of utilisation and reliability has become an issue.”
Aero-Dienst’s view is framed not as criticism of the aircraft’s past, but as the result of experience, changing mission profiles and higher medical standards. “Based on our experience, we now believe they are not suitable for the increased level of care we want to provide,” says Kosing.
FAI air ambulance aircraft are equipped as flying intensive care units – equipped to treat and transport infants and adults.
FAI air ambulance aircraft are equipped as flying intensive care units – equipped to treat and transport infants and adults.
Growth strategies
While elderly people getting out more is indirectly fostering business in the air ambulance industry, it can be difficult to define a growth strategy for an operator. You can’t increase the numbers of people requiring medical treatment.
This means strategies are conservative and growth instead centres around quality of service delivered. That focuses on a number of subsets including fleet renewal, medical equipment upgrades and, particularly in Europe, sustainability.
At European Air Ambulance, growth is explicitly not defined by size. The company’s parent organisation, Luxembourg Air Rescue, operates as a non-profit, a structure that fundamentally shapes its strategy.
“Our parent organisation is non-profit, so growth isn’t about scale or acquisitions,” explains Hienckes. “We may add one aircraft in the coming years, but our goal isn’t to become the largest operator.”
Instead, European Air Ambulance is positioning itself as a specialist provider for complex, high-acuity missions. “Our goal is to become the preferred operator in Europe for difficult medical cases, known for high medical and operational care,” Hienckes says. Any growth that does occur is incremental, with profits reinvested directly into aircraft, medical equipment and training rather than distributed externally.
Aero-Dienst takes a similarly measured approach, where strategy is driven almost entirely by members of ADAC.
Rather than diversifying its customer mix, Aero-Dienst’s growth focus is geographic and capability-led. “From mid of this year onward, we will improve our long-distance services for our members by adding the Challenger aircraft to our fleet,” says Kosing.
However, expansion is bounded by clear operational and political limits. This means overflight restrictions and geopolitical instability are now as much a part of growth planning as aircraft availability or staffing.
At FAI Medical Services, growth is closely tied to insurance and government demand. Lemke says long-term travel trends are the “primary driver”.
“According to IATA forecasts, international passenger traffic will continue to grow strongly over the next 10 years,” he says. “This will inevitably lead to an increase in the number of necessary ambulance transports.”
FAI’s response has been to expand global capability rather than fleet size. “FAI is one of the very few air ambulance companies that truly operates worldwide,” Lemke explains. Growth is pursued through long-term partnerships with travel insurers and government clients rather than acquisitions, he adds.
For many operators, staffing, particularly pilot availability, remains a key limiter. “Like many in the aviation industry, we are primarily concerned with the problem of recruiting pilots; staffing medical teams has never been a major challenge for us,” says Lemke.
FAI is currently building up additional medical personnel resources in the Middle East to provide “greater flexibility”.
Kosing echoes this point, particularly in relation to long-haul operations. “Pilot availability becomes more challenging on long-haul flights because of extended rest requirements, so we need more pilots,” he says.
European Air Ambulance has not faced such issues. Hienckes says the organisation receives a “very reasonable” amount of feedback whenever it advertises new pilot positions. “We have had for years very little fluctuation in pilot numbers,” he adds.
Lemke stresses it is crucial to keep an eye on the balance between increasing costs and passing these on to customers. “Current market prices, especially among travel insurers, are unfortunately well below the actual necessary threshold,” he says.
Despite their relatively conservative growth strategies, air ambulance operators are flying more than ever. Almost gone is the traditional seasonality, replaced by a constant flow of activity that could spike virtually anywhere on the planet. The question now is whether operators can sustain operations at such a frequency if activity continues to rise?
Meanwhile, insurers would probably have this advice for elderly travellers: “Stay indoors!”
Volker Lemke, MD at FAI Medical Services.
FAI air ambulance aircraft are equipped as flying intensive care units with the ability to transport infants to heavyweight patients.
FAI air ambulance aircraft are equipped as flying intensive care units with the ability to transport infants to heavyweight patients.
Yves Le Marquand, Reporter, Corporate Jet Investor
‘The (flying) doctor will see you now’
Ageing populations are helping to drive growth in air ambulance flights worldwide. WINGX identifies hotspots in demand and changes in the fleet. Words: Mike Stones
NOT MANY remember the Reverend John Flynn. But 98 years ago, he founded the Royal Flying Doctor Service in Queensland, Australia. Nearly a century later, the civilian air ambulance industry has blossomed worldwide. Plus, further growth is predicted in the years to 2030, according to flight data consultancy WINGX Advance.
“A key tailwind supporting continued growth is the aging demographic in developed markets, particularly in North America, Europe and Australia,” says Richard Koe, MD of WINGX. “This will drive increased demand for rapid medical transport services as elderly populations require more emergency and specialised care.”
The result is likely to be modest growth in the years to 2030, with low single-digit annual growth rates as the sector matures beyond its post-pandemic expansion phase, he says. Covid kickstarted the industry. Since 2019, it has seen 55% increase representing a 7.6% compound annual growth rate, says the consultancy. Koe puts it like this: “The sector saw a step-change following the pandemic, with steady expansion from the 2020 lows through 2025. This represents one of the strongest growth trajectories in business aviation operations during this period. Obviously – fingers crossed – that’s a one-off spike.”
But growth has moderated from pandemic-era peaks. “Last year showed the slowest year-over-year expansion of air ambulance services in the recent period,” Koe tells us. “The sector appears to be transitioning from rapid expansion to steady, sustainable growth.”
Continued growth is not simply due to aging populations in developed markets requiring more medical transport. Other factors include rising geographic coverage of air ambulance services and greater acceptance of air medical transport as standard care.
Global air ambulance activity reached more than 220,000 departures across business jets and turboprops in the first 11 months of last year. This is 3% up on the same period in 2024. Turboprop operations climbed 5% year-over-year, accounting for 76% of all flights. Jets represented 24% of activity and dipped by 1%.
“This split reflects the operational realities of air ambulance missions, where turboprops offer cost-effectiveness and capability for shorter range medical transports,” explains Koe. He also points out the data excludes piston aircraft and is based on global ATC [air traffic control) and ADSB (Automatic Dependent Surveillance Broadcast) records. Plus, WINGX tracks known medical/ambulance operators. Additional flights are flown ad hoc by aircraft normally flying passenger or cargo charter.
Reflecting the air ambulance industry’s origins, the Royal Flying Doctor Service leads the sector with more than 60,500 departures last year. This represents more than one-quarter of all global air ambulance flights, according to WINGX data.
Guardian Flight ranks second with about 25,000 flights, followed by Babcock Scandinavian Air Ambulance with nearly 13,000 operations. Air Methods operates more than 9,200 flights (ranking fourth), while CSI Aviation Services completes the top five with about 8,600 departures. Together, the five operators account for about 53% of all air ambulance activity tracked through the first 11 months of 2025.
Safe home: A Royal Flying Doctor Service Beechcraft King Air completes its mission somewhere in Queensland, Australia.
Safe home: A Royal Flying Doctor Service Beechcraft King Air completes its mission somewhere in Queensland, Australia.
Turning to aircraft types, the Pilatus PC-12 leads all air ambulance aircraft with nearly 70,000 departures, representing 32% of flights, in the first 11 months of last year. The Beechcraft King Air 200 ranks second with about 60,000 flights claiming a 27% share of the market. Together, the two types account for nearly 60% of all air ambulance missions.
Other significant aircraft flying air ambulance missions include the King Air 90, accounting for 10% of missions, and the King Air 350 and Learjet 45. Each make up 5% of flights, together accounting for 10% of total flights.
“The top 20 aircraft types show strong representation from both turboprops and light to midsize jets, with turboprops dominating due to their operational flexibility and economics.”
Not surprisingly, the US dominates air ambulance operations with more than 95,000 departures, accounting for 43% of global missions, in the first 11 months of last year. Turboprop flights represented 83% of US flights.
Australia ranks second with nearly 71,000 flights and shows even stronger preference for turboprops, which make up 91% of operations. Completing the top five countries, Norway had 13,000 flights, Canada 9,300 flights with Sweden accounting for 5,500 air ambulance missions.
“These five nations account for about 88% of global air ambulance activity, highlighting the concentration in developed markets with large geographic areas and dispersed populations,” says Koe.
Diving deeper into the statistics reveals significant regional variations. Compared with the global average of 24% of all missions, jet deployments in Sweden account for 99% of flights and in Germany 74% of missions. Newer types, such as the Pilatus PC-24 and Citation Latitude, are becoming more popular as fleets are modernised.
Fleet strategies also vary with Australia’s Royal Flying Doctor Service operating nearly 80 aircraft while Swiss Air Ambulance achieves significant activity with just three aircraft.
“The sector demonstrates resilience and adaptability, with different regional models succeeding based on local geography, regulations, and healthcare systems,” says Koe. The sector will need all that flexibility as it grapples with rising operational costs, including fuel prices and aircraft maintenance expenses, and pilot shortages, he adds. It could prove a toxic cocktail that pressures profit margins and limit fleet expansion for operators.
Nevertheless, WINGX believes the sector’s growth (albeit modest) is assured. “Despite the challenges, the fundamental need for air ambulance services in geographically dispersed regions ensures the sector will remain an essential component of healthcare infrastructure,” says Koe.
Meanwhile, tracing nearly a century of progress in aero engineering, PC-24 jets are now carrying on the work of the Royal Flying Doctor Service. A service that began with the Reverend John Flynn’s lumbering, single-engine de-Havilland DH.50 biplane in Cloncurry, Queensland.
