Nearly a year ago, in the midst of pandemic, a team led by the Air Force Life Cycle Management Center, with the Air Force Operational Test and Evaluation Center and Air Mobility Command, partnered with more than a dozen other military and civilian organizations to respond to U.S. Transportation Command’s Joint Urgent Operational Need request to develop equipment and procedures for the high capacity airlift of COVID-19 patients on mobility aircraft like the C-17 Globemaster III and C-130 Hercules, while maintaining the health and readiness of aircrews.
The result was the rapid and novel solution of transforming existing 40-foot CONEX containers into air-mobile bio-containment isolation wards – the Negatively Pressured CONEX; and designing and fabricating a similar new 30-foot aluminum container for C-130 aircraft, the Negative Pressure CONEX-Light. These systems went from concept to operations in less than 100 days.
To date, the NPC and NPCL have flown 37 missions across five geographic commands carrying 267 U.S. military, civilian, dependent and contractor COVID-19 patients with no confirmed cases of infection spreading to air or aeromedical crews in flight, according to Lt. Col. Paul Hendrickson, materiel leader and JUON lead with the Air Force Chemical, Biological, Radiological and Nuclear Defense Systems Branch, Human Systems Division at the Program Executive Office for Agile Combat Support — part of the Air Force Life Cycle Management Center at Aberdeen Proving Ground, Maryland.
Hendrickson, the leader of the NPC development team, explained that the not-so-simple goal was to design, build, test and deploy a fully-enclosed aeromedical system that would allow for the transport and in-flight care of COVID-19 patients, while keeping the virus from circulating through the aircraft and do it at breakneck speed.
“A Joint Urgent Operational Need statement is basically the way the military communicates to the acquisition community. They are saying, ‘We need something right now, as soon as humanly possible.’ So, it’s a way to streamline the acquisition and prioritize resources… to get something quickly versus months and years,” Hendrickson said.
The endeavor needed to succeed quickly to achieve one paramount goal; maintain readiness.
“When it comes to medical readiness, we need to think of the human being as a human weapon system,” said Brig. Gen. Mark A. Koeniger, a physician and commander of the Air Force Medical Readiness Agency.
“You can have all of the great equipment and technology, and the Air Force has a lot of that, yet ultimately it boils down to the Airmen. It is that Airman that turns the wrench out on the flight line or gets into the cockpit to fly the jet or is sitting in front of the computer screen assessing all of that intel. Healthy Airmen are the key to force readiness.
“While we do a great job in maintaining health readiness through prevention, something like COVID emerges and has shown that, despite all our technology and modern medicine, we can still be thrown for a loop. We have to assess and react quickly to maintain a healthy force.”
Before the NPC design was adopted and developed, AFOTEC, in conjunction with Air Mobility Command and others, first tested two existing airmobile biomedical isolation units; the Transportation Isolation System and the Portable Biocontainment Care Module.
The TIS was a system developed in response to the outbreak of Ebola in West Africa from 2014 through 2015. As U.S. forces deployed to assist in mitigating the crises, a device was needed to safely transport infected personnel.
The TIS, which was never used during the West African Ebola outbreak, but was kept in storage, is a palletized enclosure that is essentially a simple metal frame and plastic curtains with an air circulation and filter system.
However, as the only option for the DoD at the earliest stages of the COVID-19 outbreak, TIS units were taken out of storage and infectious disease specialists were sent to Joint Base Charleston, South Carolina, to assist in training AMC aircrews, aeromedical personnel and Critical Care Air Transport teams in the proper use of the system, according to Koeniger.
As the test director, Maj. Phillip Hoyt, CBRN branch chief, combat support division, AFOTEC Detachment 2, was at the center of ensuring the entire united test team was synced for the JUON.
As a bioenvironmental engineer, he was uniquely qualified for testing a proposed solution to USTRANSCOM’s needs.
“I got to utilize my previous operational experience with bio-containment units,” Hoyt said. “I was at Joint Base Charleston from 2010 to about 2015. During that time period, 2014 and 2015 in particular, we were conducting Operation United Assistance (in response to the Ebola outbreak in West Africa). I was able to help out with precautions for C-17s and their crews that were ferrying equipment and people to set up the hospitals.
“We had come up with an initial isolation plan and contingency plan for what would happen if somebody was to get sick on a plane… A joint urgent operational need arose for the Transport Isolation System, which is basically the grandfather of the NPC. So, I was at Charleston when that was fielded and had a great opportunity to come up with the concepts of how that would be employed out of the base.”
AFOTEC’s test team, in response to the COVID JUON, also included a test analyst, bioenvironmental technician, and emergency management testers who work out of Detachment 2’s CBRN Branch along with the 28th Test and Evaluation Squadron, Agile Combat Support Flight out of Eglin Air Force Base, Florida.
Subject matter experts from the Center for Sustainment of Trauma and Readiness Skills at the University of Nebraska Medical Center, U.S. Army Combat Capabilities Development Command Chemical Biological Center and USA Public Health Center volunteered to travel to JB Charleston to round out the initial test team.
During the first week, the team’s focus shifted to helping AMC medics solve TIS deficiencies that restricted the system from supporting immediate operations with COVID-19 infected patients to developing new decontamination procedures to allow greater TIS mission flexibility and quick turnaround times.
According to Hendrickson, the TIS was suitable for isolating patients with a disease transmitted only by direct physical contact, like Ebola, but was of limited utility with airborne contagions, such as COVID-19. It also had other limitations that quickly eliminated it as a permanent solution.
“The Transportation Isolation System had a low transport capacity. You could hold three ambulatory patients or one litter patient in one module, and you could fit only two modules on a C-17. It was a capable system for its intended use with Ebola patients, but it wasn’t operationally usable for long periods of time. So, looking at that and the increased demand signal for transportation of COVID patients, it was quickly ruled out as a permanent solution and TRANSCOM issued a JUON statement, looking for the ability to transport large numbers of COVID-19 patients,” Hendrickson said.
The Portable Biocontainment Care Module, an existing unit on loan from the Department of State (DOS), was also quickly assessed between DOS missions in late March 2020 during an Operational Utility Evaluation led by Hoyt, with support from Defense Threat Reduction Agency and AMC’s Test and Evaluation team.
While the PBCM is an air-isolated, hardened, roll-on-roll-off structure that met airworthiness and biocontainment requirements, medical-crew familiarization, and flight testing on the C-17 with operational crews, it could effectively accommodate only three patients as utilized by the Air Force. Again, the potential need to transport large numbers of U.S. military and civilian personnel eliminated it as an option.
Yet the evaluations of, and training on, the existing systems, yielded perhaps the most critical component of future success; it brought exactly the right people together at Joint Base Charleston to create a solution to USTRANSCOM’s need in record time.
Having key personnel already working as a team supercharged the starting-from-scratch effort, which led to the elegant solutions of transforming existing 40-foot CONEX containers and building the new NPCL into airmobile medical isolation wards; solutions that went from a drawing on a napkin to operational status in only 94 days.
“Our office had been working along with the 51st Aircraft Maintenance Squadron at Osan Air Base on a modification to a standard 40-foot CONEX to provide protection in a CBRN environment. The initial need for the AMXS was to get its aircraft maintainers rest and relief from their chem-bio gear before going back to the fight,” said Hendrickson. “We were working on the production of the ColPro CONEX and prepping to demonstrate the concept at an exercise in Korea. So, after talking to Air Mobility Command and understanding the requirements of the urgent need, I reached out to my Collective Protection Program Manager, Capt. Alexis Todaro, and she sketched out transforming the CPC into the Negatively Pressurized CONEX in a matter of hours, and we were off and running.”
The NPC has high-efficiency particulate air filters and blowers that make the air pressure inside the NPC less than that of the aircraft cargo area. It can be configured to accommodate 28 seated passengers or seats for 23 ambulatory patients and litters for eight patients. Its design has been certified for military airworthiness for the C-17 Globemaster III aircraft.
The negative air pressure inside the unit essentially makes it function like a laboratory clean room.
“It will pull in air from the outside through two layers of HEPA filters and then push out the air through the other side through HEPA filters as well,” said Col. Timothy Mach, AMC chief of requirements.
“We are getting the air as clean as possible as it moves throughout the device, which prevents the spread of an aerosol virus, like COVID-19. You have air pressure inside the device that is less than the air pressure in the cargo bay of the aircraft. That way, if a door is opened, you only get uncontaminated air rushing into the device. The difference in air pressure keeps the potentially contaminated air from leaving the device except through HEPA filters which can trap an aerosolized virus as small as 0.3 microns.”
The NPC is divided into two sections. The patient compartment is for the COVID patients, both ambulatory, seated, and those on litters, including patients requiring ventilators and the aeromedical personnel. The anteroom separates the cargo area of the aircraft from the area containing the infected patients. Control boxes with signal lights in both compartments allowing for communication between care personnel and multiple windows enable coordination of care.
Air is drawn from the aircraft into the anteroom through two sets of filters before passing into the patient area. Doors on both sides of the anteroom allow for aeromedical crew to enter the device before donning personal protective equipment and entering the patient chamber. It also allows aeromedical personnel to take breaks outside of the patient area and remove PPE and decontaminate before safely returning to the cargo area.
“Think of it as similar to an airlock in sci-fi films. You enter from the craft. Close the door and put on protective gear before you go out the other door into space. Then you come back in from space into the airlock where the atmosphere is made safe, remove your protective gear and re-enter the craft,” said Mach.
This clean air allows the patients and caregivers to travel over long distances while keeping bio-organisms or other pathogens safely contained within the NPC.
“(Upon) seeing the concept, Col. Mach said, ‘Go and prove it will meet the need,’” Hendrickson said.
Hendrickson’s team partnered with the Joint Program Executive Office for CBRN Defense and numerous experts across the CBRN, aeromedical and airworthiness communities. By April 7, a contract was awarded using the “other transaction authority” process.
The first proof-of-concept NPC was constructed in only 13 days and delivered to Joint Base Charleston for validation testing. That testing concluded April 30, when Air Mobility Command green-lit the NPC as the system to meet its requirements under the JUON.
Ensuring the NPC was proven capable of what it was designed to do was a combined effort of the academia, contract partners, and Department of Defense units.
Designing the bio-containment unit was only part of the solution; creating a system that could safely transport individuals on an aircraft presented an additional challenge to the team.
Teams from the C-17 Program Office, C-130 Program Offices and AFLCMC Engineering Airworthiness Office provided hundreds of hours of support over a few short weeks to ensure the systems were designed to achieve stringent airworthiness requirements for the safety of passengers and aircraft.
As an example of this teamwork, Matt Kilmer, Tony Bermudez, Robert Whitfield and Laura Hawthorn, engineers from the C-130 Offices, spent weeks at HEI in Michigan to support the design and manufacturing of the system. Robert David and Scott Brantley, C-17 program office engineers, supported the build at Delta in Atlanta and all individual supporting testing at JB Charleston.
“The innumerable impacts that the individuals across the aircraft program offices and engineering offices provided to this program to shave days and weeks off of the process was considerable. The nights, weekends and holidays worked by individuals who had never met before to get this system fielded is a testament to the professionalism and dedication of the entire Air Force Life Cycle Management Center team,” Hendrickson said.
Hendrickson added that the procurement, demonstration and testing of the NPC is a textbook example of rapid acquisition and development and credited the contractors involved in building the NPC and NPCL — UTS Systems, Highland Engineering Inc. and Delta Flight Products with significantly contributing to such rapid deployment.
“In just nine days, we proved the NPC concepts and capabilities 21 days after the contract award. I could not be prouder of this team of teams,” Hendrickson said.
Along with many agencies, a team led by Capt. Kerollos Marzouk and 2nd Lt. Hunter Mangueira from the AF CBRN Branch partnered with Hoyt’s AFOTEC team, Capt. Conor Favo and the 28th Test and Evaluation Squadron and the 417th Flight Test Squadron to combine and conduct concurrent test design, test planning and test execution to shorten the total time required to complete the testing process. While this usually is a process done sequentially by a single test team, these test teams joined together in a joint effort to accomplish the events concurrently.
The first production NPC was delivered to JB Charleston on June 7, had its test flight June 15, and flew its first operational mission June 30, transporting 12 patients from CENTCOM to Ramstein AB.
While the NPC was designed to protect the aircrew, aircraft, and the aeromedical evacuation crew members treating on long-haul inter-theater flights, the 30-foot-long NPC-Lite was designed to fit inside a C-130 and evacuate patients from more austere intra-theater locations.
The first production NPCL was delivered to Joint Base Charleston on June 1, where it was subjected to similar tests as the NPC but on three variations of C-130 aircraft, had its final test on June 24 and arrived at Ramstein Air Base on July 3.
While it protects aircrews, it also has the effect of supporting readiness of combat units in the field, according to Mach.
“Think of COVID-19 and how rapidly it could spread amongst personnel in the field. We are doing social distancing as a way to slow the spread across the U.S. and the world, but there are some places where we are deployed that we can’t easily socially distance; like one person per tent or a room,” Mach said.
“So, we came up with a capability that has now been used to quickly take patients from the frontline, wherever they are, and transport them to a suitable medical facility. So, think of a bare-bones base, say in Africa, we can pick up a Soldier, Sailor or Marine in a C-130 carrying an NPCL and quickly get them to treatment, but also quickly get them away from their unit before the virus can spread and negatively affect that deployed unit’s readiness.”
According to Col. Leslie Wood, Headquarters AMC medical director for en-route medical care, treating patients in place makes sense for infectious patients if you have the resources and personnel to give proper care because you completely mitigate the risk of losing operational capability in airlift medical crews.
“The U.S. military has done amazing work with trauma in being able to rapidly move patients from point of injury, through the echelons of care, to definitive care. Before Vietnam, that transition from point of injury to definitive care was often two to three weeks. Now it’s two to three days, and we have had the most amazing improvements in combat mortality; if you survive your initial injury and make it to the first echelon of care, you have like a 98 to a 99% chance of survival,” Wood said.
“However, when you take that same model and apply it to infectious disease, you actually can make the situation worse. Think about taking infectious patients who are highly contagious and moving them through echelons of care, especially without appropriate engineering controls to maintain isolation and without adequate personal protective equipment for the people taking care of them. You are going to spread the disease throughout your echelons of care and actually make the problem worse, creating new nodes of transmission, and then losing operational capability as you infect your air and medical crews.”
Wood also noted that those same aircraft are part of the logistical supply chain. Without effective biocontainment transport, the military risked not only infecting air and medical crews but also losing the very airlift capability needed to send food, supplies and equipment where personnel needed them.
However, Wood adds that there are instances where there is no other option but to transport the patient, making the NPC an absolute requirement to maintain readiness.
“COVID patients require high amounts of oxygen and full ICU support. And while we have that capability in many places across the globe, we do not have it everywhere. And in order to be able to effectively have the same standard of care for all of our deployed military personnel, it was going to require that we had a transport capability,” Wood said.
Wood believes that the team’s response to the USTRANSCOM JUON was one of the highlights of her career.
Currently, the fielding team comprised of Todaro, Deputy Program Manager 1st Lt. Donald Wiegner and Jason Adamek, JPEO CBRND chief engineer, have fielded nine NPCs and six NPCLs and provided on-site training and familiarization for ground and operational crews. The systems are positioned strategically around the world in United States Indo-Pacific Command, U.S. Northern Command, U.S. European Command and U.S. Central Command to respond to inter-theater and intra-theater airlift requirements.
Another six NPC’s and four NPCLs are being stored in ready status and postured for future responses and pandemic requirements by Marine Force Storage Command located at Marine Corps Logistics Base, Albany, Georgia, in partnership with Marine Corps Logistics Command’s Joint Enterprise Fielding and Surveillance team, who will oversee long-term monitoring and maintenance.
In total, 30 NPCs and 30 NPCLs have been ordered, with delivery expected by the end of Summer 2021.
Koeniger believes the development and acquisition of these units were necessary for the present and will be a key capability for the future; ready to go if the call comes.
“It’s possible we’re not going to be waiting another hundred years between major pandemics. The population will continue to grow, and with changes in climate and other things going on in the world, it may be a lot shorter of a time before we see something else emerge,” Koeniger said.
“If there is a bright side, it’s that COVID-19 and the development of the NPC, a winning capability, has given us a lot of lessons learned. The next pandemic could be more challenging, but thanks to the tireless work by all the Airmen involved with this project, we will be prepared and able to maintain readiness when we’re called on again.”
March 18, 2020 – NPC concept first developed based off of another development for CBRN a ColPro CONEX
March 25 – NPC concept officially “green-lit” as a Proof of Concept effort with AMC/A5Q
March 25-30 – NPC Requirements Generation and Statement of Objectives authored by community
March 28 – Joint Urgent Order of Need issued (PBCM and NPC move ahead)
March 30 – Draft Other Transactional Authority (OTA) Request for Prototype Proposal (RPP) for an Enhanced White Paper released
March 31 – OTA RPP for an Enhanced White Paper released
April 2 – OTA Enhanced White Papers Due – source selection begins
April 7 – OTA agreement awarded to Advanced Technology International (ATI), ATI issued Project Agreement to UTS Systems/Highland Engineering Inc./Delta Flight Products for NPC Proof of Concept (PoC)
April 12 – NPCL kick-off meeting with AF/Navy/USCG/USMC
April 21 – NPC Proof of Concept delivered to Joint Base Charleston for testing
April 30 – NPC PoC flight test – AMC/CC Concurs to move forward w/ NPC/NPCL programs, not pursue PBCM procurement
May 9 – $32M of funding received and NPC-001 and NPCL-001, builds begin
June 1 – NPCL arrives at JBC for testing
June 7 – NPC Arrives at JBC for testing
June 12 – NPCL conducts its Operational Utility Evaluation (OUE) flight on HC-130J
June 15 – NPC conducts its OUE flight on C-17
June 19 – NPC receives its Military Flight Release (MFR) for operations
June 23 – NPC departs for operations from JBC to Ramstein AB
June 25 – NPCL receives its MFR for operations
June 30 – NPC conducts first mission (12 Patients) from CENTCOM to Ramstein AB
July 2 – NPCL departs for operations from JBC to Ramstein AB